**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 5 resident (R43's) plan of care included a sleep assessment and sleep monitoring/tracking to ensure R43 was attaining or maintaining R43's highest mental, physical and pyschosocial well-being. R43 is receiving Melatonin for sleep and did not have a sleep assessment/tracking completed. Findings Include: R43 was admitted to the facility on [DATE] with diagnoses that include, in part: Insomnia and Anxiety Disorder (A mental health condition that causes excessive and uncontrollable fear or worry). R43's physician orders include, in part: Melatonin 6mg (milligrams) by mouth at 5:00 PM for sleep aide. Order start date: 11/25/24. Surveyor requested a policy on sleep assessments/tracking and R43's sleep assessment and monitoring documentation. No sleep assessment/tracking for R43 was provided to the surveyor. On 1/16/25 at approximately 2:44 PM Surveyor interviewed NHA A (Nursing Home Administrator) who indicated they did not have a sleep assessment policy and that a sleep assessment should have been completed for R43.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident (R) with hearing impairment received proper treatment and assistive devices for 1 (R31) of 12 residents reviewed for hearing. R31's follow-up appointment(s) to address hearing loss were not scheduled by the facility and therefore hearing aides were not obtained. Findings Include: R31 was admitted to the facility on [DATE] with diagnoses that include, in part: Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Vascular Dementia (a type of dementia that occurs when blood flow to the brain is reduced or blocked), Anxiety (A mental health condition that causes excessive and uncontrollable fear or worry), and Impacted Cerumen, bilateral (A buildup of earwax that can cause pain, hearing loss, and other symptoms). R31's most recent Quarterly MDS (Minimum Data Set), target date 11/21/24, indicates a BIMS (Brief Interview for Mental Status) of 12, indicating R31 is cognitively intact. On 1/14/25 at 11:09 AM, Surveyor interviewed R31 during the initial screening process. R31 indicated a few months ago a doctor at a clinic told him he needed hearing aids, but he has not heard anything more. R31 indicated he told his guardian and a facility staff member, but could not remember who or when, and no one has followed-up with him. On 1/16/25 at 8:32AM Surveyor interviewed RN E (Registered Nurse) who indicated she was not aware of R31 going out to the doctor or seeing a provider in house at all since she started. (Of note, RN indicated she was an agency nurse and then took a permanent position in October 2024 with the facility.) RN E indicated that if R31 had notes from a provider they would be scanned into the computer. RN E indicated they look at the after visit summary and sign off on it and then it gets scanned into the computer. If the actual physician note doesn't come back with the resident they call to get it and then the floor nurse should review it. RN E indicated she was not sure if the DON (Director of Nursing) or anyone else reviews it, but that her thought process is that the DON would review it too. On 1/16/25 at 10:00 AM, Surveyor interviewed HUC F (Health Unit Coordinator) who indicated that if a resident returns from a provider visit and there is nothing in the packet they would call and ask for the report. HUC F indicates she does a lot of these calls but the nurses do too. HUC F indicated once they have the report, she makes sure there is no appointment needed. If they are supposed to have an appointment she would call the department and see who the resident should see and set it up. HUC indicated if she is unable to make the appointment right away she keeps a copy of the note in her basket until it's scheduled. HUC indicated that for R31, the ENT (Ear, Nose and Throat) appointment must have been missed. On 1/16/25 at 9:44 AM IDON B (Interim Director of Nursing) approached surveyor with information regarding R31's appointment. IDON B provided an audiology report for R31 dated 5/31/24 that included the following information, in part: Reason for Consult: Hearing Loss Date of Consult: 5/31/24 Orders: Binaural Amplification (Hearing Aides). Insurance will be reviewed. Prior Auth obtained. Hearing Aides will be ordered. Expect a month + wait. The document is signed by the audiologist. A received date of 5/31/24 is handwritten at the bottom with initials and a note that indicates, in part: needs to see ENT (Ear Nose and Throat) need medical clear. Then go back to Audiologist. IDON B indicated that R31's POAHC (Power of Attorney for Healthcare) had disengaged, and guardianship was pursued in July 2024. During this time R31's insurance coverage had lapsed and the facility had been working with the guardian to get that completed. IDON B also provided a ENT note from 6/19/24 that indicates, in part: Patient was initially scheduled for impacted cerumen. Per outside records, audiogram had been done after cerumen impaction was cleared and he had asymmetric hearing loss .Ears were examined showing patent canals and normal TM's (Tympanic Membranes-a thin, semi-transparent membrane that separates the outer ear from the middle ear.) We will plan to reschedule a virtual visit at some point in the future when his activated power-of-attorney can consent and they or a caregiver can attend. Surveyor asked IDON B what her expectation would be for a resident whose record indicates he was in need of hearing aides back on 5/31/24. IDON B indicated that R31 did not have a payor source. Surveyor asked IDON B, if surveyors had not asked about this, how would anyone have known this needed to be scheduled. IDON B indicated she could not answer this and that if this was pending on a schedule that the HUC has, she did not know. Surveyor asked IDON B if she would have expected the appointment(s) to be made once the payor source was in place. IDON B indicated she would.