**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure care-planned interventions to promote appropriate fluid balance were consistently implemented and accurately tracked to promote continuity of care for 1 of 1 resident (R15) reviewed who received hemodialysis and was on a fluid restriction. Findings include: A National Kidney Foundation (NKF) Fluid Overload in a Dialysis Patient feature, dated 2024, identified fluid overload in a dialysis patient occurs when too much water builds up within the body. The feature added, It can cause swelling, high blood pressure, breathing problems, and heart issues. The feature explained, When you are on dialysis, your kidneys are no longer able to keep the right balance of fluid in your body . That's why it's so important to limit how much sodium (salt) and fluid you have between dialysis treatments, adding further, Follow the fluid guidelines [bolded] given to you . Most dialysis patients need to limit their fluid intake to 32 ounces per day. R15's admission Minimum Data Set (MDS), dated [DATE], identified R15 had moderate cognitive impairment and had multiple medical conditions including anemia, atrial fibrillation or cardiac dysthymia, heart failure, and end-stage renal disease. Further, the MDS recorded R15 received dialysis treatments while a resident at the center. R15's dialysis care plan, initiated 11/14/24, identified R15 had chronic kidney disease and a history of acute kidney injury (AKI) and received dialysis treatments. The care plan listed multiple goals for R15 including, Resident's fluid balance will be maintained and complications minimized as evidenced by non-labored breathing and maintenance of target weight ., along with several interventions to help R15 meet these goal(s) including, Dialysis: Document intake and output (1500ml [milliliters] fluid restriction). On 12/16/24 at 2:54 p.m., R15 was observed in her room lying in bed with family member (FM)-E present at the bedside. R15 stated she was on dialysis, which FM-E verified, and on a Tuesday - Thursday - Saturday schedule. On the wall of R15's room, a white-colored cup picture was present which had, 1500, written on it. However, present on R15's bedside table were multiple white Styrofoam cups and a single hard plastic pitcher with water in it. The cups were inspected and each had remaining fluid inside of them. FM-E stated R15 was on a fluid restriction, however, when questioned on if R15 was maintaining that restriction FM-E laughed and pointed at the multiple cups with fluid adding aloud, I don't know. R15 stated she was unsure how much fluid was given to her at meals or medication pass, nor how it was being tracked if at all adding aloud, I really don't know. FM-E and R15 verified the center' staff provided each of the cups, and R15 denied needing any extra dialysis runs due to fluid overload. When interviewed on 12/17/24 at 1:26 p.m., nursing assistant (NA)-A stated R15 was on dialysis and had been doing pretty well with eating but seemed to never drink much adding it was more just sips [fluids]. NA-A stated they had been trying to offer R15 more fluids, including flavored waters, lately as a result adding, I want to give her options. NA-A verified R15 was on a current fluid restriction, and stated the aides were tracking the consumed fluid within the point of care (POC) system on their charting. NA-A stated fluid intake should be charted every shift to capture fluids at bedside and with meals, and expressed there was no reason fluid for each shift wouldn't be entered into the POC adding aloud, You always should record. NA-A reiterated the aides were responsible to monitor and track fluid intakes for R15 adding aloud, I think it's more on us. Further, NA-A stated they were unsure who added it and monitored the totals of fluid to ensure R15 didn't breach her fluid restriction adding aloud, I really don't know the nursing part of it. R15's POC Response History, printed 12/17/24, identified data collected for the previous 17 days and listed the charting as, Amount of fluids in cc's. The charting then provided the respective dates, times and amounts recorded by the staff for each day. However, multiple days lacked evidence of three collected totals (i.e., every shift). This included but was not limited to: On 12/1/24 (Sunday), only two collected values were listed at 1:06 a.m. and 2:21 p.m. The total fluid intake for the entire day was 360 cubic centimeters (cc). On 12/2/24 (Monday), only one collected value was listed at 5:51 a.m. The total fluid intake for the entire day was 60 cc. On 12/6/24 (Friday), only two collected values were listed at 6:49 a.m. and 10:35 p.m. The total fluid intake for the entire day was 360 cc. On 12/8/24 (Sunday), only one collected value was listed at 3:45 a.m. The total fluid intake for the entire day was 60 cc. The POC charting lacked any further dictation or evidence on R15's fluid intakes for the shifts not listed, including fluids provided with meals, happened on those respective shifts. When interviewed on 12/17/24 at 1:38 p.m., licensed practical nurse (LPN)-C verified they were the current nurse assigned to R15's room for care, however, expressed it was not their typical floor to work on adding they had never worked with her [R15]. LPN-C stated they had, however, worked with other patients on dialysis and explained residents' on a fluid restriction used the smaller Styrofoam cups and staff don't bring in the big cup [pitcher]. LPN-C the smaller cups were used to better track how much fluid was being consumed and verified the aides were supposed to chart the fluid intakes under the POC. LPN-C stated the nurse then tracked the fluids in the Treatment Administration Record (TAR) which was more a running total of the data collected by the aides but combined with fluids the nurse provided to the patient, too, so the data in the TAR was the cumulative intake for both. LPN-C stated both the TAR data and POC data should be done every shift adding aloud, It's a lot of communication [between nurse and NA]. R15's TAR, dated 12/2024, identified a nursing order which read, 1500ml fluid restriction. Document Intake . every shift Total previous 24hrs on PM shift [current shift + previous AM and NOC [night]], with an order date recorded, 11/18/2024. The TAR listed three shifts along with spacing to record cc (ml) consumed and staff initials. However, the recorded data had multiple days with either blank spaces left, non-discernable amounts, or inaccurately added data. This included but was not limited to: On 12/2/24, a total fluid intake was recorded as 820 cc. The three shifts used to determine this value were recorded as 60 cc, 400 cc, and 360 cc (total 820 cc). However, the POC charting for the same period had additional fluid amounts recorded which were not included in the total recorded on the TAR. On 12/6/24, a total fluid intake was recorded as 640 cc. The three shifts used to determine this value were recorded as 60 cc, 300 cc, and 220 cc (total 580 cc). However, the POC charting for the same period had additional fluid amounts recorded which were not included in the total recorded on the TAR. On 12/13/24, the shift labeled, 11-7, was left blank and not completed. On 12/18/24, at 9:01 a.m., registered nurse unit manager (RN)-A was interviewed, and verified they had reviewed R15's medical record and fluid intakes. RN-A explained the NA was responsible to track the fluid intakes at meals and report the information to the nurse who tracked the fluid provided while giving medications or with ice chips. RN-A verified the TAR data should be the cumulative intake collected from the NA and nurse together which should be added to provide the total amount consumed for a 24 hour period as directed by the TAR directions. RN-A reviewed the POC charting and acknowledged multiple gaps of missing data adding staff should be charting it. RN-A reviewed R15's TAR and acknowledged the 'total' amount recorded on multiple days did not add up correctly given all the recorded data points which likely lead to inaccurate amounts recorded. RN-A stated it was important to ensure R15's fluid intake was tracked accurately and consistently so she's not going over her fluid restriction, adding further R15 was currently hospitalized for another reason but was found also to be a little dehydrated. A facility Care Plans policy, dated 5/2023, identified the care center provided resident-centered care in accordance with the resident's preferences and stated goals as outlined within the care plan. The policy outlined the comprehensive care plan was developed by the interdisciplinary team (IDT) and would outline interventions to help each resident meet their respective highest physical, social and mental well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R60's annual Minimum Data Set (MDS) dated [DATE], indicated R60 was cognitively intact, had no behaviors, was frequently incontinent of bowel, and didn't have a toileting program. The MDS also indicated, R60 was dependent with toileting, needed maximal assistance with dressing, transfers, bed mobility, showers, set up for eating, and oral hygiene. R60's MDS indicated diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), hypertension (high blood pressure), hyperlipidemia (high levels of fat particles in the blood), and hemiplegia (paralysis of one side of the body). R60's Diagnosis report dated 12/19/24, indicated diagnoses of slow transit constipation (a condition where the large intestine moves waste too slowly, causing chronic constipation and sometimes uncontrollable soiling), cervicalgia (neck pain), inflammatory poly-arthropathy (a condition in which multiple joints are inflamed) , and left side hemiparesis (weakness or the inability to move one side of the body) and hemiplegia. R60's medication administration record (MAR) printed on 12/18/24, included the following orders: * Senna-docusate sodium (laxative used for constipation) tablet 8.6-50 milligrams (mg)- give 2 tablets by mouth twice a day, hold for loose stools, order dated 4/10/24. * Miralax packet (laxative used for constipation) give 17 grams (gm) by mouth in the morning for constipation, hold for loose stools, order dated 5/11/22. * Miralax packet 17 gm by mouth as needed (PRN) for constipation daily, order dated 5/11/22. * Offer prune juice every morning, order dated 5/10/22. R60's Bowel/Incontinence care plan printed on 12/19/24, indicated R60 was incontinent with some control, and was dependent on staff for assistance. R60's care plan interventions directed staff to, * Implement Standing House Order for constipation if no BM in 9 shifts. * Dieticians consult as needed. * Provide loose fitting, easy to remove clothing. * Provide pericare after each incontinent episode. R60's Bowel Elimination Task form printed on 12/18/24, contained information completed by the nursing assistants caring for R60 every shift, for a total of 3 shifts a day or morning (AM), evening (PM), and night (NOC) and included documentation as follows: * 11/19/24- BM, AM & PM shifts. * 11/20/24 - no BM * 11/21/24- BM, AM shift * 11/22/24 - no BM * 11/23/24 - no BM * 11/24/24 - BM, AM shift * 11/25/24 - no BM * 11/26/24 - BM, AM shift * 11/27/24 - no BM * 11/28/24 - BM, AM shift * 11/29/24 - BM, AM shift * 11/30/24 - BM, AM & PM shifts. * 12/1/24 - no BM * 12/2/24 - no BM * 12/3/24 - no BM * 12/4/24 - BM, AM shift * 12/5/24 - BM, AM shift * 12/6/24 - no BM * 12/7/24 - BM, PM shift * 12/8/24 - BM, AM shift * 12/9/24 - BM, AM shift * 12/10/24- BM, AM shift * 12/11/24 - no BM * 12/12/24 - BM, AM shift * 12/13/24 - No BM * 12/14/24 - No BM * 12/15/24 - no BM * 12/16/24 - BM, PM shift * 12/17/24 - BM, AM shift During interview on 12/16/24 at 6:11 p.m., R60 was in his room and sitting in a wheelchair (WC). R60 stated I would like to visit with you, but I am extremely constipated. I have severe abdominal pain. It must be at least 4 to 5 days since I had the last BM. Please, please call the nurse and let her know I am in pain, I am constipated. During interview on 12/16/24 at 6:15 p.m. licensed practical nurse (LPN)-F stated we [nurses] have a 24-hour report where the evening supervisor writes the names of the residents after not having a BM for 7 shifts. We check this report, and after not having a BM for 9 shifts, our residents get prune juice or Miralax as needed. LPN-F added on the 4th day, the residents get a bisacodyl suppository. LPN-F talked to R60, and he requested a suppository. LPN-F verified based on POC BM task report, R60 had last BM on 12/12/24, therefore, there had been 13 shifts since resident had the last BM. During interview on 12/17/24 at 8:50 a.m., R60 stated yesterday he received a suppository and had a BM. R60 stated he had chronic issues with pain but had decided