CITY PARK HEALTHCARE AND REHABILITATION CENTER

A complaint survey prompted by #CO36182 was conducted on 5/28/24. No deficiencies were cited.

A revisit survey was completed on 5/3/24 for all previous deficiencies cited on 3/18/24. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO34868 and Incident #CO35052 was completed on 3/13/24 to 3/18/24. One deficiency was cited.

Based on interviews and record review, the facility failed to ensure one (#1) of three residents was free from abuse out of six sample residents. Specifically, the facility failed to prevent and protect Resident #1 from verbal abuse by a staff member who yelled and cursed at Resident #1. Findings include:I. Facility policy and procedureThe Abuse and Neglect policy and procedure, revised 9/30/22 and 1/16/23 (after the incident with Resident #1), was provided by the nursing home administrator (NHA) on 3/13/24 at 2:44 p.m. by email. It revealed in pertinent part,"Each resident has the right to be free from abuse, neglect, misappropriation of property, exploitation, involuntary seclusion, and physical or chemical restraints imposed for the purpose of discipline or convenience not required to treat the resident's medical symptoms. Residents will not be subjected to abuse by anyone, including staff (to include agency or contract vendors), residents, volunteers, consultants, family members or legal guardians, friends, or any other individuals. "Verbal abuse"The use of oral, written, or gestured language that willfully, consciously or with understanding is certain to cause harm and includes disparaging and derogatory terms to residents said within their hearing distance, regardless of their age, ability to comprehend, or their disability. Some examples of verbal abuse include threats of harm, saying things to frighten a resident such as telling a resident that he/she will never be able to see his/her family again, or using profanity to insult or scold a resident."II. Facility investigationOn 12/10/23 at approximately 1:00 p.m., Resident #1 went to a door outside the facility's main kitchen and knocked. Resident #1 went to the kitchen to request bread which was not provided on his lunch tray. The dietary cook (DC) opened the door to the kitchen, yelled profanity at the resident and told him "I'm going to shove a bread up your 'expletive.'" The incident was witnessed by other staff members. Resident #1 was interviewed and said after the DC yelled at him he became afraid, he was afraid he would be beaten up by the DC. Resident #1 said he quickly went back to his room after the incident. The social service director (SSD) progress note on 12/13/23 at 8:24 a.m. (three days after the incident) revealed she visited the resident for a mood check and he said he was okay. -There was no documentation Resident #1's representative, who was the power of attorney (POA), was called after the incident. III. Resident statusResident #1, age under 65, was admitted on 8/19/22. According to the March 2023 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus, major depressive disorder, post-traumatic stress disorder (PTSD), seizures and chronic pain syndrome. The 12/11/23 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) of 11 out of 15. He required supervision or touch assistance with showers, toilet use and personal hygiene. He was independent with eating. He used a front wheel walker to ambulate. He did not reject care from staff. IV. Resident and representative interviewOn 3/18/24 at 9:45 a.m. the resident refused to be interviewed about the incident on 12/10/23. Resident #1's representative was interviewed on 3/18/24 at 3:10 p.m. He said he was the resident's legal POA. He said no staff from the facility called him to report the incident in December 2023. He said he wished the facility had called him because when he spoke to the resident over the phone it helped the resident be calm. He said Resident #1's son moved out of state. He said he was the only family member in the state. He said before the incident, the facility had called him to explain things to the resident and it always helped. V. Record reviewThe 11/6/23 comprehensive care plan revealed Resident #1 had communication problems at times. His primary language was Ethiopian-Amharic. He was able to understand and speak English but struggled with some word finding in English. When he got frustrated when he tried to communicate, the facility was to call his representative to interpret or if the representative was not available, the facility was to call an interpreter line (see representative interview above). The Preadmission Screening and Resident Review (PASARR) Level II for post-traumatic stress disorder revealed the resident had a history of PTSD from being a police officer in Ethiopia during civil unrest and was ambushed and beaten by soldiers. He was in an African refugee camp. He perseverated on being attacked/beaten. To alleviate symptoms of trauma, the resident could talk to his representative over the phone for a coping strategy. Resident #1's identified trauma trigger was being spoken to in an accusatory manner. VI. Staff interviewsThe housekeeper (HSK) was interviewed on 3/18/24 at 1:45 p.m. The HSK said she and another housekeeper had stepped out of the elevator on 12/10/23 around lunchtime and heard the DC screaming at Resident #1. She said both housekeepers watched the DC yell at Resident #1. She said the DC was screaming profanity over and over at Resident #1. She said she heard the DC say that he was going to shove bread up Resident #1's (expletive). The DC was interviewed on 3/18/24 at 2:00 p.m. The DC said he only worked in the facility on Sundays and Mondays. He said he was helping cook in the kitchen on 12/10/23. He said Resident #1 banged on the door to the kitchen because he wanted bread. He said it was lunch time. He said Resident #1 "was a special case, who needed extra attention and was the problem child." He said he opened the door and yelled at Resident #1 and he said he yelled profanity. The DC said he told Resident #1 he was going to shove a loaf of bread up his (expletive). He said another dietary staff member came out of the kitchen while he was yelling and brought Resident #1 bread. The DC said he knew he should not have screamed at Resident #1. He said the incident occurred around 1:00 p.m. on Sunday 12/10/23 and he said he continued to work until the end of his shift at 6:00 p.m. He said he was told by the assistant dietary manager (ADM) on 12/10/23 at about 6:00 p.m., that he was suspended the next day. He said the NHA at the time called him on Wednesday 12/13/23 to ask him about the incident. He said the NHA asked him about the facts only. The DC said he did not receive an education about abuse at that time or any time after the incident. He said the NHA left him a voicemail on Friday 12/15/23 to come into work on the upcoming Sunday, 12/17/23. He said he did not know that Friday 12/15/23 was the NHA's last day to work in the facility. He said he worked Sunday 12/17/23 for a full shift and returned to work on Monday 12/18/23. He said at about 1:00 p.m. on Monday 12/18/23 he was told to go to the human resource (HR) office where he was notified he was fired. The dietary manager (DM) was interviewed on 3/18/24 at 2:20 p.m. The DM said Resident #1 liked two pieces of white bread with breakfast, lunch and dinner. He said he was not at work the day the DC yelled at Resident #1. He said from what he learned when he spoke to his employees in the kitchen, there was bread in the freezer on 12/10/23 but it was not put on the resident's food tray. He said that was why the resident came to the kitchen to get two slices of bread. The DM showed Resident #1's daily meal cards for the dining room staff to follow. The daily meal cards revealed the resident was to have two slices of bread with every meal. The DM said everyone who worked in the kitchen knew to make sure Resident #1 had his two slices of white bread with every meal. He said he had never seen the DC get angry at any residents before the incident with Resident #1. The ADM was interviewed on 3/18/24 at 2:45 p.m. The ADM said she worked on 12/10/23 and heard the DC yell at Resident #1. She said Resident #1 knocked on the kitchen doorover and over. She said she heard the DC cuss at Resident #1. She said he cursed at the resident a lot. She said Resident #1 said he just wanted bread. She said she was afraid to step in and stop the DC from yelling because of how angry she felt the DC was. The ADM said she called the DM to help her with what to do with the DC. She said when the DC's shift was over she told him he was not to return to work on Monday 12/11/23. Licensed practical nurse (LPN) #1 was interviewed on 3/18/24 at 3:00 p.m. LPN #1 said Resident #1 always had bread three times a day. She said he had two slices of bread with each of his three meals. Certified nurse aide (CNA) #1 was interviewed on 3/18/24 at 3:05 p.m. CNA #1 said Resident #1 had two slices of white bread every day, not toasted, for breakfast, lunch and dinner. She said the nursing staff all knew to never miss his bread with all three meals. The NHA was interviewed on 3/18/24 at 3:30 p.m. She said she had only worked in the facility for less than two weeks. She said Resident #1's representative was not called after the incident because the resident was his own POA. She said all the documentation the facility had about the incident in December 2023 was provided during the survey. The interim nursing home administrator (INHA) was interviewed on 3/18/24 at 2:35 p.m. The INHA said she was brought in by the facility's corporation to be the INHA on 12/18/23. She said after the incident with the DC and Resident #1 on 12/10/23 she was at work in the corporate office and was alerted to the incident. She said she told the former NHA to terminate the DC and not to let him return to the facility to work. She said when she arrived on 12/18/23 someone informed her that the DC was in the building. The INHA said she had the DC go to the HR office where he was immediately terminated. The INHA provided abuse in-service training which was provided to staff on 1/18/24 (over one month after the verbal abuse incident) and 2/16/24 -2/21/24. The INHA said the training did not happen for more than a month after the incident. She said there was no abuse education documented for the facility staff after the incident except to the two housekeepers who witnessed the 12/10/23 incident. She said there was no documentation that the dietary staff had abuse training after the incident until over a month later. The INHA said there was no documentation that the former NHA educated the DC before he returned to work.

A revisit to the 1/11/2024 survey was completed on 3/7/2024. The facility was in compliance with the regulations surveyed.

A complaint survey, prompted by #CO34511 was conducted on 12/27/23 to 1/11/24. Three deficiencies were cited.

Based on observations, interviews and record review, the facility failed to ensure residents and or their representatives were provided prompt efforts by the facility to resolve grievances for three (#1, #2 and #3) of three residents out of three sample residents. Specifically, the facility failed to address, resolve, document and follow up on grievances for: -Resident #1 regarding missing medications, call light wait times and schedule to ensure he arrived to dialysis timely;-Resident #2 regarding the staff getting him out of bed, call light wait times and providing showers; and,-Resident #3 regarding extended call light wait times. Findings include:I. Facility policy and procedureThe Grievances policy, revised November 2016, was received on 1/11/24 at 3:00 p.m. from the nursing home administrator (NHA). The policy documented in pertinent part, "Within three days of receipt of an verbal or written grievance, the Grievance Officer or designee, will give a written explanation of findings and proposed remedies, if any, to the complainant and to the aggrieved party, if other than the complainant. An oral explanation will be provided, along with the written statement whenever possible."II. Resident interviewsResident #1 was interviewed on 1/10/24 at 11:50 a.m. Resident #1 said he had reported concerns with extended call light times over one and a half hours long to the director of nursing (DON) and NHA multiple times. He said the concern had not been addressed and he had received no follow up from the DON or NHA.Resident #1 said he had been out of one of his kidney failure medications,Velphoro, for several weeks. He said the nurse on duty and the DON were aware but he had received no follow up about when the medication would be available (cross reference F760 significant medication errors). Resident #1 said he had dialysis three times per week. He said he was frequently late to dialysis. Resident #1 said the night shift was supposed to get him ready and dressed, and the day shift was supposed to put him in his chair at 6:30 a.m. He said the day shift did not get him in his chair by 6:30 a.m. The resident said the DON was aware of his concern, but there had been no resolution (cross reference F698 dialysis). Resident #1 was interviewed again on 1/11/24 at 3:27 p.m. He said the social worker had come to his room today (1/11/24) and told him he was not allowed to leave messages on the staff's voicemail with his concerns. She handed him several concern forms and told him he needed to fill out a form if he had a concern. Resident #2 was interviewed on 1/10/24 at 12:48 p.m. He said he had reported concerns about extended call light wait times for over an hour to the nurses on duty and the social worker. He said he had not heard any follow up on his concern. Resident #2 said the nursing staff would refuse to get him out of bed, put him back to bed timely, or give him a shower. He said he had reported his concerns to the nurse on duty and the DON. He said there had been no improvement to his concerns. Resident #3 was interviewed on 1/10/24 at 1:22 p.m. He said he had reported concerns with call light wait times up to one and a half hours long to the nurse on duty. He said he had not seen any improvement to the extended call light wait times. IV. Record reviewGrievance concern forms were requested from the NHA on 1/11/24 at 1:11 p.m. related to the concerns above for Residents #1, #2 and #3. -No grievances or concern forms were received by the end of the survey on 1/11/24. Grievance concern forms were requested from the DON on 1/11/24 at 1:51 p.m. related to the concerns above for Residents #1, #2 and #3. -No grievances or concern forms were received by the end of the survey on 1/11/24. On 10/15/23 at 10:56 p.m., a nursing progress note documented Resident #2 went to the second floor and told the nurse he had been waiting since 7:00 p.m. to be put to bed. The second floor nurse called the 3rd floor where the resident lived but there was no answer. The second floor nurse went to the 3rd floor and informed the 3rd floor nurse the resident had been waiting to go to bed. On 10/23/23 at 12:56 p.m. the social service note documented that Resident #2 had concerns with showers, receiving timely care and feeling his needs overall were being ignored. The SW informed the nurse manager.-However, there were no grievances or concern forms completed for Resident #2's concerns. IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 1/10/24 at 12:31 p.m. She said she was the nurse for Resident #1. LPN #1 said the resident had been out of his Velphoro medication for a few weeks. She said she did not know if his primary physician was aware. She said the DON was aware. LPN #1 said she had not followed up with the resident regarding the progress on obtaining his medication. LPN #1 said she had worked with Resident #1 during the night shift and day shift. She said she was aware of his concerns with extended call light wait times. She said sometimes he called frequently with his call light for assistance and sometimes he did not. She said he was very "picky" and liked things done a certain way. She said, as an example, Resident #1 liked the books in his room organized in a certain order. LPN #1 said the resident had expressed concerns with being late for dialysis. She said Resident #1t did not want to get up in his wheelchair before 6:30 a.m. and when the day shift arrived they would get caught up in rounds and not get him up on time. Certified nurse aide (CNA) #1 was interviewed on 1/10/24 at 1:40 p.m. CNA #1 said Resident #2 and Resident #3 had both expressed concerns to her about extended call light times, especially on the night shift. The DON was interviewed on 1/11/24 at 1:51 p.m. She said she was aware of Resident #1's missing medication, Velphoro. She said she was waiting on prior authorization from the insurance provider for the medication. The DON confirmed the resident had not had the medication in several weeks. She said "we dropped the ball" and too much time had gone by that the resident had not had the medication. She did not know if anyone had followed up with the resident regarding his concern of not having the medication. The DON said she had call light concerns reported to her from Resident #1 and Resident #2 in the past. She thought it was several months ago. She said she did not know if she had grievances reports with follow up regarding call lights. She said she would look. The DON said she was aware of Resident #1's concerns with having been late to dialysis. She said it was the resident that caused the problem. She said he always wanted one more thing done before he could get in his chair. She said 6:30 a.m. was at shift change for the nursing staff and they could not get him up at that time. The DON said she had no grievance report for Resident #1 indicating follow up or attempts to resolve the issue. The DON said she was aware of Resident #2's concerns with not getting out of bed, or being put back to bed timely, as well as his concern with call lights. She said it was a couple of months ago and did not realize it was still a concern. She said she did not have a grievance report on his concerns. The NHA was interviewed on 1/11/24 at 2:38 p.m. She said she started a few weeks ago and had identified grievance reports were not being completed. The NHA said she had not had a chance to put a corrective plan in place yet. She said if a resident had a concern the staff should complete a grievance form for them. She said a copy went to the NHA and to the department head responsible. She said the department responsible then had 72 hours to investigate the concern and respond back to the resident with possible solutions. She said she did not have grievances for Residents #1, #2 or #3, or call lights. The NHA said she had identified that the majority of concerns reported seemed to come from her night shift and she would plan to come in on that shift to observe what was happening.