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure each residents medication regimen was free of unnecessary psychotropic medications for 1 of 5 Residents (R16) reviewed for unnecessary medications. R16's physician orders include, in part: Lorazepam (a psychotropic medication used for anxiety) 0.5mg every 2 hours as needed with a start date of 7/12/24. There is no evidence of a documented end date or provider rational for extending beyond 14 days. Evidenced by: The facility policy entitled Guidelines for Safe Administration and Management of Medications, undated, states, in part: . PURPOSE: Safely and accurately administer oral medications. Medications encompass substances used for their pharmacological effects in diagnosing, treating, or preventing illnesses, including both over the counter and prescription items. Establish secure procedures for acquiring, storing, distributing, utilizing, and disposing of drugs and biologicals. PROCEDURE: . I. Psychoactive Medications (also known as psychotropic drugs are substances that alter the brain's chemistry to treat mental health conditions): . g. As needed (PRN) orders for psychotropic drugs are limited to 14 days. If the attending physician believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she needs to document their rationale in the resident's medical record & indicate the duration for the PRN order . R16 was admitted to the facility on [DATE] and has diagnoses that include dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). R16's Minimum Data set (MDS) Quarterly Assessment, dated 11/5/24, shows that R16 has a Brief Interview of Mental Status (BIMS) score of 10 indicating R16 has moderate cognitive impairment. R16's Physician Progress Note, dated 1/3/25, shows order for: Lorazepam 2 mg/mL(milligrams)/(milliliters) Oral Concentrate: 0.5mg PO (by mouth) every 2 hours PRN agitation, anxiety, dizziness. Start: 7/12/24 . No Stop Date R16's Psychotherapeutic Quarterly Medication Review, dated 11/20/24, states, in part: . Date: 7/12/24 Medication & Dose: Lorazepam 0.5 mg Every 2 hours PRN Diagnosis: Severe Anxiety, unable to take PO (by mouth) . On 1/17/25, at 1:34 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked, for a PRN psychotropic medication should there be a stop date of 14 days with a re-evaluation or if it extends 14 days a rationale. NHA A indicated yes. Surveyor asked if R16's lorazepam PRN order that was ordered 7/14/24 was re-evaluated after 14 days. NHA A looked and came back to inform Surveyor she could not find one. Surveyor asked if R16's PRN Lorazepam order should have a stop date and NHA A indicated yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure routine dental care was provided to 1 of 3 sampled residents (R12). R12 reported her dentures were ill-fitting. The facility did not assist R12 in making an appointment or arrange transportation to and from the dental services location. The facility did not promptly, within 3 days, refer R12 for dental services. The facility did not document the extenuating circumstances that led to the delay. Evidenced by: Facility policy, titled Oral Care, undated, includes: . Residents can access regular and emergency dental care from their chosen dentist or local practitioner . Transportation is provided by Nursing Home or family, with assistance available, if needed . The nursing department arranges emergency dental care if the resident's regular dentist is unavailable . Any abnormal findings such as . ill fitting dentures . are documented by the nurse and the health care team is informed . Facility will provide access to dental services as appropriate If dentures are broken or chipped or if there is a problem with dentures fitting, the nurse will refer to dental services within 3 days . R12 admitted to the facility on [DATE]. Her most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 11/26/24, indicates R12's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. On 1/16/25 at 10:36 AM R12 apologized for not having her dentures on when Surveyor began to interview. R12 indicated she must remove her denture when she is not eating due to her dentures not fitting causing pain and canker sores to develop. R12 indicated she has talked to several staff about her dentures not fitting and staff say there is not a dentist in the area that will take Medicaid. R12 indicated she is not able to pay out of pocket for a dentist in the area. R12 stated, I would go to [NAME] if I had to. R12 indicated she would like the facility to look outside of the area for dental services to address her ill-fitting dentures. R12's Speech Language Pathologist Note, dated 11/22/24m includes: . Oral mechanism exam revealed ill-fitting lower denture that R12 reported is painful . Chewing was extended due to the pain . R12 is perceived to require softer foods in order to manage nutritional intake secondary to her painful bottom denture . R12's Registered Dietician Note, 11/29/24, includes: current body weight:106.231 kg (234 pounds) 1 month (10/26/24): 108.409 kg (238 pounds); 4 pound weight loss in 1 month 3 months (8/26/24): 111.697 kg (246 pounds); 12 pound weight loss in 3 months On 1/16/25 at 10:41 AM RN D (Registered Nurse) indicated if a resident reports ill-fitting dentures she would tell the office personnel to make her a dental appointment. RN D indicated R12 puts her dentures in only for meals due to them causing pain and discomfort and management is aware. On 1/16/25 at 10:44 AM Interim DON B (Director of Nursing) indicated ill-fitting dentures could contribute to weight loss and pain. DON B indicated she was aware R12 had complained about her dentures not fitting as Resident Care Coordinator C had reported this to her. On 1/16/25 at 10:50 AM Resident Care Coordinator/RN C indicated she was aware R12 was experiencing pain and discomfort related to her ill-fitting dentures. Resident Care Coordinator/RN C indicated R12 uses polygrip to hold the dentures in place while she eats and then removed the dentures when it is not meal time due to the pain and discomfort caused by the ill-fitting dentures. Resident Care Coordinator/RN C indicated there is no dentist in town that will accept Medicaid and R12 would have to go all the way to [NAME] for dental appointment. On 1/16/25 at 10:53 AM NHA A (Nursing Home Administrator) indicated the town is a dental desert when it comes to accepting Medicaid. NHA A indicated the facility has tried to get dental service companies to come into the building but have not been successful. NHA A stated, We are not finding a dentist in the area that will take Medicaid and R12 would have to go to [NAME]. NHA A indicated the facility has not offered to transport or make an appointment for R12 in [NAME]. (It is important to note R12's medical record had no indication which dentists were called or any information on efforts made by the facility to get R12 an appointment and transportation when becoming aware R12's dentures were ill-fitting causing her pain and discomfort.)