**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure dignity was maintained during cares for 1 of 2 residents (R35) reviewed for dignity. Findings include: R35's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was dependent on staff for toileting and personal hygiene cares as well as mobility and transfers. The MDS identified R35's diagnoses of dementia and indicated she was unable to complete the mental status assessment interview. R35's care plan dated 2/5/25, identified impaired cognitive function or impaired thought processes related to dementia. Furthermore, the care plan indicated R35 had a communication problem related to finding the right words to say and directed staff to anticipate and meet R35's needs. Finally, the care plan identified activities of daily living (ADL) self-deficit related to dementia (a loss of memory, language, problem-solving and other thinking abilities) diagnosis and indicated R35 required staff assistance for dressing, personal hygiene, and toilet use. During continuous observation of evening cares on 2/26/25 between 5:56 p.m. and 6:26 p.m., nursing assistant (NA)-C and NA-D used a mechanical body lift to assist R35 into the bed at 5:58 p.m. and assisted to lay down. R35 began to call out, get out of here repetitively while NA-C pulled her pants down, removed her socks and unfastened the front tabs of her incontinence brief. NA-C told R35 they would be quick while they cleaned her up and NA-D held R35's hand and told her, It's okay. At 6:00 p.m., R35 was uncovered and exposed from the waist down and the NAs worked together to remove her top. NA-C turned her back towards NA-D and R35 and turned on the water at the sink and let the water run while R35 was completely nude and exposed on the bed. At 6:01 p.m., NA-C returned to the bedside. NA-D pulled R35's legs apart while she continued to call out, get out of here assholes. NA-C first washed her face, then they assisted R35 to turn onto her right side and began to wash her backside. NA-C stated, she's just going and she used cleansing wipes to clean feces from R35's buttocks. R35 continued to call out, get out of here. NA-C reported a new area to R35's buttock to the surveyor, calling the surveyor over to assess. NA-C changed soiled gloves and R35 remained nude, and her exposed backside faced the door. At 6:08 p.m., there was a knock at the door and registered nurse (RN)-C opened the door to R35's fully exposed buttocks. RN-C walked over to the bedside and draped the hospital gown over R35's neck, covering her front side and began to rub her back gently. RN-C stated this was done to promote her dignity and they wouldn't want their family members to be laying like that naked. RN-C expected staff to protect a resident's dignity during cares by covering them up with blankets or clothing when it would not impede cares. RN-C also stated it may help provide comfort since being naked might make the resident cold. During interview on 2/26/25 at 6:37 p.m., NA-C verified they had not provided for R35's dignity during cares. NA-C stated it was something they didn't think about and was grateful to be reminded especially for those residents who cannot speak for themselves. NA-C stated covering her also may have provided warmth, which could have promoted comfort during their cares. Per interview on 2/27/25 at 2:22 p.m., RN-D expected staff to only expose what needs to be exposed during cares. RN-D provided the example of covering the chest if perform peri-cares and keeping a resident's bottom covered if performing upper body cares. Per interview on 2/27/25 at 3:13 p.m., the director of nursing (DON) expected staff to try and maintain dignity to the highest level as possible during cares. The DON stated staff should shut the door, pull a privacy curtain if able, explain the task they are about to perform, and ask the resident how they could keep them comfortable. The DON stated staff should maintain privacy as much as they are able to in order to promote a resident's dignity. A policy pertaining to dignity was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure a self-administration of medications assessment was completed to allow residents to safely administer their own medications for 1 of 1 residents (R44) observed with medications at bedside. Findings include: R44's annual Minimum Data Set (MDS) dated [DATE], indicated he had intact cognition, was dependent on staff for personal hygiene and mobility, and required setup or clean-up assistance with eating. The MDS reported diagnoses of a stroke (when blood flow to a part of the brain is disrupted, causing a lack of oxygen and brain cell death), aphasia (a language disorder affecting a person's ability to communicate), dementia (loss of memory, language, problem-solving and other thinking abilities), and hemiplegia or hemiparesis (one-sided muscle weakness or paralysis). Additionally, the MDS identified he had a mechanically altered diet and did not exhibit signs or symptoms of a possible swallowing disorder. R44's order summary report dated 12/25/24, were reviewed on 2/24/25 and lacked documentation of an order for self-administration of medications. Additionally, his order summary report lacked an order for Tums, an antacid medication. R44's medication administration record (MAR) dated 2/2525, was reviewed on 2/24/25 and lacked documentation of an order for self-administration of medications as well as an order for Tums. R44's electronic health record (EHR) was reviewed on 2/24/25 at 9:19 a.m. and lacked documentation of an assessment to self-administer medications. During observation on 2/24/25 at 9:19 a.m., R44 was in bed with his bedside table over the bed, and on the bedside table was a bottle with the label Smoothies-flavored Tums. During observation on 2/25/25 at 10:05 a.m., the bottle of Tums remained unchanged on the bedside table. During observation on 2/27/25 at 10:02 a.m., the bottle of Tums remained unchanged on the bedside table. During interview on 2/27/25 at 10:08 a.m., registered nurse (RN)-C stated a resident wishing to administer their own medications should have an assessment for self-administration. RN-C stated the assessments were completed by nursing staff and then the provider would be updated. RN-C reviewed R44's EHR and confirmed he did not have a self-administration assessment or an order to self-administer medications. RN-C stated we did see it; we were asking our manager about the medications noted at his bedside table, and stated he has very high anxiety, he would get really upset about it if staff took the bottle away from him. RN-C walked into R44's room and confirmed there was a bottle of Tums on his bedside table and asked him where it came from. He responded, my family, and RN-C told him the bottle would not be removed right now but it would be discussed with the nurse manager. During interview on 2/27/25 at 10:16 a.m., licensed practical nurse (LPN)-B reviewed R44's physician orders and confirmed he did not have an order for Tums or a generic equivalent. LPN-B further verified he should have a self-administration assessment and order to have the Tums at his bedside and stated, I feel like he would be able to self-administer the Tums because of his pureed diet and the Tums being chewable or dissolvable. LPN-B stated, I will update the provider and the nurse manager. Per interview on 2/27/25 at 2:39 p.m., RN-D expected staff to complete a self-administration assessment first, then get an order from the provider with the okay to self-administer medications. RN-D also expected staff to remove medications from a resident's room the second someone noticed it. RN-D stated the risks could include possible medication contraindications or interactions, indications for use, safety implications and stated, we need to get the provider involved to make that decision. Per interview on 2/27/25 at 3:34 p.m., the director of nursing (DON) expected staff complete a self-administration assessment and obtain a provider order. The DON stated if a family member brought in a medication from home, staff should question why there was a need for that medication and get the provider involved. The DON indicated the risks included polypharmacy and interactions with other medications. Per facility policy titled Self Administration of Medications (SAM) revised 9/24, a self-administration of medications assessment would be completed for any resident requesting to administer any medication without the direct supervision of a nurse and the interdisciplinary team would review the recommendation to determine if the resident was safe to do so. The resident's physician would need to write an order for the resident to self-administer medications and only the medications permitted for self-administration would be left at the bedside. The resident's care plan should be updated to reflect self-administration of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure an allegation of potential harm was reported to the State Agency (SA) in the required timeframe for 1 of 1 residents (R23) reviewed for anaphylactic reaction. Findings include: R23's admission Minimum Data Set (MDS) dated [DATE], indicated R23 was cognitively intact and required setup assistance for eating. R23's diagnoses included acute ischemia of small intestine (decrease in blood flow), type 2 diabetes, and [NAME]-[NAME] syndrome [a condition affecting appetite and causing one to always feel hungry). R23's diet order/dietary communication dated 11/29/24, indicated food allergies, ginger, bee pollen. R23's allergy list printed 2/25/25, indicated the following food allergens: ginger, bee pollen/royal jelly. R23's physician order history indicated the following: -Epinephrine injection solution auto-injector 0.3mg/0.3ml. Inject 0.3 mg intramuscularly as needed for anaphylaxis, allergy to ginger, daily - start date 11/29/24 at 5:00 p.m. -11/29/24 at 9:29 p.m. on hold, insurance does not cover. -12/18/24 at 3:19 p.m. resume, ordered per provider. -Date received-12/23/24, on hand. During interview on 2/24/25 at 11:51 a.m., R23 stated a few months ago she was provided a meal consisting of a piece of chicken and stir fry vegetables. R23 stated her meal ticket did not indicate chicken; therefore, did not know what type of chicken was provided. R23 asked several unidentified staff members if the food items contained ginger, and all said no. After a couple bites, R23 stated she thought she bit into a piece of ginger and within a few seconds her lips started tingling and she felt her throat beginning to tighten. R23 notified staff she was having anaphylactic reaction and requested epinephrine. R23 was told her epinephrine order was on hold due to insurance not covering it and staff did not have epinephrine in the emergency medication kit (e-kit). Review of facility week 2 menu for Saturday was Honey Ginger chicken thighs and Asian Stir fry vegetable mix. R23's progress note dated 12/14/24 at 10:56 p.m., indicated R23 reported to staff of having a food allergy after eating part of her dinner and on assessment discovered R23 having a stick [sic] throat, and does not feel well. R23 started having shortness of breath and was put on oxygen at 4 liters/min. Resident had an order for epinephrine but it was on hold and the medication was not available. Staff called 911 and resident was sent to the hospital. R23's progress noted dated 12/14/24 at 11:05 p.m., indicated, This writer re email [sic] resident diet order to kitchen because one of the dietary stated that they don't have the food allergy in their file. R23's emergency department after visit summary (AVS) dated 12/14/24, indicated, Reason for Visit ALLERGIC REACTION Diagnoses -Shortness of breath - Anaphylaxis, initial encounter. The AVS instructed, You were seen today for an allergic reaction. Your symptoms improved after an epi pen. Return to the emergency department with any new or worsening symptoms. Review of facility risk management lacked evidence facility completed an investigation or safety incident report for R23's anaphylactic reaction event. During interview on 2/27/25 at 2:29 p/m., director of nursing stated expectation for staff to initiate a safety event or risk management entry, both process include the required report of the event to the administrator and DON regardless of date, time or shift. DON stated either herself or the administrator would then file a report with the SA and initiate an investigation. DON confirmed that this did not happen following R23's anaphylactic reaction. During interview on 2/27/25 at 3:13 p.m., administrator stated expectation of any adverse event would be reported via a group text which included herself, the DON, unit managers and the manager on call. Administrator stated either herself or DON would submit a report to the SA and initiate an investigation. Administrator confirmed that the event involving R23's anaphylactic reaction that occurred on 12/14/24, was not reported to the SA until 2/26/25. Facility policy Incident/Accident Reports dated 1/24, indicated, When the incident/accident involves a resident, nursing is responsible for notation in the medical record Risk Management and progress note describing the incident /accident, as well as, prompt follow-up action, intervention and notification of family and physician. The policy further indicated, DON or designee would review and ensure documentation was complete and when appropriate ensure incidents were reported in accordance with state and federal law. Facility policy Vulnerable Adult-Abuse Prohibition Plan dated 10/24, indicated all incidents involving abuse, neglect, exploitation or mistreatment would be reported immediately to the SA. The policy defined neglect as the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy further indicated, All incidents requiring medical intervention or follow-up are documented in the resident record and DON, Administrator or other designee would immediately institute an internal investigation of the reported allegation or incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to investigate an incident of anaphylactice reaction and need for emergency services for 1 of 1 residents (R23) reviewed for anaphylactic reaction. Findings include: R23's admission Minimum Data Set (MDS) dated [DATE], indicated R23 was cognitively intact and required setup assistance for eating. R23's diagnoses included acute ischemia of small intestine (decrease in blood flow), type 2 diabetes, and [NAME]-[NAME] syndrome [a condition affecting appetite and causing one to always feel hungry). R23's diet order/dietary communication dated 11/29/24, indicated food allergies, ginger, bee pollen. R23's allergy list printed 2/25/25, indicated the following food allergens: ginger, bee pollen/royal jelly. R23's physician order history indicated the following: -Epinephrine injection solution auto-injector 0.3mg/0.3ml. Inject 0.3 mg intramuscularly as needed for anaphylaxis, allergy to ginger, daily - start date 11/29/24 at 5:00 p.m. -11/29/24 at 9:29 p.m. on hold, insurance does not cover. -12/18/24 at 3:19 p.m. resume, ordered per provider. -Date received-12/23/24, on hand. During interview on 2/24/25 at 11:51 a.m., R23 stated a few months ago she was provided a meal consisting of a piece of chicken and stir fry vegetables. R23 stated her meal ticket did not indicate chicken; therefore, did not know what type