**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to provide medically related social services of clothing and shoes for 1 of 1 resident (R1) reviewed for clothing. This resulted in harm when R2 displayed a lack of engagement in social activities and diminished level of participation in social interactions because she felt unable to leave her room due to a lack of proper and adequate clothing and shoes. Findings include: R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 admitted to the facility on [DATE] and had diagnoses including anxiety disorder, depression, alcohol dependence, and acquired absence of left leg below knee. R1 understood others and was able to make herself understood, had mild cognitive impairment, and utilized a wheelchair and limb prosthesis. The MDS identified, it was somewhat important to R1 to choose what clothes to wear, to do her favorite activities, and to go outside to get fresh air when the weather is good. R1's social isolation score was 2, indicating she sometimes felt lonely or isolated from those around her. R1's quarterly MDS dated [DATE], indicated R1 was 48 inches (four feet) tall and weighed 90 pounds. R1's social isolation score was 2, indicating she sometimes felt lonely or isolated from those around her. R1's Social History and Social Service assessment dated [DATE], indicated R2 was historically overall self sufficient and able to manage on her own. R2's physical and functional status was has a left prosthesis at a very young age and right foot is deformed, walked with crutches and has a w/c [wheelchair]. Barriers to discharge were safe to return, needing to get a new wheelchair. The assessment did not identify that R2 lacked clothing and shoes. R1's PHQ-9 Long-Term Care assessment (a diagnostic assessment tool for depression) dated 6/3/24, identified R1 felt down, depressed, or hopeless on two to six days of the 14 day assessment period. R1's life enrichment progress note dated 6/4/24, noted R1 was alert and oriented times three. life enrichment aide (LEA)-A noted R1 had a wheelchair, walker, and she is an amputee, and does have a prosthetic device, but states she has no shoes for her foot. Life enrichment will continue to monitor her progress for the next 90 days. R1's electronic health record (EHR) contained a physician order dated 6/4/24, for R1 to be evaluated and treated by a psychology clinic. R1's progress note dated 6/12/24, indicated a care conference was conducted with R1, therapy staff, nurse supervisor, and a social worker. The note identified R1 had limited finances but did not include any information regarding R1's previously stated need for shoes identified in progress note dated 6/4/24. R1's progress note dated 6/20/24, indicated social services spoke with the manager of the apartment where R1 resided prior to admission who would hold R1's apartment and belongings for thirty days before cleaning it out. Social work was to follow up with resident and speak about vacating the apartment. R1's psychology provider note dated 6/26/24, indicated R1's mood was depressed and anxious. The note included a Clinician's Rating of Severity, a scale to assess the importance of symptoms with regard to clinical need, regulatory systems, and risk management. The severity of R1's symptoms was rated five out of nine on a scale of one to nine (with one indicating little and nine indicating high severity). The note included, she [R1] reports boredom and states that she continues to have loneliness. R1's progress note by the MDS coordinator dated 6/26/24, indicated the writer spoke with R1 about a medical insurance appeals letter and R1 stated would like to start using her prosthesis (with build in shoe), however has a concern about not having a shoe available for the right foot to perform ambulation. Writer notified SS [social services], will notify the rest of the team via email. R1's PHQ-9 Long-Term Care assessment dated [DATE], identified R1 felt down, depressed, or hopeless on two to six days of the 14 day assessment period. R1's record did not specify and/or further assess which symptom (felt down, depressed, or hopeless) R1 had nor potential causes that made R1 feel down, depressed, or hopeless. R1's life enrichment progress note dated 8/30/24, indicated R1 had not attended activities with life enrichment but had accepted one to one visits and there are no concerns at this time. R1's monthly activities attendance calendars dated July through October 2024, noted completion of 11 total one-to-one visits between 6/1/24 and 10/28/24 as follows: - One one-to-one visit in June - Zero one-to-one visits in July - Four one-to-one visits in August - Three one-to-one visits in September - Three one-to-one visits in October R1's psychology provider note dated 9/4/24, indicated R1's mood was depressed and anxious with a Clinician's Rating of Severity symptom severity level of six out of nine. The note included, Time spent in session discussing interventions that she can do to improve her energy level and quality of life. Clinician provided supportive feedback and encouraged her to continue to spend time out of her room as this might be of benefit to her mood. R1's progress note by social services designee (SSD)-A dated 9/5/24, indicated a care conference was conducted with R1, nurse manager, and social worker. The note included resident reported, she doesn't have cloths [sic, clothes]. SW [social work] will look in laundry for donation clothes. R1's PHQ-9 Long-Term Care assessment dated [DATE], identified R1 felt down, depressed, or hopeless on two to six days of the 14 day assessment period. R1's record did not specify and/or further assess which symptom (felt down, depressed, or hopeless) R1 had nor potential causes that made R1 feel down, depressed, or hopeless. R1's psychology provider note dated 9/11/24, indicated R1's mood was depressed and anxious with a Clinician's Rating of Severity symptom severity level of six out of nine. The note included, [R1] states that she continues to have difficulty with a variety of mood concerns with a treatment recommendation/plan to continue current psychological treatment plan and interventions in place. R1's psychology provider note dated 10/2/24, indicated R1's mood was depressed and anxious with a Clinician's Rating of Severity symptom severity level of five out of nine. The note included [R1] states that she continues to feel a decline. She notes confusion, not able to recall things, and a loss of energy . She notes that she thinks that she is sleeping too much during the day. The treatment recommendation/plan was to continue current psychological treatment plan and interventions in place. R1's psychology provider note dated 10/16/24, indicated R1's mood was depressed and anxious with a Clinician's Rating of Severity symptom severity level of six out of nine. The note included, She [R1] reports her mood is 'okay,' and reports her sleep continues to be 'okay' at night. Her energy level presents as low today . She stated her belief is that she is 'getting worse' . Clinician provided supportive feedback and encouraged her to continue to spend time out of her room as this might be of benefit to her mood. The treatment recommendation/plan was to continue current psychological treatment plan and interventions in place. R1's progress notes reviewed between R1's admission date through 10/16/24 did not include identification of any further follow-up regarding her expressed concerns of lack of shoes and clothing. Additionally, even though the psychology provider noted on 6/26/24 identified R1 was lonely and bored, on 9/4/24 encouraged R1 to spend time out of her room, on 9/11/24 noted R1 had difficulty with a variety of mood concerns, on 10/2/24 indicated worsening mood symptoms noting R1 continued to feel a decline, had confusion, loss of energy, and sleeping too much. On 10/16/24 psychology note indicated worsening mood symptoms noting R1 believed she was getting worse. R1's record did include a comprehensive assessment that identified potential reasons why R1 was not coming out of her room and the psychosocial impact. Further it was not evident the facility addressed the psychology providers recommendation to encourage R1 to spend time out of her room. Refer to F679 for additional information. Vulnerable Adult Maltreatment Report dated 10/25/24, indicated the unidentified anonymous reporter (AR) visited R1 the week of 10/13/24. The reporter noted R1 stated she could not go to the dining room because she did not have any clothes and reported she did not have socks, shoes, or slacks. R1 had one to two shirts and typically wore hospital gowns. During an interview on 10/28/24 at 1:23 p.m., AR stated she had visited R1 and R1 indicated she didn't think she could go anywhere because she didn't have appropriate clothing. The AR stated R1 had two shirts the facility had given her, but didn't have socks, slacks, or shoes, and had a coat but it lacked a lining. The AR reported when she visited R1 she was wearing one of the shirts, an oversized button-up shirt over a hospital gown. AR stated the shirt was the same length on R1 as the hospital gown because R1 is super tiny, she is short and on R1 a large shirt would be like a dress. During an observation on 10/28/24 at 11:31 a.m., nursing assistant (NA)-A brought lunch to R1 in her room. R1 was sitting in bed wearing an oversized button-up shirt over a hospital gown with a yellow gripper sock on her right foot. R1 requested beverages from NA-A and provided her with a list, but NA-A did not ask R1 if she wanted to eat outside of her room or encourage her to come out. R1 made an expression of her interest in socializing and speaking with other people stating, It is my job to make a person giggle, but if they laugh that's even [NAME]. During an interview on 10/28/24 at 4:23 p.m., R1 was eating in bed in her room wearing an oversized button-up shirt over a hospital gown with a yellow gripper sock on her right foot. R1 stated she had no clothes and had no clothes because her landlord had thrown them away. She stated she was eating in her room because I can't think of any way of me getting out because I don't have a lot of clothes. I have nothing proper to wear in the lunchroom. R1 indicated the facility had donated some clothes to her, but they did not fit because she was short. R1 stated I would like to try eating in the dining room. During an observation on 10/29/24 