**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 34 residents with 13 residents sampled, including five residents reviewed for unnecessary medications. Based on observation, interview and record review the facility failed to review and revise one dependent Resident's (R)29's care plan to include non-pharmacological interventions for pain. Findings included: - Review of Resident (R)29's electronic medical record (EMR) documented the following diagnoses: pain (physical suffering or discomfort) and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition. She received as needed (PRN) medications for pain and reported occasional moderate pain which did not affect her sleep or day to day activities. The Pain Care Area Assessment (CAA), dated 09/22/23, did not trigger. The Quarterly MDS, dated 03/08/24, documented the resident had a BIMS score of seven, indicating severe cognitive impairment. The resident received scheduled pain medication and denied pain at the time of the assessment. The care plan for pain, revised 06/05/24, instructed staff the resident had moderate leg pain which she received Acetaminophen (an over-the-counter medication for pain), 325 milligrams (mg), two tablets by mouth (po), every (Q) six hours and Acetaminophen 500 mg, po, three times per day (TID). The care plan lacked staff instruction on non-pharmacological interventions for pain. Review of the resident's EMR included the following physician's orders: Tylenol 500 mg, po, Q six hours, PRN for pain, ordered 03/14/24. Tylenol Extra Strength (ES) 500 mg, po, TID, for back pain, ordered 10/12/23. On 06/05/24 at 01:15 PM, Administrative Nurse D stated she would expect the resident's care plan to include non-medical interventions for pain. The facility's policy for Pain Management-Assessment, Monitoring, and Care Planning, revised 10/20/24, included: The facility shall develop and implement both non-pharmacological and pharmalogical interventions for pain, which will be included in the resident's plan of care. The facility failed to include non-medical interventions for pain in R29's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 34 residents with 13 selected for review, which included one resident reviewed for activities of daily living. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)30 received grooming per his usual preference. Findings included: - Review of Resident (R)30's medical record revealed diagnoses that included fracture of left pubis (pelvic bone), third lumbar vertebra (bone of the spinal column), dementia (progressive mental disorder characterized by failing memory, confusion),and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimal Data Set (MDS), dated [DATE], assessed the resident with moderately impaired cognitive skills, fluctuating inattention, and physical behavior directed towards others, and rejection of care. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 05/06/24, assessed the resident could be resistive to care and combative. R30 was dependent on care for personal hygiene. The Care Plan reviewed 05/10/24, instructed staff the resident required staff assistance for personal hygiene. The resident's bath days were Monday and Wednesday, on the evening shift. Observation, on 06/03/24 at 10:56 AM, revealed R30 seated in his recliner with his eyes closed and chin resting on his chest. R30 had several days' worth of facial hair. The family member stated the resident preferred a clean- shaven appearance and did not recall when the resident last received a shave. Observation, on 06/03/24 at 12:15 PM, revealed the resident seated in his wheelchair in the dining room with the family member attempting to feed the resident. The resident's chin was on his chest, and the resident did not respond to requests to hold his head up. Observation on 06/04/24 at 08:00 AM, revealed the resident positioned in bed with no response to verbal stimuli. Observation, on 06/04/24 at 10:38 AM, revealed the resident remained in bed, with minimal response to verbal and tactile stimulus. Interview at that time with Certified Nurse Aide M revealed R30 had a decline and became less responsive for approximately one week. CNA M states the resident usually received shaving with bathing but did not know what shift or day. Interview, on 06/04/24 at 01:03 PM, with Licensed Nurse (LN) H, confirmed the resident's increased somnolence and decline in status over the past two weeks and notified the physician for assessment. Interview, on 06/05/24 at 01:30 PM, with Administrative Nurse E, revealed the resident resisted care when first admitted and recently had a decline in condition, and now would receive hospice services. Administrative Nurse E stated she would expect staff to provide grooming opportunities to the resident as he allowed, not just on scheduled bath days. The facility policy Activities of Daily Living reviewed 09/18/23, instructed staff to provide grooming opportunities according to their care plan. The facility failed to ensure staff provided grooming opportunities for this dependent resident with a decline in condition and decline in resistive behaviors.