of chicken was provided. R23 asked several unidentified staff members if the food items contained ginger, and all said no. After a couple bites, R23 stated she thought she bit into a piece of ginger and within a few seconds her lips started tingling and she felt her throat beginning to tighten. R23 notified staff she was having anaphylactic reaction and requested epinephrine. R23 was told her epinephrine order was on hold due to insurance not covering it and staff did not have epinephrine in the emergency medication kit (e-kit). Review of facility week 2 menu for Saturday was Honey Ginger chicken thighs and Asian Stir fry vegetable mix. R23's progress note dated 12/14/24 at 10:56 p.m., indicated R23 reported to staff of having a food allergy after eating part of her dinner and on assessment discovered R23 having a stick [sic] throat, and does not feel well. R23 started having shortness of breath and was put on oxygen at 4 liters/min. Resident had an order for epinephrine but it was on hold and the medication was not available. Staff called 911 and resident was sent to the hospital. R23's progress noted dated 12/14/24 at 11:05 p.m., indicated, This writer re email [sic] resident diet order to kitchen because one of the dietary stated that they don't have the food allergy in their file. R23's emergency department after visit summary (AVS) dated 12/14/24, indicated, Reason for Visit ALLERGIC REACTION Diagnoses -Shortness of breath - Anaphylaxis, initial encounter. The AVS instructed, You were seen today for an allergic reaction. Your symptoms improved after an epi pen. Return to the emergency department with any new or worsening symptoms. Review of facility risk management lacked evidence facility completed an investigation or safety incident report for R23's anaphylactic reaction event. During interview on 2/27/25 at 2:29 p/m., director of nursing stated expectation for staff to initiate a safety event or risk management entry, both process include the required report of the event to the administrator and DON regardless of date, time or shift. DON stated either herself or the administrator would then file a report with the SA and initiate an investigation. DON confirmed that this did not happen following R23's anaphylactic reaction. During interview on 2/27/25 at 3:13 p.m., administrator stated expectation of any adverse event would be reported via a group text which included herself, the DON, unit managers and the manager on call. Administrator stated either herself or DON would submit a report to the SA and initiate an investigation. Administrator confirmed that the event involving R23's anaphylactic reaction that occurred on 12/14/24, was not reported to the SA until 2/26/25. Facility policy Incident/Accident Reports dated 1/24, indicated, When the incident/accident involves a resident, nursing is responsible for notation in the medical record Risk Management and progress note describing the incident /accident, as well as, prompt follow-up action, intervention and notification of family and physician. The policy further indicated, DON or designee would review and ensure documentation was complete and when appropriate ensure incidents were reported in accordance with state and federal law. The policy further indicated, Designated staff member [designated by the administrator or DON] will initiate an internal investigation as needed to determine the root cause of the incident. Facility policy Vulnerable Adult-Abuse Prohibition Plan dated 10/24, indicated all incidents involving abuse, neglect, exploitation or mistreatment would be reported immediately to the SA. The policy defined neglect as the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy further indicated, All incidents requiring medical intervention or follow-up are documented in the resident record and DON, Administrator or other designee would immediately institute an internal investigation of the reported allegation or incident. The policy indictated the investigation may include but not limited to the following: -Interviews and written statements with staff and any witnesses -Resident and resident representative interviews -Care observations -Environmental review -Resident health status and medical record review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to notify the physician of a change in condition for 1 of 1 resident with congestive heart failure (CHF) and a significant weight gain. The facility further failed to ensure appropriate wound care orders were followed for 1 of 1 resident (R35) reviewed for wound care. Findings include: R40 R40's discharge Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of CHF, acute and chronic respiratory failure with hypoxia, acute kidney disease, and fluid overload. It further indicated R40 required partial/moderate assistance with most activities of daily living (ADL) and mobility. R40's physician's orders dated 1/20/2025, indicated daily weights and to update the provider of a weight gain of 2 pounds (lbs.) in one day and/or 5 lbs. in one week, every shift. R40's care plan dated 1/3/25, indicated R40 had CHF, peripheral heart disease (PAD), and hyperlipidemia (HLD). Check breath sounds and monitor/document for labored breathing. Monitor/document for the use of accessory muscles while breathing. Notify provider of abnormalities. It further indicated the following interventions: -Daily weights, call medical doctor (MD)/nurse practioner (NP) for weight gain of more than 2 pounds per day and/or 5 pounds per week. -Encourage adequate nutrition. Offer small frequent feedings. -Give cardiac medications as ordered. -Monitor lab work; potassium (K+), sodium (NA), blood urea nitrogen (BUN), and creatinine. -Monitor/document sleeping pattern. Inform physician of any insomnia or anxiety. Give sedatives as ordered. Monitor/document/report (as needed) any signs or symptoms of CHF: dependent edema of legs and feet, periorbital edema, shortness of breath (SOB) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rate (tachycardia) lethargy and disorientation. Report to provider as indicated. R40's treatment administration record (TAR) for January and February of 2025 indicated, during the week of 1/20/25-1/26/25 R40 had a weight gain of 11.4 lbs., from 1/25/25-1/26/25 a weight gain of 8.8 lbs., and from 2/6/25-2/27/25 a weight gain of 13 lbs. as evidenced by the weights below: -1/20/25 443.4 lbs. -1/24/25 443.8 lbs. -1/25/25 446.0 lbs. -1/26/25 454.8 lbs. -1/27/25 445.6 lbs. -2/6/25 433.0 lbs. -2/7/25 446.0 lbs. -2/10/25 442.0 lbs. -2/11/25 448.0 lbs. R40's progress notes for the month of January and February of 2025, lacked any indication the doctor had been notified of a change in condition regarding weight gain During interview on 2/26/25 at 4:40 p.m., RN-F verified R40's weights on her January and February TAR were more than 2 lbs. in one day and 5 lbs. in one week (as referenced above) and stated the physician should have been notified and documentation should have occurred. During interview on 2/26/25 at 4:46 p.m., RN-G verified R40's weight gain of more than 2 lbs. in one day and 5 lbs. in one week (as referenced above ) and stated the nurses were responsible for calling the provider and documenting in the progress notes. RN-G further stated if a resident needed to be re-weighed, they should document it in the progress notes. During interview on 2/27/25 at 9:45 a.m. the nurse practioner (NP) stated the only time she had been notified of R40's weight gain was when she sent her to the hospital for hypervolemia on 2/12/25. The NP further stated she was in the facility 4 days per week and reviewed the weights of the patients she planned to see that day. She didn't see every resident every time she was there, therefore the order indicated to notify the physician and that's what the nursing staff were expected to do. The nurses were responsible for re-weighing a resident if there was an issue with the weight. The NP also verified the order was intended to be for a 7 day period typically from Monday to Sunday. During interview on 2/27/25 at 12:45 p.m. the director of nursing (DON) stated the nurses were responsible for notifying the provider of a change in condition and the provider should have been notified regarding R40's weight gain. This was important because R40 had CHF and was at risk for fluid overload which could have negative effects on her cardiac health. The facility's policy regarding weight and height dated 10/2021, indicated to document resident weight in PCC and update the provider of weight increases or decreases as needed and per physician's orders. R35 R35's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was dependent on staff for toileting and personal hygiene cares as well as mobility and transfers. The MDS identified R35's diagnoses of dementia (a loss of memory, language, problem-solving and other thinking abilities) and indicated she was unable to complete the mental status assessment interview. Additionally, the MDS identified she was at risk for developing a pressure injury and had moisture-associated skin damage (MASD, or skin irritation or breakdown caused by prolonged exposure to moisture such as urine, saliva, sweat, or wound drainage). R35's Care Area Assessment (CAA) for pressure ulcer/injury dated 10/31/24, identified her MASD to left gluteal fold with treatment. The CAA directed staff to the care plan for goals and interventions. R35's care plan revised on 2/5/25, identified her impaired skin integrity and risk for further breakdown as evidenced by MSAD to her buttocks. The care plan directed staff to provide treatment and wound care as ordered. R35's signed order summary dated 1/6/25, included the wound order: - wound care 1. Facility staff to perform every other day and as needed 2. Cleanse open areas to buttocks and upper thigh. Allow to dry. Apply Mepilex over open areas every day shift every other day for MASD, dated 12/17/24. R35's TAR dated 2/25, reflected the following wound care orders: - wound care to buttocks: cleanse open areas with wound cleanser. Pat dry. Cover with Mepilex dressing, change every evening shift every other day for MASD, dated 2/26/25 at 7:08 p.m. - wound care for left heel: cleanse with wound cleanser. Pat dry. Apply Medihoney and cover with Mepilex dressing. Change daily and PRN (as needed) every evening shift, dated 1/23/25. During observation on 2/26/25 at 6:14 p.m., registered nurse (RN)-C and RN-D were at R35's bedside during evening cares. RN-D stood at the head of the bed and talked to R35 while RN-C performed wound cares. RN-C sprayed a wound cleanser over R35's buttocks to cleanse the area before patting it dry with gauze. RN-C applied a dark, honey-colored gel from a tube to her gloved fingertips and dabbed it onto each of the opened and red areas on her buttocks, and then applied more from the tube to her fingertips and dabbed it onto the fluid-filled sacs on R35's buttocks. RN-C then applied foam dressings to cover the areas and dated each dressing. During interview on 2/26/25 at 6:42 p.m., RN-C reviewed R35's wound care orders and TAR dated 2/25 and was unable to find current or active wound treatment orders for her. RN-C verified the wound treatment orders for R35's pressure ulcer to her left heel, which included Medihoney, and confirmed applying it to R35's buttock during wound cares. During interview on 2/27/25 at 2:26 p.m., RN-D verified the MSAD treatment order should have been cleanse with a wound cleanser, pat dry with gauze and cover with a Mepilex. RN-D confirmed witnessing RN-C applying the Medihoney to R35's MSAD on her buttocks and stated, I thought I saw RN-C doing that. RN-D expected staff to verify and double check orders before applying treatments if staff were unsure. Per interview on 2/27/25 at 3:13 p.m. with the director of nursing (DON), staff were expected to review treatment orders if they were unsure of an order before administering the treatment or order. Per facility policy titled Management of Skin Alterations dated 9/11/24, residents with wounds would have at minimum weekly monitoring for appropriateness of treatment/care plan, signs of healing and would report to the provider as needed. Education would be provided to staff as needed on alterations in skin integrity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure adaptive equipment was used for 1 of 1 residents reviewed for adaptive equipment. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 had cognitive impairment and diagnoses of dementia, stroke, and dysphasia (difficulties swallowing). R9 had was dependent for eating, had difficulty swallowing and required a mechanically altered diet. R9's nutritional assessment dated [DATE], indicated R9 required varying level of assistance with meals and required a nosey cup for drink. R9's [NAME] printed 2/25/25, indicated R9 required honey thick liquids and adaptive equipment of a nosey cup. (cup that assists resident with drinking fluids) R9's care plan revised 12/13/24, indicated R9 had severe nutrition deficit related to demean, dysphasia and history of weight loss. Interventions included honey thick liquids and use of nosey cup. R9's meal tickets dated 2/24/25 and 2/26/25, directed staff to provide a nosey cup with meals. An observation on 2/24/25 at 11:47 a.m., lunch started to be served. R9's tray had three cups of juice, however did not have a nosey cup. Nursing assistant (NA)-B placed R9's tray in front of him and set it up before delivering other resident trays. R9 was able feed self with spoon a few bites of pureed diet. R9 reached for cup, but did not pick up. After delivering trays, NA-B sat down and assisted R9 with lunch. NA-B assisted with the juice and NA-B had not obtained a nosey cup. R9 was not able to tip head back to drink all the juice and NA-B poured juices together. When interviewed on 2/24/25 at 12:24 p.m., NA-B stated R9 was dependent with eating and was not able to do eat or drink on their own. NA-B verified R9's meal ticket indicated R9 required a nosey cup however R9 liked to hold the normal cup and sometimes refused it. The cup would be sent up from the kitchen and NA-B stated there were not any on the unit. When interviewed on 2/24/25 at 12:24 p.m., dietary aide (DA)-A verified if adaptive equipment was listed on the ticket, the kitchen would send it up on the tray. When observed on 2/26/25 at 12:16 p.m., NA-E assisted R9 with lunch. R9's tray did not have a nosey cup. When interviewed on 2/26/25 at 12:30 p.m., NA-E verified R9's meal ticket indicated R9 required a nosey cup, however, did not use one during lunch. NA-E stated the cups do not always come on the trays from the kitchen. When the cup was not available, NA-E would see how R9 was doing with drinking out of a normal cup and if there was not a lot of coughing, then the normal cup would be used. If R9 wasn't doing well with the normal cup, then the kitchen would be notified to bring a nosey cup. When interviewed on 2/27/25 at 8:30 a.m., kitchen manager (KM)-B expected adaptive equipment that was included on the meal ticket to be sent with the residents tray. KM-B further stated if it was not, nursing staff should reach out. When interviewed on 2/27/25 at 10:55 a.m., registered nurse (RN)-D stated if adaptive equipment was needed, it should be available and used. RN-D stated the nosey cup was needed to assist with fluid intake and make it easier to