to stop taking Ultram (pain medication) because of his problems with constipation. R60 stated, I prefer to have pain rather than being constipated. Review of R60's MAR, printed on 12/17/24, indicated R60's Ultram had been discontinued on 12/6/24. During interview on 12/17/24 at 1:28 p.m., nursing assistant (NA)-B stated R60 sometimes complained of abdominal pain, and when he asks for prune juice, we give it to him, and report to the nurse before the end of her shift. During interview on 1/17/24 at 1:34 p.m., LPN-G stated R60 received scheduled Miralax and Senna twice a day. LPN-G stated the nurses followed the bowel protocol which directed them to use PRN Miralax. LPN-G added, we have standing orders for enemas, and we have suppositories as well. During interview on 12/17/24 at 1:57 p.m., nurse manager/LPN-A stated the 24-hour report was started by the overnight supervisor. The supervisor checks the resident's bowel records and writes the names of residents who didn't have a BM for 7 shifts. LPN-A stated if a resident doesn't have a BM in 9 shifts, they receive a suppository. LPN-A stated R60's senna order was increased in April and stated a couple of weeks ago, R60's scheduled Ultram was discontinued per his request because it seemed R60 had increased problems with constipation. During interview on 12/18/24 at 10:09 a.m., LPN-B stated everyday he looked at the bowel records in the computer and the 24-hour report. If a resident hasn't had a BM in 7 shifts, he will use the resident's PRN orders for constipation. LPN-B stated if a resident didn't have a BM for 9 shifts, he will follow the bowel protocol that directs nurses to administer a bisacodyl suppository. LPN-B stated all interventions, effectiveness of interventions and/or residents refusals needed to be documented in the MAR and residents' progress notes. During interview on 12/18/24 at 10:18 a.m., the director of nursing (DON) stated their bowel protocol indicated when a resident doesn't have a BM for 9 shifts, the resident will receive PRN Miralax or Senna. If they refuse these meds, they will receive a bisacodyl suppositories. If a resident refuses all interventions the primary physician needs to be notified. The DON stated all interventions need to be documented. DON verified R60 did not receive any PRN medications or a suppository after not having a BM for 11 shifts between 11/30 and 12/4, and once again after not having a BM for 13 shifts between 12/12 and 12/16. DON stated the nurses should have activated the bowel protocol after the 9th shift. DON also stated, based on documentation and medical history, R60 should have a more individualized bowel program. Facility's policy titled Bowel Management Protocol dated 12/2018, indicated nurses will routinely check the BM record to ensure residents have bowel movements according to standard of practice or as identified on the individualized care plan. This policy includes the Bowel Management Standing House Orders which read, Bowel Management Standing House Orders Constipation: if no documented BM in last 8 shifts. * Ask Resident when their last BM occurred. If they can accurately report their last BM, place a progress note regarding last BM. * On shift 9 start pushing fluids (unless contraindicated or has a fluid restriction) and give a Bisacodyl suppository 10mg PR, document results. * If no results, then the next shift will give another Bisacodyl suppository 10mg PR, document results. * If no results, by the end of the shift, call practitioner for further orders. Based on observation, interview and document review, the facility failed to follow physician orders, or notify the provider of resident's refusal for 1 of 1 residents (R88) reviewed for cervical collar use. In addition, the facility failed to implement and reassess an individualized bowel management (BM) protocol for 1 of 1 resident (R60) reviewed for constipation. Findings include: R88's face sheet, printed on 12/17/24, included diagnoses of posterior displaced type II dens fracture (involving the area of the dens between the inferior aspect of the anterior C1 vertebrae {upper neck} which occurs due to forces such as trauma and can be life threatening due to its proximity to the spinal cord and brainstem) , Alzheimer's disease, and dementia. R88's significant change Minimum Data Set, dated [DATE], indicated R88 had severe cognitive impairment with delirium including inattention that fluctuates, but no behaviors including rejection of care. In addition it documented R88 required substantial to maximal assistance for transfers, bed mobility, and eating. R88 had one fall with major injury and is receiving pain medications for pain management and R88 was enrolled in hospice. R88's plan of care dated 12/17/24, included medical problems with a history of falls. Care plan interventions included cervical collar on at all time and if R88 removes collar, report to nurse immediately as the nurse needs to place it back on. A separate intervention dated 11/26/24 included to leave cervical collar in place. A hospital Discharge summary, dated [DATE], included discharge diagnoses of traumatic closed fracture of C1 vertebra with minimal displacement with cause of injury accidental fall. A provider order, dated 12/7/24, included cervical collar to be in place at all times. If R88 removes it, nurse to replace collar every shift for cervical fracture. During observation and interview on 12/17/24 at 10:44 a.m., R88 was lying in bed, head of bed at 30 degrees with her cervical neck collar off and located at the top of the mattress to R88's left side. Registered nurse (RN)-B was present in the room giving R88 her pain medication. R88 stated she was having pain in her neck. RN-B stated R88 is supposed to have her cervical collar on at all times but frequently takes it off. RN-B did not request R88 to put on the cervical collar. RN-B indicated she is not sure if R88's hospice team or the provider is aware R88 is removing her cervical collar or refusing to wear it at times. During observation and interview on 12/17/24 at 1:00 p.m., R88 was laying across her bed side ways with no cervical collar on with her neck unsupported by the mattress and feet on the other side of the mattress not touching the floor. At 1:02 p.m., nursing assistant (NA)-E entered the room and helped R88 sit on the edge of the bed. R88's cervical collar remained on the top of the mattress. Using an EZ stand (mechanical lift), NA-E got R88 standing and assisted with toileting prior to placing in a Broda chair (specialty chair with head support) at 1:26 p.m. NA-E put on cervical collar and stated R88 removes her collar and doesn't like it on until she is up in her chair. NA-E added R88 frequently refused to wear the cervical collar and the nurses were aware of this. On interview 12/17/24 at 2:46 p.m., licensed practical nurse (LPN)-D, also identified as nurse manager, indicated R88 should have her cervical collar on at all times per provider order and it is not okay to get her up without it on. LPN-D stated if she is refusing, the physician or hospice should be notified. LPN-D confirmed there is no documentation in her electronic medical record at present indicating she has been refusing to wear the cervical collar or that the hospice agency or provider have been notified. On observation and interview 12/18/24 at 7:34 a.m., R88 was lying in bed with cervical collar out of reach on her bedside table. LPN-E entered the room and stated R88 is supposed to have her cervical collar on at all times but frequently refuses to wear it. LPN-E indicated sometimes R88 cooperates with wearing it and other times she refuses. On interview 12/18/24 at 8:52 a.m., registered nurse (RN)-C, hospice nurse, indicated he wasn't aware R88 was refusing to wear her cervical collar. RN-C indicated if the orders states she should wear it at all times, then the facility should ensure she is wearing it or let hospice or the provider know of the refusal. On interview 12/18/24 at 10:37 a.m., the director of nursing (DON) indicated if the provider order states she is to wear the cervical collar at all times, she should be wearing it. The DON added if she takes it off, staff should notify hospice and see if she if she really needs it or not. A policy on devices, and physician orders was requested and none received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively assess wounds including measurements weekly for 1 of 3 residents (R52) reviewed for pressure ulcers. Findings include: R52's Diagnosis Report, dated 12/18/24, included diagnoses of infection and inflammatory reaction to internal right knee prosthesis (artificial joint), type 2 diabetes mellitus with neuropathy (nerve pain), osteomyelitis (infection of the bone) of right ankle and foot, methicillin resistant staphylococcus aureus (type of bacteria that many antibiotics don't work on) and peripheral vascular disease (slow and progressive disorder of narrowing of blood vessels, usually in legs). R52's quarterly Minimum Data Set (MDS), dated [DATE], identified R52 was cognitively intact, was dependent on staff for toileting, bathing, and required, substantial to maximal assistance with bed mobility and transfers. The MDS documented R52 was high risk for pressure ulcers and currently had one unstageable pressure ulcer due to coverage of wound bed by slough (dead tissue) and/or eschar (thick, black, necrotic tissue that forms as a result of dead tissue). R52's physician orders dated 12/11/24, included wound care to left heel. Cleanse with wound cleanser, pat dry and apply betadine and cover with dry dressing. An order dated 7/25/24, included primary nurse to assess bilateral lower extremity wounds on Wednesdays; enter wound assessment with measurements entered into the progress note. R52's plan of care dated 9/6/24, included R52 had a risk for skin integrity impairment related to being admitted with multiple medical issues .and left heel pressure ulcer. Interventions included observe heel integrity daily, float heels off surface of bed, air mattress, ., follow facility protocols for treatment of injury and observe for signs of infection such as redness, swelling, pain, fever and purulent drainage. Report abnormal findings to provider. On interview and observation 12/16/24 at 3:03 p.m., R52 was lying in her bed with both heels elevated off bed with wedged cushion, on an air mattress. R52 stated she had a pressure ulcer on her left heel that she developed while at this facility. R52 added she has had amputation of several of her toes and had poor circulation. R52 stated her wound has remained unchanged and she has the wound specialist at the facility see her weekly on Wednesdays. R52's Braden scale (tool used to predict pressure ulcer risk) skin assessments were completed monthly beginning 5/1/24 through 11/26/24 with a continued score of 18 indicating at risk for pressure ulcers. Weekly wound assessments and measurements were completed weekly except 5/26/24, 7/4/24, 8/1/24, 8/7/24, 10/2/24, 10/17/24, 11/12/24, and 12/4/24 which were missing. On interview 12/18/24 at 7:23 a.m., registered nurse (RN)-E stated the wound care nurse is responsible for wound assessments and measurements weekly but if she is gone, R88's nurse was responsible to complete. On interview 12/18/24 at 8:12 a.m., licensed practical nurse (LPN)-A, also identified as nurse manager, stated the wound nurse is responsible for completing wound assessments and measurements and if she is gone, the wound nurse will put an order in for the nurse to complete. LPN-A was unsure why the above dates were missing and stated R88 has only been on this unit for 3 months and referred to wound care nurse to assist with locating them. On interview 12/18/24 at 8:44 a.m., registered nurse (RN)-D, also identified as wound care manager, stated she does wound rounds on R88 weekly and completes comprehensive wound assessment and measurements. RN-D stated she will place an order for nursing to complete the wound assessments and measurements when she is gone. RN-D added she may forget at times to document the wound assessments as she does a lot of wound care and assessments every day. RN-D indicated R88's left heel pressure wound was present on admission, is likely chronic and was unavoidable due to R88's poor arterial blood flow. RN-D stated the goal is to keep the wound from becoming infected and to keep it stable, which they have been able to do. A request was made for above dates that were missing wound assessments and measurements. On interview 12/18/24 at 11:25 a.m., RN-D indicated on 6/19/24, R88 saw her podiatrist and measurements and wounds were assessed at that time. RN-D confirmed the rest of the wound assessments and measurements were not able to be located. RN-D stated it was discovered