The facility reported a census of 34 residents. Based on observation, interview, and record review, the facility failed to prepare food consistent with required recipes to ensure nutritional value and preservation of vitamins for three residents identified to receive pureed diets. Findings included: - On 06/04/24 at 10:43 AM, dietary staff FF identified she prepared pureed diets for three facility residents. The menu included beef tips, mashed potatoes, and brussel sprouts. Upon inquiry, she stated she did not have recipes to follow to puree the residents' food. She stated she would add water, gravy, or butter, till she got the food to the right consistency. When asked how she knew which to add to maintain the nutritional value, she stated she did not know. On 06/04/24 at 10:48 AM, dietary staff BB confirmed the facility had three residents that received pureed diets and the facility lacked recipes to prepare the pureed diets to ensure the nutrients and vitamins preserved. Additionally, he reported he was not aware the pureed diets should have recipes to direct the staff in the preparation of pureed diets to preserve the nutritional value of the food. On 06/04/24 at 10:58 AM, dietary staff BB confirmed he had contacted the facility dietician who confirmed the facility should have recipes to follow for each food item in the menu for residents who receive a pureed diet. The facility lacked a policy to address the use of recipes for preparation of pureed diets to ensure nutritional value and maintain vitamin preservation. The facility failed to prepare food consistent with required recipes for three residents that received pureed diet.

The facility reported a census of 34 residents. Based on observation and interview, the facility failed to prepare food under sanitary conditions, for the residents of the facility related to the appropriate use of hair restraints, beard restraints, and cross contamination following handwashing. Findings included: - On 06/03/24 at 10:11 AM, an initial tour of the kitchen with Dietary Staff CC, revealed the following areas of concern: 1. Dietary staff DD walked through the food preparation area with his hair unrestrained and exposed outside of his ball cap. 2. Dietary staff EE worked in the food preparation area with his hair exposed and unrestrained outside of his ball cap. Dietary staff EE had a facial beard and he lacked a beard guard. Dietary Staff CC confirmed the above findings during the initial tour and stated the dietary staff should wear hair nets and beard guards while in the food preparation area to prevent staff hair from contaminating the food and resulting in food borne illnesses. On 06/03/24 at 10:30 AM, dietary staff BB stated dietary staff should wear beard guards and hair restraints when food preparation area to prevent contamination of the food. He reported he had provided ball caps for dietary staff to use as hair restraints. Dietary staff BB verified the above noted staff with unrestrained hair loose and exposed which extended beyond the ball caps. Additionally, he confirmed the staff lacked required beard guards. On 06/04/24 at 10:43 AM, observed dietary staff FF wash her hands at the kitchen handwashing sink, dry her hands with paper towels, walk to a large, covered trash barrel in the food prep area, lift the lid with the used paper towel, throw the paper towel in the barrel and then slid the garbage can lid with her bare hand. She then proceeded to prepare the pureed foods. Dietary staff BB stated dietary staff should wash and dry their hands and dispose of paper towels in the foot operated trash can without having direct contact with the trash can lid to prevent cross contamination of food during preparation. The facility lacked a policy to address appropriate use of hair restraints, beard restraints, cross contamination following handwashing. The facility failed to prepare food under sanitary conditions, for the residents of the facility related to the appropriate use of hair restraints, beard restraints, cross contamination following handwashing.