swallow. When interviewed on 2/27/25 at 11:55 a.m., the Director of Nursing (DON) expected resident adaptive equipment to be provided by the dietary staff. If the equipment was not provided, nursing staff should reach out to the kitchen to obtain what was needed. A facility policy titled Adaptive Equipment effective 4/5/23, directed staff to assure all residents were assessed and provided the special equipment necessary for them to reach their highest level of functioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure hand hygiene was completed during incontinent cares for 2 of 4 residents (R31 and R9) who were observed for cares. Furthermore, the facility failed to ensure urine was cleaned in a manner to prevent infection for 1 of 1 residents (R31) reviewed for clean environment. Findings include: R31 R31's quarterly Minimum Data Set (MDS) dated [DATE], indicated R31 had cognitive impairment and diagnoses of dementia and heart failure. R31's care plan revised 11/27/24, indicated R31 was had bladder incontinence and tended to void in available garbage cans or receptacles. R31 requires assist of one staff to find the bathroom and assist with incontinent cares. Furthermore R31's care plan indicated R31 would urinate in inappropriate places. An observation on 2/25/25, at 7:07 a.m., R31's door was open with the commode moved away from the wall and placed in front of the R31's door. R31 was laying in bed and then started getting up from bed. R31 walked to the bathroom doorway, stood there for a moment before returning to bed. At 7:33 a.m., nursing assistant (NA)-B entered the room and asked R31 if wanted to go down for breakfast. R31 declined. NA-B then took the commode bucket out of the commode and went into the bathroom and rinsed it out. NA-B then took the commode bucket, now filled with soap and water and poured the soapy water onto R31's floor. NA-B placed the commode bucket back into the commode and then took towels and using their feet, wiped up the soapy water from the floor. A disposable pad and towel were placed on the floor and NA-B then put the commode on top of them. At 7:42 a.m., writer entered the room as R31 was now getting out of bed. Without glove exchange or hand hygiene, NA-B assisted R31 by the arm to the bathroom to urinate NA-B stated the floor may be wet as R31 goes all over the place. After R31 urinated, NA-B obtained a wipe and wiped the toilet seat as R31 walked back to the room. NA-B moved clean towels from the sink in R31's room to his bed and asked R31 to come to the sink. Still without removing gloves or performing hand hygiene, NA-B took R31's toothbrush, added toothpaste and prompted R31 to brush their teeth. When R31 was done, NA-B took the toothbrush and rinsed it off in the sink, using a gloved thumb to rub the bristles. NA-B prompted R31 to wash their hands while NA-B took some clean towels from the bed and placed them back onto the sink. Without hand hygiene or glove exchange, NA-B placed body soap on the towel and got it wet. Assisted resident to wash face. NA-B placed towel in garbage bag. NA-B then lowered R31's soiled pants and took a clean towel placed soap on it and got it wet. NA-B cleaned R31's front groin side and with the same towel wiped down R31's legs to the knees before coming back up to wipe the backside. The wet towel was placed in the garbage bag before NA-B opened a drawer to obtain a dry towel and dried off R31. R31 sat down on the bed. Without hand hygiene or glove exchange, NA-B went to R31's closet and obtained clean clothing. NA-B assisted R31 with a clean sweatshirt and clean pants. R31 put on shoes and NA-B prompted R31 to walk down for breakfast. NA-B finished up with collecting the dirty linens and clothes before removing gloves and performing hand hygiene. When interviewed on 2/25/25 at 8:05 a.m., NA-B verified hand hygiene and glove exchange was not completed after handling soiled towels and the commode bucket and before working with R31. NA-B further acknowledged hand hygiene and glove exchange was not completed in between cleaning soiled areas and working with clean areas. NA-B explained R31 would just get up an urinate anywhere in the room. NA-B used the soapy water from the commode bucket to help keep the smell of urine out of the room. NA-B verified the soap used in the water was a Dial men's 3 in 1 soap. When interviewed on 2/25/25 at 2:02 p.m., universal services staff (USS) stated all resident rooms were cleaned daily. USS stated they just started at one end to the next end. USS stated staff had not informed them of any room needing cleaning due to urine being spilled. USS stated they had not cleaned R31's room yet and left that one for last. USS said R31 urinates on the floor often so that room was saved for last as rooms were completed only once a day. When interviewed on 2/27/25 at 8:33 a.m., universal services manager stated nursing staff should clean up any bodily fluids and then environmental staff should be notified to sanitize the floor. It was expected the USS would clean the floor right away and after each occurrence. Furthermore, body soap would not properly disinfect the floor and would not be used and should not be dumped from a commode bucket. R9 R9's quarterly MDS dated [DATE], indicated R9 had cognitive impairment and diagnoses of dementia, stroke, and dysphagia (difficulties swallowing). Furthermore, R9 was dependent on staff for toileting and bed mobility. R9's care plan revised 12/19/24, indicated R9 was incontinent of bowel and bladder and dependent on staff for toileting. An observation on 2/26/25 at 3:45 p.m., nursing assistant (NA)-E and NA- B assisted R9 back to bed with a lift. R9's was assisted with turning back and forth in bed to remove sling and pull down pants to change brief. NA-A tucked in the left side of brief and then turned R9 to the right. R9 has a small bowel movement. NA-E used a wipe to clean R9 and removed the soiled brief. NA-E then placed the soiled brief on the floor. NA-E then looked at their gloves and took an incontinent wipe and wiped their soiled gloved hands. Without hand hygiene or glove exchange, NA-E assisted with placing R9's clean brief. NA-E and NA-A then assisted with R9's pants. NA-E lowered R9's bed and placed the call light within reach. NA-E moved R9's wheelchair and then picked up R9's soiled brief from the floor and placed in the garbage. NA-E doffed the gloves, tied up the garbage and took to the soiled utility room where hand hygiene was then completed. When interviewed on 2/26/25 at 1:00 p.m., NA-E verified she had not performed hand hygiene or changed gloves after handling R9's soiled brief. NA-E stated since R9's brief was only a little dirty, glove change was not needed. NA-E further verified the soiled brief should not have been on the floor and should have been placed in the garbage right away. When interviewed on 2/27/25 at 10:00 a.m., the infection preventionist (IP) stated hand hygiene and glove exchange was required after handling soiled or potentially dirty items and moving to clean areas during resident cares. IP further stated nursing staff were responsible to clean up any bodily fluids that were on the floor and notify the universal workers to come disinfect the floor. The floors can be cleaned as often as needed. When interviewed on 2/27/25 at 11:49 a.m., the Director of Nursing (DON) expected staff to change gloves and perform hand hygiene when moving from soiled cares to clean cares. Dirty briefs should not be placed on the floor and should be placed in the garbage right away. DON further expected staff to clean up any bodily fluids from the floors and then seek out environmental services to clean or disinfect the floor. All of these were important to prevent infection. A facility policy titled Environmental Cleaning revised 3/2024, was received and did not outline cleaning procedures for bodily fluids. A facility policy for hand hygiene was requested however not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure 4 of 4 residents (R15, R33, R54, R110) were offered and/or provided updated vaccinations for pneumococcal disease and 2 of 5 residents (R33, R110) for influenza in accordance with the Centers for Disease Control (CDC) vaccinations. Findings include: R15 R15's discharge Minimum Data Set (MDS) dated [DATE], indicated R15 was admitted on [DATE], was currently [AGE] years old, had intact cognition and diagnosis of diabetes which puts him at higher risk for pneumococcal diseases. R15's Minnesota Immunization report dated 2/7/25, indicated R15 received the pneumococcal polysaccharide vaccine (PPSV23) on 7/17/12 and the pneumococcal conjugate vaccine (PCV13) on 4/26/19. The CDC's PneumoRecs VaxAdvisor for Vaccine Providers dated 2/26/25, identified based on R15's age and vaccine history: Give one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. Regardless of which vaccine is used (PCV20 or PCV21), their pneumococcal vaccinations are complete. R15's medical record lacked documentation of a discussion of shared clinical decision making regarding additional pneumococcal vaccines. It further lacked a declination or documentation of risk and benefits regarding the pneumococcal vaccination. R33 R33's admission Minimum Data Set (MDS) dated [DATE], indicated R33 was admitted on [DATE], was currently [AGE] years old, had intact cognition and diagnosis of diabetes which puts her at higher risk for pneumococcal diseases. It further indicated her pneumococcal vaccinations were up to date. R33's Minnesota Immunization report dated 1/10/25, indicated R33 received the pneumococcal polysaccharide vaccine (PPSV23) on 10/10/19 and the pneumococcal conjugate vaccine (PCV13) on 11/211/16. It further indicated R33's most recent influenza vaccination was administered on 10/1/2020. The CDC's PneumoRecs VaxAdvisor for Vaccine Providers dated 2/26/25, identified based on R33's age and vaccine history: though the vaccines were considered complete, based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. Regardless of whether PCV20 or 21 is administered, their pneumococcal vaccinations are complete. R33's medical record lacked documentation of a discussion of shared clinical decision making regarding additional pneumococcal vaccines. It further lacked a declination or documentation of risk and benefits regarding the pneumococcal and/or influenza vaccination. R54 R54's quarterly Minimum Data Set (MDS) dated [DATE], indicated R54 was admitted on [DATE], was currently [AGE] years old, had intact cognition and diagnosis of intracerebral hemorrhage (brain bleed). R54's Minnesota Immunization report dated 11/20/24, indicated R54 received the pneumococcal polysaccharide vaccine (PPSV23) on 9/19/19 and the pneumococcal conjugate vaccine (PCV13) on 10/28/15. The CDC's PneumoRecs VaxAdvisor for Vaccine Providers dated 2/26/25, identified based on R54's age and vaccine history: though the vaccines were considered complete, based on shared or clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. Regardless of whether PCV20 or PCV21 was administered, their pneumococcal vaccinations are complete. R54's medical record lacked documentation of a discussion of shared clinical decision making regarding additional pneumococcal vaccines. It further lacked a declination or documentation of risk and benefits regarding the pneumococcal vaccination. R110 R110's discharge Minimum Data Set (MDS) dated [DATE], indicated R15 was admitted on [DATE], was currently [AGE] years old, had moderately impaired cognition and of diagnosis of hepatic encephalopathy and alcoholic cirrohosis of the liver (with ascites). It further indicated his pneumococcal vaccinations were up to date. R110's Minnesota Immunization report dated 2/20/25, indicated R110 received the pneumococcal conjugate vaccine (PCV13) on 4/30/1997. It further indicated R110's last influenza vaccine was administered on 4/30/1956. The CDC's PneumoRecs VaxAdvisor for Vaccine Providers dated 2/26/25, identified based on R110's age and vaccine history: Give one dose of PCV15, PCV20 or PCV21. If PCV20 or PCV21 is used, their pneumococcal vaccinations are complete. If PCV15 is used, follow with one dose of PPSV23 to complete their pneumococcal vaccinations. The recommended interval between PCV15 and PPSV23 is at least 1 year. The minimum interval is 8 weeks and can be considered in adults with immunocompromising conditions, cochlear implants, or cerebrospinal fluid leaks. R110's medical record lacked documentation of a discussion of shared clinical decision making regarding additional pneumococcal vaccines. It further lacked a declination or documentation of risk and benefits regarding the pneumococcal and/or influenza vaccination. During interview on 2/27/25 at 10:00 a.m. the infection preventionist (IP) stated the process regarding vaccinations for new admissions was to print of their Minnesota Immunization Information Connection report (MIIC) in order to determine what vaccinations the resident had already received and which ones they needed. Then the facility would ask the resident if they are interested in receiving those vaccines and give them a Vaccine Information Sheet (VIS), and request a physician's order. If the resident refused, they sign a declination form, were educated on the risk versus (vs) benefits, and it was documented in their medical record. The facility offered COVID, influenza, RSV, and pneumococcal vaccinations. The IP verified R15, R33, R54, R110 lacked documentation of vaccines being offered, refused, or educated on risk vs. benefits and was still following up on those residents. The nursing staff try to offer the residents vaccinations in the first day or two following admission. The IP also stated influenza vaccinations are offered from October 1st-March 31st each year. During interview on 2/27/25 at 12:49 p.m., the director of nursing (DON) stated when there was a new admission, the nursing staff were responsible for putting in an order set which would populate the vaccinations and schedule a Tuberculin blood test at the lab. Then the results would be documented. The nursing staff and IP were responsible for following up and ensuring the residents were offered and/or received the vaccinations. Documentation for refusals was not put in Point Click Care (computer program) it was tracked internally. The facility's policy regarding influenza (11/7/24) and pneumococcal vaccinations (11/5/24) indicated, all patients including those admitted during the influenza season, will be offered an influenza immunization, September 1st through March 31st annually, unless the immunization is medically contraindicated, or the resident had already been immunized during this time period. All residents or resident representative will receive information regarding the benefits and potential side effects of immunization prior to a vaccine being offered. In the case of a refusal, staff will discuss the risk and benefits of the influenza vaccine and return later to re-offer, preferably having another nurse offer, and if the resident refuses, document the refusal in the medical record. In regards to the pneumococcal vaccination the policy indicated all residents are encouraged to receive a pneumococcal vaccine as defined by the Minnesota Department of Health or CDC unless medically contraindicated, refused, or already immunized or due to circumstances outside the facility's control. The resident will be give the opportunity to refuse the vaccine and refusals will be documented in the medical record. All residents or legal representatives will receive information regarding the benefits and potential side effects of the immunization prior to a vaccine being offered. In the case of a refusal, the staff will discuss risks and benefits of the pneumococcal vaccine, return later to re-offer (preferably having another nurse offer), if the resident refuses, it will then be documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to determine causal factors and develop new interventions to prevent falls for 1 of 1 residents (R1) reviewed for falls who had a history of falls and slid out of wheelchair while transporting to appointment. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had dementia, schizophrenia and moderate cognitive impairment. R1's MDS further indicated she used a wheelchair for mobility and could not ambulate. R1's care plan dated 7/18/24, indicated R1 was at risk for falls related to deconditioning, balance problems, incontinence, psychoactive drug use and history of falls. R1's care plan directed staff to anticipate needs, give resident verbal reminders not to transfer without assistance and offer to lie down when observed restless in wheelchair. R1's Fall assessment dated [DATE], indicated R1 had intermittent confusion, chair bound, required assistive device and scored a fall risk of 13 (moderate risk for falls). A fall Interdisciplinary Note (IDT) note dated 5/28/24, indicated resident found lying on the floor, right side wheelchair nearby, shoes on. Resident stated she was trying to get back into bed. No injuries observed, impaired memory, confused, impaired safety judgement and misjudgment ability was noted. An Interdisciplinary Note (IDT) dated 8/28/24, indicated Driver called for res' called nursing station to say that res {R1} fell out of her wheelchair and that he could not get her to stay in the wheelchair. Writer told driver to call 911 to get assistance from EMT (emergency medical technician) but he refused to do that. The driver brought res back to facility as she sat on the floor of the van. When res arrived at facility, staff assessed her and returned her to her wheelchair. Resident {R1} unable to give description. The IDT note indicated using a gait belt and three staff members, res {R1} was returned to her wheelchair and then wheeled out of the van. Writer took her to dining room and sat with her while she ate dinner. When she was returned to her bed, nurse assessed her skin for any bruising and did a set of vitals. The IDT note indicated no injuries were observed, and she was wearing shoes, was confused and incontinent. A progress note dated 8/29/24 at 10:06 a.m., indicated reviewed R1's fall reported by transportation company on 8/28/24. Resident slid from her wheelchair while being transported back to facility following appointment. No injuries appears to be an isolated occurrence. Not reportable, abuse/neglect is not suspected. Care plan reviewed. Review of R1's electronic health record lacked documentation a post-fall assessment had been completed which identified the cause of the fall and updated interventions put in place to prevent additional falls from occurring while transporting R1 to appointments. During an interview on 9/26/24 at 9:04 a.m., family member (FM)-A stated R1 had her appointment on 8/28/24, she had surgery that day and the appointment was supposed to be canceled however there was a mix up. FM-A stated she was informed on R1's way back from her appointment she fell out of her wheelchair, the driver called for help, and refused to follow the facility's request to send R1 to the hospital. The facility informed FM-A they would follow up with the transportation company on what exactly happened and a week later FM-A stated she had called and the transportation company had no knowledge of the incident with R1. During an interview on 9/30/24 at 2:08 p.m., the health unit coordinator (HUC)-A for memory care/long term care stated on 8/28/24, when R1 returned from her appointment she remembered the driver informing her R1 slid out of her wheelchair and had raised her seat belt. The HUC-A further stated R1 had been refusing her medications, was confused as she was talking about Jesus, drinking margaritas and being pregnant by Jesus when she returned from her appointment. During an interview on 9/30/24 at 2:30 p.m., the facility administrator stated she was aware of the incident with R1 sliding to the floor of the transportation van. The administrator stated the transporting company called the facility stating R1 slid out of her wheelchair on her way back from her appointment and asked what was wrong with our resident because she kept wanting to sit on the floor. The driver said she was sitting on the floor for 10 minutes before arriving back to the facility after her appointment. The administrator did state after the incident, she had attempted to reach the transportation company with no return calls. During an interview on 10/01/24 at 9:45 a.m., nursing assistant (NA)-A stated R1 was at risk for falls and when she was in her wheelchair she always attempted to slide out of her chair. In addition, NA-A stated it never felt safe to have her in a wheelchair for transportation for appointments. During an interview on 10/01/24 at 10:00 a.m., NA-B stated whenever R1 was placed in her wheelchair, she attempted to get out and wanted to slide out. NA-B stated the nursing staff had been informed of it and the only way R1 would have been safe to be transported to appointments was in a reclining wheelchair, not a regular wheelchair. During an interview on 10/01/24 at 10:05 a.m., transportation company owner stated the incident occurred around on 8/28/24, at 4:20 p.m., during traffic time after the driver picked R1 up from her appointment. At first R1 was sliding a little and asked the driver to slid her back into her chair, and once the driver started to drive he had to stop and slid her back into her chair, and then she ended up on the floor shortly after he started to drive again. The owner stated she did not understand how they could have sent R1 alone in the van with just the driver since she would not sit in a wheelchair alone. The owner stated R1 would not be allowed to use their company again unless a staff member was with or in a stretcher. During an interview on 10/01/24, at 12:00 p.m., the facility director of nursing (DON) stated she was not informed R1 was at risk of sliding out of her wheelchair. The DON further stated the staff should have informed her prior to R1's fall. Ebenezer Policy Fall Risk, Post Fall investigation, Follow Up, and Care, revision 12/23 indicated, the purpose is to define nursing role in the management of patients at risk for falls and post fall investigation, follow up and care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide adequate supervision when staff allowed a family member to take a resident into the community where R4 subsequently fell and was hospitalized . R4's significant change Minimum Data Set (MDS) dated [DATE], indicated R4 had impaired cognition with diagnoses including dementia. R4's care plan dated 7/24/24, indicated was an elopement risk due to cognitive ability, and history of wandering during the night and when out in the community. R4 was also a fall risk due to confusion and deconditioning. R4's hospital Discharge summary dated [DATE], included a note by the hospital social worker which indicated there was an open vulnerable adult protection case as of 4/21/24. R4 had been placed in an assisted living and family member (FM)-B removed R4 against medical advice. FM-B also had lost R4 in their apartment building. She was unable to locate R4 and external parties were involved in locating R4. The note further indicated there would likely be concerns from the long-term care facilities about FM-B removing R4 against medical advice. Additionally, the note indicated part of the hospital discharge plan was for the receiving facility to not allow FM-B to bring R4 out of the facility. R4's Electronic Health Record (EHR) included special instructions: resident is not to go on outings or leave of absence with family, and call security for assistance as needed. On 7/24/24, a progress note indicated FM-B asked the nurse if she could take R4 out of the building. The nurse said she could not, and directed FM-B to talk to the nurse manager. At 3:50 p.m. R4 was discovered missing, and FM-B was called. FM-B told staff they were at the train station, and R4 had fainted. Staff went to the train station then called 911. Emergency medical services (EMS) transported R4 to the hospital for possible stroke. On 7/25/24 at 2:44 p.m., registered nurse (RN)-B stated there was information placed in R4's EHR on admission to not let him go out with FM-B because there were some problems with FM-B not keeping track of him in the community. On 7/25/24 at 3:48 p.m., RN-C stated she had told FM-B she could not take R4 out of the building. RN-D told FM-B she could take R4 out of the building because she was his primary contact. Later, when R4 was discovered missing, RN-B told RN-C FM-B was not allowed to take R4 out of the building. RN-C stated she did not see the information in the EHR about R4 not going out of the building with family. On 7/25/24 at 4:57 p.m., nursing assistant (NA)-A stated FM-B had requested a four wheeled walker so she could take R4 into the community. She relayed the request to RN-C and RN-D. The nurses requested NA-A to find out FM-B's name so they could confirm FM-B was allowed to take R4 into the community. Upon confirming FM-B's name, RN-D stated it was ok for FM-B to take R4 into the community. NA-A opened the locked memory care door for FM-B because RN-D confirmed it was ok. NA-A had gone to the train station three blocks away after FM-B informed the facility R4 had fainted. NA-A checked for a pulse and breathing then called 911. NA-A stated R4 was stiff and would not wake up. On 7/25/24 at 5:34 p.m., the director of nursing (DON) stated at the beginning of R4's stay, staff were nervous because of what they had been told about FM-B from hospital staff. R4 had a WanderGuard (alarm) placed on admission to prevent FM-B from removing R4 from the unit, but R4 was not exit seeking and FM-B had not visited, so it was removed. R4 continued to remain on the locked memory care unit where a staff badge was required for exit. The DON confirmed staff should not have allowed FM-B to remove R4 from the unit. R4 had been admitted to the hospital on [DATE] for suspected seizure. A policy on allowing visitors to take residents out of the building was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure residents were free of significant medication errors for 2 of 3 residents (R2, R3) reviewed for medication errors. R2's admission Minimum Data Set (MDS) dated [DATE] indicated R2 had severely impaired cognition, with diagnoses including dementia and depression. R2's hospital discharge orders dated 6/14/24 included vortioxetine (an antidepressant medication) 5 milligrams (mg) daily for adjustment disorder with mixed anxiety and depressed mood. R2's Medication Administration Records (MAR) for June 2024 and July 2024 lack indication vortioxetine was administered. R2 missed 16 doses in June 2024 and 17 doses in July 2024. R2's Consultant Pharmacist (CP) note dated 7/17/24 indicated the hospital discharge order for vortioxetine could not be located in R2's electronic health record (EHR) Physician Orders list. A facility report to the State Agency (SA) on 7/18/24 indicated R2 had not received vortioxetine since admission on [DATE]. R3's quarterly MDS dated [DATE] indicated R3 had moderately impaired cognition, with diagnoses including depression, anxiety, and psychosis. R3's provider Telephone Order (TO) dated 6/7/24 instructed Abilify 5 (antidepressant) mg PO (by mouth) daily and 2mg PO Q2H (every 2 hours) PRN (as needed) x 14 days for delusion, paranoia, and hallucinations. R3's handwritten TO dated 7/22/24 instructed Abilify oral tablet give 5mg by mouth daily for paranoia. There are no initials in the column that indicated the order was transcribed into Point Click Care electronic medication administration record (eMAR) or that the order was second checked. R3's June MAR indicated Abilify 5 mg by mouth one time a day for delusions, paranoia, hallucinations for 14 days. It was administered daily from 6/8/24 through 6/21/24. There were no administrations of Abilify from 6/22/24 through 6/30/24 (8 doses). R3's July MAR lacked instruction to administer Abilify from 7/1/24 through 7/25/24 (25 doses). On 6/19/24 R3's psychiatrist note indicated Abilify seemed to have helped with targeting hallucinations as staff reported there have been no notes or concerns regarding psychosis or concerns of bugs crawling all over her. On 6/26/24 R3's behavior note indicated R3 told the trained medication assistant there were bugs crawling all over her body. On 7/10/24 R3's nurse practitioner (NP)-A note indicated R3 reported seeing bugs on her body and bed. R3 was anxious about this and wanted medication adjustment as able. NP-A indicated Oxycodone would be restarted because that has been the first medication change which perhaps prompted the hallucinations of bugs. The medication list on NP-A's note did not list Abilify. On 7/22/24 R3's NP-A note indicated R3 reported worsening hallucinations of seeing bugs all over her body, into her hair and into her eyes. R3's left eye was visibly red suspected to scratching eye. Also, various scratch marks over face, chin and chest. R3 was moderately distressed given hallucination complaints. NP-A reached out to R3's psychiatrist with current medication orders. It was discovered R3's scheduled and PRN Abilify had been discontinued instead of just the PRN order. NP-A advised to monitor for worsening symptoms of hallucinations and delusions. NP-A ordered to restart Abilify 5mg daily per psychiatrist recommendations. On 7/25/24 at 10:52 a.m., family member (FM)-A stated R3 had hallucinations a while ago, but then they went away. The hallucinations were back again. R3 was feeling bugs crawl on her, so she was scratching at her skin. FM-A thought the hallucinations were disturbing to R3. On 7/24/24 at 3:22 p.m., licensed practical nurse (LPN)-A verified R3 did not have an active order for Abilify. On 7/25/24 at 12:02 p.m., registered nurse (RN)-A stated she transcribed the order for Abilify on 6/7/24. She thought both the scheduled and PRN dosing were for 14 days. She should have clarified with the provider. There was no procedure for nursing to follow up with a provider when a medication was ordered for a specific time frame. She would assume the provider would be reassessing automatically. The nurse would only follow up if the order specified to follow up with provider. On 7/25/24 at 4:42 p.m., psychiatrist (MD-A) stated R3 was prescribed Abilify for tactile hallucinations. She was contacted by NP-A regarding R3's increased hallucinations on 7/22/24. She reviewed R3's medication orders because she wanted to increase R3's Abilify dose. The Abilify was not on R3's current medication list. She communicated to NP-A to reorder Abilify. She confirmed she had not given an order to discontinue the Abilify, and the scheduled dose should not have been transcribed for 14 days. Missing doses of Abilify may have contributed to R3's increased hallucinations. She expected orders to start the day after she wrote the order to give the facility time to obtain the medication from the pharmacy. Abilify should have been administered starting 7/23/24. On 7/25/2024 at 5:34 p.m. director of nursing (DON) stated when a new admission arrived at the facility, provider orders were first entered by the health unit coordinator or by a nurse. All orders must be second checked by a nurse. All pages of a resident's discharge order summary should be checked for provider orders. R2's discharge order summary had been double checked, but the order for vortioxetine was on the top of the last page of orders and had been missed by both nurses. The missing order was discovered by the consulting pharmacist. A facility wide chart audit was not completed to assess if there were any other medications that had not been transcribed. R3's Abilify order should have been clarified by the provider before entering the 14-day time frame. R3's provider order dated 7/22/24 for Abilify was not transcribed according to facility policy. There should have been initials in the column that indicated the order was transcribed into Point Click Care electronic medication administration record (eMAR) or that the order was verified. Handwritten provider orders should be placed in appropriate bins for order to be entered, second checked then uploaded. It appeared the order was placed into the to be uploaded bin before the order was transcribed. Abilify had been ordered for R3 to treat hallucinations. The Transcription of Physician's Orders policy dated 8/23 directed to ensure accurate transcription of physician orders the order is documented by physician or nurse practitioner. The HUC or nurse transcribes the order into Point Click Care and signs off. The order is faxed to pharmacy. The order is double checked by a nurse and signed off as checked. HUC uploads any paper copies of orders into point Click Care.