Based on observations, record review and interviews, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one (#1) of three residents reviewed for dialysis out of three sample residents. Specifically, the facility failed to ensure Resident #1 was ready to leave the facility timely in order to get to dialysis to receive all ordered dialysis treatment. Findings include:I. Facility policyThe Dialysis Care policy, revised 7/12/23, was received on 1/11/24 at 3:00 p.m. from the nursing home administrator (NHA). The policy documented in pertinent part, "Coordination of dialysis care will include communication about care concerns and appropriate interventions, if dialysis is postponed or canceled the provider will be notified."II. Resident statusResident #1, age less than 65, was admitted on 6/18/19 and readmitted on 11/15/23. According to the January 2024 computerized physician orders (CPO), diagnoses included end stage renal disease. The 11/24/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required setup assistance with personal hygiene, parietal to moderate assistance with toileting and bed mobility. He required substantial maximum assistance with transfers. The assessment documented the resident was on dialysis. III. Resident interviewResident #1 was interviewed on 1/10/24 at 11:50 a.m. Resident #1 said he had dialysis three times per week. He said he was frequently late to dialysis. Resident #1 said the night shift was supposed to get him ready and dressed, and the day shift was supposed to put him in his wheelchair at 6:30 a.m. He said the day shift did not get him in his chair at 6:30 a.m. IV. Record reviewThe January 2024 CPO documented the resident had physician orders dated 5/25/2023 for dialysis on Tuesday, Thursday and Saturday at 12:10 p.m. The January 2024 CPO documented Resident #1 was to be gotten up by 6:00 a.m. by night shift staff for dialysis. -However, the resident's dialysis was scheduled to begin at 7:30 a.m. not 12:10 p.m. -The resident did not want to sit up in his chair earlier than 6:30 a.m. Dialysis communication records for Resident #1,dated 12/19/23 and 12/26/23, were reviewed on 1/11/24. Both records documented the resident was late for dialysis. The dialysis care plan, initiated 2/26/2020, documented the staff was to ensure the resident was ready for dialysis at 6:30 a.m. On 12/18/23 at 2:43 p.m., the social services progress note documented the resident was non- compliant with his dialysis pick up time. -However, according to a staff interview, the resident did not want to wait for extended periods of time sitting up in his wheelchair for transport to dialysis and the staff frequently got caught up in their rounds and did not have him ready at 6:30 a.m. V. Additional interviewsLicensed practical nurse (LPN) #1 was interviewed on 1/10/24 at 12:31 p.m. lpn #1 said the resident had expressed concern with being late for dialysis. She said the resident did not want to get up in his wheelchair before 6:30 a.m. and when the day shift arrived they would get caught up in rounds and not get him up on time. The director of nursing (DON) was interviewed on 1/11/24 at 1:51 p.m. The DON said she was aware of Resident #1's concerns with having been late to dialysis. The DON said the nursing staff told her it was the resident that caused the problem. She said the nursing staff told her Resident #1 always wanted one more thing done before he could get in his chair. She said 6:30 a.m. was at shift change for the nursing staff and they could not get him up at that time. The DON said she had not spoken to the resident about the problem and did not know what his story version was regarding being late. The DON said she had not heard the nursing staff got caught up in their rounds and did not get Resident #1 up timely. The dialysis center clinical manager (DCM) was interviewed on 1/11/24 at 11:20 a.m. She said the resident had dialysis three times per week on Tuesday, Thursday and Saturday at 7:30 a.m. She said Resident #1 was late for almost every session. The DCM said this resulted in the resident having to be taken off dialysis before he had a full session because he started late. The DCM said this meant the resident missed about one and a half hours per week of dialysis. She said receiving the full dialysis time was critical to the resident's health. The DCM said with a shortened dialysis time Resident #1 was not getting enough fluid, chemicals and waste pulled off of his body. She said this could lead to significant issues with his heart and breathing and lead to increased hospitalizations.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents out of 3 sample residents did not experience a significant medication error. Specifically, the facility failed to ensure that Resident #1 received all doses of his prescribed kidney failure medication, Velphoro, which resulted in a significant medication error of omission. Findings include:I. Facility policyThe Medication Administration policy, dated 7/25/19, was received on 1/11/24 at 3:00 p.m. from the nursing home administrator (NHA). The policy documented in pertinent part, "Medications will be administered in accordance with written orders authorized by the attending physician."II. Resident statusResident #1, age less than 65, was admitted on 6/18/19 and readmitted on 11/15/23. According to the January 2024 computerized physician orders (CPO), diagnoses included end stage renal disease. The 11/24/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required setup assistance with personal hygiene, parietal to moderate assistance with toileting and bed mobility. He required substantial maximum assistance with transfers. The assessment documented the resident was on dialysis. III. Record reviewThe January 2024 CPO revealed the following:On 2/13/23 at 4:00 p.m. the resident had an order for Sucroferric Oxyhydroxide (Velphoro) tablet chewable 500 mg (milligram). Give two tablets by mouth three times daily. On 12/28/23 at 5:19 p.m. there was an order to hold the Velphoro because prior authorization was needed. The order listed the start date as 12/28/23 and the end date as 12/31/23. The January 2024 CPO no longer listed an order to hold the medication because the order to hold the medication had ended on 12/31/23. The December 2023 medication administration record (MAR) documented the last time the resident received the medication was 12/24/23, four days prior to the order to hold the medication. IV. InterviewsResident #1 was interviewed on 1/10/24 at 11:50 a.m. He said he had been out of one of his kidney failure medications,Velphoro, for several weeks. He said the nurse on duty and the DON were aware but he had received no follow up about when the medication would be available. Licensed practical nurse (LPN) #1 was interviewed on 1/10/24 at 12:31 p.m. LPN #1 said she was the nurse for Resident #1. LPN #1 said the resident had been out of his Velphoro medication for a few weeks. She said she did not know if his primary physician was aware. Looking at her laptop and the resident's orders, she said there was no order to hold the medication. She said the DON was aware. The DON was interviewed on 1/11/24 at 1:51 p.m. She said she was aware of Resident #1's missing medication Velphoro. She said she was waiting on prior authorization. The DON confirmed the resident had not had the medication in several weeks. She said "we dropped the ball" and too much time had gone by that the resident had not had the medication. The DON said she did not know if the medication was at the facility yet. She said the facility had obtained an order to hold the medication from the primary physician on 12/28/23 while prior authorization was obtained. However, she said that order was to have ended as of 12/31/23 (see record review above). The dialysis center clinical manager (DCM) was interviewed on 1/11/24 at 11:20 a.m. She said she was concerned the resident had not been getting the phosphorus binding medication, Velphoro. The medication removed excess phosphorus from the blood. The DCM said dialysis did not remove phosphorus from the blood like the kidneys. She said the phosphorus would build up in the blood and act as a toxin affecting all the other electrolytes. The DCM said the build up of phosphorus would lead to muscle cramps and pain, bone breaks, joint pain, itching of the skin and many other problems. She said the resident was supposed to take it three times per day. The DCM said the resident reported he had not received the medication for several weeks and the facility said they were waiting on a prior authorization. The DCM said she and several other staff members at the dialysis center had sent the facility the prior authorization multiple times. The DCM called regarding the phosphate level results after the survey exit on 1/18/24 at 9:08 a.m. She said the resident's phosphate level on 12/14/23 was 2.6 mg/dL (milligrams per deciliter). The DCM said on 1/11/24 the phosphate level was 6.0 mg/dL. She said the phosphate level should be less than 5 mg/dL which was the high end of an acceptable range. The DCM said the elevated phosphate level was a result of Resident #1 not receiving the Velphoro. V. Facility follow upOn 1/10/23 at 12:02 p.m. a nursing progress note documented the medication would be sent to the facility as of that date, according to the pharmacy.

A revisit to the 10/12/23 survey was completed on 12/28/2023. The facility was in compliance with the regulations surveyed.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID Prefix Tag # K 000), are informational only and a representation of the facility's general characteristics. This survey conducted November 6, 2023 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies." The facility was constructed in 1964 and is licensed for 125 beds. This structure is a six (6) story, Type I (332) construction with no basement and fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system. The facility is classified as fully-sprinklered. The facility is currently utilizing Time Limited Waiver for tag K521, Evaporative Cooler Plenum Space Supply in the Corridor. The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the exit access doors so that exits are readily accessible at all times in accordance with Life Safety Code 101 Section 7.2.1.4.5. This deficient practice could affect residents, staff and visitors within the facility if the Means of Egress is not maintained throughout the facility. This was evidenced by the following:Kitchen double doors used as an exit opening into the corridor found screwed shut and would not open. Life Safety Code 101 Section 7.2.1.5.1. Door leaves shall be arranged to be opened readily from the egress side whenever the building is occupied. The Maintenance Director acknowledged the condition of the door during the time of the tour.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected areas in accordance with Life Safety Section 19.3.2.5. This deficient practice could affect all residents and staff in the main smoke compartment including the kitchen should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidence by the following. Doors used as an opining protective for hazardous area requiring 1-hour separation between the main corridor and kitchen were not equipped with a self-closing device. 19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4. The Director of Maintenance acknowledged the area enclosures and door condition during a tour of the facility.

STANDARD not met: Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain the transfilling of oxygen from one cylinder to another in accordance with NFPA 99 - Health Care Facilities, 11.5.2.3. This deficient practice could affect all residents and staff within the facility should a fire emergency was to occur. The following evidenced this:The oxygen trans-filling room not mechanically ventilated correctly per NFPA 99. 9.3.7.5.3.1 Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction. 9.3.7.5.3.2 Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 cfm per 5 ft3 of fluid) designed to be stored in the space and not less than 24 L/sec (50 cfm) nor more than 235 L/sec (500 cfm). 9.3.7.5.3.3 Mechanical exhaust inlets shall be unobstructed and shall draw air from within 300 mm (1 ft) off the floor and adjacent to the cylinder or containers. The Director of Maintenance acknowledged the ventilation issue during a tour of the facility.

A recertification survey with complaint #CO32358, #CO32359 and Incident #33930 was completed from 10/9/23 to 10/12/23. Seventeen deficiencies were cited.

An Emergency Preparedness survey was conducted from 10/9/23 to 10/12/23. No deficiencies were cited.

Based on observation, record review and interviews the facility failed to ensure self-administration of medications was clinically appropriate for one (#39) resident out of 46 sample residents. Specifically the facility failed to:-Ensure Resident #39 was assessed for the appropriateness and safety of self-administration of oral medications; and,-Ensure there was a physician order for self-administration of oral medications. Findings include:I. Facility policy and procedureThe Medication- Self Administration policy and procedure, dated 2/24/14, received from the nursing home administrator (NHA) on 10/12/23 at 4:45 p.m. revealed in pertinent part "an assessment will be completed prior to self administering medications to ensure residents safety. If the nurse and/or interdisciplinary team (IDT) deems the resident safety and competent, a physician order will be obtained containing specifics about the medications itself and an order for the medication to be self-administered by the resident."The Medication Administration General Guidelines policy and procedure, dated 10/15/10, received from the NHA on 10/12/23 at 4:45 p.m. revealed in pertinent part, "Residents will be observed after medication administration to ensure the dose was completely swallowed."II. Resident #39A. Resident statusResident #39, age 79, admitted on 4/8/22. According to the October 2023 computerized physician orders (CPO), diagnosis included pneumonia (infection in the lungs), chronic obstructive pulmonary disease (air flow blockage), heart failure (decrease in the pumping mechanism of heart), myocardial infarction (heart attack), hypertension (high blood pressure), and gout (urea crystallization in the joints). The 7/20/23 minimum data set (MDS) revealed the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She required one person's assistance with dressing. Set up assistance with bed mobility and eating. She was independent with transfers, toileting and personal hygiene. B. Record reviewThe October 2023 CPO revealed Resident #39 had an order to self administer inhalers, eye drops, ear drops, topicals, nasal sprays/creams and could be stored at bedside ordered on 7/3/23. The medication self-administration safety screen dated 7/3/23 documented the following medications safe for resident to administer independently and be kept at bedside: Ventolin inhaler; Trellegy inhaler; Debrox ear solution; Biofreeze topical; Latanoprost eye drop. The 7/20/23 comprehensive care plan identified that the resident was safe to keep medication at bedside and be re-evaluated for self administration quarterly. C. ObservationsLicensed practical nurse (LPN) #1 was passing medication on 10/11/23 at 7:54 a.m. LPN #1 dispensed the following medications for Resident #39; Omeprazole (used for acid reflux); tylenol (pain medication); acidophilus (good gastrointestinal bacteria); Amoxicillin-Pot Clavulanate (antibiotic); aspirin (clot prevention); azithromycin (antibiotic); Furosemide (decrease fluid retention); losartan (decreases blood pressure); metoprolol (blood pressure reducer); senna (stool softener); and spironolactone (decrease fluid retention). LPN #1 entered Resident #39's room and handed the medication to the resident and left the room prior to the resident taking the medications. LPN #1 returned to medication cart and charted the Resident #39 took her medications. -None of the medications LPN #1 dispensed were approved in the physician order for self administration or to be kept at bedside (see order above). LPN #1 failed to observe Resident #39 take her oral medications. III. Staff interviewsLPN #1 was interviewed on 10/11/23 at 3:39 p.m. He said only residents who have been assessed to self administer medications could have medications left in their rooms. LPN #1 said medications could not be left with a resident as medications could be not taken, lost or another resident may get a hold of them and lead to complications. The director of nursing (DON) was interviewed on 10/12 23 at 2:41 p.m. She said residents were assessed with a self administration tool to prove they could safely self-administer medications. Medications should not be left in the resident room during medication pass as it places the risk of the resident not taking them or someone else taking them.