when she was putting the order in for nursing staff to complete in her absence, it was entered incorrectly so it did not flow over as an order for the floor nurse to complete. RN-D confirmed these likely were not completed due to the error, which has now been corrected. On interview 12/18/24 at 10:33 a.m., the director of nursing (DON) confirmed wound assessments and measurements should be completed weekly. The DON indicated in the absence of the wound care nurse, the licensed nurse should be completing these. The DON indicated starting two weeks ago, the unit manager and licensed nurse are supposed to round with the wound care nurse so this should help improve communication. A Skin and Wound Management policy dated 10/23 included chronic wounds, wounds related to pressure, severe wounds and wounds with high microbial bioburden are followed by the wound care manager or designee who assesses the wound weekly. Wound care is coordinated in collaboration with members of the interdisciplinary team, which include the wound care manager, nurse manager, therapy, MDS coordinator, nurse, nursing assistant and/or dietician. At each weekly wound assessment, a progress note is written to document a description of the wound, any changes from the week prior, pain with wound care, and any new interventions or changes in plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to immediately report incidents of potential resident to resident sexual abuse to the state agency (SA) within two hours, as required for 2 of 2 residents (R97, R112) reviewed for abuse. Findings include: R97's quarterly Minimum Data Set (MDS) dated [DATE], indicated R97 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS, tool used to determine cognition level) score of 11 and required maximal assistance with lower body dressing and moderate assistance with upper body dressing and bathing. R97's significant change MDS dated [DATE], indicated R97 had moderately impaired cognition with a BIMS score of nine and required maximal assistance with dressing, bathing, turning in bed, and moving from a lying to a sitting position. R97's Diagnosis Report dated 9/8/23, indicated diagnoses of a stroke with resulting right-sided weakness and cognitive dysfunction, kidney disease, and diabetes with vision decline. R97's care plan: - dated 8/29/22, indicated R97 was interested in a relationship with R112 and staff were to facilitate private time behind closed doors for R97 and R112 by placing a do not disturb sign on R97's door. The care plan indicated the responsible party was aware of the relationship and interventions. - dated 9/9/23, indicated R97 is vulnerable related to cognitive impairment, had decreased awareness for potential harm, decreased mobility, strength, and function requiring assistance from others to meet daily needs. - dated 9/20/23, indicated R97 had a potential for impaired communication related to forgetfulness, confusion, severe cognitive impairment, barely speaks when spoken to, and impaired hearing. - dated 9/27/23 indicated R97 had limited physical mobility related to generalized weakness, impaired cognition, and right-sided weakness and required the extensive assistance of one person for rolling and sitting at the side of the bed. R97's Associated Clinic of Psychology (ACP) progress note dated 7/19/22, indicated R97 was diagnosed with adjustment disorder and symptoms affecting cognitive function and awareness. The progress note indicated R97 had impaired and scattered cognition. The progress note did not indicate R97's ability to give sexual consent, obtain sexual consent, avoid sexual exploitation, or understand the ramifications of sexual acts was not assessed. R97's progress note dated 8/29/22 at 3:06 p.m., indicated facility staff reported R97 was interested in a relationship with a female resident on the unit. The progress note indicated that R97's responsible party was made aware of the relationship and informed sexual wellness would be reviewed with R97. The progress note also indicated that private time would be given to R97 and the female resident. The progress note indicated R97's cognitive score was reviewed, but the progress note did not indicate an assessment of R97's ability to give sexual consent, obtain sexual consent, avoid sexual exploitation, or understand the ramifications of sexual acts had been completed. R112's quarterly MDS dated [DATE], indicated R112 had moderately impaired cognition with a BIMS score of 11, requiring help setting up dressing activities, but R112 was independent with toileting, bed mobility, and transferring. R112's quarterly MDS dated [DATE], indicated R112 had severely impaired cognition with a BIMS score of six and was independent with dressing, toileting, bed mobility, and transferring. R112's Diagnosis Report dated 7/12/23, indicated diagnoses of dementia, major depression, anxiety, right hip replacement, and kidney disease. R112's care plan: - dated 11/13/20 indicated R112 is vulnerable related to moderate cognitive impairment and a diagnosis of dementia. The care plan indicated the following interventions related to vulnerability: to speak slowly and repeat messages as needed, observe for changes in cognition, and anticipate and assist with needs. - dated 8/29/22, indicated R112 was interested in a relationship with R97 and staff were to facilitate private time behind closed doors for R97 and R112 by placing a do not disturb sign on the R112's door. The care plan indicated the responsible party was aware of the relationship and interventions. - dated 10/18/23, indicated R112 had a severe to moderate cognitive impairment related to dementia requiring the following interventions: break tasks into one step at a time to support short-term memory loss, cue, reorient, and supervise R112 as needed. R112's progress note dated 8/29/22 at 2:59 p.m., indicated facility staff had reported R112 was interested in a relationship with a male resident on the unit. The progress note indicated that R112's responsible party was notified of her desire for a relationship. The progress note also indicated that sexual wellness would be reviewed and private time would be given to R112 and the male resident. The progress note indicated that R112's cognitive score was reviewed but did not indicate an assessment of R112's ability to give sexual consent had been completed before the start of these sexual acts. During observation and interview on 10/16/23 at 2:17 p.m., R97 and R112 were in R97's room, fully clothed, lying in bed together. A please do not disturb sign was on the door and the door was halfway open. R112 stated she and R97 were in a relationship together but cannot recall how long. R97 did not respond when asked about their relationship. Before R97 could answer further, R112 stated the details of the relationship were private and not for anyone else to know, refusing to answer any further questions. During an interview on 10/17/23 at 11:58 a.m., nursing assistant (NA)-D stated that R97 and R112 had an intimate relationship. NA-D stated when he witnessed R97 and R112 engaging in intimate activities, he applied a do not disturb sign as instructed and closed the door to provide privacy. During an interview on 10/17/23 at 11:59 a.m., licensed practical nurse (LPN)-D stated R97 and R112 had been intimate and unclothed together a couple of times before the assistant director of nursing (ADON) notified their families of the relationship and she witnessed a do not disturb sign on the door. LPN-D stated she had observed R97 and R112 unclothed and being intimate in bed together multiple times during the previous few months. During an interview on 10/18/23 at 9:53 a.m., ACP-A stated R97 had impaired cognition and was minimally engaged in conversations. ACP-A stated she was concerned R97 would not be able to express if he was uncomfortable with a sexual encounter, leading to an unsafe situation. ACP-A stated R112 had not been referred to her, but she would be worried a resident R112's current cognition would not be able to consent. During an interview on 10/18/23 at 11:19 a.m., the ADON stated she was aware of the sexual relationship between R97 and R112. The ADON stated she had not encountered this situation before, and the facility did not have a policy or procedure to reference for guidance on how to handle sexual relationships between residents. The ADON further stated she did not report the incident to the state agency (SA) as she did not believe there was a concern for either resident's safety. The ADON stated that based on the Brief Interview for Mental Status (BIMS, tool used to determine cognition level) scores and Patient Health Questionnaire (PHQ-9, tool used to screen and monitor depression) scores, she determined the residents could consent to a sexual relationship. The ADON stated the ability to consent had not been reassessed as cognition declined. During an interview on 10/18/23 at 11:42 a.m., the director of nursing (DON) stated she was aware of the sexual relationship between R97 and R112; however, she was not involved in assessing the residents or interventions related to the sexual relationship and referred to the ADON. The DON stated although neither resident could make decisions regarding their medical care, R97 and R112 could consent to a sexual relationship. The DON confirmed she did not report the sexual relationship to the state agency (SA) as she believed both residents could consent to the relationship although they had impaired cognitions. The DON stated the facility did not have a policy regarding sexual relationships between two residents. The facility Resident Protection Plan policy dated 12/22, indicated resident-to-resident altercations including alleged sexual advances that were not consensual or alleged sexual abuse should have been reported immediately to the Minnesota Health Department (MDH) and if a crime is suspected, to law enforcement. The policy indicated sexual assault as any sexual activity that occurred when an individual could not give consent. The policy did not give guidance on determining sexual consent capacity or investigating a sexual relationship between two residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure a potential incidence of sexual abuse for was investigated for 2 of 2 residents (R97, R112) reviewed for potential abuse. Findings include: The American Psychological Association's handbook, Assessment of Older Adults with Diminished Capacity, dated 2008, indicates sexual behaviors ranging from touching to sexual intercourse, require sexual consent capacity. This differs from all other forms of consent capacity. Sexual consent capacity requires the partaker to be able to make a rapid, independent decision in the present and does not allow time for family or physician input as with a medical decision. Sexual consent must be given by the partaker each time a sexual act occurs, not previously by a surrogate decision maker. The handbook indicates that for a resident to possess sexual consent capacity, they must possess knowledge of the results of their decisions, understand how these decisions interact with their values, and be free from the coercion of others. Furthermore, a resident must have the ability to demonstrate an understanding of sexually transmitted diseases (STD), be able to determine if the other member of the sexual activity is also able to consent to sexual activity, and determine what times and places are appropriate for this sexual activity. The handbook indicates that when assessing a resident for the ability to consent, cognitive assessments may be helpful, but it must be ensured that the resident's consent ability remains the same as the first assessment during every sexual act the resident partakes in. The handbook suggests assessing these additional areas: resident vulnerability, ability to avoid sexual exploitation or say no to any uninvited sexual contact, and disorders that could limit or increase sexual activity. The handbook goes on to suggest facilities have policies and procedures addressing sexual relationships between residents coinciding with state statutes. R97's quarterly Minimum Data Set (MDS) dated [DATE], indicated R97 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS, tool used to determine cognition level) score of 11 and required maximal assistance with lower body dressing and moderate assistance with upper body dressing and bathing. R97's significant change MDS dated [DATE], indicated R97 had moderately impaired cognition with a BIMS score of nine and required maximal assistance with dressing, bathing, turning in bed, and moving from a lying to a sitting position. R97's Diagnosis Report dated 9/8/23, indicated diagnoses of a stroke with resulting right-sided weakness and