Based on observation, interview, and document review the facility failed to ensure handwashing and appropriate glove usage was implemented for 1 of 1 resident (R9) observed for personal cares. Findings include: During observation of personal cares on 3/20/24 at 8:54 a.m., nursing assistant (NA)-A was changing R9's brief. NA-A applied gloves, used wipes to clean R9's peri area and bottom, put on a new brief and pulled up his pants. Then NA-A (without removing her gloves) removed R9's shirt, put on a new shirt, pulled the covers up to his chin, adjusted the pillow (under his head), put the bolster under the fitted sheet on his bed, and used the bed controller to put the bed in a low position. NA-A then walked out of the room (wearing the same gloves) and brought R9's shirt to the soiled utility room, removed her gloves, and used hand sanitizer. During interview on 3/20/24 at 9:05 a.m., NA-A verified she had not removed her gloves and washed her hands after changing R9's brief and should have. NA-A stated staff should always change their gloves and wash or sanitize their hands when going from a dirty area to a clean one (Ex: changing a brief to adjusting the residents pillow). During interview on 3/20/24 at 10:34 a.m., the Infection Preventionist (IP) stated staff should always remove their gloves and wash/use hand sanitizer after changing a residents depends or going from a dirty to clean area. The IP further stated if staff do not remove their gloves, they could be spreading bacteria to other residents and/or surfaces. During interview on 3/20/24 at 1:35 p.m., the director of nursing (DON) stated staff should be removing their gloves and washing their hands/using hand sanitizer after providing peri cares and then don a new pair of gloves before moving on to other areas. A facility policy on handwashing/appropriate glove usage was requested and received but it didn't address when staff should change their gloves or wash their hands when providing cares to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure a pressure relief air mattress was assessed for safe size in relation to the bed frame and grab bars for 1 of 1 residents (R51) reviewed for accidents. Findings include: The Guidance for Industry and Food and Drug Administration (FDA) Staff - Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated 3/10/06, indicated Zone 3, the space between the mattress and the bed rail, should be small enough to prevent head entrapment when taking into account the mattress compressibility, any lateral shift of the mattress or rail, and degree of play from loosened rails, and recommended a dimensional limit of less than 4 ¾ inches (in.) for the area between the inside surface of the rail and the compressed mattress. R51's admission Minimum Data Set (MDS) dated [DATE], indicated they were cognitively intact, and had diagnoses of sepsis, muscle weakness, and encephalopathy. R51 required substantial/maximal assistance for rolling left and right in bed and was dependent on staff for transfers and toileting. R51 was at risk for pressure ulcers, had one stage II pressure ulcer, and used a pressure reducing device for their bed. The MDS indicated R51 did not use bed rails. R51's Fall Risk assessment dated [DATE], indicated they had intermittent confusion and took 3-4 medications which could impact fall risk. A Custom Medical Solutions delivery ticket dated 2/14/24 at 4:23 p.m., indicated a low-profile air mattress measuring 36 in. by 80 in. by 8 in. and one control unit were delivered for R51. R51's Order Summary Report dated 3/20/24, included an order for an air mattress to assist with wound healing starting 2/16/24. R51's Fall Care Area Assessment (CAA) dated 2/20/24, included R51 was at risk for falls related to loss of arm or leg movement, incontinence, cognition, infection, and pain, with an objective to minimize risks. The Functional Abilities CAA indicated they required assistance with all activities of daily living (ADLs) and was dependent for all transfers. R51's care plan dated 2/20/24, included R51 had and ADL self-care performance deficit, required a full body lift and two staff to transfer, and assistance of two staff for repositioning and turning in bed. Their falls care plan dated 3/4/24, included modify environment as needed to meet current needs: Non-slip surface for bath/shower, bed in lowest position with wheels locked, floors that are even and free from spills and clutter, and provide adequate, glare-free light. The skin integrity focus revised 2/20/24, included R51 had an air mattress on their bed. R51's Device Assessment and Consent dated 3/4/24, indicated R51 used an air pressure mattress and bilateral grab bars to enable or enhance independence, position, or body alignment. The form identified potential risks as strangulation, suffocation, serious bodily injury, and death when residents or parts of their bodies are caught between rails/bars, in openings in the rails/bars, or between the rails/bars and the mattress. During observation and interview on 3/18/24 at 3:22 p.m., R51 was lying in bed with the head of the bed elevated about 40 degrees on an inflated pressure-relieving air mattress, and one grab bar was affixed to each side of the bed frame. The flat surface of the bad frame was visible one each side of the mattress, leaving an approximately four to five inches of space between the edges of the mattress and the grab bars. R51 stated they used the grab bars to assist in turning and repositioning, and staff often put pillows in the gaps. One standard bed pillow was on the chair in R51's room. The bed was identified as a Zenith 9200 Slide-W-I-D-E (adjustable up to 42 inches wide for bariatric use.) The air mattress was labeled as Matrix ALAL. During observation on 3/19/24 at 8:25 a.m., R51 was not present in their room. The air mattress slid side to side freely on the bed frame, allowing up to an eight-inch gap on one side and two-inch gap on the other. During observation on 3/19/24 at 10:28 a.m., R51 was observed asleep in bed with the gap between the air mattress and the grab bars visible on the left side. No pillows filled the gaps. During observation and interview on 3/19/24 at 2:40 p.m., R51 was lying on bed on the air mattress at a 35-degree angle with the air mattress pushed toward the right side of R51's bed frame. The space between the left side of the mattress and the left grab bar measured approximately eight inches, while the one on the right measure approximately two inches. During interview and observation on 3/19/24 at 2:42 p.m., registered nurse (RN)-B stated if a pressure-relief mattress was needed for a resident staff rented one from a vendor based upon the resident's weight and size. They stated standard sized mattresses were interchangeable with standard sized bed frames, however a bariatric frame required a bariatric mattress. They stated when the specialty mattress arrived the staff moved the resident off the original bed, the vendor placed it on the frame and demonstrated how to use it, and staff assisted the resident back to their bed. They stated air mattresses had belts to attach them to the frame, and they had never encountered a situation where a mattress did not fit. RN-B indicated side rails/grab bars could only be installed on a bed if they assisted a resident with being more independent, were assessed to be safe for the resident, and with a provider order. Upon review of R51's bed, RN-B confirmed R51's mattress was attached with straps to the bed frame; however, the mattress was free to move from side to side allowing large gaps next to the grab bars. RN-B stated the mattress configuration was a little off, was supposed to fit snugly within the rails, and could be remedied by placing a pillow tucked in the gap. They then placed a pillow in the eight-inch gap between the left side of R51's mattress and the left the grab bar. During observation and interview on 3/19/24 at 2:58 p.m., RN-A assessed R51's mattress and bed frame with the grab bars and confirmed the mattress and frame were not compatible. RN-A stated R51 previously used a bariatric bed and mattress, and when staff ordered the standard sized air mattress for pressure relief, they did not change out the frame. They were unsure why it was not identified sooner, and stated if R51 rolled over they could have been stuck between the mattress and the grab bar, obtained skin tears, or slid off the bed. During interview on 3/19/24 at 3:02 p.m., director of nursing (DON) stated nurses completed assessments for R51's grab bars to see if there was a need or benefit, maintenance installed the brackets, and nurses or maintenance attached the rails once determined safe. They were unaware R51's mattress did not fit the bed frame and expected mattresses to be appropriate for the frame to prevent entrapment. DON stated when gaps were identified, the mattress or the bed frame should have been replaced by staff or the medical device supplier. During interview on 3/20/24 at 2:02 p.m., administrator stated staff checked each room and reviewed the equipment at the time of admission prior to transferring a resident into the room, and all resident bed and rails/grab bars were checked by maintenance monthly. They stated the facility had some replacement air mattresses for use, but sometimes they were rented from a medical supply company, so they were unsure who placed R51's mattress on the bed frame. They indicated if a mattress needed to be changed, they expected staff to ensure the replacement was the appropriate size, and if not, follow through by obtaining a different one, or contacting the vendor or maintenance to correct the issue to prevent entrapment concerns. During a subsequent interview on 3/21/24 at 10:12 a.m., administrator stated the vendor who delivered the air mattress placed it on R51's bed and did not inform the staff at the time of delivery. The Matrix ALAL Operating Instructions (undated) included entrapment may occur. Patient entrapment with bed side rails and mattress may cause injury or death. Mattress MUST fit bed frame and side rails snugly to prevent patient entrapment. Follow the manufacturer ' s instructions and monitor patient frequently. Proper patient assessment and monitoring, and proper maintenance and use of equipment is required to reduce the risk of entrapment. Variations in bed rail dimensions, and mattress thickness, size, or density could increase the risk of entrapment. Visit the FDA website at http://www.fda.gov to learn about the risks of entrapment. Refer to the owner ' s manual for beds and rails for additional product and safety information. Mattress MUST fit bed frame and bed rails snugly to reduce the risk of entrapment. The Basic American Zenith 9200 operating manual dated 2023, indicated all Basic American beds are designed in full compliance with the FDA's Hospital Bed System Guidance to Reduce Entrapment. Further, Risk of entanglement or injury may occur if the mattress used with mattress retainers does not fill the entire width between stops or which compresses to less than 1.50 inches under user's weight. Mattress must be properly sized to fit the mattress support platform and must remain centered on the support platform relative to State and Federal guidelines. Length and width should match the mattress support platform. Use of an improperly fitted mattress could result in injury or death. IMPORTANT: Powered air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefits outweigh the risk of entrapment. The document indicated patients at high risk for entrapment include those with confusion, lack of muscle control, and altered mental status due to medication. The facility Adaptive Equipment policy dated 4/5/23, indicated mattresses must fit snug against the bed frame, and the distance between the rail and the mattress was not to exceed 4.75 inches.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure the necessary coordination of services between the facility and the hospice agency for 1 of 1 residents (R2) reviewed for hospice services. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment. R2's Diagnoses List printed 3/6/24 included diagnoses of schizoaffective disorder (disorder with a combination of symptoms of schizophrenia and a mood disorder), bipolar type. On 3/5/24 at 4:00 p.m., R2's medical record lacked current contact information for hospice staff (the case manager was not updated), and lacked a current medication list with a list of resident-specific hospice-covered medications, a care plan, goals for care, hospice certification and recertifications of the terminal illness, the hospice election form, and hospice orders. Additionally, the medical record lacked a schedule for hospice visits for March 2024. The most recent visit note in the hospice chart by a nurse was dated 2/2/24. On 3/6/24 at 11:39 a.m., social worker (SW)-A stated the facility had some coordination issues with the hospice agency including unanswered emails, forms not completed correctly, and inaccurate contact information for hospice team members. SW-A stated the phone number on the business card for the designated contact for hospice provided by the hospice agency was incorrect. Further, SW-A stated she expected the hospice staff to communicate with facility staff weekly. SW-A also stated she would expect a hospice plan of care for R2 as R2 had been with hospice since July 2023. On 3/6/24 at 11:50 a.m., the director of nursing (DON) stated R2's chart should contain a hospice plan of care, team member names and contact numbers, the frequency of visits, a visit schedule, a current medication list with hospice-covered meds listed, and visit notes by hospice team members. On 3/6/24 at 12:03 p.m., the hospice director (HD)-A stated she expected hospice staff to respond to facility staff emails, and the documents in the resident's medical record were current and complete with the required information. HD-A acknowledged the new updated paperwork provided to the facility on 3/1/24 lacked a care plan, a current provider's name (the provider identified no longer worked for the hospice agency), and the paperwork had blank pages that should have been completed. HD-A further acknowledged the last nurse visit documented visit was 2/2/24. Additionally, HD-A stated a nursing assistant (NA) should see R2 once or twice weekly, but the hospice record did not indicate NA visits in February. HD-A stated, It's sad how we missed so many things. The facility Hospice contract dated 7/26/24, indicated coordination of care between the facility and Hospice included a plan of care for each hospice patient, where Hospice retained primary responsibility for determining each hospice patient's appropriate plan of care, the facility would provide the description of services furnished by the facility. The contract indicted the facility communicates with Hospice physician and other practitioners participating in care to the Hospice patient as needed to coordinate hospice care with the medical care team. Additionally, the contract indicated Hospice would provide the most recent plan of care, medication information, and physician orders specific to each patient, the Hospice Election Form, physician certification and recertifications of the terminal illness specific to each Hospice patient, and contact information for Hospice personnel involved in care of each Hospice patient. The facility Hospice Care and Referrals in SNF [Skilled Nurse Facility] policy updated 2/24 directed social service (or delegate) obtained information from hospice including the hospice plan of care, hospice election form, physician certification and recertification of the terminal illness, names and contact information for hospice personnel involved in the hospice care, hospice medication information specific to each patient, and the hospice physician and attending physician orders. The policy further directed the hospice provider assured notes were provided to the facility in a timely manner and communicated the schedule of upcoming visits with the resident to the facility for care coordination purposes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively assess and develop person-centered interventions to reduce behaviors and promote well-being for 1 of 1 resident (R1) reviewed with dementia who repeatedly displayed disruptive and aggressive behaviors which could place herself and/or others at risk for injury or harm. Findings include: R1's annual Minimum Data Set (MDS), dated [DATE], identified R1 had severe cognitive impairment and several medical diagnoses including unspecified dementia with behavioral disturbance, non-traumatic brain dysfunction and depression. The MDS outlined R1 was independent with bed mobility, transfers, ambulation, toileting and personal hygiene however, demonstrated no behavioral symptoms (i.e., verbal, or physical behaviors) during the review period. R1's care plan, dated 1/24/23, identified R1 had cognitive and behavioral difficulties due to poor cognition and dementia. R1 was recorded as being restless, walking the hallways (i.e., wandering), having sometimes aggressive behaviors towards staff members, and taking items from other residents' rooms. A goal was listed which outlined, . will have no evidence of behavior problems by review date, along with several interventions to meet the established goal including removing R1 or other residents from any unsafe situation or when R1 becomes disruptive; approaching resident slowly and calmy; maintaining a calm, consistent demeanor; monitor R1's whereabouts at all times; and to discourage naps during the day to allow R1 to sleep at night. On 1/26/23, at 10:57 a.m. and 11:30 a.m., respectively, R1 was observed to be laying in her bed with her eyes closed. There were no other residents in R1's room and R1 appeared without obvious physical symptoms of pain or discomfort. Further, there was no staff engagement witnessed with R1 during these periods. However, R1's progress notes, dated 11/15/23 to 1/26/23, identified the past 72 days of recorded behaviors for R1 while at the nursing home. These included the following: On 11/15/22, R1 was re-admitted to the nursing home after being hospitalized for behavioral symptoms which, at times, required intramuscular medication and restraints to control. On 11/17/22 at 8:02 p.m., R1 was separated from another resident during dinner for raising her voice at the other resident. On 11/23/22 at 4:00 p.m., R1 was documented to be physically aggressive towards staff and other residents, attempting to hit them with a hand sanitizer bottle R1 had pulled off the wall. This resulted in 911 being called. R1 was taken to the acute care hospital but released back to the facility on the same day with no new orders. On 12/5/22 at 11:20 p.m., R1 was documented pacing the hallways and entering other residents' room. On 12/6/22 at 6:00 p.m., R1 was documented as calling names and being verbally aggressive. On 12/6/22 at 10:17 p.m., R1 was recorded as agitated, calling staff idiots and shouting loudly. On 12/11/22 at 9:31 p.m., R1 wandered into another resident's room and urinated on the floor. On 12/27/22 at 2:53 p.m., R1 was recorded as agitated, and stealing another resident's art. On 1/1/23 at 1:18 p.m., R1 pulled down her pants in the dining room and urinated in her walker basket. On 1/2/23 at 1:53 p.m., R1 was recorded as confused and agitated. R1 grabbed another resident's walker and attempted to hit the other resident. On 1/2/23 at 9:20 p.m., R1 wandered into another resident's room and became very upset attempting to punch, kick and bite at staff. R1 locked and barricaded herself into the room, and she required multiple staff members to remove her. On 1/3/23 at 11:50 p.m., R1 was recorded as wandering and entering other residents' rooms. R1 left the unit and became agitated and yelled when redirection by staff was attempted. On 1/4/23 at 2:57 a.m., R1 had entered another resident's room and urinated on floor. R1 was found sitting on the other resident's bed by staff when they entered the room. On 1/8/23 at 4:56 a.m., R1 was recorded as having wandered in the hallways until 2:00 a.m., and then had been found in another resident's room. On 1/10/23 12:03 a.m., R1 was recorded as wandering into other residents' rooms. On 1/14/23 at 2:04 p.m., R1 was recorded as wandering room to room, and she attempted to hit staff and residents. On 1/19/23 at 5:40 p.m., R1 was documented wandering in the hallway and entering R2's room. According to R2, R1 entered her room and took one of R2's teddy bears. R1 pushed R2 to the ground when R2 attempted to get her teddy bear back. A subsequent note, dated 1/19/23, identified R1 would be reviewed for a significant change in status MDS due to her increased . socially inappropriate behaviors. On 1/22/23 at 2:46 p.m., R1 was documented as continuously wondering into other residents' rooms and urinating all over the place. On 1/23/23 at 1:26 p.m., R1 was reported being combative with staff during activities of daily living. In addition, on 1/20/23, the interdisciplinary team (IDT) reviewed the resident-to-resident altercation with R1 and another resident (see note dated 1/19/23). A section of the note identified a 'root cause' for the incident which outlined, [R1 has] . diagnosis of dementia and wanders into other residents' rooms. She is not aware of what belongs to her or others. However, the note lacked any further assessment of R1's behaviors, including over a period of time to review for trends, patterns, or potential triggers, despite the repeated notes of R1 wandering and, at times, being physically aggressive with staff and other residents. In total, the completed progress notes identified 20 episodes of behavioral symptoms (i.e., aggression with staff and residents, wandering, and urinating in inappropriate places) for the period of notes reviewed. Of these recorded behaviors, three (3) episodes occurred on the 'day shift' (i.e., 6:00 a.m. to 2:00 p.m.); nine (9) episodes occurred on the 'evening shift' (i.e., 2:00 p.m. to 10:00 p.m.); and eight (8) episodes occurred on the 'night shift' (i.e., 10:00 p.m. to 6:00 a.m.). The pattern of more behaviors occurring on the evening and night shifts was acknowledged by the administrator on 1/26/23 at 1:15 p.m. when interviewed. R1's physician order indicated R1 was receiving several medications for her mental health and well-being. These included Trazadone (an antidepressant medication) 25 milligrams (mg) every evening with an additional 12.5 mg dose at bedtime as needed (PRN) dated 11/15/22; and Risperidone (an antipsychotic medication) 0.5 mg twice a day with an additional 0.5 mg dose daily as needed dated 11/28/22. The last medication change noted in R1's record was 12/19/22, when R1's sertraline was decreased from 150 mg daily to 100 mg daily. In addition, on 12/13/22, R1 had an as-needed order for Zyprexa (an antipsychotic medication) renewed on 12/13/22, with a stop date of 12/26/22. The record lacked evidence this order was renewed and/or current at the time of the abbreviated survey. R1's Medication Administration Record (MAR), dated 1/1/23 - 1/26/23, identified R1 received PRN Trazadone 12 times since 1/1/23, with administrations being recorded on 1/1/23, 1/8/23, 1/9/23, 1/10/23, 1/11/23, 1/12/23, 1/15/23, 1/16/23, 1/18/23, 1/22/23, 1/24/23, and 1/25/23. Further, the MAR indicated R1 had received PRN Risperidone four times since 1-1-23, with administrations being recorded on 1/2/23, 1/3/23, 1/4/23, and 1/22/23. R1's Psychiatric Progress Note, dated 1/18/23, identified R1 had been seen a month prior with no changes made at the time. The note outlined R1 as being 'rigid' with her behaviors, however, had not been disruptive . in the sense of aggressive behaviors. The psychiatrist identified, I do not believe that she has required [as needed] Risperidone. A mental status examination was completed which outlined R1 as being currently soiled (i.e., incontinent), with poor insight and judgment. A section labeled, Assessment, identified R1 as having dementia and a history of irritable personality. R1 had a history of multiple episodes of agitation and aggression in 2022, which at times, required hospitalization. The assessment concluded, She has had a few changes, but overall seems to be stable. Further, a section labeled, Suggest, outlined different approaches or interventions for staff to attempt or be aware of. These included, [R1] may respond well to positive incentives for changes . might include things like Dr. Pepper or wine coolers, something she used to get. If this could be arranged, I do think it would be helpful. However, R1's medical record lacked evidence this had been acted upon or considered by the nursing home thus far. R2's annual MDS indicated she had moderate cognitive impairment. When interviewed on 1/26/23 at 10:58 a.m., R2 recalled the altercation between herself and R1 from 1/19/23. R2 explained it was around 8:00 p.m. when R1 had entered her (R2) room and started playing with her stuffed animals. R1 wanted to take them and became upset when R2 protested and tried to take them back from her which caused R1 to push her (R2) causing her to fall on the ground. R2 stated she was scared to death of R1 since the incident and expressed the situation remained concerning to her. Further, R2 expressed she didn't seem to feel the staff did anything to help the situation and had heard other residents yell for help when R1 enters their rooms. On 1/26/23 at approximately 11:30 a.m., an interview was completed with nursing assistant (NA)-A and NA-B. NA-A stated R1 has lived at the facility for about 3 years and used to be independent. R1 still ambulated with or without a walker but required assistance with all other activities of daily living (ADLs). NA-A and NA-B expressed R1 had behaviors, and NA-B stated, We have to keep other residents away from her (R1) when she is out in the common area (due to her disruptive behaviors). NA-A and NA-B stated R1 often takes things from other residents and staff let R1 take the object to her room until she calms down. NA-A stated R1 has a doll that can sometimes help to calm her down; however, if that doesn't help the staff merely just try their best to calm R1 down by talking with her or giving her space. NA-A and NA-B further stated that since R1's hospitalization approximately one month ago her behaviors have become worse. They are at times fearful of R1's aggressive behaviors and will only provide cares for her if two staff members are present R1's entire medical record was reviewed. The record lacked evidence R1 had been comprehensively assessed for her behavioral symptoms, or even attempted prior to 1/19/23 after being re-admitted on [DATE] despite the need for emergency room care intervention on multiple occasions, to include identification or evaluation of observed patterns, trends, or other extrinsic factors which could exacerbate them (i.e., increased behaviors on the evening hours). There was no evidence demonstrating the facility had identified, assessed and responded or adjusted the care plan with specific, person-centered interventions on the evening or night shift prior to the resident-to-resident altercation on 1/20/23; despite multiple recorded behaviors during these periods, the psychiatry note (dated 1/18/23) outlining potential interventions to consider to reduce the risk of altercations, and the prescence of these behaviors since R1 returned from the hospitalization (on 11/15/22). Further, the medical record lacked evidence the cessation of R1's as-needed Zyprexa order, on 12/26/22, had been assessed for need or subsequent re-start despite these ongoing physical behaviors. During an interview on 1-26-23 at 11:45 p.m., licensed practical nurse (LPN)-A stated she does see aggressive behaviors from R1. LPN-A stated if R1's behaviors are affecting other residents, staff try to separate them but usually staff back off when R1 gets aggressive. LPN-A further indicated there is nothing different on R1's care plan for evenings but staff did have a meeting about a month ago on how to approach and care for R1. If R1 becomes physically aggressive they notify the DON and the physician. On 1/26/23 at 1:30 p.m., the director of nursing (DON) and licensed social worker (LSW)-A were interviewed. DON stated behavioral symptoms were assessed using an interdisciplinary model and, if a concern was raised (i.e., behavior), it was reviewed at their IDT meetings which were held every morning and included other various disciplines. LSW-A explained they recognized an escalation of R1's behaviors back in October 2022 and, at the time, R1 did not consume any psychotropic medications. However, due to the