Based on observations, interviews, and record review, the facility failed to provide a clean, comfortable, homelike environment. Specifically, the facility failed to ensure resident rooms were clean to minimize odors and in good repair. Findings include:I. Facility policyOn 10/12/23 at 3:33 p.m. A request was made for the facility's home like environment policy, the nursing home administrator (NHA) said the facility did not have a homelike environment policy. II. Resident #100A. Observation and interviewsOn 10/9/23 at 3:01 p.m. Resident #100 was observed laying in bed with a bedpan containing feces. A trash can beside the bed contained multiple wipes stained brown matter. There were two urinals that were half full with urine hanging on the side of the waste basket. The room had the odor of urine and stool. On 10/10/23 at 10:53 a.m. to 4:10 p.m. Resident #100 was observed laying in bed. The bed pan was covered with brown paper towels and was on the resident's bed leaning against a pillow pushed against the wall. The resident has two urinals with one urinal completely full and the other half full. The room had the odor of feces and urine. Resident #100 was interviewed on 10/10/23 at 3:01 p.m. The resident said he kept the bed pan on his bed against the wall for easy access. The resident said he preferred the bedpan to be close to him in the event he needs to go "now." The resident said he used his call light to call for help with toileting but they take too long and he can not always wait for staff to arrive. The resident said he was not bothered by the smell and did not think his roommate was bothered by the smell either. Resident #100's roommate was interviewed on 10/10/23 at 3:15 p.m. The resident's roommate said he kept the curtain closed 100 percent of the time and he was not bothered by the odor because he had Lysol spray which he used to keep the odor down. On 10/11/23 at 7:47 a.m. Resident #100 was observed in bed with a soiled bed pan on the bed next to him; the waste basket was full of stool soiled wipes. The room had the odor of stool. -At 8:36 a.m. The resident's breakfast arrived. The certified nurse aide (CNA) delivering the resident's food emptied the resident's urinals but left the trash can full of the stool soiled wipes at the resident's bedside next to where he ate. The resident's room smelled of stool. -At 10:15 a.m., a housekeeper entered the resident's room to empty the waste basket after the resident had finished his meal. On 10/12/23 at 10:43 a.m. a housekeeper entered the resident's room to empty the trash can containing the soiled wipes but the urinals were not emptied. The urinals were left hanging on the side of the resident's waste basket. A staff member near the resident's room was notified by the housekeeper about the urinals. The staff member did not enter the resident's room. B. Staff interviews CNA #7 was interviewed on 10/12 23 at 11:42 a.m. CNA #7 said Resident #100 was very independent and used the urinal and bedpan on his own. CNA #7 said the resident could lift himself up to put the bedpan underneath him. CNA #7 said the resident would sometimes call staff to assist him with wiping. CNA #7 said she always cleaned the bedpan after use and flushed the wipes but returned the bed pan to the resident per his request. CNA #8 was interviewed on 10/12/23 at 12:15 p.m. CNA #8 said most CNAs respected the resident's independence and tried to keep up with cleaning the bedpan, urinals and emptying the waste baskets after he used them. However, some of the other CNAs did not touch the waste basket unless they were told to. The infection preventionist (IP) was interviewed on 10/11/23 at 3:40 p.m. The IP said staff should be emptying urinals routinely and empty the bed pan immediately after use. The IP said the bedpan should be removed from the resident's bed. The IP said if waste baskets were full of dirty wipes they should be emptied immediately and on a consistent basis. The director of nursing (DON) was interviewed on 10/12/23 at 3:25 p.m. The DON said it was the responsibility of all staff to create a homelike environment and immediately address cleaning needs. III. Resident #36A. Observations and interviewResident #36 was interviewed on 10/9/23 at 9:45 a.m. He stated he had rheumatoid arthritis and had difficulty holding things with his hands resulting in the condition of his room. The facility did not want to help him clean his room and he did not believe the staff wanted to come into his room. The holes in his walls were a result of hitting the wall with his electric wheelchair. During the interview on 10/9/23, food and debris were observed on the floor. A brown banana, a sandwich in a bag, garbage and clothes were on his floor by his bed and heater. Brown matter was observed on the toilet seat and floor of his bathroom. There was a urinal full of urine with a drinking cup full of urine on his bedside table. Several baseball size holes were observed in the walls when first entering the room. Staff came into the resident's room to clean it on 10/9/23 at 10:15 a.m. The resident's room was observed on 10/10/23 at 10:30 a.m. Garbage and food was observed on the resident's floor. What appeared to be brown matter was observed on the floor next to the resident's bed. A cup of urine and a urinal with urine were sitting on his bedside table. Brown matter was observed covering the toilet seat. The holes in the walls remained the same as from 10/9/23. Staff came into the resident's room to clean it on 10/10/23 at 10:45 a.m. and removed all the debris and brown matter. The cup of urine remained on his bedside table. B. Staff interviewRegistered nurse (RN) #1 was interviewed on 10/10/23 at 10:45 a.m. He stated the resident had no behaviors he was aware of. CNA #1 was interviewed on 10/10/23 at 11:20 p.m. She stated the resident could be verbally aggressive and agitated with the staff. He would allow staff to clean his room, but he would yell at the staff while it was being cleaned. The resident was not incontinent of bowel or bladder, smearing stools was a behavior of the residents. He required staff assistance to go to the toilet and transfer but he would try to do it on his own. He used to have a bedside commode but he did not want to use it. The DON was interviewed on 10/12/23 at 3:40 p.m. The DON stated the resident often would throw his urinal on the floor with urine inside of it. He would throw food and garbage onto his floor. He would allow one particular housekeeper to clean his room but would tell the other staff to leave. She said his room had to be cleaned daily and after the room was cleaned, the resident would start throwing things on his floor again. She did not have daily cleaning documentation for the resident and had not documented this behavior on a daily basis. The resident's wall had been repaired several times, but he continued to run into the wall creating holes. She did not have documentation of the room repairs. C. Facility follow-upThe housekeeping's daily cleaning schedule was provided on 10/12/23 at 1:15 p.m. from the NHA. It revealed the resident's room had been last cleaned 9/22/23. The scheduled documented resident rooms were to be cleaned daily between 6:00 a.m. to 2:00 p.m. Monday through Sunday. The floor of each room was to be cleaned daily. Any concerns were to be brought to management's attention and documented by the nurses.

Based on record review and interviews, the facility failed to ensure one (#48) of two residents reviewed for abuse out of 46 sample residents were free from abuse. Specially, the facility failed to prevent a resident to resident altercation between Resident #48 and Resident #66. Findings include: I. Facility policy The Abuse and Neglect policy, dated 7/11/21, was received from the nursing home administrator (NHA) on 10/12/23. It read in pertinent part:"Physical abuse is defined as including hitting, slapping, pinching, and kicking of residents. The two elements needed are:-Intent or knowingly or recklessly-Bodily injury and/or serious bodily injury, and/or-Unreasonable confinement or restraint." II. Resident to resident physical altercation between Residents #48 and #66. A. Facility investigation Incident 9/2/23 The incident between Resident #48 and Resident #66 occurred in the room where both residents reside. Resident #48 alerted the nurse Resident #66 had punched him in the nose after Resident #48 accidentally ran over his foot with the electric wheelchair. The residents were separated by staff and assessed for injuries, Resident #48 had a bloody nose. Resident #66 was moved to a different room the same day. Resident #48 was interviewed by manager on duty, where he stated Resident #66 was sitting in a chair in the room when Resident #48 bumped into him with his electric wheelchair. Resident #66 became upset and punched him in the nose. Resident #66 was interviewed by the manager on duty, where he stated Resident #48 ran over his foot with the wheelchair and this aggravated him so he turned and punched Resident #48 in the nose. The facility failed to substantiate the abuse citing Resident #66 did not intend harm to Resident #48 when he punched him.-However, the abuse should have been substantiated due to Resident #66 punching Resident #48 in the face and causing a bloody nose. During the facility investigation, Resident #66 admitted to punching Resident #48 because he was aggravated with Resident #48. B. Resident #48 (victim) 1. Resident statusResident #48, aged 78, was admitted on 4/1/23. According to the October 2023 computerized physician orders (CPO), diagnoses included anxiety, post traumatic stress disorder, Parkinson's disease and congestive heart failure. The 8/23/23 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. He had no behaviors indicated. 2. Resident interviewResident #48 was interviewed on 10/10/23 at 12:45 p.m. He stated his former roommate, Resident #66, thought he had deliberately ran over his foot with his electric wheelchair and punched Resident #48 in the front of his face. The staff moved his roommate the same day and he did not feel fearful. 3. Record review The comprehensive care plan, revised 5/23/23, revealed the resident had impaired cognitive functioning related to impaired thought processes due to Parkinson's disease. And was to be monitored for elopements. He required a wheelchair for mobility. He received one person assist with bed mobility, transfer, dressing, toileting, hygiene. No behaviors were indicated. C. Resident #66 (assailant) 1. Resident status Resident #66, age 88, was admitted on 10/5/21 According to the October 2023 CPO, diagnoses included unspecified dementia and depression. The 9/25/23 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of seven out of 15. He only required staff set up for bed mobility, transfers, walking, dressing, eating, toileting, and personal hygiene. He had no behaviors indicated. 2. Resident interviewResident #66 was approached on 10/10/23 at 2:15 p.m. and refused to be interviewed. 3. Record review The comprehensive care plan, revised 9/12/23, identified the resident had behavior of perseverating on the location of his money and needing staff reminders to look in his lock box. The resident had behaviors of urinating on washcloths and hanging the cloths in his room to dry instead of using the bathroom. Staff were to encourage and remind the resident to use the restroom. III. Staff interviewThe nursing home administrator was interviewed on 10/12/23 at 4:15 p.m. This was the first incident of this nature between Resident #48 and #66. Nether resident had a history and Resident #66 was moved to another floor of the building the same day of the incident. The facility did not substantiate the incident as physical abuse due to determining Resident #66 reacted to Resident #48 running over his foot and would not have hit him otherwise. The NHA did not believe Resident #66 intended to be physically abusive.