cognitive dysfunction, kidney disease, and diabetes with vision decline. R97's care plan: - dated 8/29/22, indicated R97 was interested in a relationship with R112 and staff were to facilitate private time behind closed doors for R97 and R112 by placing a do not disturb sign on R97's door. The care plan indicated the responsible party was aware of the relationship and interventions. This care plan section did not indicate updates had occurred to correlate with R97's decreasing cognition. The care plan also did not include methods to assess R97's ability to give sexual consent, obtain sexual consent, avoid sexual exploitation, or understand of ramifications of sexual acts. - dated 9/9/23, indicated R97 is vulnerable related to cognitive impairment, had decreased awareness for potential harm, decreased mobility, strength, and function requiring assistance from others to meet daily needs. - dated 9/20/23, indicated R97 had a potential for impaired communication related to forgetfulness, confusion, severe cognitive impairment, barely speaks when spoken to, and impaired hearing. - dated 9/27/23 indicated R97 had limited physical mobility related to generalized weakness, impaired cognition, and right-sided weakness and required the extensive assistance of one person for rolling and sitting at the side of the bed. R97's Associated Clinic of Psychology (ACP) progress note dated 7/19/22, indicated R97 was diagnosed with adjustment disorder and symptoms affecting cognitive function and awareness. The progress note indicated R97 had impaired and scattered cognition. The progress note did not indicate R97's ability to give sexual consent, obtain sexual consent, avoid sexual exploitation, or understand the ramifications of sexual acts was assessed. R97's progress note dated 8/29/22 at 3:06 p.m., indicated facility staff reported R97 was interested in a relationship with a female resident on the unit. The progress note indicated that R97's responsible party was made aware of the relationship and informed sexual wellness would be reviewed with R97. The progress note also indicated that private time would be given to R97 and the female resident. The progress note indicated R97's cognitive score was reviewed, but the progress note did not indicate an assessment of R97's ability to give sexual consent, obtain sexual consent, avoid sexual exploitation, or understand the ramifications of sexual acts had been completed. R97's progress note dated 9/25/23, indicated a care conference was held with facility staff but R97 and the responsible party were not present. The progress note indicated that R97's BIMS score had declined, now indicating severe cognitive impairment. R97's ability to give sexual consent, obtain sexual consent, avoid sexual exploitation, or understand the ramifications of sexual acts was not reassessed. R112's quarterly MDS dated [DATE], indicated R112 had moderately impaired cognition with a BIMS score of 11, requiring help setting up dressing activities, but R112 was independent with toileting, bed mobility, and transferring. R112's quarterly MDS dated [DATE], indicated R112 had severely impaired cognition with a BIMS score of six and was independent with dressing, toileting, bed mobility, and transferring. R112's Diagnosis Report dated 7/12/23, indicated diagnoses of dementia, major depression, anxiety, right hip replacement, and kidney disease. R112's care plan: - dated 11/13/20 indicated R112 is vulnerable related to moderate cognitive impairment and a diagnosis of dementia. The care plan indicated the following interventions related to vulnerability: speak slowly and repeat messages as needed, observe for changes in cognition, and anticipate and assist with needs. - dated 8/29/22, indicated R112 was interested in a relationship with R97 and staff were to facilitate private time behind closed doors for R97 and R112 by placing a do not disturb sign on the R112's door. The care plan indicated the responsible party was aware of the relationship and interventions. This care plan section did not indicate updates had occurred to correlate with R112's decreasing cognition. The care plan also did not include methods to assess R112's ability to give sexual consent, obtain sexual consent, avoid sexual exploitation, or understand of ramifications of sexual acts. - dated 10/18/23, indicated R112 had a severe to moderate cognitive impairment related to dementia requiring the following interventions: break tasks into one step at a time to support short-term memory loss, cue, reorient, and supervise R112 as needed. R112's progress note dated 8/29/22 at 2:59 p.m., indicated facility staff had reported R112 was interested in a relationship with a male resident on the unit. The progress note indicated that R112's responsible party was notified of her desire for a relationship and was understanding. The progress note also indicated that sexual wellness would be reviewed and private time would be given to R112 and the male resident. The progress note indicated that R112's cognitive score was reviewed but did not indicate an assessment of R112's ability to give sexual consent had been completed before the start of these sexual acts. During observation and interview on 10/16/23 at 2:17 p.m., R97 and R112 were in R97's room, fully clothed, lying in bed together. A please do not disturb sign was on the door and the door was halfway open. R112 stated she and R97 were in a relationship together but cannot recall how long. R97 did not respond when asked about their relationship. Before R97 could answer further, R112 stated the details of the relationship were private and not for anyone else to know, refusing to answer any further questions. During an interview on 10/17/23 at 11:58 a.m., nursing assistant (NA)-D stated that R97 and R112 had an intimate relationship. NA-D stated when he witnessed R97 and R112 engaging in intimate activities, he applied a do not disturb sign as instructed and closed the door to provide privacy. During an interview and document review on 10/17/23 at 11:59 a.m., licensed practical nurse (LPN)-D stated R97 and R112 had been intimate and unclothed together a couple of times before the assistant director of nursing (ADON) notified their families of the relationship and she witnessed a do not disturb sign on the door. LPN-D stated she had observed R97 and R112 unclothed and being intimate in bed together multiple times during the previous few months. The medical record did not indicate an investigation into the sexual acts or initial separation of R97 and R112 to ensure safety had taken place. During an interview on 10/18/23 at 9:53 a.m., ACP-A stated R97 had impaired cognition and was minimally engaged in conversations. ACP-A stated she had not been informed by the facility of R97's relationship and was concerned R97 would not be able to express if he was uncomfortable with a sexual encounter, leading to an unsafe situation. ACP-A stated that R112 had not been referred to her, and she would be worried a resident with R112's current cognition would not be able to consent. During an interview on 10/18/23 at 11:19 a.m., the ADON stated she was aware of the sexual relationship between R97 and R112 and intervened by providing education on STDs, contraception, and preventing UTI's. The ADON stated she did not use a specific method to ensure R97 and R112 would be able to apply the education. The ADON stated she had not encountered this situation before, and the facility did not have a policy or procedure to reference for guidance on how to handle sexual relationships between residents. The ADON further stated she did not report the incident to the state agency (SA) or do a complete investigation regarding the potential for abuse as she did not believe there was a concern for either resident's safety. The ADON stated that based on the BIMS scores and PHQ-9 scores, she determined the residents could consent to a sexual relationship. The ADON stated the ability to consent had not been reassessed as cognition declined. During an interview on 10/18/23 at 11:42 a.m., the director of nursing (DON) stated she was aware of the sexual relationship between R97 and R112; however, she was not involved in assessing the residents or interventions related to the sexual relationship and referred to the ADON. The DON stated although neither resident could make decisions regarding their medical care, R97 and R112 could consent to a sexual relationship. The DON confirmed she did not report the sexual relationship to the state agency (SA) or do a complete investigation regarding the potential for abuse as she believed both residents could consent to the relationship although they had impaired cognitions. The DON stated the facility did not have a policy regarding sexual relationships between two residents. The facility Guideline for Responding to an Alleged Incident of Abuse policy dated 2/23, indicated covered individuals should provide for the immediate safety of the resident if abuse is suspected. Potential abuse should then be reported to the SA and 911 if applicable. The policy indicated investigation into suspected abuse should begin as soon as possible and include: interviewing residents using the appropriate interview form, completing a physical examination if needed, interviewing witnesses, and ruling out abuse to other residents. The policy indicated care plan interventions should be updated or added to maintain the resident's highest practical well-being. A policy regarding sexual relationships between two residents or safety measures involved was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a level I Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for 1 of 1 residents (R96). Findings include: R96's quarterly Minimum Data Set (MDS) dated [DATE], indicated R96 had moderately impaired cognition with diagnoses including a stroke with left sided weakness and delusional disorder. R96's PASARR dated 6/6/22, indicated the PAS [PASARR] is not final until the lead agency sends the documentation to the nursing facility. R96's entire medical record was reviewed and lacked evidence a final determination had been received by the county or managed care program as directed by the PAS. During an interview on 10/19/23 at 8:51 a.m., the director of admissions (DOA) stated she was responsible for managing resident PASARRs. The DOA stated she thought R96's PASARR had been misfiled and was unable to locate it. During an interview on 10/18/23 at 2:48 p.m., the director of nursing (DON) stated she was unaware of the PASARR process, and the DOA was responsible for PASARR completion and maintenance. No policy regarding PASARR completion or maintenance was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure a comprehensive agenda and selection of meaningful activities, including group-based activities, was provided or offered for 2 of 2 residents (R19, R92) reviewed for activity participate on the short-term stay (i.e., TCU) unit. Findings include: R19's admission Minimum Data Set (MDS), dated [DATE], identified R19 had intact cognition, and it was, Very important, for R19 to attend her favorite activities. R19's Activities: TCU (Transitional Care Unit) Comprehensive Leisure Form - V2, dated 9/28/23, identified R19 was provided with magazines and a power strip for her hearing aides and cell phone. The evaluation outlined, [R19] uses her phone to read & get news updates. [R19] lives in an ALF [assisted living] where she likes to participate in some group activities, especially cards. TR [therapeutic recreation, i.e., activities] will assist with leisure pursuits as needed. On 10/16/23 at 6:00 p.m., R19 was observed seated in her wheelchair while in her room. The room had no posted activity calendars visible. R19 was questioned on what, if any, activities she attended while at the TCU for rehab services and responded she did not attend any group-based activities as the activities staff told her they don't have any, while providing her with various magazines. R19 stated she enjoyed playing cards and listening to group-based, current event-type activities but neither had ever been offered. R19 stated she was never told about or offered activities in the other parts of the building (i.e., long-term care [LTC] units) and would have likely attended them if she knew they were an option. R19's care plan, dated 9/29/23, identified R19 lived alone at an ALF prior to their TCU admission adding, . she does attend some group activities and especially enjoys playing cards, which is also an offered activity at her ALF setting. A goal was listed which read, The resident will attain or maintain the highest practicable mental and phychosocial [sic] well-being ., with several interventions including allowing R19 to make choices