behaviors, medication was subsequently started. Then, on 11/10/22, R1 had behaviors which the nursing home could not control, and she was hospitalized ; being re-admitted on [DATE]. The DON confirmed there was no formal comprehensive assessment completed or recorded for R1's behavioral symptoms (including patterns, trends, etc.); and they both acknowledged the medical record demonstrated increased and more frequent behaviors on the evening shift without any specific care planned interventions to address them for the time of day. However, the DON added, Staff is aware she has issues at night because they are monitoring her. The DON stated she felt the direct care staff did verbal reports and just know to monitor her more closely in the evening hours; however, acknowledged they had not assessed for the need or considered doing one-to-one monitoring or even periodic safety checks (i.e., 15-minute checks) for R1 during these hours. DON and LSW-A expressed such interventions would be unrealistic due to staffing considerations despite them being informally (i.e., not documented) done during waking hours. The DON expressed they tried to not have unfamiliar staff work with R1; however, explained multiple staff members had been injured by R1 and her behaviors since she returned from the hospital. The DON added, This is why this resident needs to go somewhere else. Facility policy Vulnerable Adult - Abuse Prohibition Plan revised on 10-6-22, indicated that the facility has Zero Tolerance for resident abuse, neglect, and mistreatment with a goal to provide, . our residents with a safe, secure environment free from maltreatment. A facility' policy on dementia care was requested, however, was not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement interventions to prevent further potential abuse for 1 of 1 resident (R1) after an allegation abuse was reported. Findings include: R1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had moderately impaired cognition. R1 required extensive assistance of one with personal hygiene, dressing, and toilet use, assistance of two for bed mobility and transfers, and total dependence of one for eating. The Report of Potential Maltreatment dated 10/25/22, indicated R1 reported two females enter his room and the blond female pushed him into the wall and slapped him on the right side of face. R1 was unable to identify if this was a staff. Report indicated on assessment, no redness, bruising, swelling, injury or discoloration to face or body parts and other residents interviewed denied similar or unacceptable treatment and verbalized feeing safe in the environment. The immediate action to ensure R1 was protected included two staff to enter room for care when staffing allows. Abuse prevention plan for R1 identified two staff to enter room when providing care as staffing allows/or able. The 5-day Investigation Report, dated 11/5/22, indicated the action taken to prevent reoccurrence for R1 was two staff to enter room when providing care. R1's care plan, revised on 11/10/22, identified R1 displayed delusional thoughts, paranoid thinking, believed he was bed ridden, does not remember getting out of bed and doing things. R1 made statements others are throwing him against the wall, slaps him, or holds him down. R1's care plan focus area had been updated on 11/10/22, after 11:00 a.m. with additional information added to the focus area: staff advised to give care in pairs as able. R1's interventions had also been updated at the same time to include an additional intervention that read: 2 staff to enter room for cares revised on: 11/10/2022. Review of nursing assistant (NA)-B's nurse aide third floor float AM/PM shift document identified words written by NA-B next to R1's name, assist of one and feeding tube. R1's [NAME] hung inside the closet door identified assist of one to turn from side to side and sit up in bed, assist of one and transfer belt to transfer on/off toilet, and assist of one for personal hygiene, oral care, and dressing. During an observation on 11/10/22, at 9:20 a.m. NA-A entered R1's room, turned off call light, and asked resident what he needed. R1 stated my pants are soaking wet and needed to be changed. NA-A indicated she was in middle of helping two other residents and will be back to help him. NA-A left the room. At 9:22 a.m. NA-A re-entered R1's room alone held a pile of wet wash cloths in a towel, stated cannot find your NA so guess I will have to change you, and closed the door. NA-A raised R1's bed up, applied gloves and uncovered R1. NA-A pulled the front of the urine saturated brief down and placed it between R1's thighs. NA-A washed the peri area with one wash cloth, cued R1 to turn onto his right side, then wiped stool from the rectal area with a wet washcloth, removed soiled brief and placed a clean brief under R1. At 9:40 a.m. there was a knock at the door, NA-B entered the room and asked NA-A if she needed help, applied gloves and remained in the room until all cares were completed. During an interview on 11/10/22, at 11:47 a.m. licensed practical nurse (LPN)-A stated R1 had behaviors, yelled at staff, and was forgetful at times. LPN-A also stated R1 required two staff in the room to take care of him and/or complete cares. During an interview on 11/10/22, at 12:03 p.m. R1 verified he had reported a concern to the facility about one month ago a couple of nurses came into his room while he sat on the edge of bed. R1 stated the nurses thought he would get up and leave, came towards him, shoved him against the wall, and left the room. R1 also stated it all happened so fast he could not recall their names, but one had blond hair and one had dark hair. R1 indicated he ended up with a lump on his head. R1 stated the facility had not changed anything with his cares and was unaware of what had been done with the report. During an interview on 10/11/22, at 12:15 p.m. registered nurse (RN)-A verified staff received NA sheets when they come to work and typically took notes on them and the NA [NAME] that was located in the resident room closet should be used to identify how to take care of each resident. RN-A also stated the nurse manager was responsible to update the NA [NAME], but we do not have a nurse manager as of today. RN-A verified R1's NA [NAME] had been updated/printed last on 9/28/22. During an interview on 11/10/22, at 12:30 p.m. NA-A stated R1 needed assistance of one for pretty much all his cares. NA-A indicated R1 had behaviors at times and then required assistance of two for transfers. During a follow up interview on 11/10/22, at 2:30 p.m. NA-A the [NAME] in R1's closet tells us how to care for him. NA-A verified she told [NA-D] R 1 was assist of one to dress, check and change, and one to two assists but usually two assist to transfer. NA-A indicated sometimes I call for help with R1 but the check and change usually go by myself because he can help roll. During an interview on 11/10/22, at 12:40 p.m. NA-D stated R1 required assistance of one with all his cares but when he had behaviors it may take two staff to transfer him. NA-D verified when assigned to R1 she usually completed cares alone. During an interview on 11/10/22, at 1:30 p.m. NA-C stated she had taken care of R1 two days ago. NA-C verified R1 had verbal behaviors and swore at staff. NA-C indicated nothing had changed regarding R1's cares. NA-C stated a communication book and during report was how they would update staff on changes. NA-C also verified R1 remained assist of one for staff check and change and all cares and R1's [NAME] remained in his room with the same information and had not been updated for a while. During an interview on 11/10/22, at 2:18 p.m. NA-B indicated when she arrived at facility for the first day NA-A handed her an assignment list of 9 residents. NA-B stated her assignment included R1 and was told he was an assist of one for all cares and tube feeding. NA-B stated during her shift at 1:00 p.m. she checked and changed and assisted R1 to the wheelchair using a walker without assistance from another staff member. NA-B verified the [NAME] located in R1's closet indicated he was an assist of one. During an interview on 11/10/22, at 3:06 p.m. director of nursing (DON) stated staff are expected to go find another staff so there are two staff in R1's room to provide cares. DON also stated she preferred staff do not complete R1's cares alone. DON verified the purpose of two staff required to assist R1 during cares was needed in case something happened, to protect staff and resident, and R1 was very vulnerable. DON verified she had changed R1's care plan on 10/27/22, to included two staff assist however this afternoon on 11/10/22, she had been informed by NA-A there were not two staff available to be there at times. DON indicated on 11/10/22, the care plan was then changed by adding, as staffing allows. DON verified on 11/10/22, she had also changed the Report of Potential Maltreatment final copy dated 10/25/22, from, two staff to enter room when providing care, and then added as staffing allows/able. DON verified the [NAME] had not been updated since 9/28/22 and should have been when the plan of care was changed so that agency staff and new employees knew how to care for R1. DON indicated once she was made aware of the incident a huddle was held and education was provided to the regular staff members that were there which included one nurse and five nursing assistants. DON stated they talked about the situation and how R1's needs can best be met but no documentation was completed on this meeting. The DON confirmed no other training was provided to staff on R1's care plan revisions to provide two staff during care when available/able for the protection of R1 and staff. Review of a facility policy titled Vulnerable Adult - Abuse Prohibition Plan updated 10/6/22, indicated purpose of policy was to provide residents with a safe secure environment free from maltreatment. The care plan will include goals and measure to be taken to protect that individual from abuse and to minimize the risk of abuse to other vulnerable adults. The facility will assure assignment of a sufficient number of staff on each shift will meet the needs of the residents and staff assigned to a resident has knowledge of the individual care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and document review the facility failed to provide audiology services for 1 of 1 resident (R5) reviewed for communication devices. Findings include: R5's admission Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact. R5's quarterly MDS dated [DATE], indicated R5 was cognitively intact, and indicated adequate hearing with no need for hearing aids. R5's face sheet dated 10/27/22, did not indicate R5 was hard of hearing on her diagnoses list. R5's Sensory/ Communication assessment imbedded in the Nursing assessment dated [DATE], indicated adequate hearing and no hearing aids. R5's Sensory/Communication assessment imbedded in the Nursing assessment dated [DATE], indicated moderate difficulty with hearing, and no hearing aids, although the subsequent MDS assessment on 10/13/22, indicated R5 had adequate hearing. When interviewed on 10/24/22, at 3:39 p.m. R5 stated she had hearing aids, but they were missing. R5 stated she had informed staff and stated she needed her hearing aids. R5 had difficulty hearing at a normal level of conversation and surveyor had to speak loudly and repeat self so R5 could hear. During observation on 10/24/22, at 3:39 p.m. R5 was not wearing hearing aids. When interviewed on 10/26/22, at 10:21 a.m. licensed practical nurse (LPN)-A stated the process for a resident to obtain hearing aids was for nurses to report the need to the in-house healthcare provider, and the provider would write an order to see the audiologist. The LPN-A stated the health records team was in charge of scheduling appointments. When interviewed on 10/26/22, at 10:28 a.m. registered nurse (RN)-A stated the supervisor for the health unit coordinators (HUCs) would schedule audiology appointments for residents as needed. When interviewed on 10/26/22, at 10:53 a.m. social worker (SW)-A stated nursing staff had not informed her R5 needed hearing aids or was missing them. The SW-A stated nursing staff could tell her, or the supervisor for the HUCs to schedule an appointment, but hearing tests could be scheduled as needed. When interviewed on 10/26/22, at 11:03 a.m. the director of medical records (DMR) stated he had not been notified R5 needed an audiology appointment and he had no consent for the service on file. The DMR stated he had to have a consent on file to schedule an appointment, and then the HUCs would schedule it. When interviewed on 10/27/22, at 08:56 a.m. SW-B stated the process to obtain hearing aids was for the clinical team to assess the need for hearing aids. Upon admission, residents were asked if they want any in-house services, like audiology services which would help with hearing aids. Then, if the resident required hearing aids, nursing staff would ask the resident to sign a consent form, and then the appointment for audiology could be scheduled. Further, SW-B stated R5's hearing aids were found in her room in a drawer on 10/27/22, with a broken wire, and R5 signed the consent for an audiology appointment. SW-B stated residents can change their minds, and if the resident initially declined in-house services, which R5 did upon admission, and then later wanted an in-house service, a consent would be obtained at the time of request or identified need. Additionally, SW-B stated if nursing assessed a change in R5's hearing abilities, the nurse should have informed the provider on the clinical team, and then the provider could have written an order for the service. When interviewed on 10/27/22, at 10:10 a.m. RN-B stated if she assessed a need for hearing aids, she would inform the nurse manager, and e-mail the DMR to get the resident on the list for audiology services, or may tell the DMR in person. RN-B stated she assessed R5's hearing during a nursing assessment as documented on the 8/23/22, communication assessment, and documented a decline in hearing ability, but did not ask R5 if she wanted hearing aids nor did she ask if she wanted an audiology appointment. RN-B stated she did not recall if she notified the DMR that R5 needed hearing aids, and did not chart about it. RN-B stated she had not and would not normally document the communication to the DMR, but that it was possible she had not communicated the need at all. When interviewed on 10/27/22, at 10:19 a.m. the director of nursing (DON) stated she expected nursing staff to assess for change, and to refer to the required services. The DON further stated if a nurse assessed a need that a resident previously declined, she expected staff to re-approach the resident who previously declined the service to ask again for the consent, and document the response. A policy about hearing and audiology services was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure adequate, routine monitoring of a pressure injury was completed and recorded for 1 of 2 residents (R45) reviewed for pressure ulcer care and services. Findings include: R45's quarterly Minimum Data Set (MDS) dated [DATE], indicated R45 was cognitively intact and had diagnoses of failure to thrive and stage IV pressure ulcer that was present upon