Based on record review and interviews, the facility failed to prevent misappropriation of property for four (#19, #44, #48 and #49) of five residents reviewed for misappropriation out of 46 sample residents. Specifically, the facility failed to prevent staff members from exploiting money from Residents #19, #44, #48 and #49. Findings include: I. Facility policy The Abuse and Neglect policy and procedure, revised 1/16/23, was provided by the nursing home administrator (NHA) on 10/10/23 at 10:12 a.m. It read in pertinent part, "Each resident has the right to be free from abuse, neglect, misappropriation of property, exploitation, involuntary seclusion, and physical or chemical restraints imposed for the purpose of discipline or convenience not required to treat the resident's medical symptoms. Residents will not be subjected to abuse by anyone, including staff (to include agency or contract vendors), residents, volunteers, consultants, family members /legal guardians, friends, or any other individuals. II. Resident #48 A. Resident status Resident #48, age 78, was admitted on 4/1/23. B. Resident interview Resident #48 was interviewed on 10/9/23 at 1:19 p.m. Resident #48 said he loaned a certified nurse aide (CNA) money with the understanding that she would pay him back, but when he found out she quit he realized he was not going to get his money back. Resident #48 said he no longer gives staff money and was working with the police to see if he could get his money back. C. Facility investigation Incident investigation dated 6/6/23 read in pertinent part: On 5/25/23 it was reported by Resident #48 that CNA #11 borrowed around $8,000.00 from him and he was worried he would not get paid back. CNA #11 was suspended immediately. Resident #48 told the investigator he gave CNA #11 $8,600.00 plus in loans which he expected to be paid back but the CNA had not paid anything back. Resident #48 said he started giving CNA #11 money back in August 2022 she asked to borrow $5000.00 because she had wrecked her car, needed dental work and new glasses. Then she said she needed to move and needed a deposit so he loaned CNA #11 an additional $2,800.00 in January 2023. There was an additional check that he endorsed over to CNA #11 totaling $845.00. Resident #11 said CNA #11 had not seen any repayment and he stated to question if he would ever see his money again. CNA #11 was interviewed on 5/26/23, at first CNA #11 said Resident #48 gave her the checks to cash for him and bring back to him. The facility asked for proof that she did not deposit the money into her account and that the money had been provided to the resident. CNA #11 said she would provide proof but instead, she resigned from her position. CNA #11 was reported to the police and to the State Nursing Board. CNA #11's licensure as a nurse aide was revoked. Resident #48 was educated to not give money to staff he agreed. On 6/5/23, an email education notification was sent to all staff. The email read: Subject: "Accepting gifts, gratuities, and payments from residents: Please be advised and reminded of page 16 in the Employee Handbook. Gifts, Gratuities, and Payments: It is the policy of (facility name) to prohibit any employee from receiving or giving any gifts, gratuity, or payment for services rendered, the making of any promise (s) on behalf of (facility name), or engaging in any activity, practice, or act which conflicts with the interest of (facility name) or its customers. For further clarification, speak to your supervisor or reference (facility name) Compliance Program." III. Resident #19 A. Resident status Resident #19, age 87, was admitted on 3/5/22. B. Resident interviewResident #19 was interviewed on 10/9/23 at 9:02 a.m. Resident #19 pointed to her dresser drawer and said, someone took my purse to take money from her, "who would do something like that, who would do something like that?" Resident #19 said she did not have a way to lock up her purse prior to it going missing. Resident #19 said she did not know the name of the person who took her banking information and bank cards. Resident #19 was upset that someone would try to steal from her. C. Facility investigation Incident investigation dated 9/13/23 read in pertinent part: Resident #19 reported that her purse went missing on 8/16/23, but no report was made at that time. On Friday 9/8/23 at approximately 4:00 p.m. when she still could not find her purse and the contents of her purse, the resident reported that her purse was still missing. The unit nurse reported to the social worker and an investigation was initiated. The resident said she kept her purse in the bottom drawer of her dresser. A search was conducted and the purse was not found. A review of bank documents revealed evidence of fraudulent activity and attempts to divert the resident's money. The facility identified a suspect and suspended the staff pending an investigation. The resident bank account was frozen and the police were notified. The investigator found that the assailant cashed a check for $700.00 on 8/9/23 and attempted to cash a second check for $2,650.00 on 8/16/23. Additionally, there was an attempted charge to the local energy company for $1,195.51 and a cellphone company for $369.44. The $2,650.00 check was written out to CNA #10 and the $700.00 check was written out to a known associate with the same last name as CNA #10. CNA #10 was interviewed by facility staff and confessed to forging the $2,650.00 but did not believe it was a crime because he did not get any money. CNA #10 denied knowing anything about other fraudulent activity. The staff was no longer working in the facility. The State Nursing Board was notified during the survey (on 10/12/23). The outcome of the police investigation was ongoing. IV. Resident #44 A. Resident status Resident #44, under the age of 65, was admitted on 7/15/23. B. Resident interview Resident #44 was interviewed on 10/9/23 at 1:22 p.m. Resident #44 said a staff stole his credit card and charged approximately $400.00 to his card at a local big box store. Resident #44 said the same staff stole another resident's check and tried to get money for that resident. Resident #44 said the staff was no longer working at the facility and he now kept his card safe in a locked box provided by the facility. C. Facility investigation Incident investigation dated 9/13/23 read in pertinent part: Resident #44's son called the NHA on 8/28/23 to inform the facility that the credit card that he left with his dad had been used for a purchase at a local box store (store name) on Saturday night 8/26/23. The son said he immediately called Resident #44 to see if the credit card was still in his possession and it was not. The resident was not able to identify when it had gone missing, he was just able to say that he used it to buy Chinese food the night before which was Friday 8/25/23. The resident's son was able to work with the credit card company to report the charge as fraudulent and stop the payment to the box store. The police in the county where the crime occurred had video evidence but because the resident resided in a different county, the facility was not able to view the video evidence to verify if the assailant was a staff member. The investigation was ongoing. The facility suspected the assailant was the same staff (CNA #9) who committed a crime against Resident #19. On 8/28/23, the facility provided Resident #44 with a locked box, provided education on using the locked box to secure valuables and ensured the resident could use the locked box effectively. V. Resident #49 A. Resident status Resident #49, age 67, was admitted on 7/26/23. B. Resident interview Resident #49 was interviewed on 10/9/23 at 9:55 a.m. Resident #49 said she withdrew $50.00 from her personal account to purchase a couple of things and shortly after $25.00 turned up missing. Resident #49 said she reported it to the leadership and they were investigating. She did not know any more about who might have taken her money. Resident #49 said she now kept her money in a locked box. C. Facility investigation Incident investigation dated 9/13/23 read in pertinent part: Resident #49 stated that on 9/14/23, she took $50.00 out of her account to buy soda and a candy bar; on 10/2/23 she noticed that $25.00 was missing. The resident's room was searched with the resident's permission. The social services provided emotional support and the resident was given a locked box on 10/2/23, to protect other valuables and encouraged to use the lockbox. The facility had no leads and was unable to determine who might have taken the resident money. VI. Staff interview The activities director (AD) and the NHA were interviewed on 10/12/23 at 9:13 a.m. The AD said the police department community representative came to the facility last April 2023 to provide in-services for residents on protecting themselves from scammers who may target them through phone calls, emails and text messages. The AD said the training did not include information for residents to know how to protect themselves from being taken advantage of financially. The residents had not been provided education regarding asset misappropriation and theft of intellectual property. The residents were not educated on how another person could take advantage of them financially if they had access to their credit cards, checkbooks, banking statements, social security cards and other government identification. The NHA said the facility provided education for staff to refresh orientation that was provided to them at orientation. This training was provided to staff on a couple of occasions. In that training, facility staff were reminded that taking money or property from a resident was not permitted by facility policy. Additionally, the facility would look into providing residents with additional education to protect themselves financially. The NHA said they had locked boxes available for any resident who wanted a way to protect their personal belongings only upon request.

Based on observations, record review and interviews, the facility failed to ensure a resident was free from physical restraints imposed for purposes of convenience, and that are not required to treat the resident's medical symptoms, the least restrictive alternatives was not used for one (#102) of one resident reviewed for restraint use out of 46 sample residents. Specifically, the facility failed to-Attempt to assess less restrictive alternatives to prevent Resident #102 from falling out of his wheelchair;-Evaluate the risks and benefits for using a lap belt or personal restraint on Resident #102; -Obtain a physician's order before implementing the use of a lap belt personal restraint on Resident #102 while in his wheelchair; -Re-evaluate the ongoing use of a lap belt personal restraint on Resident #102; and -Perform periodic removal/release of Resident #102's lap belt personal restraint to assess for continued need. Findings include: I. Facility policy and procedure The Restraint Assessment and Consent Policy, revised October 2023, was received from the nursing home administrator (NHA) on 10/12/23 at 4:33 p.m. It read in pertinent part: "A physical restraint-free or least restrictive environment will be the standard for resident care. If restraints are present, the interdisciplinary team will make every effort to reduce then eliminate restraints. Purposes for restraint use include resident safety, injury prevention, and protection of the medical devices. When evaluating restraints, a risk-benefit of device use will be completed. "Restraint definition: A physical restraint is any physical or mechanical device, attached or adjacent to the resident's body that the individual cannot easily move. It restricts movement or access to one's body. When determining if a device is a restraint or assistive device, the focus will be the effect on the resident, not the intent or reason for use. "1. Assessment and treatment of potential underlying conditions and environment (reasons for behaviors/impulsivity, pain, boredom, restlessness, quality of life) will be completed prior to initiation of a restraint. Evaluations will be documented on the evaluation/consent form. 2. Restraints will not be implemented based on family/POAs (power of attorney) requests. Instead, a facility assessment will be completed to evaluate the restraint request, including less restrictive alternatives. Families will be interviewed to understand their concerns and educated regarding restraint alternatives. 3. The following will be documented on the evaluation/consent form:-Alternative measures tried prior to device use, with trial results-Evaluation of self-release ability and potential movement or access to body restriction-Observation of device effect on the resident-Identification of potential risks and benefits of the device-Medical symptoms "A Physician's order will be obtained for restraints. The order will include the type and purpose of the restraint and duration of application, as well as a diagnosis for the restraint."II. Resident #102 A. Resident statusResident #102, age 69 years, was admitted on 6/7/23. According to the October 2023 computerized physician's orders (CPO), diagnoses included intracranial (brain) injury with loss of consciousness, fracture of nasal bones, injury to face and abnormality of gait/mobility. The 9/13/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The resident needed extensive assistance from staff to complete all activities of daily living, used both a manual wheelchair and walker with expensive staff assistance and had limited function range of motion (ROM) mobility in both the upper and lower extremities, one sided. It did not document the use of a lap belt or restraint on the resident's person. B. Observations and resident interview On 10/9/23 at 1:31 p.m. Resident #102 was sitting up in a wheelchair with a seat belt across his lap. On 10/10/23 at 10:23 a.m. Resident #102 was sitting in a wheelchair, a certified nurse aide (CNA) noticed the resident was leaning forward in the wheelchair sleeping, the lap belt was in place. -At 12:14 p.m. and 2:43 p.m., Resident #102 was observed sitting in his wheelchair in the common area. The resident was restrained in the wheelchair with a lap belt personal restraint. The resident's wheelchair was reclined; he was seated upright and back at the base of the seat and was not leaning forward. Resident #102 was interviewed on 10/10/23 at 2:55 p.m. The resident said he had to wear the lap belt/restraint to not get in trouble. -The resident was not able to say anything more about the lap belt and the resident was unable to demonstrate ability to remove the lap belt. On 10/11/23 at 7:31 a.m. and 10:47 p.m. the resident was seated in a wheelchair in the dining room, the belt across the resident's lap was in place. C. Record review -The care plan did not have a care focus for the use of a lap belt personal restraint while up in a wheelchair. -The October 2023 CPO did not include a physician's order for the use of a lap belt/restraint. -The resident's medical record failed to have documentation to show that the resident was assessed for the use of the lap belt restraint or a risk benefit statement prior to the initiation of the use of a lap belt personal restraint or consent for use. -A review of the resident's treatment administration records (TAR) contained entries for behavioral tracking but failed to document any behaviors to support the use of a lap belt/restraint.-There are no progress nursing notes documenting the use of the lap belt personal restraint. III. Staff interviewsActivities Assistant (AA) #1 was interviewed on 10/11/23 at 8:54 a.m. AA #1 said she was assigned to help the resident eat on occasion, but did not know much else about the resident. AA #1 said she believed the resident came to the facility with the lap belt which was attached to the wheelchair. AA #1 said she did not know why the resident used the lap belt and has never seen the resident try to take it off. CNA #6 was interviewed on 10/12/23 at 11:19 a.m. CNA #6 said the resident was moved to long-term care after receiving rehabilitation services on the second floor. CNA #6 said the resident's wheelchair with an attached lap belt was brought in by the resident's son. The resident's son asked staff to place the lap belt on the resident to prevent him from falling out of the wheelchair because the resident had a tendency to lean forward while in the wheelchair. CNA #6 said she had never seen the resident try to take off the lap belt and did not believe the resident knew how to release the lap belt. CNA #6 said she did not receive training on the use of the lap belt or positioning the resident in his wheelchair. Licensed practice nurse (LPN) #3 was interviewed on 10/12/23 at 11:30 a.m. LPN #3 said the resident wore the lap belt because he tilted forward while sitting upright in the wheelchair. LPN #3 said she did not believe the lap belt bothered the resident because he did not try to remove it. LPN #3 said the resident's son brought in the wheelchair with the lap belt attached; staff used the lap belt at the son's request. LPN #3 said she had never seen a wheelchair with a lap belt attached and had no training on how to use it. The director of nursing (DON) was interviewed on 10/12/23 at 3:30 p.m. The DON said no resident in the facility used any type of restraint. When told that staff were using a lap belt to secure Resident #102 in his wheelchair, the DON said she was not aware that the resident had a lap belt secured in his wheelchair.. The DON said she would call the resident's family to discuss the use of the lap belt and inform them the device needed to be removed from the wheelchair.

Based on interviews, observations and record review, the facility failed to incorporate the recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation report into the assessment, care planning and transitions of care for one (#83) of four residents reviewed for PASRR out of 46 sample residents. Specifically, the facility failed to take steps to:-Ensure services were timely provided as recommended in Resident #83's PASARR level II; and, -Develop a PASARR level II care plan for Resident #83. Findings include:I. Resident statusResident #83, under the age of 65, was admitted on 11/24/22. According to the October 2023 computerized physician orders (CPO), the diagnoses included major depressive disorder and post-traumatic stress syndrome (PTSD). According to the 9/10/23 minimum data set (MDS) assessment, the resident had a moderate cognitive impairement with a brief interview for mental status (BIMS) score of 10 out of 15. He required set up help only for walking and transfers. The resident was independent for all other activities of daily living (ADLs). The resident did not have signs of depression. The resident did not exhibit behavioral symptoms. The resident was not triggered for having a PASARR level II. The resident received antidepressant medication. II. Resident interviewResident #83 was interviewed on 10/11/23 at 3:11 p.m. Resident #83 said he had distress from past abusive experiences both in his country and at a different facility. Resident #83 said he did not receive help from the facility. Resident #83 said he wanted a case manager and someone to talk to about the past trauma. Resident #83 said he had asked for help multiple times and the social worker ignored him and did not provide assistance with his concerns. III. Record reviewAccording to The PASRR II evaluation dated 12/19/22 documented the resident was evaluated because the resident had diagnoses of PTSD and major depressive disorder. The recommendations included the following psychiatric case consultation so the resident was able to discuss adjustment concerns and depression, psychosocial consultation, case management services so the resident can discharge into lower level of care. According to the care plan dated 8/25/23 documented Resident #83 did not have a PASARR level II care plan. According to the behavior care plan revised 7/1/23 documented the resident was known for becoming verbally and physically aggressive when he did not get his meal preference. Interventions included the following, staff should allow the resident to calm down and temporarily leave the residents room. Staff should check in on the resident prior to meals to ask for his preference. Monitor and notify director of nursing (DON) and team of behaviors like screaming, yelling and becoming physically aggressive. According to the psych note dated 5/23/23 documented the resident had an evaluation and management of medications. According to the psych note dated 6/22/23 documented the resident had an evaluation and management of medications. The practitioner reviewed medication changes with the resident. According to the psych note dated 6/22/23 documented the resident had an evaluation and management of medications. The practitioner reviewed medication changes. They discussed mental health progress and Resident#83 should continue licensed clinical social worker (LCSW) therapy check ins.-There was no additional documentation of psychosocial consultations, outside case management or additional psychiatric case management services. According to the trauma behavior plan, revised 4/5/23, documented the resident had PTSD from an event he experienced in Ethiopia. Interventions included the following activities should provide Ethiopian gospel music. The staff would call the residents brother. Notify the DON (director of nursing), social worker or ADON (assistant director of nursing) if the resident experiences symptoms of trauma. Observe signs of psychosocial distress, anger, tearfulness, irritability and restlessness. According to the mental health care plan revised 4/1/23 the resident was being seen by a psychiatrist for emotional support. IV. Staff interviewsLicensed practical nurse (LPN) #4 was interviewed on 10/12/23 at 9:39 a.m. LPN #4 said Resident #83 had physical and verbally aggressive behaviors. LPN #4 said the resident did not have interventions in place to help him. LPN #4 said the resident did not have outside services to help with his behaviors. Certified nurse aide (CNA) #5 was interviewed on 10/12/23 at 9:53 a.m. CNA #5 said Resident #83 had very aggressive behaviors and would yell at staff and would sometimes become physically aggressive. CNA #5 said the staff did not have interventions to help Resident #83 when he became aggressive. CNA #5 said the resident had PTSD from past events. CNA #5 said the staff walked away if he became aggressive. Resident #5 said Resident #83 did not receive outside services for his PTSD.The social services director (SSD) was interviewed on 10/11/23 at 1:28 p.m. The SSD said PASRR recommendations were used to build the resident's care plan. The SSD said recommendations are important to follow to appropriately care for the resident that had been diagnosed with a major mental illness. The SSD said if the recommendations could not be followed the SSD would communicate the challenges with the state mental health agency. The SSD said she had not communicated with the mental health agency about a refusal or difficulty meeting recommendations for Resident #83. The SSD said Resident #83 had PASRR II with recommendations. The SSD said the resident refused to get services from a case manager or get a psychosocial consultation and the resident had a handful of psychiatric visits. The SSD said the residents PASRRII recommendation and refusals were care planned.-However, the resident did not have documentation of refusals and it was not care planned.