regarding preferences as needs as appropriate, chaplain services as needed, and providing opportunities for R19 and her family to participate in their own care. R19's POC (Point of Care) Response History, dated 10/18/23 (with 30 day look-back period), listed a section labeled, Activity Participation (MMH), along with the ability to record active, passive, or refusal of any offered or provided activities. However, this report pulled no data or evidence R19 had been offered or provided with any activities, including individual or group-based activities, with the report responding, No Data Found. Further, R19's entire medical record was reviewed and lacked documented evidence any activities, including self-based and group-based events, had been offered or provided after 9/28/23, despite R19 admitting to the TCU several weeks prior and staff having assessed R19 as having enjoyed group-based activities in their ALF prior to admission. R92's admission MDS, dated [DATE], was listed as, In Progress, and not finalized prior to or during the onsite survey. R92's Activities: TCU Comprehensive Leisure Form - V2, dated 10/3/23, identified R92 had been a previous resident on the unit and was provided an [NAME] (virtual assistant). The evaluation outlined, . enjoys reading, music, watching the MN Twins & National Geographic TV. It's important for [R92] to keep up with the news on TV & in newspaper . says she is a 'Night Owl' . TR [therapeutic recreation] will assist with leisure pursuits as needed. However, the completed evaluation lacked any dictation on what, if any, group-based activities were desired or offered to R92 while on the TCU. On 10/19/23 at 2:02 p.m., R92 was observed lying down in bed while in her room. The room had a television mounted on the wall, however, there were no posted activity or program calendars visible on the walls or within the room. R92 was interviewed and expressed she was admitted to the nursing home a few weeks prior for therapy services. When questioned on what, if any, involvement with the facility' activities programs she participated in, R92 explained when she was not involved with therapy there were not a lot of options for other out-of-room activities of interest (i.e., group events). R92 added the lack of such activities, at times, made her feel captured in this room. R92 stated she did bring some of her own reading materials from home prior to coming as, I knew I was going to need it. R92 stated she had asked about getting some other magazines to read, however, had been told the facility did not provide much, if any, of those because of COVID. R92 stated the facility did offer puzzles and various crossword puzzles, however, due to a dexterity issue she was unable to complete those adding the provided materials were very elementary [i.e., easy and not challenging], which R92 did not care for as they were a teacher prior to retirement. R92 stated she was unable to recall an activities calendar being provided to her to help outline what, if any, activities were available within the building, including on the long-term care side, and voiced no such information had been expressed to her, either. R92 reiterated a sense of boredom while residing at the nursing home for their short-term therapy, and she stated she would have liked to have been offered and attended group-based activities, if available, but added it was likely a little late now since she was looking to discharge soon. R92's care plan, revised 10/18/23, identified R92 was independent with leisure pursuits with dictation, . has anticipated short term stay, focus is on therapy. The care plan listed several interventions including assisting with independent leisure pursuits as needed, offering ala carte activities (i.e., books, magazines), and, Inform resident of recreational services offered, provide TR telephone number and encourage patient to call with requests and questions. R92's POC Response History, dated 10/18/23 (with 30 day look-back period), listed a section labeled, Activity Participation (MMH), along with the ability to record active, passive, or refusal of any offered or provided activities. However, this report pulled no data or evidence R92 had been offered or provided with any activities, including individual or group-based activities, with the report responding, No Data Found. Further, R92's entire medical record was reviewed and lacked documented evidence any activities, including self-based and group-based events, had been offered or provided after 10/3/23, despite R92 admitting to the TCU several weeks prior. On 10/17/23 at 12:37 p.m., nursing assistant (NA)-B and NA-C were interviewed on the TCU. NA-B explained staff don't do much for activities on the unit which NA-C stated was due to most of the time [on the unit] consumed with therapy. NA-B stated they thought the residents' were provided a calendar for activities, but expressed they were unsure who provided it to them. NA-B and NA-C both expressed there were much more activities in the long-term care building (i.e., D-Building), however, the NA staff had never been told or asked to offer those activities to the TCU residents adding, We don't. Further, NA-C stated they had seen some activities staff personnel on the TCU offering and handing out various books or magazines, but added such was only once in awhile and not regularly observed. When interviewed on 10/17/23 at 12:58 p.m., registered nurse (RN)-B stated there aren't a lot of activities on the TCU, which RN-B attributed to COVID-19 precautions, however, acknowledged the nursing home was not in outbreak status and had no recent COVID cases to their knowledge. RN-B explained there was an activity staff member, who they named as therapeutic recreation coordinator (TRC)-A, who did meet the residents and interview them upon admission to the unit but outside of some public puzzles and non-leisure group therapy sessions (i.e., PT, OT) there was not much offered for group-based activities. RN-B stated they had never been asked or directed to offer TCU residents' the long-term care building activities before and reiterated they didn't feel comfortable doing so since COVID. Further, RN-B stated any activities programming, schedules, or questions were best answered by TRC-A. On 10/18/23 at 10:17 a.m., TRC-A was interviewed. TRC-A verified they were the person who helped manage and run the activities in the TCU setting. TRC-A stated they visited with each admission to the TCU and provided in-rooms items, as best able, to help them have self-guided activities. TRC-A explained they felt residents on the TCU were more focused with in room activities due to their stay at the nursing home being short-term, however, if someone expressed wanting to go to the long-term care building for activities then such would be possible. TRC-A stated prior to the pandemic the flow between the units was more open and, lately, there still was apprehension on mixing the groups (i.e., long-term care and TCU). As a result, TRC-A reiterated the activities offered on the TCU were almost solely individually based and self-guided adding they felt most people likely would not want to have more robust activities scheduled due to therapy work. TRC-A stated offered, attended, or provided activities were not tracked (i.e., charted) on the TCU, and they verified the long-term care activities schedules were not advertised or provided to the TCU residents adding such had not been done since pre-pandemic times. TRC-A stated they were unaware R19 and R92 had wished to do more group-based activities, however, acknowledged hearing some complaints on the lack of more activities within the TCU on occasion over the years. Further, TRC-A reiterated the activities programming on the TCU was it's all individual. A provided Activities Program policy, dated 3/2023, identified the nursing home would provide an ongoing program of activities, including both facility-sponsored group and individual activities, in accordance with the resident' assessment, care plan, and preferences. The policy outlined, Activities should be individualized and based on resident's previous lifestyle, preferences and comforts. The policy included a section which specified some additional guidance for short-term stay residents including offered ala carte activities (i.e., puzzles, cross words), technology equipment as desired, and, Offer opportunities to attend group activities in all parts of the building when not attending therapy if resident is interested. However, the policy lacked further information on how these group-based activities would be advertised, offered or provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to comprehensively assess the root cause of falls, and incorporate new fall interventions, to prevent falls and injury for one of one resident (R110) who had frequent falls. Findings include: R110's significant change Minimum Data Set, dated [DATE], indicated R110 was severely cognitively impaired and required extensive assist with bed mobility, dressing and personal hygiene, and required total assistance with toileting. R110's Medical Diagnoses list, dated 8/18/23, indicated R110 had a primary diagnoses of left femur fracture and presence of a left artificial hip joint. The medical diagnoses list, dated 7/3/20, indicated secondary diagnosis of Alzheimer's disease and a history of falling. R110's progress notes indicated R110 had six falls in the past seven months, with one serious injury requiring hospitalization. R110's progress notes detailed the following; On 3/23/23, it was documented R110 was found sitting on the floor, watching TV with a new skin tear. (Unclear as to where the skin tear was.) On 5/9/23, it was documented R110 was found sitting on the floor in her room next to her bed with spilled pop on the floor and her wheelchair next to her. On 7/2/23 it was documented R110 was found sitting on the floor with her wheelchair close to her. On 8/12/23 it was documented R110 was found sitting on the floor with her wheelchair next to her and stated she fell trying to sit on her wheelchair. R110 had complaints of left leg pain and was given scheduled Tylenol. On 8/13/23 it was documented R110's x-ray results indicated an acute left femoral neck fracture and R110 was sent to the hospital. On 9/18/23 it was documented R110 was found sitting on the floor, stating she, slid down to the floor. R110's care plan, revised 9/6/23, indicated R110 was at risk for falls due to needing assistance with mobility, potential side effects of medication, impaired cognition, and a history of multiple falls. Updated interventions in the past 5 months included an antiroll-back wheelchair, dated 6/6/23, and encouraging resident to participate in activities that promote exercise and to wear appropriate non-slip footwear, dated 9/6/23 (originally on care plan 7/5/20). R110's care plan also included an intervention, revised 4/10/23, to place a star icon on R110's doorframe. R110's entire medical record (EMR) lacked a comprehensive assessment and root cause analysis of the potential cause of falls and why R110 was self-transferring. The EMR also lacked new interventions in place to prevent future falls. During observation on 10/17/23, R110 did not have a star icon on her doorframe. During an interview on 10/18/23 at 11:00 a.m., nursing assistant (NA)-A stated R110 was a high fall risk due to frequent falls and that she should have a red check mark on her door frame which indicated a resident requires frequent checks. NA-A stated R110 was ambulating with therapy only. NA-A also stated she was unaware of what a star on a resident's doorframe would indicate. During an interview on 10/18/23 at 11:25 a.m., nurse manager and licensed practical nurse (LPN)-E stated that the expectation after a fall was for the staff member who found the resident to notify the nurse and assist the resident in getting off the floor. LPN-E stated if a resident was a frequent faller, the staff will often 'just get them up off the floor. LPN-E stated a fall scene report would be filled out indicating how the resident was found, what was on their feet and when they were last toileted. Falls were then discussed at a weekly fall meeting. LPN-E stated that R110's root cause for her falls was always going to be self-transferring as she does not remember to call for help and that interventions to prevent falls would only be updated if something new was identified but not with each fall. During an interview on 10/19/23 at 9:59 a.m., nurse manager and LPN-E stated she was unable to locate a fall scene report from R110's fall on 5/9/23. LPN-E confirmed that the interventions on the care plan are what had been put in place for R110 and stated there were no new interventions that could be