The facility reported a census of 34 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests. Findings included: - On 06/03/24 at 10:33 AM, initial tour with Dietary Staff BB revealed a three compartment outside dumpster with open lids. One of the three compartments contained a full garbage bag. Dietary staff BB confirmed the dumpster lids should be closed at all times to prevent rodents and wildlife in the area from entering the garbage and spreading it throughout the facility grounds to attract pests and prevent the spread of contaminations. Additionally, dietary staff BB stated the dumpsters were used by all facility staff. He reported the staff should have ensured the lid was closed to contain the trash/garbage when placed into the dumpster. On 06/05/24 at 10:50 AM, Administrative Staff AA, confirmed all facility staff used the dumpsters for disposal of trash and garbage. She verified facility staff should close the lids to contain the contents when placing trash or garbage in the dumpster. Additionally, she stated there were multiple wildlife in the general area which came on facility grounds which could have access to the content of the dumpsters if the lids were not closed and trash contained. The facility lacked a policy to address garbage and refuse disposal and containment. The facility failed to maintain and/or dispose of garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of Resident (R)13's electronic medical record (EMR) included a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for pain revealed severe cognitive impairment. She required extensive assistance of one staff for locomotion with her wheelchair. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 01/25/22, did not trigger for further review. The quarterly MDS, dated 10/21/22, documented the staff assessment for cognition revealed severe cognitive impairment. She required extensive assistance of one staff for locomotion with her wheelchair. The care plan for ADLs, revised 10/25/22, instructed staff the resident required total assistance of one staff for propelling her wheelchair as the resident was non-ambulatory. The care plan lacked interventions to support the resident's feet/legs when unable to hold them above the floor while being transported in the wheelchair, to prevent accidents. Review of the resident's EMR, revealed from 10/17/22 through 11/14/22, the resident required limited to total assistance of one staff for locomotion on the unit with her wheelchair. On 11/14/22 at 11:53 AM, Licensed Nurse (LN) H propelled the resident into the dining room for lunch. The resident's shoed feet bounced on the floor multiple times during transport. The resident's wheelchair lacked foot pedals. On 11/15/22 at 11:43 AM, Certified Nurse Aide (CNA) N propelled the resident to the dining room for lunch. The resident's shoed feet skimmed the floor during transport. The resident's wheelchair lacked foot pedals. On 11/15/22 at 11:43 AM, CNA N stated staff do not use foot pedals on the resident's wheelchair due to she will propel herself at times. On 11/14/22 at 11:53 AM, LN H stated the resident did not have footpedals on her wheelchair because she would propel herself at times using her feet. On 11/15/22 at 03:34 PM, LN G stated the resident would propel herself at times in her wheelchair. Staff should probably place foot pedals on the wheelchair when they propelled her. On 11/16/22 at 11:25 PM, Administrative Nurse E, stated she was responsible for updating the care plans. Anything that triggers on a MDS should be included on the care plan. If a resident uses foot pedals on a wheelchair, it would need to be included on the care plan. On 11/16/22 at 02:53 PM, Administrative Nurse D stated the staff will transport the residents in the wheelchairs slowly without foot pedals in place. Many residents will propel themselves and foot pedals would act as a restraint. The facility policy for Comprehensive Assessment Policy Including the MDS, CAAs and Care Planning, approved 01/11/21, included: Any changes in the resident's condition will require an immediate reassessment with changes in the plan of care reflecting the change in condition. The facility failed to review and revise the care plan to include interventions for the use of foot pedals on this resident's wheelchair to ensure resident safety when staff propelled the resident. The facility reported a census of 34 residents with 16 selected for review. Based on observation, interview, and record review the facility failed to review and revise the plan of cares for two of the 16 sampled residents, including; Resident (R)6 and R13 with the lack of intervention to support the residents' legs during transport in wheelchairs to prevent accidents with potential foot/leg injury. Findings included: - Review of resident (R)6's electronic medical record, revealed diagnoses included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), dementia (progressive mental disorder characterized by failing memory and confusion), neuropathy (damage to nerves outside of the brain and spinal cord), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and chronic pain. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive status. The resident required extensive assistance of one staff for transfer and locomotion on and off the unit. The resident had functional impairment in range on motion on one side of her upper and lower extremities. The resident used a wheelchair for mobility. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/07/22, assessed the resident had decline in cognition but was able to make needs known. The resident had a diagnosis of dementia. The Falls CAA dated 06/07/22, assessed the resident made poor choices and was wheelchair bound. The Quarterly MDS, dated 09/03/22, assessed the resident with severely impaired cognitive status. The resident required extensive assistance on one staff for transfers and required limited assistance of one person for locomotion on and off the unit. The resident had functional impairment in range on motion on one side of her upper and lower extremities. The resident used a wheelchair for mobility. The Care Plan, revised 09/11/22, instructed staff the resident required up to extensive assistance of one staff for locomotion on and off the unit. The resident propelled herself in the wheelchair for very short distances The Care Plan lacked interventions for use of foot pedals on her wheelchair. Observation, on 11/14/22 at 08:00 AM, revealed Certified Nurse Aide (CNA) N, propelled the resident in her wheelchair from her room to the dining room. The wheelchair lacked foot pedals and her feet skimmed along directly on the floor. The resident intermittently raised her feet up but did not maintain her feet in an elevated position. Observation, on 11/15/22 at 08:47 AM, revealed CNA Q, propelled the resident in her wheelchair from the dining room to her room. The wheelchair lacked foot pedals and the resident's feet skimmed along directly on the floor. Interview, on 11/15/22 at 09:00 AM, with the resident revealed she often had pain in her legs and staff assisted her in her wheelchair. The resident stated she did not walk. Observation, on 11/16/22 at 08:41 AM, revealed CNA NN propelled the resident seated in her wheelchair from the dining room to her room. The wheelchair lacked foot pedals and the resident's feet skimmed along directly on the floor. Interview, at that time, with CNA NN, revealed the resident did have foot pedals for the wheelchair, but did not know where they were. CNA NN stated the resident did propel herself in her room at times but could not self-propel long distances. Interview, on 11/16/22 at 11:25 PM, with Administrative Nurse E, revealed the care plan included triggers from the MDS. Administrative Nurse E stated use of foot pedals on a wheelchair should be included on the care plan. Interview, on 11/16/22 at 01:33 PM, with Licensed Nurse (LN) H, revealed the resident did have foot pedals, but did not know where they were. The resident informed LN H where the foot pedals were located, in her room at that time. LN H attempted to attach the foot pedals to the wheelchair and noted the left foot pedal did not attach completely and requested assistance from CNA MM. Interview with CNA MM, at that time, revealed she did not know why the foot pedals were not attached to the chair, and would notify maintenance to assist with attaching them. Interview, on 11/16/22 at 02:53 PM, with Administrative Nurse D, revealed she would expect staff to propel the resident in her wheelchair slowly, as she thought the resident could hold her feet up off the floor. She expected staff to place one hand on the resident's shoulder in case the resident lurched forward unexpectedly. Administrative Nurse D stated staff should apply foot pedals when the resident could not hold their feet off the floor. Administrative Nurse D stated the resident often refused interventions and the care plan indicated her refusal but did not know if she refused foot pedals. The facility policy for Comprehensive Assessment Policy Including the MDS, CAAs and Care Planning, approved 01/11/21, included: Any changes in the resident's condition will require an immediate reassessment with changes in the plan of care reflecting the change in condition. The facility failed to review and revise the care plan to include interventions for the use of foot pedals on this resident's wheelchair to ensure resident safety when staff propelled the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 34 residents, with 16 residents sampled, including two residents reviewed for Activities of Daily Living (ADL). Based on observation, interview, and record review, the facility failed to provide adequate care for the two dependent Residents (R) 32 and R25 regarding oral hygiene cares. Findings included: - Review of Resident (R) 32's electronic medical record (EMR), including a diagnosis of Dementia (a progressive mental disorder characterized by failing memory and confusion). The annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed moderately impaired cognition with disorganized thinking and delirium (sudden severe confusion, disorientation, and restlessness). The Activities of Daily Living (ADL) Function/Rehabilitation Potential Care Area Assessment (CAA) dated 7/29/22 stated the resident was dependent on staff to anticipate needs and assistance with all ADLs. The care plan, revised on 10/26/22, reports has own teeth. Staff to assist with oral cares at least twice daily and as