at 12:16 p.m., R1 was eating in bed in her room wearing an oversized button-up shirt over a hospital gown with a yellow gripper sock on her right foot. During an interview on 10/29/24 at 12:38 p.m., licensed practical nurse (LPN)-A stated R1 did not go to activities and did not go to the dining room, she always said no, and this was also what staff had reported to her. LPN-A noted she wished all residents would eat in the dining room as it provided more socializing. LPN-A noted she had only seen R1 outside of her room in her wheelchair one time, for physical therapy. During an interview on 10/29/24 at 12:51 p.m., nursing assistant (NA)-A stated she assisted R1 with cares and would clean R1 up and change her hospital gown in the morning. NA-A noted R1 ate meals in her room. During an interview on 10/29/24 at 1:31 p.m., NA-C stated R1 never wanted to come out of her room. NA-C reported she had tried to come to R1 and say 'let's go somewhere together' to get her to come out of her room but when asked if she wants to come out R1 says I have no clothes. NA-C stated two or three weeks ago staff had told the director of nursing (DON) R1 needed clothes when the DON had asked staff if anybody needed clothes to be given out, discussed R1 and DON told the aides everybody should have clothes. NA-C reiterated that R1 never wants to come out and she just wants to stay in her room. During an observation and interview on 10/29/24 at 3:09 p.m., R1 was observed in her bed in her room wearing an oversized button-up shirt over a hospital gown and a yellow gripper sock on her right foot. R1 stated she had some clothing that the facility provided from lost and found, but it was very little, and she did not have any of her own clothing at the facility. R1 stated she had a yellow gripper foot cover, but did not have socks, shoes, or a bra and classified the hospital gown she was wearing as a night gown. R1 noted she needed shoes to be able to use her prosthetic because she needed a shoe for her right foot for balance, a shoe gives me stability and not having shoes has impacted my mobility. R1 indicated the facility had provided her with two shirts, one sweatshirt, and one pair of pants but the pants did not fit appropriately. R1 stated not having clothes makes me not want to go out It is keeping me from wanting to get up and get out . if I looked proper I would love to go out, but I don't want to go out in this, and I don't even know if they allow it. If I were dressed properly, I would enjoy getting out and about. I don't feel my attire is proper. R1 made an expression of hopelessness, stating she felt like she was missing out on things, but had learned to accept whatever there is. R1 recalled mentioning needing clothes to one or two staff members but did not recall who. R1 re-iterated that if I had clothing I was comfortable in, I think I would ask to go to the dining room and ask to go to activities. She believed someone from laundry brought the donated clothes to her room and had noticed clothes in her shared closet but was not sure who they belonged to because no one had spoken to her about them. R1 did not indicate she had any other winter weather clothing apart from one unlined coat. R1 stated she didn't know if she had a social worker, so did not know if they had discussed shoes or clothes with her. R1 showed the surveyor her clean folded clothing which she kept in a plastic bag at the foot of her bed along with other personal belongings. They included one additional button-up shirt, a sweatshirt, and a pair of pants that she indicated was not the correct size. During an interview on 10/29/24 at 3:29 p.m. with the director of social services (DSS) and SSD-A, SSD-A confirmed she wrote a progress note about R1 dated 9/5/24 regarding a care conference. SSD-A stated it was brought up to her that R1 needed clothes, she believed it was nursing staff who informed her, and she went to the laundry department who gave her some donated clothes from the lost and found. SSD-A stated R1 had arrived at the facility without clothing of her own and when she spoke to R1, R1 stated she had no clothing. SSD-A stated, they just gave her basic clothes for now, whatever they can find in the laundry and noted R1 did not have family to call for assistance and R1 was her own responsible party. SSD-A stated laundry provided her with some shirts and pants but she doesn't walk, she's amputated like her foot, so she doesn't need shoes. SSD-A was unable to articulate how she assessed what R1's specific needs were regarding clothing and shoes apart from I just asked her what she needed . I told her 'Oh, will shirts and pants be okay,' she said 'Yes,' so that's how I knew. During an interview on 10/29/24 at 3:29 p.m. with the DSS and SSD-A, the DSS stated if someone needed clothes you could offer a short-term fix like getting things from laundry, but long term we need to ask about finances and if a resident had money to get clothes or had family to assist with getting clothes. The DSS noted social services staff needed to ask R1 what specifically she needs and get her what she needs as soon as we can and find a long-term fix because donated clothes from laundry is a temporary fix, we