put in place because the root cause of her falls was always that she self-transfers. LPN-E stated R110 should have a star on her doorframe to indicate she was a frequent faller and confirmed it wasn't there. LPN-E also confirmed the fall interventions were repetitive and repeatedly indicated R110 should have frequent checks which LPN-E stated meant for staff to check on R110, often as they walk by. LPN-E confirmed they had not tried a sign in her room to remind her to call for help and had not assessed why she was self-transferring such as a potential need for her toileting plan to be reassessed, did she need a different call light, should her wheelchair be next to her or away from her, etc. During an interview on 10/19/23 at 11:13 a.m., the director of nursing (DON) stated she would expect a comprehensive assessment to be completed with each fall and a root cause analysis of why R110 was trying to self-transfer. The DON further stated with each fall there should be new interventions to try to prevent future falls. A facility policy titled Fall Management Protocol, revised 5/23, indicated information from a fall would be gathered and analyzed at quality assurance (QA) meetings and that frequent fallers would have a star symbol on their doorframe and walker or wheelchair if used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure a feeding tube was in functioning order to promote comfort, prevent the spread of infection and prevent further malnutrition for 1 of 1 residents (R134) reviewed for tube feedings. Findings include: R134's quarterly Minimum Data Set (MDS) dated [DATE], indicated R134 had severe cognitive impairment and required extensive assistance for bed mobility, eating, and personal hygiene. The MDS indicated R134 received 51 percent (%) or more of her nutrition through a feeding tube. R134's Diagnosis Report dated 2/24/23, indicated R134 had diagnoses including stomach cancer that spread to the lungs and liver, dysphagia (swallowing disorder), malnutrition, and dehydration. R134's Order Summary Report dated 10/17/23, indicated an order to administer R134's tube feeding (TF) from 8:00 p.m. to 8:00 a.m. daily at a rate of 100 milliliters/hour (mL/hr). The report indicated staff were to communicate R34's physical and emotional needs with the hospice team. The report also indicated staff were to notify the provider of feeding tube concerns including clogging or leaking. R134's care plan dated 10/18/23, indicated R134 had severe malnutrition and received 75 to 100 % of her nutrition through a feeding tube. The care plan indicated family was to be informed of feeding tube concerns. The care plan indicated staff were to report and document any tube feeding malfunction. The care plan also indicated R134 was at risk for impaired skin integrity related to nutritional status, staff dependence, and incontinence; therefore, R134's skin was to be kept clean and dry. The care plan indicated R134 had a terminal prognosis and maximum comfort was to be provided. R134's progress note dated 10/17/23 at 7:29 a.m., indicated R134's TF was stopped for the night at 12:00 a.m., due to a broken port (entrance site of feeding tube for TF). The progress note indicated tape had not prevented the TF from leaking onto R134, R134's recliner, and floor. The progress note did not indicate the provider had been updated. R134's progress note dated 10/17/23 at 10:19 a.m., indicated R134's feeding tube had two ports, one of which had been broken for a while. R134's progress note dated 10/17/23 at 3:30 p.m., indicated R134 started receiving hospice services related to a terminal prognosis. The progress note indicated R134's family would not want the feeding tube replaced if both ports became non-functional and instead would stop TF. R134's progress note dated 10/19/23 at 6:04 a.m., indicated at 1:00 a.m., R134's TF had flooded all over the floor- running from the bathroom to recliner and the feeding tube port was noted to be broken. The progress note indicated the feeding was not restarted until 4:00 a.m., when the port was manually held shut, allowing formula to run. The progress note did not indicate the provider had been updated. During observation on 10/16/23 at 5:39 p.m., R134's feeding tube had two ports, one covered with discolored tape and the other closed with a cap. R134 was not receiving TF at this time. During observation and interview on 10/18/23 at 8:05 a.m., R134's TF was administered through the first port while the second port was covered in discolored, wet-appearing tape with the closure cap hanging freely. Licensed practical nurse (LPN)-A removed the tape, cleaned the port, left the closure cap hanging freely, and applied tape directly to the end of the port. LPN-A stated the port broke a month or two ago, so staff wrapped the end very tightly in tape. During an interview on 10/19/23 at 8:34 a.m., the hospice nurse (RN)-A, stated the facility had informed her one port was broken so they taped the cap into the port, eliminating leakage. RN-A stated she was not made aware the cap was not being used or the TF was leaking. During an interview on 10/19/23 at 10:00 a.m., family member (FM)-A stated he had been informed by hospice of a slight issue with the feeding tube and had observed tape over the port. FM-A stated he had not been informed of the feeding tube leakage. FM-A stated if the feeding tube broke or malfunctioned, the family would want feedings stopped. During an interview on 10/19/23 at 10:16 a.m., R134's medical doctor (MD)-A stated he was aware one of the ports was malfunctioning but not of the extensive leakage or the tape being used to cover the port. MD-A stated the family did not want the feeding tube replaced and was open to weaning R134 off the TF if the tube was not working. MD-A stated he would be worried about the risk of infection and discomfort related to the leaking port and the nurse practitioner in charge of care should have been contacted. During an interview on 10/19/23 at 11:20 a.m., the director of nursing (DON) stated nursing staff should have contacted the provider when R134's TF was observed leaking so a better solution could be found. The facility Enteral Tubes policy dated 8/23, indicated the TF should be administered according to the practitioner's order. The policy indicated notification of the practitioner should have been completed if a feeding tube broke, cracked, or clogged and with questions or concerns related to this tube.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure proper cleaning of a continuous positive airway pressure (CPAP) machine to reduce the risk of complication (i.e., respiratory infection) for 1 of 1 residents (R76) observed for CPAP use. Findings include: R76's admission Minimum Data Set (MDS) dated [DATE], indicated R76 had intact cognition and was independent with eating, required moderate assistance with toileting, and minimal assistance with personal hygiene. R76's Diagnosis Report dated 10/6/23, indicated R76 had diagnoses of pneumonia (onset of 10/14/23), obstructive sleep apnea, asthma, chronic obstructive pulmonary disease (COPD, incurable lung disease causing breathlessness, frequent coughing, and chest tightness), and kidney disease. R76's Order Summary Report dated 10/6/23 (admission date), indicated R76 was approved to use her CPAP machine with home settings. The report indicated R76 started a seven-day course of Doxycycline (antibiotic) for pneumonia on 10/14/23. The report indicated R76's daily CPAP cleaning was ordered on 10/18/23. R76's care plan dated 10/9/23, indicated R76 was diagnosed with obstructive sleep apnea requiring CPAP machine use at pre-programmed settings while sleeping. The care plan indicated the nurse was to clean the CPAP machine weekly. R76's Treatment Administration Record (TAR) dated 10/18/23, did not indicate cleaning of R76's CPAP had been completed since admission. The patient CPAP machine was set up for use by staff on 10/12/23, 10/13/23, 10/14/23, 10/15/23, and 10/17/23. During observation and interview on 10/16/23 at 2:26 p.m., R76's ResMed CPAP machine was observed on the bedside dresser with condensation inside the water chamber and the mask still attached. R76 stated she used her CPAP machine several times in the past week. During observation and interview on 10/18/23 at 8:22 a.m., R76's CPAP machine was observed on the bedside table with condensation in the water chamber with the mask still attached. R76 stated her CPAP machine had not been cleaned since before admission. During an interview on 10/18/23 at 8:25 a.m., licensed practical nurse (LPN)-B stated CPAP machine cleaning should have been completed daily but this was not documented anywhere. LPN-B stated she was unsure if R76 had worn her CPAP the previous night, and because of this the CPAP machine had not required cleaning this morning. During an interview on 10/18/23 at 2:12 p.m., LPN-C stated he was unfamiliar with R76, but CPAP machines were expected to have been cleaned daily and this should have been documented in the TAR. During an interview on 10/18/23 at 2:49 a.m., the director of nursing (DON) stated CPAP cleaning should have been ordered on admission and documented in the TAR. The DON stated she would have expected staff to refer to the facility policy to determine the frequency of CPAP cleaning. The DON stated scheduled CPAP cleaning was important to decrease resident risk for respiratory infection. ResMed's undated Cleaning CPAP Equipment instructions, indicated mask cushion and humidifier water tub should be cleaned daily while the mask frame system, mask headgear, and air tubing should be cleaned weekly. The undated facility Cleaning Your CPAP policy, indicated the CPAP mask and water chamber required daily cleaning, while the mask, tubing, and headgear required weekly disassembly and cleaning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure dementia services were provided which included an initial comprehensive assessment and on-going assessments regarding sexual consent capacity for 2 of 2 residents (R97, R112) with cognitive impairment who were reviewed for dementia care. Findings include: The American Psychological Association's handbook, Assessment of Older Adults with Diminished Capacity, dated 2008, indicates sexual behaviors ranging from touching to sexual intercourse, require sexual consent capacity. This differs from all other forms of consent capacity. Sexual consent capacity requires the partaker to be able to make a rapid, independent decision in the present and does not allow time for family or physician input as with a medical decision. Sexual consent must be given by the partaker each time a sexual act occurs, not previously by a surrogate decision maker. The handbook indicates that for a resident to possess sexual consent capacity, they must possess knowledge of the results of their decisions, understand how these decisions interact with their values, and be free from the coercion of others. Furthermore, a resident must have the ability to demonstrate an understanding of sexually transmitted diseases (STD), be able to determine if the other member of the sexual activity is also able to consent to sexual activity, and determine what times and places are appropriate for this sexual activity. The handbook indicates that when assessing a resident for the ability to consent, cognitive assessments may be helpful, but it must be ensured that the resident's consent ability remains the same as the first assessment during every sexual act the resident partakes in. The handbook suggests assessing these additional areas: resident vulnerability, ability to avoid sexual exploitation or say no to any uninvited sexual contact, and disorders that could limit or increase sexual activity. The handbook goes on to suggest facilities have policies and procedures addressing sexual relationships between residents coinciding with state statutes. R97's quarterly Minimum Data Set (MDS) dated [DATE], indicated R97 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS, tool used to determine cognition level) score of 11 and required maximal assistance with lower body dressing and moderate assistance with upper body dressing and bathing. R97's significant change MDS dated [DATE], indicated R97 had moderately impaired cognition with a BIMS score of nine. and required maximal assistance with dressing, bathing, turning in bed, and moving from a lying to a sitting position. R97's Diagnosis Report dated 9/8/23, indicated diagnoses of a stroke with resulting right-sided weakness and cognitive dysfunction, kidney disease, and diabetes with vision decline. R97's care plan: - dated 8/29/22, indicated R97 was interested in a relationship with R112 and staff were to facilitate private time behind closed doors for