needed. A review of the resident's EMR, from 10/20/22 through 11/17/22, reveals the resident's hygiene performance, including brushing teeth, ranging from: requires supervision (oversight, encouragement, or cueing), extensive assistance (resident involved in activity) and total dependence (full staff performance). On 11/14/22 at 08:23 AM, the resident was resting in her bed on her left side. She was alert and confused at times. She reported being concerned she was not getting any oral care, explicitly brushing her teeth. She stated, If they would take 2 minutes to stand me up, I can brush my teeth. The resident's teeth contained a large amount of off-white, thick buildup between her bottom teeth and redness at her bottom gumline. She denied any mouth or tooth pain. On 11/1/22 at 10:49 AM, the resident was sitting up in her recliner. She denied having her teeth brushed today. She still has a thick buildup between and on her bottom teeth, and her bottom gumline is red. Her toothbrush was dry and in an emesis basin on her bathroom sink countertop. On 11/15/22 at 09:15 AM, Certified Nurse Aid (CNA) N and (CNA) P assisted the resident in returning to her bed from her wheelchair. When questioning of (CNA) N when the resident got her teeth brushed, he stated, once on first shift, but I don't know about second and third shift. At that point, (CNA) N asked the resident if she wanted to brush her teeth. She stated, yes. (CNA) N gathered supplies and asked the resident if she wanted to brush her own teeth or if she wanted him to do it for her. She stated, I want you to. (CNA) N brushed the resident's teeth. Dental floss was lying on the resident's bathroom counter, which staff failed to use. On 11/16/22 at 08:17 AM, the resident was in the dining room in her wheelchair, drinking her nutrition shake. She had a significant buildup of debris between and on her bottom teeth, and the bottom gumline was red and inflamed. On 11/16/23 at 08:26 AM, (LN) N asked when the resident received oral care. She stated, for the most part, everyone gets their teeth brushed twice a day. On 11/17/22 at 08:23 AM, the resident was sitting in the dining room in her wheelchair, waiting on breakfast. She had an excessive buildup of debris between and around her bottom teeth, and her bottom gumline was red and inflamed. On 11/17/22 at 10:28 AM, the resident was asleep in her bed on her left side. Her toothbrush, emesis basin, and cup used to rinse her mouth after brushing her teeth on her bathroom countertop are all dry. The facility policy for Oral Care includes: routinely assess oral health status; staff will assess thorough and consistent monitoring of each resident's oral status time at the time of admission, quarterly, if a resident experiences unintended weight loss, and with any significant change in the residents' health status including, but not limited to: lips, tongue, gums and tissue, saliva, natural teeth condition including decay or broken teeth, dentures, oral cleanliness, and dental pain. The facility failed to provide adequate oral hygiene care for this dependent resident. - Review of Resident (R) 25's electronic medical record (EMR), including a diagnosis of Cerebrovascular accident (CVA) (stroke) - (the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery). The annualMinimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition and revealed cognitive loss and dementia (a progressive mental disorder characterized by failing memory and confusion). In addition, the resident required the total assistance of one staff for personal hygiene and had no dental issues. The Care Areas Assessment (CAA) dated 8/20/22, revealed the resident had no teeth and was NPO (nothing to eat or drink by mouth). He was totally dependent on staff to complete oral care twice a day and had recurrent thrush (an infection of the mouth and throat, producing whitish patches) on his tongue. The care plan, dated 8/29/22, reported the resident had no teeth and refused to wear dentures. Per his spouse, He does not like them at all and has not worn them for years. In addition, the care plan lacked any instruction for oral care. There was a resident care information sheet on the back of the resident's bathroom door that documented, Staff will assist with oral care at least twice a day. A review of the resident's EMR, from 10/20/22 through 11/17/22, reveals the resident requires limited assistance (resident needs guided maneuvering of limbs from staff) to total dependence (full staff performance) for personal hygiene, including brushing his teeth. On 11/14/22 at 9:20 AM, the resident rested on his back in bed. His mouth had a white, thick filmy buildup coating his tongue. He denied any pain or discomfort in his mouth. On 11/14/22 at 11:17 AM, the resident was sitting up in his recliner. Licensed Nurse (LN) H was in the resident's room. She reported that the nurses perform oral care for the resident when they administer