need to find a long term fix. It is not okay for somebody to not have shoes. The DSS stated R1 should also have a hat, gloves, and a scarf for winter wear. The DSS noted residents needed clothing that meets their needs to feel comfortable, covered, and safe and this could affect mental health . it could affect your socialization, you're not comfortable. The DSS further stated not having adequate comfortable clothing could cause psychosocial harm and it is kind of degrading . like if I was in their shoes I wouldn't like to be walking in a hospital gown . and we don't even know her preferences. The DSS noted sometimes should have followed up and asked if she got the things she needed and if there was anything else she needed. The DSS confirmed R1's progress note dated 6/4/24 from life enrichment identified concerns about have a shoe available for her right foot to perform ambulation and a progress note dated 9/5/24 identified R1 didn't have clothes. The DSS was not sure what had happened after these concerns were noted. The DSS confirmed clothing, including shoes, socks, and bras were a basic need and one pair of pants was not sufficient as dirty clothes could be gone for days while processed by laundry. The DSS confirmed clothing and shoes are a medically related social service and is in our scope, because we help people get the services and things they need to be successful. The DSS confirmed clothing and shoes are important for attaining and maintaining mental and psychosocial health and sometimes your appearance can make you feel a certain type of way. The DSS identified a lack of clothing and shoes could affect a resident by not participating in therapy, self-isolating, I think we would see it across the board affect almost every aspect of their life . I don't know [R1] very well but if she feels like she can't leave her room because of it and she feels uncomfortable, that actually is a problem and is harmful . if I was in her shoes I would not want to be out. During an interview on 10/30/24 at 8:28 a.m., life enrichment aide (LEA)-B stated R1 had not participated in activities and a couple of the times that I talked to her she said it's because she doesn't have any clothes . as far as I know it seemed she wasn't comfortable going to activities in one of the nursing gowns. LEA-B noted being around others in the nursing gown she [R1] didn't feel comfortable. LEA-B stated she gotten R1's clothing sizes and left a note in the mailbox for laundry to find some clothes for her when she became aware of the concern but was not sure when that had occurred. LEA-B confirmed she had continued to see R1 wearing hospital gowns since then and didn't follow up further when she was still wearing them. During an interview on 10/30/24 at 9:32 a.m., R1 noted she loved to crochet and do crafts, but no one had ever offered to do crafts with her in her room. R1 noted she would like to play cards, but no one had ever offered to play games with her in her room and I play solitaire in bed by myself. She stated she may have said no when staff had invited her to attend group activities because she didn't have proper clothing. During an interview on 10/30/24 at 10:02 a.m., trained medication aide (TMA)-A stated R1 always stayed in her room, and she had only seen R1 outside of her room once when someone came to have a meeting with her. TMA-A was not aware of why R1 did not want to come out. During an interview on 10/30/24 at 10:12 a.m., LPN-A stated R1 preferred to stay in her room and would say 'nope' if asked to attend an activity or come to the dining room. LPN-A stated R1 was not very social and I told her you know you should talk to more people, people need to communicate . I would want to be around people. During an interview on 10/30/24 at 11:45 a.m., DON stated R1 doesn't come out of her room a whole lot and I was told she just isn't a very social person. The DON stated she was now aware it was noted in June that R1 had concerns about clothing and shoes, but staff had not told her at the time. The DON stated, adequate clothing and shoes is a basic need and the facility is responsible for meeting that need. The DON identified potential impacts of a lack of adequate clothing and shoes as an impact on dignity, not feeling so good about themselves, psychosocial impact and noted that for a resident with diagnoses of anxiety and depression the potential impact could be higher. The DON confirmed R1 had diagnoses of anxiety and depression. The DON stated if she did not have adequate clothing and shoes I wouldn't feel good about it, I would not be very happy if it was a family member of mine and noted a resident would not feel good about themselves . it may make them feel isolated if that was the reason why they didn't want to come out of their room was because of their clothing. The DON noted isolation could progressively lead to further anxiety and depression. The DON stated if R1 doesn't have shoes to wear her prosthetic and come out of her room it definitely would affect her mood, isolation and it affects her mobility. During an interview on 10/30/24 at 12:41 p.m., R1's primary care provider, nurse practitioner (NP)-A, stated she had never seen R1 outside of