R97 and R112 by placing a do not disturb sign on R97's door. The care plan indicated the responsible party was aware of the relationship and interventions. This care plan section did not indicate updates had occurred to correlate with R97's decreasing cognition. The care plan also did not include methods to assess R97's ability to give sexual consent, obtain sexual consent, avoid sexual exploitation, or understand of ramifications of sexual acts. - dated 9/9/23, indicated R97 is vulnerable related to cognitive impairment, had decreased awareness for potential harm, decreased mobility, strength, and function requiring assistance from others to meet daily needs. - dated 9/20/23, indicated R97 had a potential for impaired communication related to forgetfulness, confusion, severe cognitive impairment, barely speaks when spoken to, and impaired hearing. - dated 9/27/23 indicated R97 had limited physical mobility related to generalized weakness, impaired cognition, and right-sided weakness and required the extensive assistance of one person for rolling and sitting at the side of the bed. R97's Associated Clinic of Psychology (ACP) progress note dated 7/19/22, indicated R97 was diagnosed with adjustment disorder and symptoms affecting cognitive function and awareness. The progress note indicated R97 had impaired and scattered cognition. The progress note did not indicate R97's ability to give sexual consent, obtain sexual consent, avoid sexual exploitation, or understand the ramifications of sexual acts was assessed. R97's progress note dated 8/29/22 at 3:06 p.m., indicated facility staff reported R97 was interested in a relationship with a female resident on the unit. The progress note indicated that R97's responsible party was made aware of the relationship and informed sexual wellness would be reviewed with R97. The progress note also indicated that private time would be given to R97 and the female resident. The progress note indicated R97's cognitive score was reviewed, but the progress note did not indicate an assessment of R97's ability to give sexual consent, obtain sexual consent, avoid sexual exploitation, or understand the ramifications of sexual acts had been completed. R97's progress note dated 9/1/22 at 12:50 p.m., indicated a Do Not Disturb sign was given to R97 for privacy. The progress note indicated sexual health education on keeping clean and dry when intimacy was anticipated, was given to R97. The progress noted indicated that R97 was instructed that monogamy and prophylactics could assist in decreasing STD risk. The progress note did not indicate that R97 was able to articulate an understanding of the sexual health teaching and R112's ability to give sexual consent, obtain sexual consent, avoid sexual exploitation, or understand the ramifications of sexual acts was not documented to have been reassessed. R97's ACP progress note dated 10/4/22, indicated R97 had withdrawn, tired behavior, and R97 demonstrated low insight while tending to minimize concerns. R97's ACP progress note dated 11/8/22, indicated R97 had a new Geriatric Depression Scale (GDS) score of six, indicating depression. The progress note indicated R97 had a flat affect with guarded behavior with no interest in activities. The progress note did not indicate that R97's sexual relationship had been evaluated to determine possible effects on mental health. R97's progress note dated 4/10/23 at 11:49 a.m., indicated R97 and his responsible party declined to attend the care conference. The progress note indicated that R97 continued to have access to a privacy sign to place on his door as needed. The progress note indicated a decline in R97's BIMS score but did not indicate a reassessment of his ability to consent to a sexual relationship. R97's ACP progress note dated 5/30/23, indicated R97, had a flat affect, withdrawn behavior, and impaired cognition. The progress note indicated R97 often is contradictory in his statements. R97's progress note dated 9/25/23, indicated a care conference was held with facility staff but R97 and the responsible party were not present. The progress note indicated that R97's BIMS score had declined, now indicating severe cognitive impairment. R97's ability to give sexual consent, obtain sexual consent, avoid sexual exploitation, or understand the ramifications of sexual acts was not reassessed. R112's quarterly MDS dated [DATE], indicated R112 had moderately impaired cognition with a BIMS score of 11, requiring help setting up dressing activities, but R112 was independent with toileting, bed mobility, and transferring. R112's quarterly MDS dated [DATE], indicated R112 had severely impaired cognition with a BIMS score of six and was independent with dressing, toileting, bed mobility, and transferring. R112's Diagnosis Report dated 7/12/23, indicated diagnoses of dementia, major depression, anxiety, right hip replacement, and kidney disease. R112's care plan: - dated 11/13/20 indicated R112 is vulnerable related to moderate cognitive impairment and a diagnosis of dementia. The care plan indicated the following interventions related to vulnerability: speak slowly and repeat messages as needed, observe for changes in cognition, and anticipate and assist with needs. - dated 8/29/22, indicated R112 was interested in a relationship with R97 and staff were to facilitate private time behind closed doors for R97 and R112 by placing a do not disturb sign on the R112's door. The care plan indicated the responsible party was aware of the relationship and interventions. This care plan section did not indicate updates had occurred to correlate with R112's decreasing cognition. The care plan also did not include methods to assess R112's ability to give sexual consent, obtain sexual consent, avoid sexual exploitation, or understand of ramifications of sexual acts. - dated 10/18/23, indicated R112 had a severe to moderate cognitive impairment related to dementia requiring the following interventions: break tasks into one step at a time to support short-term memory loss, cue, reorient, and supervise R112 as needed. R112's progress note dated 8/29/22 at 2:59 p.m., indicated facility staff had reported R112 was interested in a relationship with a male resident on the unit. The progress note indicated that R112's responsible party was notified of her desire for a relationship and was understanding. The progress note also indicated that sexual wellness would be reviewed and private time would be given to R112 and the male resident. The progress note indicated that R112's cognitive score was reviewed but did not indicate an assessment of R112's ability to give sexual consent had been completed. R112's progress note dated 9/1/22 at 12:54 p.m., indicated a Do Not Disturb sign was given to R112 to promote privacy. The progress note indicated sexual health education on keeping clean and dry if R112 was anticipating intimacy. The progress noted indicated that R112 was instructed that monogamy and prophylactics could assist in decreasing her STD risk. R112 also received education to decrease her urinary tract infection (UTI) risk. The progress note did not indicate that R112 was able to articulate an understanding of the teaching. R112's ability to give sexual consent, obtain sexual consent, avoid sexual exploitation, or understand of ramifications of sexual acts was not documented to have been assessed. R112's progress note dated 8/8/23 at 1:35 p.m., indicated R112 had a decrease in cognition, was now severely cognitively impaired, and needed assistance finding her room. The progress note did not indicate that R112's ability to give sexual consent, obtain sexual consent, avoid sexual exploitation, or understand the ramifications of sexual acts was reassessed with her decrease in cognition. R112's progress note dated 8/28/23 at 12:25 p.m., indicated R112 had a decreased BIMS score and Patient Health Questionnaire (PHQ-9, tool used to screen and monitor depression) score. The progress note indicated that R112 had more difficulty tracking conversations and was now unable to use the text feature on her phone. R97's ability to give sexual consent, obtain sexual consent, avoid sexual exploitation, or understand the ramifications of sexual acts was not reassessed. During observation and interview on 10/16/23 at 2:17 p.m., R97 and R112 were in R97's room, fully clothed, lying in bed together. A please do not disturb sign was on the door and the door was halfway open. R112 stated she and R97 were in a relationship together but cannot recall how long. R97 did not respond when asked about their relationship. Before R97 could answer further, R112 stated the details of the relationship were private and not for anyone else to know, refusing to answer any further questions. During an interview on 10/17/23 at 11:58 a.m., nursing assistant (NA)-D stated that R97 and R112 had an intimate relationship. NA-D stated when he witnessed R97 and R112 engaging in intimate activities, he applied a do not disturb sign as instructed and closed the door to provide privacy. During an interview and document review on 10/17/23 at 11:59 a.m., licensed practical nurse (LPN)-D stated R97 and R112 had been intimate and unclothed together a couple of times before the assistant director of nursing (ADON) notified their families of the relationship and she witnessed a do not disturb sign on the door. LPN-D stated she had observed R97 and R112 unclothed and being intimate in bed together multiple times during the previous few months. During an interview on 10/18/23 at 9:53 a.m., ACP-A stated R97 had impaired cognition and was minimally engaged in conversations. ACP-A stated she had not been informed by the facility of R97's relationship and was concerned R97 would not be able to express if he was uncomfortable with a sexual encounter, leading to an unsafe situation. ACP-A stated that R112 had not been referred to her, and she would be worried a resident with R112's current cognition would not be able to consent. During an interview on 10/18/23 at 11:19 a.m., the ADON stated she was aware of the sexual relationship between R97 and R112 and intervened by providing education on STDs, contraception, and preventing UTI's. The ADON stated she did not use a specific method to ensure R97 and R112 would be able to apply the education. The ADON stated she had not encountered this situation before, and the facility did not have a policy or procedure to reference for guidance on how to handle sexual relationships between residents. The ADON stated that based on the BIMS scores and PHQ-9 scores, she determined the R97 and R112 could consent to a sexual relationship, but this ability had not been reassessed as cognition declined. During an interview on 10/18/23 at 11:42 a.m., the director of nursing (DON) stated she was aware of the sexual relationship between R97 and R112; however, she was not involved in assessing the residents or interventions related to the sexual relationship and referred to the ADON. The DON stated although neither resident could make decisions regarding their medical care, R97 and R112 could consent to a sexual relationship. The DON stated she believed both residents could consent to the relationship although they had impaired cognitions. The DON stated the facility did not have a policy regarding sexual relationships between two residents. A policy regarding sexual relationships between two residents or safety measures involved was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure identified preferences for rising were honored and implemented for 1 of 2 residents (R39) reviewed for choices. Findings include: R39's quarterly Minimum Data Set (MDS), dated [DATE], identified R39 had intact cognition and displayed no delusional behaviors (misconceptions or beliefs which are firmly held, contrary to reality). Further, R39 required extensive assistance to complete several activities of daily living (ADLs) including bed mobility and transfers. On 7/25/22 at 2:48 p.m., R39 was asked about his quality of life in the nursing home and responded aloud, No comment. R39 was interviewed and stated the staff who work at the nursing home change often and, as a result, the staff don't adhere to schedules [i.e., rising times] with him and his care. This caused him to become anxious and wonder are they going to come or not and help him. R39 stated he wanted the staff to honor the schedules they have set-up with him and reiterated the schedule doesn't seem to go along with each change of personnel. R39's care plan, dated 6/21/22, identified a section which listed interventions to appears in R39's Point of Care (POC). This included, 7:30 a.m. Wake Time. R39's corresponding Visual/Bedside [NAME] Report, printed 7/28/22, identified a section labeled, About