the resident's gastrostomy feeding (G-tube) (introducing a nutrient solution through a surgically inserted tube into the stomach through the abdominal wall) twice a day. Because of the resident's g-tube, he may have nothing to eat or drink by mouth (NPO). On 11/14/22 at 11:28 AM, LN N gave the resident Biotene 5 millimeters of oral mouth rinse. The resident swished and spit out the mouth rinse. (LN) N obtained the resident's tongue brush from an emesis basin on the resident's bathroom countertop, gave it to him in his left hand, and assisted him in brushing his tongue. LN N then rinsed the tongue brush in the bathroom sink and replaced it in the emesis basin. The resident still had a white, thick, filmy coating on his tongue. However, LN N reported the appearance of his tongue was normal because of his dry mouth. On 11/15/22 at 08:06 AM, the resident was sitting up in his recliner. He still had a white, thick, filmy coating on his tongue which appeared unchanged since yesterday. On 11/15/22 at 08:11 AM, the resident's tongue brush was dry in the emesis basin on his countertop. On 11/15/22 at 02:58 PM, (LN) G was in the resident's room preparing to administer water into his G-tube. She reported the resident gets oral care once or twice on this shift. When asked what times, she stated, I try to do it when I'm doing his g-tube. LN G finished administering the water to the resident through his g-tube and left the room without offering or providing any oral hygiene care to the resident. The resident's tongue remained unchanged since this morning, with a white, thick, filmy coating. On 11/16/22 at 08:05 AM, the resident was sitting in his recliner. He still had a white, thick, filmy coating on his tongue. The resident's tongue brush was dry in the emesis basin on his bathroom countertop. According to the Medication Administration Record (MAR) in the EMR, nutrition and water were administered to the resident into his g-tube at 6:00 AM, and Biotene moisturizing (mouth) rinse was given at 8:00 AM. On 11/16/22 at 08:21 AM, LN N reported she administered his Biotene moisturizing rinse this morning and explained he gets oral care three times a day with his (g-tube) flushes and feedings. Then LN N reported, the resident had a history of thrush (an infection of the mouth and throat, producing whitish patches). She noted that she had seen the white, thick, filmy buildup on his tongue and said it was from his mouth being dry. She reported the resident would have his tongue brushed again at 12:00 PM by either LN J or LN I. On 11/16/22 at 12:45 PM, the resident was sitting up in his recliner. The resident still had a white, thick, filmy buildup on his tongue and said he has no pain in his mouth. His lips and mouth were moist. The resident's tongue brush in the emesis basin on his bathroom countertop was wet, and the medication cup used for administering the Biotene moisturizing mouth rinse was in the trashcan. On 11/16/22 at 01:03 PM, LN I reported she did the resident's 12:00 PM Biotene moisturizing oral rinse and assisted the resident in brushing his tongue with the tongue brush in the emesis basin on the resident's bathroom countertop. On 11/16/22 at 01:39 PM, Administrative Nurse D reported that she expects oral care to be done twice daily and as needed for every resident. On 11/17/22 at 08:30 AM, Administrative Nurse D said she looked in the resident's mouth and spoke with (LN) N, who takes care of the resident a lot. She said, LN N told me that is his normal, and I trust her. She could not say when the doctor saw the resident's tongue and mouth the last time. She reported she would speak with the dietary manager about the resident's formula and see if that has any effect. She also noted he had this since he got here, and they had tried Nystatin (an antifungal medication used to treat thrush) multiple times in the past. She acknowledged recontamination could occur from the resident's tongue brush not being cleaned or stored correctly. On 11/17/22 at 08:35 AM, the resident was sitting up in his recliner. There was less white, thick film on his tongue. He still denied any pain in his mouth. His tongue brush in the emesis basin on his bathroom countertop was wet. The facility policy for Oral Care includes: routinely assess oral health status; staff will assess thorough and consistent monitoring of each resident's oral status time at the time of admission, quarterly, if a resident experiences unintended weight loss, and with any significant change in the resident's health status including, but not limited to: lips, tongue, gums and tissue, saliva, natural teeth condition including decay or broken teeth, dentures, oral cleanliness, and dental pain. The facility failed to provide adequate oral hygiene care for this dependent resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of Resident (R)13's electronic medical record (EMR) included a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for pain revealed severe cognitive impairment. She required extensive assistance of one staff for locomotion with her wheelchair. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 01/25/22, did not trigger for further review. The quarterly MDS, dated 10/21/22, documented the staff assessment for cognition revealed severe cognitive impairment. She required extensive assistance of one staff for locomotion with her wheelchair. The care plan for ADLs, revised 10/25/22, instructed staff the resident required total assistance of one staff for propelling her wheelchair as the resident was non-ambulatory. Review of the resident's EMR, revealed from 10/17/22 through 11/14/22, the resident required limited to total assistance of one staff for locomotion on the unit with her wheelchair. On 11/14/22 at 11:53 AM, Licensed Nurse (LN) H propelled the resident into the dining room for lunch. The resident's shoed feet bounced on the floor multiple times during transport. The resident's wheelchair lacked foot pedals. On 11/15/22 at 11:43 AM, Certified Nurse Aide (CNA) N propelled the resident to the dining room for lunch. The resident's shoed feet skimmed the floor during transport. The resident's wheelchair lacked foot pedals. On 11/15/22 at 11:43 AM, CNA N stated staff do not use foot pedals on the resident's wheelchair due to she will propel herself at times. On 11/14/22 at 11:53 AM, LN H stated the resident did not have footpedals on her wheelchair because she would propel herself at times using her feet. On 11/15/22 at 03:34 PM, LN G stated the resident would propel herself at times in her wheelchair. Staff should probably place foot pedals on the wheelchair when they propelled her. On 11/16/22 at 02:53 PM, Administrative Nurse D stated the staff will transport the residents in the wheelchairs slowly without foot pedals in place. Many residents will propel themselves and foot pedals would act as a restraint. The facility policy for Wheelchair Positioning, approved 07/19/2016, included: Staff should recognize that many frail residents cannot maintain proper wheelchair alignment due to age related physical changes, dementia and generalized weakness. Resident's feet should rest firmly on the floor or the wheelchair footplates. The facility failed to safely transport this dependent resident in her wheelchair by not ensuring foot pedals were in place. - Review of Resident (R)28's electronic medical record (EMR) included a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She required limited assistance of one staff for locomotion on the unit with the use of a wheelchair. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 09/10/22, did not trigger. The quarterly MDS, dated 06/20/22, documented the resident had a BIMS score of three, indicating severe cognitive impairment. She required limited assistance of one staff for locomotion on the unit with the use of a wheelchair. The care plan for ADLs, revised 02/17/22, instructed staff the resident used a wheelchair for mobility and was able to propel herself with directional assist from staff, at times. Review of the resident's EMR from 10/18/22 through 11/15/22, revealed the resident required independent to total assistance of one staff for locomotion in her wheelchair. On 11/15/22 at 03:10 PM, Certified Medication Aide (CMA) R propelled the resident in her wheelchair to her room. The resident's shoed feet bounced off of the floor during transport. The resident's wheelchair lacked foot pedals. On 11/17/22 at 09:13 AM, Certified Nurse Aide (CNA) O propelled the resident from the commons area to the resident's room. The resident's shoed feed skimmed the floor during transport. The resident's wheelchair lacked foot pedals. On 11/15/22 at 03:10 PM, CMA R stated the staff do not use foot pedals on the resident's wheelchair due to the resident being able to propel herself with her feet at times. On 11/17/22 at 09:13 AM, CNA O stated the staff do not use foot pedals on the resident's wheelchair as she will propel herself at times. On 11/15/22 at 03:34 PM, LN G stated the resident would propel herself at times in her wheelchair. Staff should probably place foot pedals on the wheelchair when they propelled her. On 11/16/22 at 02:53 PM, Administrative Nurse D stated the staff will transport the residents in the wheelchairs slowly without foot pedals in place. Many residents will propel themselves and foot pedals would act as a restraint. The facility policy for Wheelchair Positioning, approved 07/19/2016, included: Staff should recognize that many frail residents cannot maintain proper wheelchair alignment due to age related physical changes, dementia and generalized weakness. Resident's feet should rest firmly on the floor or the wheelchair footplates. The facility failed to safely transport this dependent resident in her wheelchair by not ensuring foot pedals were in place. The facility reported a census of 34 residents with 16 selected for review which included five residents reviewed for accidents. Based on observation, interview, and record review the facility failed to ensure staff provided foot pedals on wheelchairs to prevent accidents, while propelling three of the five residents (R)6, R13 and R28, reviewed for accident hazards. Findings included: - Review of resident (R)6's electronic medical record, revealed diagnoses included Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), dementia (progressive mental disorder characterized by failing memory and confusion), neuropathy (damage to nerves outside of the brain and spinal cord), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and chronic pain. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive status. The resident required extensive assistance of one staff for transfer and locomotion on and off the unit. The resident had functional impairment in range on motion on one side of her upper and lower extremities. The resident used a wheelchair for mobility. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/07/22, assessed the resident had decline in cognition but was able to make needs known. The resident had a diagnosis of dementia. The Falls CAA dated 06/07/22, assessed the resident made poor choices and was wheelchair bound. The Quarterly MDS, dated 09/03/22, assessed the resident with severely impaired cognitive status. The resident required extensive assistance on one staff for transfers and required limited assistance of one person for locomotion on and off the unit. The resident had functional impairment in range on motion on one side of her upper and lower extremities. The resident used a wheelchair for mobility. The Care Plan, revised 09/11/22, instructed staff the resident required up to extensive assistance of one staff for locomotion on and off the unit. The resident propelled herself in the wheelchair for very short distances The Care Plan lacked interventions for use of foot pedals on her wheelchair. Observation, on 11/14/22 at 08:00 AM, revealed Certified Nurse Aide (CNA) N, propelled the resident in her wheelchair from her room to the dining room. The wheelchair lacked foot pedals and her feet skimmed along directly on the floor. The resident intermittently raised her feet up but did not maintain her feet in an elevated position. Observation, on 11/15/22 at 08:47 AM, revealed CNA Q, propelled the resident in her wheelchair from the dining room to her room. The wheelchair lacked foot pedals and the resident's feet skimmed along directly on the floor. Interview, on 11/15/22 at 09:00 AM, with the resident revealed she often had pain in her legs and staff assisted her in her wheelchair. The resident stated she did not walk. Observation, on 11/16/22 at 08:41 AM, revealed CNA NN propelled the resident seated in her wheelchair from the dining room to her room. The wheelchair lacked foot pedals and the resident's feet skimmed along directly on the floor. Interview, at that time, with CNA NN, revealed the resident did have foot pedals for the wheelchair, but did not know where they were. CNA NN stated the resident did propel herself in her room at times but could not self-propel long distances. Interview, on 11/16/22 at 01:33 PM, with Licensed Nurse (LN) H, revealed the resident did have foot pedals, but did not know where they were. The resident informed LN H where the foot pedals were located, in her room at that time. LN H attempted to attach the foot pedals to the wheelchair and noted the left foot pedal did not attach completely and requested assistance from CNA MM. Interview with CNA MM, at that time, revealed she did not know why the foot pedals were not attached to the chair, and would notify maintenance to assist with attaching them. Interview, on 11/16/22 at 02:53 PM, with Administrative Nurse D, revealed she would expect staff to propel the resident in her wheelchair slowly, as she thought the resident could hold her feet up off the floor. She expected staff to place one hand on the resident's shoulder in case the resident lurched forward unexpectedly. Administrative Nurse D stated staff should apply foot pedals when the resident could not hold their feet off the floor. Administrative Nurse D stated the resident often refused interventions and the care plan indicated her refusal but did not know if she refused foot pedals. The facility policy for Wheelchair Positioning, approved 07/19/2016, included: Staff should recognize that many frail residents cannot maintain proper wheelchair alignment due to age related physical changes, dementia, and generalized weakness. Resident's feet should rest firmly on the floor or the wheelchair footplates. The facility failed to ensure staff provided foot pedals for the wheelchair of this dependent resident with dementia, neuropathy and lower extremity pain, when propelling the resident to prevent accidents to the lower extremity with injury.