admission. The MDS further identified R45 was independent with bed mobility and transfers. R45's skin Care Area Assessment (CAA) dated 9/20/21, indicated R45 had a stage IV pressure ulcer on the left ischial tuberosity (IT) (backside of hip) that measured 6 centimeters (cm) by 3.5 cm. Furthermore, R45 was at risk for further skin breakdown related to decreased mobility and malnutrition. R45's provider order dated 6/5/22, indicated R45's left IT wound required measurement of length, width, and depth on bath day every Sunday evening. Staff were to document measurements in R45's electronic medical record (EMR) under progress notes and skin alteration tab. R45's care plan dated 10/22/22, indicated R45 was at risk for skin breakdown and had a stage IV pressure area to the left IT. R45's care plan further indicated R45 required weekly wound treatment documentation that included measurement of width, length, and depth and any other notable changes. A review of R45's weekly bath and pain assessments indicated R45's wound was measured a total of 5 times during the 17-week review between 7/1/22- 10/23/22. These dates included 7/10/22, 7/24/22, 8/21/22, 9/4/22, and 10/16/22. R45's EMR lacked indication R45's wound was measured for the other weeks 12 weeks during the time reviewed. During observation on 10/27/22, at 9:16 a.m. registered nurse (RN)- A was providing wound cares for R45's left IT wound. R45's wound measured 1.5cm x 1.5 cm and a depth of 5cm. RN-A stated he had measured R45's wound earlier in the week when nurse practitioner (NP)-A was in house and the measurement was the same. RN-A acknowledged the practitioner was told verbally and no documentation was completed in R45's record. When interviewed on 10/24/22, at 4:56 p.m. R45 stated she was not sure if wound cares were done appropriately as there was so many steps to it and felt the wound was getting worse. R45 further stated staff were doing dressing changes twice a day but was unsure how often the wound was being measured. When interviewed on 10/27/22, at 9:48 a.m. RN-A stated R45 received wound care twice a day and while the open area was getting smaller, the depth was not changing much. RN-A stated RN-B completed weekly wound rounds on every Tuesday and RN-B measured R45's wound at that time. R45 was no longer followed by the wound doctors as R45 declined services as the service was not covered by R45's insurance and was an out-of-pocket expense. RN-A confirmed R45's wound was managed by NP-A. RN-A reviewed R45's medical record and was not able to identify a wound measurement since the wound provider stopped seeing R45 in 6/2022. RN-A further stated he was unaware of any other documentation of R45's wound measurements. When interviewed on 10/27/22, at 10:41 a.m. NP-A confirmed she was managing R45's wound. NP-A stated the course of treatment required a wound vac, but R45 was reluctant due to the out-of-pocket expense. NP-A verified the wound measurements were the same today as earlier in the week and was aware of how deep the wound was. NP-A further explained the wound is doing well but needs the wound vac to help fill in the depth. NP-A stated she was not involved in the weekly monitoring or measuring of R45's wound. NP-A further stated she expected the facility to measure R45's wound as ordered and update the provider team with any changes or concerns. When interviewed on 10/27/22, at 11:51 p.m. RN-B confirmed R45 was not on wound rounds as R45 requested not to have wound pictures taken. RN-B explained weekly measurements were completed by the floor nurses. When interviewed on 10/27/22, at 12:27 p.m. the director of nursing (DON) confirmed R45 was not followed in weekly skin rounds and wound assessment and measurements were completed on bath days. DON verified R54's wound monitoring was not documented consistently and was not able to verify if it was done. DON stated staff were expected to document measurements of R54's wound once a week. DON further stated wound measurements were important to obtain weekly to ensure the wound was not worsening. A facility policy titled Management of Skin Alterations revised 10/2021, directed residents with wounds will have at minimum weekly monitoring for appropriateness of treatment/care plan, signs or symptoms of infection, pain or discomfort and signs of healing and will report to the provider as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide services to maintain range of motion (ROM) for 1 of 1 residents (R50) reviewed for hand contractures and limited ROM. Findings include: R50's face sheet indicated a diagnosis of left hand contracture (a tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) and osteoarthritis (inflammation of the joints). R50's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R50 was moderately cognitively impaired and required assist of one person for bed mobility, dressing, toileting, and personal hygiene. R50's care plan revised on 2/16/22 indicated: -Splint/Brace Program Left palm protector on in Am off with PM cares to be done by nursing staff. R50's care conference note on 9/6/22 indicated a splint be applied for left hand contracture. R50's treatment administration record (TAR) for October 2022 for dated 10/1/22 to 10/25/22 indicated no documentation by nursing staff for applying and removing the splint. R50's occupational therapy evaluation and plan of treatment for 1/27/22, indicated the establishment of a range of motion (ROM) program to maintain and prevent further contracture with fitting of left hand splint to maintain skin integrity and caregiver training on splint use. On 10/24/22 at 4:19 p.m., R50 was observed to be sitting up in her wheelchair with left hand on lap. Splint was not present. R50 stated staff was aware of missing splint and did not help her find the splint. R50 stated the splint, should be on all the time. Left hand noted with contractures with left small finger curled and pressing onto palm of hand which was reddened. R50 stated she was unable to use left hand. On 10/25/22 at 9:47 a.m., R50 observed to be laying in bed without the splint on. R50 stated staff were aware of missing splint and offered no other alternative to relieve pressure of left small finger pressing into palm of hand. On 10/26/22 at 11:13 a.m., R50 observed to be sitting in wheelchair with a rolled up washcloth on left hand. Wash cloth was not placed under little finger of left hand to relieve pressure of little finger onto palm of hand. Nursing assistant care sheet posted in R50's bedroom printed 2/25/22 stated: Nursing Rehab/Restorative: Splint/Brace Program Left palm protector on in AM off with PM cares. Hand was with soap and water and let air dry. Interview with nursing assistant (NA)-D on 10/26/22, at 7:53 a.m., (NA)-D stated the nursing assistant care sheets posted in resident rooms assist the nursing assistants with types of cares required by the resident such as ambulation, turning, feeding, dressing, preferences, and communication needs. NA-D stated the care sheets indicate if a splint or brace is needed and when it should be applied and removed. NA-D stated if the resident refuses to wear a splint or brace then staff should reapproach the resident and inform the nurse so the nurse can approach the resident about it. NA-D stated the nurse was responsible to chart refusals and attempts in the electronic medical record (EMR). Interview with NA-E on 10/26/22, at 2:18 p.m., NA-E stated the care sheets posted in resident rooms stated if resident is to have a splint or not. NA-E stated she recalled seeing the hand splint for R50, last week and that R50 has worn the splint for at least a year. NA-E stated she discovered the splint was missing earlier in the day and notified therapy to replace it. Interview with licensed practical nurse (LPN)-D on 10/26/22 at 11:20 a.m., (LPN)-D stated R50 required assistance with all her personal cares and, uses a left hand brace and is expected to wear it. LPN-D stated that nursing is responsible to chart in the EMR if R50 refuses to wear it or if it is missing. LPN-D confirmed R50's left hand brace was missing and believed it was missing for one day. LPN-D stated the nursing assistance assigned for R50 on 10/26/22 discovered the splint was missing and notified therapy to replace it. LPN-D stated that R50's left hand could become, more contracted or tight and more painful without the splint. Interview with occupational therapist (OT)-A on 10/27/22, at 10:50 p.m., (OT)-A stated the purpose of a hand splint is to prevent fingers from curling further and contracting more. In addition, R50's hand splint was needed to prevent any skin breakdown to her palm. Interview with rehabilitation director (RD)-B on 10/26/22 at 11:39 a.m., (RD)-B stated nursing staff were responsible for donning and doffing the splint. RD-B stated the risk of not wearing a hand splint could be worsening of contracture. Interview with director of nursing (DON) on 10/26/22 at 1:34 p.m., DON stated therapy staff are expected to assess the resident for splint use and then demonstrate to nursing staff how to don and doff the device. DON stated expectation for nursing staff to document application of splint on R50's EMR treatment record. DON stated that there is nothing on R50's treatment record that addresses splint use including number of times staff attempted to apply it and if resident refuses or declines to have it on. Facility policy titled Applying a brace or splint, updated 10/21, stated the primary responsibility for applying the splint is nursing and to document the procedure in the resident's record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and document review the facility failed to provide dental services for 1 of 4 residents (R5) reviewed for dental services. Findings include: R's admission minimum data set (MDS) dated [DATE], and significant change MDS dated [DATE], indicated R5 was cognitively intact and had no natural teeth. R5's face sheet dated 10/27/22, did not indicate R5 was edentulous (had no teeth) in her diagnoses list. Subsequent MDS assessments dated 4/14/22, 7/14/22, 8/21/22, 8/23/22, and the most recent a quarterly MDS dated [DATE], indicated R5 was cognitively intact, but the oral/dental section was not completed. R5's care plan dated 10/14/22, indicated R5 had full upper and lower dentures. R5's Oral/Dental assessment imbedded in the Nursing assessment dated [DATE], indicated R5 had no natural teeth. R5's Oral/Dental assessment imbedded in the Nursing assessment dated [DATE], indicated R5 had broken or loosely fitted full or partial dentures. R5's Nutritional assessment dated [DATE], indicated R5, Has dentures but does not have here. R5's Nutritional assessment dated [DATE], indicated R5, Has dentures but does not have here. R5's Nutritional assessment dated [DATE], indicated R5, Has dentures but does not have here. Ebenezer Oral Exam dated 4/8/22, indicated, Resident preference is not to wear dentures and no more routine dental appointment. Ebenezer Oral Exam dated 7/12/22, indicated, Resident states lower denture is causing her some discomfort and would like to see a dentist. Will forward her request for dental visit when available. There was no evidence in the medical record of follow-up for a dental appointment. R5's Appletree Dental Consent dated 11/26/21, indicated, Plans to refuse all dental services. There was no evidence the service was offered again. When interviewed on 10/24/22, at 3:39 p.m. R5 stated she had some pain when she wore her dentures, and they did not fit well and could not wear them but would like to. R5 stated she had told staff, but staff reported back to say she would have to wait as the dental service did not have a opening. During observation on 10/24/22, at 3:39 p.m. R5 was not wearing dentures. When interviewed on 10/26/22, at 10:21 a.m. licensed practical nurse (LPN)-A stated the process for a resident to obtain dentures was the nurses report the need to the in-house healthcare provider, and the provider would write an order to see the dentist. The LPN-A stated the health records team was in charge of scheduling the appointments. The LPN-A further stated each resident gets an oral exam by nursing annually to assess for changes. When interviewed on 10/26/22, at 10:53 a social worker (SW)-A stated the facility did not currently have dental services available, and the director of medical records (DMR) was trying to find a new provider, but residents could go to an outside provider. When interviewed on 10/26/22, at 11:03 a.m. the director of medical records (DMR) stated he had not been notified R5 needed a dental appointment and he had no consent for the service on file. The DMR stated he had to have a consent on file to schedule an appointment, and then the HUCs would schedule it. The DMR said he could send R5 to an outside provider, but some providers were scheduled out to 2023. The DMR stated he would work on getting R5 on the list for a dental appointment. When interviewed on 10/26/22, at 10:48 a.m. the registered dietician (RD) stated she had assessed that R5 had no teeth but had not informed the SW or nursing staff R5 had no teeth and wound benefit from having teeth. The RD stated having dentures could prevent R5 from having chewing issues and that it was logical that she, rht RD, should have told someone. When interviewed on 10/27/22, at 08:56 a.m. SW-B stated the process to obtain dental services was for the clinical team to assess the need for dentures or a dental appointment. SW-B stated then, the nursing staff would ask the resident to sign a consent form, and then the appointment for dentistry could be scheduled. SW-B stated residents can change their minds, and if the resident initially declined in-house services, and then later wanted an in-house service, a consent would be obtained at the time of request or identified need. Additionally, SW-B stated If nursing assessed R5's dentures were broken, the nurse should have informed the provider on the clinical team, and then the provider could have written an order for the service. When interviewed on 10/27/22, at 10:10 a.m. RN-B stated if she assessed a need for dentures, she would inform the nurse manager, and e-mail the DMR to get the resident on the list for dental services, or may tell the DMR in person. RN-B stated she did not recall if she notified the DMR R5 needed hearing aids, and did not chart about it. RN-B stated she had not and would not normally document the communication to the DMR, but that it was possible she had not communicated the need. When interviewed on 10/27/22, at 10:19 a.m. the director of nursing (DON) stated she expected nursing staff to assess for change, and to refer to the required services. The DON further stated if a nurse assessed a need that a resident previously declined, she expected staff to re-approach the resident who previously declined the service to ask again for the consent, and document the response. The Dental and Dentures Policy dated 10/2017, indicated upon admission, annually, and with significant change of condition and as needed Ebenezer Oral Exam would be completed by licensed staff on each resident, and any changes or issues would be addressed with the resident and/or resident representative. The policy further stated if dentures were broken, chipped, or ill-fitting the nurse will promptly refer the resident to dental services within three days.