Based on interviews and record review, the facility failed to notify the state mental health agency promptly after a significant change in the mental condition of three (#33, #36 and #97) of seven residents reviewed for preadmission screening and resident review (PASRR) out of 46 sample residents. Specifically, the facility failed to:-Notify the state mental health agency of Resident #33, and Resident #97 necessity for inpatient psychiatric hospitalizations, and, -Notify the state mental health agency of worsening symptoms for Resident #36. Findings include:I. Resident #33A. Resident statusResident #33, age under 70 years, was admitted on 7/7/21. According to the October 2023 computerized physician orders (CPO), the diagnoses included bipolar disorder. The 9/29/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of 10 out of 15. It did not identify level II PASRR. B. Record reviewThe comprehensive care plan, initiated on 7/10/23, revealed the resident exhibited behaviors of yelling obscenities towards staff and other residents. Interventions included allowing the resident to calm down, educating the resident on appropriate communication with others, frequent checks to ensure her needs were met, and offering mental and emotional support services as needed. The resident took medications to manage symptoms of bipolar disorder and had a level II PASRR for major mental illness. Interventions included frequent mood checks and behavior monitoring. According to the October 2023 CPO, the resident had orders dated 7/19/23 to be sent out for a psychological and psychiatric evaluation and treatment. Progress notes dated 7/5/23 through 10/10/23 revealed in pertinent part:Social services progress note date 7/18/23 revealed a referral was sent per the resident's request for psychological servicesSocial services progress note dated 7/19/23 revealed the resident was scheduled to see the psychology provider on 7/25/23 and the resident had been notified. PASRR progress note dated 7/21/23 revealed the resident was reviewed in the psychotropic medication committee. The resident had recently returned from a psychiatric hospitalization. -No progress notes were located documenting the behaviors leading up to the resident's need for an inpatient psychiatric hospitalization or an update being sent to the state mental health agency. The resident's pre-admission level II PASRR was reviewed on 10/12/23. The level II notice of determination dated 2/8/23 identified the resident as meeting criteria for PASRR mental illness. The level II evaluation dated 2/16/23 identified a history of psychiatric hospitalizations over her lifetime related to bipolar instability. II. Resident #36A. Resident statusResident #36, aged 74 years, was admitted on 3/31/18. According to the October 2023 CPO, the diagnoses included post traumatic stress disorder and major depressive disorder. The 8/30/23 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. It indicated the resident did not meet criteria for a level II PASRR diagnosis. B. Record reviewThe comprehensive care plan, initiated on 9/21/18, revealed the resident exhibited behaviors of getting easily annoyed with others and changes in appetite. He had periodic episodes of suicidal ideations but not currently. Interventions included follow up from the social services director (SSD) and for staff to notify the SSD or the physician of suicidal ideations. The resident took medications to manage symptoms of post traumatic stress disorder (PTSD), major depression, and anxiety. He had a level II PASRR for major mental illness. Interventions included behavior monitoring for depressive symptoms and frequent check ins to meet his needs. Progress notes dated 6/1/23 through 10/10/23 revealed in pertinent part:Social services progress note date 7/26/23 revealed the resident expressed suicidal ideations and desiring to end his life. He was assessed and determined to be at low risk for attempting suicide. Social services progress note date 8/1/23 revealed the resident expressed suicidal ideations and desiring to end his life. He was assessed and determined to be at low risk for attempting suicide. Social services progress note date 8/21/23 revealed the resident expressed suicidal ideations and desiring to end his life. He was assessed and determined to be at low risk for attempting suicide. -No progress notes were located documenting an update was sent to the state mental health agency for worsening symptoms. The resident's resident review level II PASRR was reviewed on 10/12/23. A status change had been submitted 3/25/19 due to a time limit expiration. The level II notice of determination dated 5/28/19 identified the resident as meeting criteria for PASRR mental illness. The level II evaluation dated 6/4/19 identified the resident without a history of suicidal ideations. Suicidal ideations were first care planned 9/21/18.-However, this was not included in his status change PASRR 3/25/19 or subsequent PASRRs to the state mental health agency and behaviors continued. III. Resident #97A. Resident statusResident #97, age under 70 years, was admitted on 2/2/23. According to the October 2023 CPO, the diagnoses included post traumatic stress disorder, suicidal ideations and major depressive disorder. The 8/30/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. It did not identify level II PASRR. B. Record reviewThe comprehensive care plan, revised on 2/15/23, revealed the resident exhibited behaviors of suicidal ideations and suicidal attempts. The resident had a history of being hospitalized for a suicide attempt via medication overdose related to frustration over medical condition. Interventions included mood check ins and behavior tracking. His last suicide attempt was 7/19/23 via wrapping a call light cord around his neck (this was added to the care plan 10/12/23, during the survey). Interventions included following a safety plan which outlined activities he enjoyed. It included frequent checks from the SSD and encouragement to socialize. According to the October 2023 CPO, the resident had orders dated 4/24/23 to receive psychological and psychiatric evaluation and treatment. Progress notes dated 7/1/23 through 10/10/23 revealed in pertinent part:Order administration note dated 7/17/23 revealed the resident had a behavior related to suicidal ideations and verbal aggression. The resident had been throwing water. Social services note dated 7/18/23 at 7:14 a.m. revealed the SSD completed a suicide lethality assessment with the resident due to statements he wanted to die due to increased pain. The resident was determined to be low risk and without a plan. Nursing progress note dated 7/18/23 at 9:05 p.m. revealed the nurse entered the resident room after his call light had been pulled to find the resident had wrapped the call light around his neck. 911 was contacted. Nursing progress note dated 7/19/23 reveled the resident had been admitted to the hospital on a mental health hold due to suicide attempt. Admission summary note dated 7/20/23 revealed the resident returned to the facility. -No progress notes were located documenting an update being sent to the state mental health agency. The resident's pre-admission level II PASRR was reviewed on 10/12/23. The level II notice of determination dated 9/29/22 identified the resident as meeting criteria for PASRR mental illness. The level II evaluation dated 10/6/22 identified the resident had a history of suicidal ideations and a suicide attempt in 2022 via medication overdose. IV. Staff interviews The social services director (SSD) was interviewed on 10/11/23 at 1:28 p.m. She stated residents with a mental health diagnosis have a level II PASRR. An update was sent to the state mental health agency when a resident's mental health condition worsened, the resident had a new diagnosis or a new medication. An update was needed if a resident had an inpatient psychiatric hospitalization. Resident #36 had expressed to her suicidal ideations on three occasions. Resident #33 and #97 had been sent out to inpatient psychiatric units for worsening mental health symptoms requiring evaluation. She had not sent in updates for Resident #33, #36, and #97.

Based on observation, record review and interviews, the facility failed provide care and services for activities of daily living including speech, language and other communication systems for one (#12) resident of one reviewed out of 46 sample residents. Specifically, the facility failed to:-Ensure Resident #12 was able to communicate in her preferred language; and,-Ensure the communication book was available for Resident #12 use. Findings include:I. Facility policy and procedureThe Dignity, Voice and Choice policy and procedure, dated 2/28/23, was received from the nursing home administrator (NHA) on 10/12/23 at 4:45 p.m. It revealed in pertinent part, "Residents will be cared for in a manner and environment that maintains or enhances their dignity, privacy, and respect in full recognition of their individuality. Residents were addressed by their preferred name in respectful and in a language they understand."II. Resident #12A. Resident statusResident #12, age 89, admitted on 7/17/23. According to the October 2023 computerized physician orders (CPO) diagnosis included fracture of the left humerus (broken bone in the lower arm), COPD (airway blockage) and hypertension (high blood pressure). The 7/23/23 minimum data set (MDS) revealed the resident was mildly cognitively impaired with a brief interview of mental status (BIMS) score of 10 out of 15. She required two person assistance with bed mobility. Transfers, dressing and toileting. One person assistance with eating and personal hygiene. B. Resident interviewResident #12 was interviewed on 10/9/23 at 1:04 p.m. She said she was told to speak English a lot but could not express herself well or make her needs known because she did not know some words in English. Resident #12 said the staff have never used a communication line or a book to help communicate with her. Resident #12 said she got frustrated when she could not tell staff what she needed and had no one to talk to most days. C. ObservationsOn 10/10/23 at 11:42 a.m. Resident #12 was observed in the dinning room for lunch and was attempting to communicate with certified nurse aide (CNA) #2. Resident #12 was asking for coffee to drink and was unable to ask for the sugar of choice. CNA #2 told the resident to talk to her in English and Resident #12 was able to speak in English. It took Resident #12 over two minutes to communicate she wanted a pink sugar packet. CNA #2 told Resident #12 to speak in English four times during the conversation. Resident #12 appeared to be frustrated by shaking her head side to side and frowning. At 2:50 p.m. Resident #12 was observed sitting by herself at a table during bingo. Resident #12 said bingo and an unidentified staff member came to the residents table from across the room, reviewed her card and told the resident "no but close." Resident #12 appeared to be confused and not understanding why she did not have a bingo. On 10/11/23 at 1:26 p.m. registered nurse (RN) #2 was observed speaking with Resident #12. RN #2 told the resident to speak English as he did not understand her. -The facility staff failed to use any translation aids (see record review below) to communicate with the resident in her preferred language. D. Record reviewThe 7/26/23 comprehensive care plan documented Resident #12 had a communication problem related to Spanish speaking only. Interventions staff documented for Resident #12 would be able to make basic needs known on a daily basis using an interpreter, staff were to anticipate and meet needs, provide translators as necessary to communicate with the resident and use cue cards for simple communication. III. Staff interviewsCNA #2 was interviewed on 10/11/23 She said Resident #12 spoke Spanish and had to be reminded to speak English. CNA #2 was unaware of any interpreting services available to help communication between the staff and Resident #12. RN #2 was interviewed on 10/11/23 at 1:26 p.m. He said Resident #12 could speak English but needed to be reminded to speak English. RN #2 was unaware of any communication aids available to help with translation. The activities director (AD) was interviewed on 10/12/23 at 11:30 a.m. She said that Resident #12 was added to one-to-one visits about a month ago and a Spanish speaking staff member assisted Resident #12 during activities she attended. The NHA was interviewed on 10/12/23 at 11:30 a.m. She said therapy department initiated a communication book for Resident #12 and the director of therapy trained staff to use the book to help communicate with the resident. The director of nursing (DON) was interviewed on 10/12/23 at 2:41 p.m. She said staff had access to an interpreter line and could call family members to assist in translating. The DON said she did not know staff were not aware of the interpreter service or Resident #12 had a communication binder at the nurses station.