her room and assumed she did not eat in the dining room or attend activities. NP-A stated clothing and shoes are basic needs, and she recalled that R1 didn't have any belongings because R1 had mentioned that all her belongings were removed from her apartment. NP-A stated she thought she always saw R1 dressed in a hospital gown. NP-A stated, If the reason someone won't leave their room is because they don't have clothing, if she has stated I'm uncomfortable to leave my room because I don't have these things, I would say it is a priority to have those things. It would have an impact. NP-A noted it could have a negative psychosocial impact, possible increased depression, anxiety, dissatisfaction, it would impair self-esteem . not leave a room for meals or activities could even have a negative cognitive impact in a way because of the lack of stimulation. NP-A noted it could have caused harm and impacted well-being if R1 didn't have clothes and shoes and wasn't comfortable leaving her room because of that. NP-A stated she would feel restricted in the activities she participated in if she did not have adequate and comfortable clothing and stated I don't think the average person would be comfortable attending group activities or dining communally in a hospital gown . I wouldn't be. NP-A noted she was not previously aware of this concern. During a return phone call interview on 11/7/24 at 9:50 a.m., R1's psychology provider, licensed independent clinical social worker (LICSW)-A, confirmed she had been treating R1 over the course of her admission to the facility. LICSW-A stated R1's mood was kind of hit or miss and confirmed she presented as depressed and anxious. LICSW-A noted R1 was having a hard time adjusting to the facility and displayed symptoms including loneliness, boredom, increased confusion, decreased energy, and sleeping too much. LICSW-A noted R1's Clinician's Rating of Severity scores were a scale based on what staff and R1 told her and the clinician's impression. LICSW-A identified R1's scores ranging from five to seven as reflective of R1 not totally doing well. LICSW-A noted R1 was not able to self-soothe effectively and relied on staff to anticipate her needs. LICSW-A identified R1's treatment plan and interventions to include attending activities, talking to others and not bottling feelings up, reaching out to others, and taking medications as prescribed. LICSW-A stated she encouraged R1 to spend time outside of her room, her being around people, and not being alone and recommended this because if she is feeling loneliness or boredom having people around her and eating meals in the dining room, those kind of things might help her. LICSW-A stated the impact on R1 of being isolated and in her room would be a continued decline, more experiencing and expressing being lonely. Her roommate leaves to do things so then she is in her room alone. LICSW-A noted prior to R1's admission to the facility, she lived in a big apartment complex and a lot of people would sit outside or in the common areas and I think she used to do that. LICSW-A believed R1 used to socialize and drink alcohol and believed she missed doing this, though noted R1 was no longer drinking which was a good thing. LICSW-A noted R1 got along well with her roommate and talked to her, and R1 said she wanted to do activities. LICSW-A thought R1 was declining activities when asked by staff because she was usually tired and her energy was low. LICSW-A was unaware of R1's concerns regarding a lack of clothing and shoes and indicated R1 was always in her room when LICSW-A arrived. LICSW-A stated she thought social services staff should get R1 clothing and shoes, and noted the facility needed to work on this. LICWS-A stated if R1 felt she did not have adequate and proper clothing the impact would be R1 continuing to be symptomatic. LICSW-A noted if R1 said she lacked adequate and proper clothing to leave her room it could be harmful to her psychosocial well-being. LICSW-A stated R1 isolating, not socializing, and remaining in her room was harmful. Facility policy titled Quality of Life - Dignity and Privacy dated 12/19, included Procedures: 1.) Resident will be treated with dignity and respect at all times. a. Being 'treated with dignity' means the resident will be assisted in maintain and enhancing their self-esteem and self-worth . 3.) Residents will be assisted in attending the activities of their choice, including activities outside of the facility. Facility job description for Director of Social Services, undated, included Position Summary: . Developing care plans to meet the psychosocial well-being and needs of residents and to enable residents to achieve their optimal level of independence . Responsibilities and duties: . 3.) Provides support services for new residents and their families to facilitate initial adjustment to [facility]. Provide ongoing counseling and problem solving services to residents and family members . 5.) Assess resident's social, psychological, and emotional status and develops a plan of care that meets the residents' needs . 9.) Serves as an advocate for residents, interpreting and upholding the Minnesota [NAME] of Rights and the Vulnerable Adult Act.