Me / Activities, which listed R39's preferences and activities. This included, 7:30 a.m. Wake Time. On 7/27/22 at 8:46 a.m., R39's bedroom door was observed partially closed with nursing assistant (NA)-E being heard inside the room conversing with R39 and helping him with morning cares. At 8:59 a.m. R39's doorway was opened and NA-E left the room with a clear plastic bag which contained soiled linens and trash. When interviewed on 7/27/22 at 9:03 a.m., NA-E stated she had just completed R39's morning cares and acknowledged it was over an hour after 7:30 a.m. when she started his cares adding, I think he [R39] wasn't very happy [due to being late]. NA-E stated she had just recently completed orientation and expressed she was late getting to R39 for morning cares as she was still trying to get used to everything around here. NA-E explained there was no orientation or step by step explained to her on which residents had preferences for rising or how to ensure all resident' preferences for such were honored. NA-E stated she had asked some of her colleagues on how to better ensure rising routines and preferences were provided timely and was told, It just takes time. On 7/28/22 at 10:38 a.m., registered nurse manager (RN)-E stated preferences for rising and other routines were assessed upon admission, added to the care plan and re-evaluated quarterly thereafter. RN-E explained some of the folks were more willing to be fluid with their routines and some were more regimented adding she was unaware R39 had voiced concerns with schedules not being adhered to while in the nursing home. However, RN-E stated it was important to ensure preferred times and schedules for residents were met to promote patient centered care, adding the nursing assistant should make sure to check the [NAME] when the shift starts to know who has desired times for rising and go from there and plan her day. A provided Resident Rights Self-Determination policy, dated 9/2021, identified the nursing home would support, promote and facilitate resident self-determination through support of resident choices. The policy directed, . residents have the right to choose activities, schedules (including sleeping and waking times) . consistent with his or her interest, assessments, and plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure routine grooming and personal hygiene was offered and/or provided for 1 of 7 residents (R65) reviewed for activities of daily living (ADLs) and who was dependent on staff for care. Findings include: R65's annual Minimum Data Set (MDS), dated [DATE], identified R65 had moderate cognitive impairment and required extensive assistance with personal hygiene cares. On 7/25/22 at 2:29 p.m., R65 was observed seated in her wheelchair while in her bedroom. R39 had several long, visible white hairs extending off her upper lip and chin which were several millimeters (mm) in length. R39 was questioned on these hairs and if she would like them removed, however, did not verbally respond to the surveyor. R65's care plan, dated 5/20/22, identified R65 had a self-care performance deficit and needed assistance to complete ADLs. A goal was listed which read, Resident will be clean, appropriately dressed, and odor-free, and will participate in ADL's as able ., along with several interventions to help R65 meet this goal including, HYGIENE ROUTINE: Staff to do hair. Set-up and encourage her to wash face and hands, do if does not. Routine pericare. The care plan lacked any dictation or guidance for how often, or when, to assist R65 with facial hair removal. On 7/27/22 at 8:43 a.m. (two days later), R65 was observed with her eyes squinted closed. R65 continued to have the same visible, long white hairs present on her upper lip and chin; and again, did not verbally respond to the surveyor when asked about personal hygiene preferences and care. R65's medical record was reviewed and lacked evidence R65 had been shaved, or been offered and declined shaving, in the past several weeks despite having visible long hairs on her upper lip and chin. When interviewed on 7/27/22 at 9:36 a.m., nursing assistant (NA)-D stated she assisted R65 with morning cares that morning, and she described R65 as needing help to complete most cares and personal grooming. NA-D explained R65 would infrequently refuse cares to be done but most of the time allow hair combing and such cares to be completed. NA-D stated if someone was offered and refused shaving, she would notify the nurse and they could record it in the record as the NA staff don't have anywhere to record that. NA-D then observed R65 at the request of the surveyor and verified the presence of long, white hairs on her upper lip and chin. NA-D stated she didn't notice them when she did R65's morning cares and added she did not even know if R65 had a shaver or not to use to remove them. During interview on 7/27/22 at 10:07 a.m., registered nurse (RN)-D stated shaving should be completed on male and female residents during the shower day and verified a community-style shaver was available to complete such care if a resident didn't have a personal one. RN-D reviewed his clipboard and stated R65 was scheduled for a bath on Monday evening (PM) and, if shaving was refused, it should have been recorded in the progress notes. RN-D stated it was very necessary to ensure routine cares, such as shaving, were being completed. On 7/28/22 at 10:12 a.m., registered nurse manager (RN)-E stated facial hair removal depended on the person but should be reviewed and removed, if needed, with daily cares adding it should be something they're [NA] looking at. RN-E stated R65 would, at times, refuse cares from staff; however, there was not a specific space in the record to record shaving offers and/or refusals. Rather, if a resident refuses care, it should be reported to the nurse and they were responsible to record such in the medical record. RN-E reviewed R65's medical record and verified it lacked evidence R65 had been offered, refused, or provided shaving and stated shaving was part of routine care, so it should be done. RN-E added this was important to do to help make sure they're [residents] as clean as possible. A provided Shaving a Resident - Using an Electric Razor or Using a Safety Razor policy, dated 11/2021, identified shaving should be provided daily as needed or as care planned to maintain comfort and cleanliness of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively reassess to ensure appropriateness and safety in bed with use of bilateral attached grab bars for 1 of 1 resident (R195) who developed seizures and continued to use these devices. Findings include: R195's admission Minimum Data Set (MDS), dated [DATE], identified R195 was rarely understood and demonstrated both long-term and short-term memory impairment. Further, R195 required total assistance to complete bed mobility. R195's Nursing: admission Evaluation, dated 7/12/22, identified a section labeled, SECTION 6. [GRAB BARS] Evaluation for Use, which outlined R195 was able to follow directions and did not have a history of entrapment using assistive devices. The evaluation outlined R195 was unable to turn independently while in bed, and use of a grab bar device would enhance R195's bed mobility. A question on the evaluation was listed which read, On which side(s) of the bed is a grab bar required?[,] which was answered, c) Right. R195's care plan, dated 7/12/22, identified R195 was bedfast and had limited physical mobility. The care plan outlined R195, . used right grab bar to maintain ability to participate in turning/repositioning . observe for continued ability to use/appropriateness. On 7/26/22 at 9:15 a.m., R195 was observed lying in bed in his room. R195's bed was in a low position and had metallic, grab bars attached to both sides (bilateral) of the bed and not just the right side as had been assessed on 7/12/22. R192 was positioned on his back with several pillows under his lateral hips and his call light was in reach. However, when questioned by the surveyor at this time, R195 did not verbally respond or open his eyes. R195's progress notes, dated 7/12/22 to 7/27/22, identified the following: On 7/12/22, R195 was admitted to the nursing home after having a recent stroke. On 7/14/22, R195 did not verbally respond to his family member (FM) when conversed with. The note included, [NA] has stated he is total assist of 2 with bed mobility . total assist to change . does not make needs known. However, on 7/25/22, registered nurse (RN)-D recorded R195 as having a, extended episode of seizure, which was described as, . bodily spasms and jerking movements to upper and lower body. The note identified this seizure lasted for approximately one hour and was witnessed by RN-D and registered nurse manager (RN)-E. The note concluded, . did not sustain any physical injuries . rails [grab bars] padded for safety. On 7/27/22 at 12:49 p.m., subsequent observation was made of R195 laying in bed in his room. The bilateral grab bars remained affixed to the side of the bed and there was no visible padding present on the rails despite the note recorded on 7/25/22 outlining they had been padded. R195 was again positioned on his back with pillows on his hip' sides and, again, did not verbally respond to the surveyor when questioned. When interviewed on 7/27/22 at 12:53 p.m., nursing assistant (NA)-E stated she was assigned to R195 for the day and voiced R195 did not have verbal responses most of the time, and he required total assistance to complete his cares. NA-E stated she was unaware if R195 used the grab bars attached to his bed to help with repositioning or turning adding, I don't know. On 7/27/22 at 1:12 p.m., RN-D was interviewed and verified R195 was total assist with cares and bed mobility due to a stroke. RN-D stated R195 used to help with cares but did not any longer as his condition declined. RN-D recalled R195 had a seizure on 7/25/22, and described it as R195 laying in bed and just shaking a lot with visible fluids coming out of his mouth. The nurse practitioner (NP) was notified and Ativan (a medication used to treat anxiety and seizure disorders) was provided. RN-D stated he can't say if he had ever observed R195 to use the attached grab bars on his bed and then observed the devices at the request of the surveyor. RN-D verified the attached grab bars were not padded and explained when he dictated such language in his note (dated 7/25/22) he was referring to the pillows used to position R195 in bed adding he pulled them up to provide protection between R195 and the metal rail. RN-D stated he had communicated to keep the pillows positioned between R195 and the attached grab bars to the NA staff. However, during subsequent interview on 7/27/22 at 1:26 p.m., NA-E stated she had never been told or directed to keep pillows between R195's head and/or torso and the installed grab bars. R195's medical record was reviewed and lacked evidence R195 had been comprehensively reassessed for safety with the use of bilateral grab bars after sustaining a seizure on 7/25/22, and requiring total assistance to complete bed mobility. Further, there was no indication the facility had implemented any increased monitoring of R195 while he was in bed to ensure safety with these devices despite having seizure activity. On 7/28/22 at 10:24 a.m., RN-E was interviewed, and she explained grab bars were assessed for safety and use upon admission then normally just quarterly thereafter. However, if a resident declines, RN-E verified their use and safety should be re-evaluated. RN-E reviewed R195's medical record and stated she was unsure why R195 had been initially assessed as needing only a right-side grab bar on admission, however, had bilateral bars installed and in place. RN-E stated she had just completed a re-evaluation of R195's grab bars on that same day (7/28/22) and had them removed due to R195 declining and no longer being able to use them. However, RN-E stated she had not considered re-evaluation the grab bars due to R195's seizure activity but rather just due to his general decline. RN-E verified a seizure patient should not have side rails or grab bars attached to the bed for safety. A provided Grab Bars policy, dated 7/2022, identified the nursing home used grab bars as an alternative to full, half or quarter side rails, and they were properly designed and placed to reduce the risk of entrapment. However, entrapment and death were still possible for certain individuals such as, . people with frailty, incontinence or altered mental status. The policy outlined an evaluation for the use of grab bars would be completed upon admission, quarterly, and as needed, which assessed for entrapment risk, need or continued need for use, and goals of use.