Based on record review, and staff interviews, the facility failed to clarify resuscitation choices and document them accurately in the medical record for one (#70) of three residents reviewed for advance directives out of 46 sample residents. Specifically, the facility failed to ensure the medical orders for scope of treatment forms (MOST) form matched the physician's orders for Resident #70's cardiopulmonary resuscitation (CPR) wishes. Findings include:I. Facility policy and procedureThe Advance Directives and Resident Representative policy and procedure, dated 10/15/10, was received from the nursing home administrator (NHA) on 10/12/23 at 4:45 p.m. It revealed in pertinent part, "A facility representative usually social services or nursing will provide advanced directive information as needed to assist with health care decisions prior to or upon admission, with potential changes of condition, and as needed based on resident and representative needs. The physician should discuss choices offered on the MOST form and educate the resident regarding the choices made."II. Resident #70A. Resident statusResident #70, age 71, admitted on 6/7/23. According to the October 2023 computerized physician orders (CPO) diagnosis included chronic obstructive pulmonary disease (air flow blockage), pneumonia (lung infection), myocardial infarction (heart attack) and hypertension (high blood pressure). The 9/14/23 minimum data set (MDS) revealed the resident was cognitively intact with a brief interview of mental status (BIMS) score of 13 out of 15. B. Record reviewThe MOST form signed on 6/7/23 by Resident #70 documented he was not to be resuscitated. The October 2023 CPO documented an order for Resident #70 as a full code ordered on 6/8/23.-The MOST form and physician order failed to match. III. Staff interviewsRegistered nurse (RN) #2 was interviewed on 10/11/23 at 11:14 a.m. He said when a resident was admitted to the facility the nurse admitting them went over the MOST form with the resident and obtained their signature. The admitting nurse would then add an order to the resident physician order to indicate their wishes as full code or do not resuscitate. RN #2 said in an emergency situation the nurse could look at the computer or the paper chart to identify the resident's wishes. RN #2 identified Resident #70 as being full code by looking at the CPO and then reported he would try to revive the resident to full extent. When RN #2 reviewed the MOST form in the resident paper chart it documented that Resident #70 was a do not resuscitate and said the order and the MOST form did not match. RN #2 immediately notified to the social worker and then changed the order in the CPO to do not resuscitate. RN #2 said if Resident #70 coded this would have been a problem because staff could have performed life saving measures on a resident who did not want those measures taken. The director of nursing (DON) was interviewed on 10/12/23 at 2:41 p.m. She said during the admission process the admitting nurse or the social worker share the responsibility of getting the MOST form signed. The DON said once the MOST form was signed the nurse was to place the residents wishes into the computer system and the order was to match the MOST form. The DON said if the order and MOST form did not match staff could revive the resident and it not be their wishes or not revive them when they wished to be revived.

Based on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental and psychosocial well-being were provided for two (#11 and #83) of four residents reviewed for meaningful activity programming activities out of 46 sample residents. Specifically, the facility failed to ensure:-Resident #11 received individualized meaningful activities to meet her social, emotional and recreational needs; and,-Resident #83 received a schedule of upcoming activities and was invited to activities and informed where the activity would be occurring. Findings include: I. Facility policy and procedure A request was made for the activities policy on 10/12/23 at 4:33 p.m. The nursing home administrator (NHA) said the facility did not have and activities policy. II. Resident #11 A. Resident status Resident #11, age 69, was admitted on 7/24/23. According to the October 2023 computerized physician orders (CPO), diagnoses included chronic respiratory failure, anxiety and diabetes. The 7/31/23 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status exam score of 13 out of 15. The resident required extensive assistance from staff to get out of bed and move around the facility. The assessment documented that the resident said it was very important to have books, newspapers, and magazines to read; be around animals and pets; do her favorite activities; and participate in activities. The resident said it was important to listen to music, keep up with the news, do things with groups of people, and somewhat important to go outside and enjoy with fresh air. B. Resident interview and observation Resident #11 was interviewed on 10/9/23 at 10:36 a.m. Resident #11 said the facility did not offer her any activities, so she spent a lot of time on her phone doing research to keep from being bored. Resident #11 said staff did not regularly ask her what kinds of activities she was interested in, or offer to get her up in her wheelchair so she could attend an activity. The resident said she felt like she was in jail because the staff would not get her out of bed and take her out of the room. Resident #11 said that staff told her she was too weak to get up in her wheelchair. The resident said, "I will never get stronger if they do not get me up. Every day I lay in bed I lose 10 percent of my strength and I haven't been up and in my chair in several weeks."Resident #11 said she just wanted the opportunity to get out of the room, even if it was only for 15 minutes a day. Resident #11 said she received a weekly massage and visits from the hospice pastor. The visits from the pastor helped when she was at her "wits end" Resident #11 said she was grateful for hospice services but still felt like she was in jail. Resident #11 said upon admission she was told that she would have a great view from her room window but all she had to look at all day was the tops of trees and an apartment building roof. The resident was a little teary as she talked about what her day was like. Resident #11 said she had severe post-traumatic stress disorder (PTSD) her daily thoughts led her to thoughts of her childhood and the abuse she suffered as a child. Staying in her room all day long day in and day out did not help her emotionally. Resident #11 said again said she would really like to get out of the room and be able to see what was going on throughout the facility. What bothered her most was that she was not able to attend religious services because they were important to her. Observations of Resident #11 throughout the survey from 10/9/23 to 10/12/23 revealed the resident remained in her room and did not have the opportunity to attend any group activities socialize with other like-minded residents or even attend and in-person religious event. C. Record review The activities director (AD) provided Resident #11's activities care plan and activity participation records for 7/26/23 to 9/27/23, on 10/12/23 at approximately 9:33 a.m. The resident participation records revealed the resident participated in: -One-to-one activity programming with or without a snack (social visits) four times in August 2023; 10 times in September 2023; and zero times from 10/1/23 to 10/11/23. Several times the resident's attendance was documented to be independent with one-to-one activity. -Spiritual activity program was not provided as a part of the activities programming it was marked as not applicable (N/A) in August 2023 and provided once in September 2023 and four times in 2023. There were no details of the activity given. -Other types of activity including creative, cognitive, and sensory activities were provided at the same time as the one-on-one activity with facility staff. The resident's activity care plan, revised on 8/3/23, documented Resident #11 was "independent for meeting her emotional, intellectual, and social needs. Resident #11 requires some assistance with her physical needs. In the past, she used to express interest in gardening, bingo, and going outdoors. She currently prefers to stay in her room using her phone and watching television (TV). She is accepting of visits from the priest." The goal of the activities care plan was to help Resident #11 maintain involvement in cognitive stimulation and socially independent activities as desired. Interventions included:-Allow Resident #11 to be self-directed with daily independent leisure as desired;-Provide preferred activities such as watching TV, visiting with friends, and going on outings with activities staff;-Promote and explain the importance of social interaction and leisure activity time;-Encourage the resident's participation by (reminding and inviting her to social events);-Invite and encourage Resident #11 and family members to attend activities in order to support participation;-Monitor for safety during activity functions;-Provide Resident #11 with a monthly activities calendar; and,-Remind Resident #11 that she may leave activities at any time and is not required to stay for the entire activity. D. Staff interview The AD and NHA were interviewed on 10/11/23 at 9:15 p.m. The AD said there was not much that Resident #11 liked to do. Most days the resident was active on her phone doing independent activities. The AD said this was by the resident's choice. The AD said she visited the resident for one-to-one activities at least once a week and brought the resident her favorite snack, popcorn. Activities provided the resident with pen and notebooks so she could keep records about her care and daily activity. Additionally, the resident received periodic visits from the hospice chaplain, weekly visits from a pastor from a local church and visits from church volunteers. Both provided the resident with emotional and spiritual support. The AD said Resident #11 was able to get her nails done when requested and the social services director conducted mood check-ins. The resident, however, never left her room. III. Resident #83A. Resident statusResident #83, under the age of 65 was admitted on 11/24/22. According to the October 2023 computerized physician orders (CPO), the diagnoses included major depressive disorder and PTSD (post-traumatic stress syndrome). According to the 9/10/23 minimum data set (MDS) assessment, the resident was moderately cognitively impaired as evidenced by a brief interview for mental status (BIMS) score of 10 out of 15. The resident was independent and able to perform most activities of daily living (ADL) independently but needed minimal assistance to walk and transfers According to the assessment activities preferences the resident said being able to participate in preferred activities was very important. Listening to music; keeping up with the news; and being able to go outside were somewhat important. B. Observation and resident interviewOn 10/9/23 from 10:00 a.m. until 2:35 p.m. Resident #83 was observed, the resident was in his room sleeping staff did not go into the resident's room to offer any activities programming or invite the resident to the scheduled activity ball toss at 10:15 a.m., cafe social at 11:00 a.m., or good vibes music at 1:00 p.m. The resident was not offered gospel music to listen to in his room. On 10/10/23 from 9:22 a.m., until 12:10 p.m. Resident #83 was observed. The resident was in his room sleeping. Staff passed the resident's room three times but did not go into the resident's room to offer activities programming or invite the resident to the Caffe social at 11:40 a.m. The resident was not offered Ethiopian gospel music. Observation on 10/11/23 from 2:40 p.m. until 3:15 p.m. Resident #83 was observed. The resident was in his room on his phone. The staff did not go into the resident's room to invite the resident to a pizza party that was on the third floor. Resident #83 was interviewed on 10/11/23 at 3:11 p.m. Resident #83 said he would like to participate in activities but no one asked or reminded him of the scheduled activity. Resident #83 said he would especially have liked to participate in food activities. Resident #83 said he did not know there was a pizza activity. Resident #83 did not know where he would find the activities the facility offered. Resident #83 said he was not offered Ethiopian gospel music. Resident #83 said he did not have an activities calendar. Resident #83 said the activities staff could have given it to him but he did not know where it was. -The resident's room was observed and there was no activity calendar posted in the room. C. Record reviewAccording to the activities care plan revised 4/18/23, documented the resident was independent and would make leisure needs known. The resident preferred food socials, special events, being outside, visiting with family and going outdoors. The resident liked to use the facility's computers and using his personal phone. Interventions included providing the resident with an activities calendar. Inform the resident of ongoing activities. Provide the resident with food whenever there was a food activity. Thank the resident for participating. Provide the resident with independent supplies. Remind the resident to call his brother when he has phone issues. Be patient with the resident when he had phone issues. Provide the resident with a daily large print calendar, on a weekly basis or per request. According to the trauma care plan initiated 4/5/23, documented the resident had PTSD. Interventions included that the activities department should offer to play Ethiopian gospel music for the resident in order to soothe his mood. The activity participation records dated 9/11/23 through 10/11/23 documented the following:-The resident participated in one-on-one activity independently seven times, four times with family, and three times with staff, and was marked as not occurring for the remaining 16 times.-The resident participated in snack activities 20 times independently, three times with staff, and refused four times.-The resident participated in sensory activities 24 times independently and refused six times.-The resident participated in spiritual activities three times independently, refused three times, and the activity was not offered 25 times.-The resident participated in physical activities 27 times independently and two times refused.-The resident participated in outings two times with family and 30 times the activity was not applicable.-The resident participated in creative activities ten times independently and refused 19 times.-The resident participated in a social group 10 times independently, four times with staff and 15 times the resident refused.-The resident participated in cognitive activities independently 11 times and the resident refused 19 times.-The participation record documented that the resident was left to participate mostly in independent activities when his activity preferences included attending food socials, special events, and being outside. D. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 10/12/23 at 9:53 a.m. CNA #5 said Resident #83 did not come out of his room often. CNA #5 said the resident liked food activities and to go outside. CNA #5 said the activities staff gave out a calendar at the beginning of the week. CNA #5 said the staff did not always tell every resident about activities. The activities director (AD) was interviewed on 10/12/23 at 11:33 a.m. The AD said activities staff go door to door to ask residents if the resident would like to participate. The AD said they did this right before the activities started. The AD said the activities programs were held on different floors. The AD said the resident would know which floor the activity was on according to the activities calendar. The AD said the activities staff asked residents at the beginning of the month if he wanted to go on outings. The AD said the residents received a calendar at the beginning of the week. The AD said Resident #83 was often on his phone in his room doing independent activities. The AD said that when residents do things in their rooms that activity was counted as independent participation in an activity. The AD said Resident #83 did like to go to café or food activities.

Based on observations, record review and interviews, the facility failed to provide one (#99) of five residents reviewed for pressure injuries out of 46 sample residents with the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing. Specifically,the facility failed to:-Reposition the resident, who had pressure injuries; -Follow orders specifically to float heels while the resident was in bed; and, -Follow current orders for supplements to assist with wound healing and minimize further skin breakdown. Findings include: I. Professional referenceA. The National Pressure Injury Advisory Panel, NPIAP Pressure Injury Stages 2016,http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ revealed the following pertinent information:"A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear."B. According to the National Pressure Injury Advisory Panel (NPUAP), Prevention and Treatment of Pressure Ulcers, Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014:"Steps to prevent the emergence of pressure injuries in individuals identified as being at high risk include: scheduled repositioning and floating heels. "Steps to prevent the worsening of existing pressure injuries and to promote healing include: Avoiding positioning that places pressure on the pressure injury, floating heels, assessment and documentation of the pressure injury when discovered and reassessment and documentation at least weekly. Assessment should include location, category/stage, size, tissue types, color, periwound (the skin around the wound) condition, wound edges, and evidence of undermining or tunneling, exudate, and odor."II. Facility policies and proceduresThe Pressure Wound Prevention and Skin Management policy and procedure, revised April 2021, was provided by the nursing home administrator on 10/12/23 at 4:45 p.m. It revealed in pertinent part, "The primary purpose of the pressure wound prevention and skin management program is to reduce the occurrence of pressure. injuries and promote healing of wounds. Identification, prevention, and treatments will be based on NPUAP definitions, recommendations, and practice standards. The interdisciplinary team will partner when the resident when planning and providing care. Weekly wound rounds and community education will be coordinated by wound team members. residents with skin issues should be discussed during report. The following business day IDT (interdisciplinary team) members will review admission records and corresponding care plan. Additional assessment such as nutrition, therapies, social service, wound rounds, and activities will be completed within the first week of admission. The long-term resident plan of care for prevention and management of wounds will be completed and reviewed during a care conference by the 21st day of care."The nurse identifying a new pressure injury or wound should obtain treatment orders based on the resident's individualized needs. The following people will be notified by the physician, the resident, and or responsible party, the IDT members, including the DON (director of nursing), RD (registered dietitian), social services, activity and therapy, a nutritional evaluation should be completed. Depending on the factors contributing to the wound, the therapy, social service, and activities evaluation may be initiated. Pain, pressure, redistribution, nutrition, and incontinence management will be evaluated as part of a potential overall change of condition when new pressure wounds are identified. Using the pressure injury, QA (quality assurance) investigation tool, the DON will evaluate the cause of all new in-house acquired pressure injuries. This will be initiated during the next business day, following identification of pressure wounds based on this evaluation additional interventions may be implemented. Wound consult will be obtained as needed for stage three in for pressure, injuries or other ones when complications impede healing. If a wound does not stabilize, show some evidence of healing within 2 to 4 weeks, the wound and residents overall clinical condition and treatment should be reassessed. If the wound appears to be deteriorating an evaluation and practitioner notification should occur before two weeks. The wound nurse will coordinate weekly wound rounds, evaluate new residents admitted with wounds or existing residents with newly acquired wounds, and coordinate the program. Wounds and interventions will be evaluated during rounds. The wound weekly observation to be utilized for weekly wound. evaluations. Documentation will include type of wounds, measurements, notification, pain, tolerance, type of treatment and effectiveness and other areas as prompted by the tool. The care plan will be updated as needed."Residents will be observed for skin breakdown by a licensed nurse, a minimum of weekly and documented on the skin observation tools. Skin should be assessed upon return from a leave of absence residents who identified as high risk for breakdown, should be educated regarding pressure injury prevention and conversation should be documented a comprehensive care plan, including identification of individual risk factors, and interventions will be initiated. Weight shifts may be implemented as part of both prevention and treatment for pressure wounds. When possible, weight shifting and offloading will allow sufficient capillary, refill and tissue perfusion, may be implemented. Tissue tolerance should be considered when identifying individualized turning schedules. Inspection, for the following will be evaluated before, and after position change discoloration, change in temperature, change, inconsistency. Pressure injury education should be completed upon hire, annually, and as needed on skin breakdown concerns in the community."Stage 3: full thickness, tissue loss. Subcutaneous fat may be visible, but bones, tendons, or muscles are not exposed. Slough may be present, but does not obscure the depth of the tissue loss. May include undermining, and or tunneling. The depths of a stage three pressure ulcer varies by anatomical location. Stage 4: full thickness, tissue loss with exposed, bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable: full thickness, tissue, loss in which the base of the wound is covered by slough and or eschar in the wound bed. Most or all of the wound bed cannot be visualized."II. Resident #99A. Resident statusResident #99, age 65, was admitted on 3/9/23. According to the October 2023 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbances, major depressive disorder and anxiety disorder. According to the 9/23/23 minimum data set (MDS) assessment, the resident was cognitively severely impaired with a brief interview for mental status (BIMS) score of two out of 15. She required extensive assistance of two people with toileting, bed mobility and dressing. She required extensive assistance of one person with transferring, locomotion, eating and personal hygiene. The resident was at risk for acquiring pressure injuries. The resident currently had one stage 3 pressure ulcer and two unstageable pressure injuries. III. Observation and representative interviewObservations on 10/9/23-At 10:14 a.m. the was on her back with her feet were touching the wall and her head was almost off of the bed. There was no pillows near her; she did not have her heels off loaded off of her bed. -At 2:30 p.m. the resident remained in the same positionA continuous observation on 10/10/23 beginning at 9:10 a.m. and ended at 2:47 p.m. revealed:-At 9:10 a.m. the resident was in her bed and was on her back on the slight right sideline; she did not have her feet offloaded from her bed.-At 10:22 a.m. an unknown nurse went into the resident's room to do wound care. An unknown certified nurse aide (CNA) change the resident's brief. -At 11:11 a.m. an unknown CNA brought water into the residents room and did not offer to assist the resident and placed the water on the other side of the room. Her heels were not floated.-At 12:38 p.m. the representative asked the nurse if she had her Ensure (supplement) yet and the nurse said Resident #99 had not and handed her the supplement. -At 1:38 p.m. the resident remained in the same position.-At 2:47 p.m. the resident remained in the same position. The representative came out and told a CNA the resident had not been repositioned and she needed to be repositioned.-The staff had not repositioned the resident since 10:22 a.m. which was over four hours. The representative was interviewed on 10/10/23 at 2:50 p.m. The representative said the CNAs did not reposition Resident #99 unless she asked them to. The representative said this happened every day so she came to the facility to ensure they reposition her and give the resident the supplements. The representative said the resident had pressure injuries and she needs to be repositioned and given supplements to help heal the pressure injuries. IV. Record reviewThe skin care plan initiated on 9/6/23 documented the resident had pressure injuries on her sacrum and bottom. Interventions included an air mattress, coordinated with the dietitian for supplements. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Reposition with the use of pillows to assist residents to stay off bony prominences as tolerated and offload pressure as tolerated. Wound physician to evaluate and treat pressure injuries. Treat the wounds according to orders. According to physician orders dated 3/9/23 the resident's heels should be floated in bed as tolerated. According to physicians ordered dated 7/21/23 the resident received ensure three times a day between meals. According to physician orders dated 6/21/23 the resident received liquid protein three times a day.-The supplemented were not evaluated after she developed wounds (see below). According to October 2023 CPO orders documented wound care with Dakins external solution 0.25 % apply to sacral/buttocks wounds topically one time a day Tuesday and Thursday and Saturday. According to a progress note dated 8/17/23 at 5:54 a.m. documented the resident had a skin opening on her left hip due to prolonged pressure on skin. Clean with antiseptic and dress it. Nurse notified the physician and wound team. According to a progress note dated 8/17/23 at 8:00 a.m. documented the resident had a small open area on her right hip. The resident was underweight and her hips were very boney. The open area was on a pressure point. She positions herself on her right side in bed. When positioned on her left side she would reposition herself to her right side. According to an interdisciplinary team (IDT) note dated 8/17/23 at 10:06 a.m. documented the IDT intervention was for the resident to be repositioned in her bed with use of pillows to assist residents to stay off of bony prominences as tolerated. According to an incident note dated 8/24/23 at 7:13 p.m. the resident had an open area to the buttock. Assessment documented the resident had two open areas to the left and right sacrum. Treatments were put in place. Sites were cleansed and covered. The resident will have a wound physician evaluation the following week. Current treatment was to use air mattress and staff to provide repositioning as tolerated. According to IDT review notes dated 8/25/23 documented the resident had a new pressure wound. The resident had a decline in food intake. Intervention included coordinating with registered dietitian (RD) for supplements to assist with wound healing and minimize further skin breakdown. Continue to reposition residents as tolerated. According to the wound notes dated 8/31/23 the resident had acquired three pressure injuries. The resident had an unstageable pressure ulcer on her sacrum. The resident had a stage 3 pressure ulcer on her right buttock. The resident had an unstageable pressure ulcer on her right buttocks distal. The most recent wound notes dated 9/28/23 the resident had documented two pressure injuries. The resident had a stage 4 pressure ulcer on her sacrum. The resident had a stage 3 pressure ulcer on her right buttocks. According to the physician note dated on 10/9/23 documented Resident #99 was seen for wounds on sacrum, buttock and periarea wound. The resident intake remains poor and the resident remained on hospice. Decubitus ulcer of buttock, unspecified laterally and unspecified ulcer stage. Treatment included daily wound care and oral medications for decubitus ulcer. V. Staff interviewLicensed practical nurse (LPN ) #4 was interviewed on 10/12/23 at 9:39 a.m. LPN #4 said residents at high risk for pressure injuries should be repositioned every two hours. LPN #4 said CNAs reposition the residents who were at high risk. LPN #4 said nursing staff should follow orders and care plans to prevent or heal pressure injuries. LPN #4 said Resident #99 pressure injuries were healed and was better. LPN #4 said the nurses bring the Ensure to Resident #99 three times a day. CNA #5 was interviewed on 10/12/23 at 9:53 a.m. CNA #5 said Resident #99 had pressure injuries. CNA #5 said residents who were at high risk for pressure injuries should be repositioned every two hours, sometimes every hour. CNA #5 said Resident #99 should be repositioned every two hours. CNA #5 said the resident could not reposition herself. CNA#5 said the resident did not have preventative boots to offload her feet. CNA #5 said the staff did not offload the residents feet. CNA #5 said interventions for residents with pressure injuries were located in the resident's care plan. CNA #5 said the nurses administered any ordered supplements. The director of nursing (DON) was interviewed on 10/12/23 at 2:43 p.m. The DON said residents who were at high risk should be repositioned every two hours. The DON said all orders should be followed to prevent and heal pressure injuries. The DON said the care plan should be followed and documented if the resident refused interventions. The DON said Resident #99's feet should be offloaded but she did not like it. The DON said Resident #99 had pressure injuries. The DON said the resident did not like being repositioned and would go back into the same position. The DON said nursing staff should continue to try to reposition the resident. The DON said the staff should try to offload the resident's feet. The DON said the resident had supplements put into place to help since she had weight loss and pressure injuries. The DON said the staff should give the supplements in between meals since that was what the order indicated.

Based on record review and interviews, the facility failed to ensure one (#99) resident of two out of 46 sample residents had pain management services consistent with professional standards of practice. Specifically, the facility failed to: -Ensure as needed (PRN) pain scale was implemented and followed for administration of morphine for Resident #99; and, -Pain medication was not administered according to the physician's orders for Resident #99. Findings include:I. Resident statusResident #99, age 65, was admitted on 3/9/23. According to the October 2023 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbances, major depressive disorder, anxiety disorder, and pancolitis (affects the entire colon and causes bouts of bloody diarrhea that may be severe, abdominal cramps and pain). According to the 9/23/23 minimum data set (MDS) assessment, the resident was cognitively severely impaired with a brief interview for mental status (BIMS) score of two out of 15. She required extensive assistance of two people with toileting, bed mobility, and dressing. She required extensive assistance of one person with transferring, locomotion, eating and personal hygiene. The resident was on a pain medication regimen. The resident did not receive PRN medications. II. Record reviewAccording to the medication administration record (MAR) from 9/16/23 to 10/4/23 Morphine sulfate oral solution 20 mg (milgrams) /5ml (militers) give 0.25 ml by mouth every four hours as needed.-There was no pain scale to determine when the morphine should be administered. Morphine sulfate oral solution 20 mg/5ml give 0.25 ml by mouth every four hours as needed for pain 6-10. According to the MAR, the resident received morphine on the following days:10/7/23 the resident received morphine with a zero pain scale entered. 10/8/23 the resident received morphine with a zero pain scale entered. 10/9/23 the resident received morphine with a zero pain scale entered. 10/10/23 the resident received morphine with a zero pain scale entered. 10/11/23 the resident received morphine with a zero pain scale entered. According to the order note dated 10/5/23 documented, "Morphine sulfate oral solution 20 mg/5ml give 0.25 ml as needed for pain 6-10 was outside of recommended doses and frequency. This dose fails dose range check based on drug inputs and/or the patient information provided. This drug's dose should be adjusted based on renal functioning."III. Staff interviewsLicensed practical nurse (LPN) #4 was interviewed on 10/12/23 at 9:39 a.m. LPN #4 said Resident #99 was on pain medication. LPN #4 received pain medication on an as needed basis. LPN #4 said Resident #99 was unable to verbally tell staff if she was in pain. LPN #4 said Resident #99 had anxiety and would yell out and it did not indicate the resident was in pain. LPN#4 said there were not specific things she would look at to determine when the resident was in pain. LPN #4 said she knew the resident so she would just know if the resident was in pain. LPN #4 said since the resident did not verbally tell the staff member a number she would put zero for pain scale. LPN #4 said it was important to document pain scale correctly so the providers know where the resident was at with pain. The director of nursing (DON) was interviewed on 10/12/23 at 2:43 p.m. The DON said if a resident was in pain the nurse should assess pain and treat according to physician orders. The DON said if a resident was unable to verbally express their pain the nurse should use the Wong-baker scale (a method for someone to self-assess and effectively communicate the severity of pain they may be experiencing). The DON said nurses should use a zero to 10 pain scale even when the resident was not verbal. The DON said she had educated the staff that it was important to use pain levels to determine what pain medication should be used. The DON said it was important to only give pain medications according to the orders.

Based on record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services for s to attain and maintain the highest practicable mental and psychosocial wellbeing for two (#33 and #97) of three residents reviewed out of 46 sample residents. Specifically, the facility failed to ensure individualized, non-pharmacological approaches to care were being identified and promoted to meet the mental and psychosocial needs for Resident #33 and Resident #97. Findings include:I. Resident #33A. Resident statusResident #33, age under 70 years, was admitted on 7/7/21. According to the October 2023 computerized physician orders (CPO), the diagnoses included bipolar disorder. The 7/23/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of 10 out of 15. Her depression assessment score was two indicating no depression. B. Resident interview and observation The resident was observed on 10/9/23 at 10:00 a.m. waiting to enter the elevator. She was yelling profanities and no staff responded to her. The resident was observed on 10/9/23 at 1:15 p.m. She was sitting in the dining room with other residents and yelling her bottom hurt and she needed to use the bathroom. She yelled she had diarrhea and no one cared about her. After two minutes of yelling, the staff came to take her to her room. The resident was observed on 10/9/23 at 1:21 p.m. leaving her room. She was yelling she wanted to take a shower and needed help. Another resident was in the shower and Resident #33 went to the shower room door and yelled obscenities until the staff were able to get her into the shower room. After several attempts on 10/9/23, the resident was unable to be interviewed due to behaviors. C. Record reviewThe comprehensive care plan, initiated 7/10/23, revealed the resident exhibited behaviors of yelling obscenities towards staff and other residents. Interventions included allowing the resident to calm down, educating the resident on appropriate communication with others, frequent mood checks, behavior monitoring and offering mental and emotional support services as needed. -The care plan failed to reveal the recent psychiatric hospitalization and any new interventions as a result. The October CPO revealed the following physician orders;-Ativan 0.5 MG (milligrams)-give one tablet by mouth three times a day for anxiety-ordered on 10/6/23;-Depakote 500 MG- give three tablets a day at bedtime for bipolar disorder-ordered on 10/6/23;-The resident is known to call 911 for psychological reasons. Offer reassurance, try distraction with music, or call sister so the resident can speak to her- ordered on 10/2/23. Progress notes dated 7/17/23 through 10/10/23 revealed in pertinent part,-Social services progress note date 7/18/23 revealed a referral was sent per the resident's request for psychological services. -Social services progress note dated 7/19/23 revealed the resident was scheduled to see the psychology provider on 7/25/23 and the resident had been notified. -Preadmission screening and resident review (PASRR) progress note dated 7/21/23 revealed the resident was reviewed in the psychotropic medication committee. The resident had recently returned from a psychiatric hospitalization. There were no progress notes explaining the necessity for psychiatric hospitalization. -Order administration note on 7/24/23 revealed the resident was having a behavior or yelling out for her food. No interventions or outcomes were provided.-Order administration note dated 7/30/23 revealed a behavior was observed but there was no further information regarding what the behavior was or the outcome.-Nursing note dated 8/14/23 revealed the resident verbalized increased depression to the nurse. The provider was notified and labs requested. -Psychiatric provider note dated 8/24/23 revealed the resident was placed on a mental health hold in June 2023, but the provider was unclear as to why. The provider documented the resident's record and showed she was manic at the time of the hold. The provider documented the resident verbally expressed depressive symptoms during the visit.-Nursing note dated 8/29/23 revealed the resident was perseverating on a medication change and became verbally aggressive with the nurse. The nurse advised the resident the provider would be notified of her concerns.-Social services note dated 9/12/23 revealed the social services director (SSD) reached out to the resident's sister for items to purchase for the resident. -Order administration note dated 9/19/23 revealed a behavior was observed but there was no further information regarding what the behavior was or the outcome.-Order administration note dated 9/20/23 at 2:00 p.m. revealed a behavior was observed but there was no further information regarding what the behavior was or the outcome.-Order administration note dated 9/20/23 at 4:16 p.m. revealed a behavior was observed but there was no further information regarding what the behavior was or the outcome.-Order administration note dated 9/22/23 at 6:00 a.m. revealed a behavior was observed but there was no further information regarding what the behavior was or the outcome.-Alert note dated 9/22/23 at 6:45 a.m. revealed the resident called 911 because she had a cough. The resident was transported to the hospital. The note did not include the physician ordered interventions were tried or the family was contacted. -Admission note on 9/26/23 revealed the resident returned to the facility from the hospital.-Order administration note dated 9/28/23 at 5:53 a.m. revealed a behavior was observed but there was no further information regarding what the behavior was or the outcome.-Order administration note dated 9/29/23 at 4:00 a.m. revealed a behavior tracking order had been entered for the resident's behavior of screaming obscenities, name calling, and non compliance. Behaviors observed were to be included in the progress notes.-Order administration note dated 9/29/23 at 10:29 p.m. revealed a behavior was observed but there was no further information regarding what the behavior was or the outcome.-Order administration note dated 9/29/23 at 10:35 p.m. revealed a behavior was observed but there was no further information regarding what the behavior was or the outcome.-Nurse note dated 9/29/23 at 10:38 p.m. revealed the resident called 911 and demanded medication from the staff she had already taken then used profanity. The note did not include the physician ordered interventions were tried or the family was contacted.-Nurse note dated 9/30/23 revealed the resident did not go to sleep until 4:00 a.m. The resident was waking other residents due to yelling and throwing things at the staff. The resident attempted to exit the floor and staff had to call other staff from another floor for back up. The nurse documented the resident was putting staff and other residents' safety at risk. She finally fell asleep.-Order administration note dated 10/1/23 release the resident was at the hospital after calling 911 herself. The note failed to include the reason the resident called 911 and transported to the hospital. The note did not include the physician ordered interventions were tried or the family was contacted.-Nursing note dated 10/2/23 at 3:00 a.m.revealed the resident came to the nurses and wanted to call her son. She was informed the staff would assist her once shift change was completed. The resident yelled profanity and the staff and then went to her room and called 911. She reported to the police she was having chest pain and not receiving care. The resident was taken to the hospital and then returned several hours later. She then began yelling for the staff to call 911 again. The note did not include the physician ordered interventions were tried or the family was contacted.-Order administration note dated 10/2/23 at 10:26 a.m. revealed the resident was having behaviors of restlessness, tremors, and agitation. No interventions or outcomes were documented. -Behavior note dated 10/5/23 revealed the resident used her call light and started yelling for help. She threw her food tray across her room. The resident was assisted to the toilet where she declared she was having a baby and was corrected it was a bowel movement not a baby. The resident was given a shower but continued to need constant verbal reassurance or she would begin to yell. She was taken to activities.-Order administration note dated 10/6/23 at 9:24 p.m. revealed yelling profanity at staff. No intervention or outcome was documented. -Order administration note dated 10/6/23 at 9:48 p.m. revealed a behavior was observed but there was no further information regarding what the behavior was or the outcome.-Nursing note dated 10/8/23 at 6:10 p.m. revealed the resident called paramedics complaining of chest pain. She was transported to the hospital and returned to the facility within three hours. The note did not include the physician ordered interventions were tried or the family was contacted.-Nursing note dated 10/8/23 at 8:21 p.m. revealed the resident was yelling profanity at staff. No intervention or outcome was documented. -Order administration note dated 10/9/23 at 9:48 p.m. revealed a behavior was observed but there was no further information regarding what the behavior was or the outcome.-Order administration note dated 10/10/23 revealed the resident had an episode of yelling and calling out. No intervention or outcome was documented. The progress notes failed to reveal the social services director (SSD) followed up with the resident or the staff regarding the repeated behaviors or the interventions used. The resident's pre-admission level II PASRR was reviewed on 10/12/23. The level II evaluation dated 2/16/23 identified a history of psychiatric hospitalizations over her lifetime related to bipolar instability. A review of the CNA tasks on 10/12/23 failed to reveal behavior tracking. II. Resident #97A. Resident statusResident #97, age under 70 years, was admitted on 2/2/23. According to the October 2023 CPO, the diagnoses included post traumatic stress disorder, suicidal ideations, and major depressive disorder. The 7/23/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. His depression assessment score was a five indicating mild depression. The resident expressed feeling down and hopeless. B. Resident interview and observation Resident #97 was interviewed on 10/9/23 at 10:15 am. The resident stated he had some issues with the staff and yelled at them when frustrated. He had been working with his therapist on emotional regulation when he became frustrated with the staff. During the interview, the resident became tearful when discussing feeling the staff did not provide physical care consistent with how he requested (turning, repositioning). Resident #97 was interviewed on 10/10/23 at 11:30 a.m. The resident had expressed suicidal ideations to the staff and was on 15 minute checks. He stated he was triggered because the staff had told him he could be helped out of bed after breakfast and the staff had not been getting him up. It affected his mood that he was dependent on the staff. He denied he wanted to attempt suicide when he made the statements but sometimes he stated he to become upset to the point of expressing suicidal ideations to receive attention for his feelings. The resident said the facility had never done 15 minute checks on him before and he was not sure the purpose. He did not feel he should have to become frustrated and angry enough to feel suicidal in order for the facility staff to realize he is being made feel dependent and helpless. During the interview, the resident described his prior suicide attempt of hanging himself with his call light and became tearful when explaining how the staff made him feel. He was observed with his call light and his phone charger cord across his chest. C. Record reviewThe comprehensive care plan, revised on 2/15/23, revealed the resident exhibited behaviors of suicidal ideations and suicidal attempts. The resident had a history of being admitted for a suicide attempt via medication overdose related to frustration over medical condition. Interventions included mood check ins and behavior tracking. His last suicide attempt was 7/19/23 via wrapping a call light cord around his neck (this was added to the care plan 10/12/23, during the survey). Interventions included following a safety plan which outlined activities he enjoyed. It also included frequent checks from the SSD and encouragement to socialize. -The resident's suicide attempt and new interventions were not added to the care plan until 10/12/23 and failed to reflect the psychiatrtic hospitalization. -No safety plan for the 7/19/23 suicide attempt was located in the resident's chart. The October CPO revealed the following physician orders;-Refer to behavior health for psychological and psychiatric evaluation and treatment-ordered on 4/24/23;-Lamotrigine (anticonvulsant) 50 MG milligrams-give one tablet one time a day for history of seizures-ordered on 8/23/23;-Behavior monitoring for suicidal ideations. Check to make sure the resident does not pocket medications to attempt suicide-ordered on 10/9/23;-Behavior monitoring for escalating verbal aggression towards staff-ordered on 10/9/23. Orders failed to reveal behavior monitoring was started after the recent suicide attempt on 7/19/23 nor did behavior monitoring reflect to monitor for attempts to hang self with call light. Progress notes dated 7/17/23 through 10/10/23 revealed in pertinent part,-Order administration note dated 7/17/23 revealed the resident had a behavior related to suicidal ideations and verbal aggression. The resident had been throwing water. -Social services note dated 7/18/23 at 7:14 a.m. revealed the SSD completed a suicide lethality assessment with the resident due to statements he wanted to die due to increased pain. The resident was determined to be low risk and without a plan. -Nursing progress note dated 7/18/23 at 9:05 p.m. revealed the nurse entered the resident room after his call light had been pulled to find the resident had wrapped the call light around his neck. 911 was contacted. -Nursing progress note dated 7/19/23 reveled the resident had been admitted to the hospital on a mental health hold due to suicide attempt. -Admission summary note dated 7/20/23 revealed the resident returned to the facility. -PASRR progress note dated 7/21/23 revealed the resident had been reviewed regarding his recent hospital visit for attempted suicide. The physician recommended trialing the resident on Lithium (mood stabilizer).-Social services note dated 7/26/23 revealed the SSD had a mood check in with the resident. The resident expressed feeling ashamed of his suicide attempt. Continues with behavioral health. The SSD had been working with the resident on a discharge plan to another facility per his request But had not found an accepting facility.-PASRR progress note dated 7/27/23 revealed the resident started on a trial of Lithium 300 MG twice a day for mood and impulsive behavior related to depression.-Social service note dated 8/2/23 revealed the SSD and director of nursing (DON) met with the resident per his request. The resident expressed being upset about the care he had received the previous evening. The resident expressed feeling anger and frustration as a result.-Social service note dated 8/4/23 revealed the SSD invited the resident's family to his care conference for 8/8/23.-Social service note dated 8/8/23 at 12:35 p.m. revealed the resident had a care conference with the family present. The care conference was for the discussion of discharge planning.-Nursing note dated 8/8/23 at 3:24 p.m. revealed the resident had been upset and throwing items in his room. He had tipped over his bedside table and was using profanity at staff related to being unhappy with the discharge care conference earlier in the day. The SSD and DON were notified however, no follow up progress note was made.-Nursing note dated 8/16/23 revealed the resident had been having upset stomach symptoms of nausea and diarrhea for several days and was sent out to the hospital.-Nursing note dated 8/19/23 at 3:35 p.m. revealed the resident readmitted to the facility from the hospital-Order administration note dated 8/19/23 at 10:21 p.m. revealed a behavior was observed but there was no further information regarding what the behavior was or the outcome.-Social services note dated 8/28/23 at 12:32 p.m. revealed the SSD checked in with the resident. The resident expressed no concerns.-Social service note dated 8/28/23 at 1:40 p.m. revealed the social worker did a mood check in with the resident. The resident was tearful, expressing he was struggling with pain and concerns he would not be able to discharge in December.-Nursing note dated 9/15/23 at 2:59 p.m. revealed the resident contacted paramedics to transport him to the hospital stating he was in pain and unhappy with his care at the facility. The resident returned within 24 hours. No follow up note from the SSD was located regarding his expressing unhappiness at the facility until 9/27/23..-Social service note dated 9/27/23 at 8:18 a.m. revealed the SSD did a mood check in with the resident. A safety plan was discussed for the resident to identify and manage warning signs and symptoms of increased stress. The resident expressed he becomes more angry when he is stressed and then yells at staff, kicks staff out of his room, and uses profanity. The resident stated individual activities were helpful to decrease stress.-Social service note dated 10/2/23 at 11:14 a.m. revealed the SSD discussed with the family the resident's discharge plan and the SSD was now looking for new placement for the resident instead of a discharge home.-Order administration note dated 10/2/23 at 2:37 p.m. revealed a behavior was observed but there was no further information regarding what the behavior was or the outcome.-Social service note dated 10/2/23 at 2:41 p.m. revealed the resident had spoken with the SSD earlier and expressed a desire to transfer to another facility citing he did not feel the current facility could meet his needs. The SSD submitted referrals on his behalf.-Nursing note dated 10/5/23 3:47 p.m. revealed the resident returned from the hospital. There were no precipitating notes documenting the reasons the resident had gone to the hospital. -Order administration note dated 10/11/23 at 2:37 p.m. revealed a behavior was observed related to suicidal ideations but there were no further information regarding what the behavior was or the outcome. A review of the CNA tasks on 10/12/23 failed to reveal behavior tracking. III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 10/10/23 at 10:45 a.m. He was not aware of where to find the non pharmacological interventions for residents in the medical record. Resident #97 was moody and wanted care promptly from the staff. He was currently on 15 minute checks for expressing suicidal ideations but RN #1 was not aware the resident had a history of suicidal ideations or attempts and did not know the method he used to attempt suicide in July 2023. He did not know care plan interventions or identified triggers for Resident #97. RN #1 said he did not know the facility's expectations of him when a resident expressed suicidal ideations. RN #1 said Resident #33 had behaviors of yelling for care, using profanity, racial slurs at staff, and calling 911 if she did not receive care promptly. Staff would try to redirect her or take her to activities. He did not know care plan interventions or identified triggers for Resident #33. CNA #1 was interviewed on 10/10/23 at 11:02 a.m. She stated Resident #97 was on 15 minute checks due to expressing suicidal ideations. She was unaware he had a history of suicidal ideations or attempts prior to the current incident. CNA #1 did not know care plan interventions or identified triggers for Resident #97. She said CNAs track behaviors generated in the CNA tasks. If management wants the staff to be aware of a new behavior, it will be posted on the board in the CNA charting room (no behavior notes were observed on the board). The DON will also come to the staff and let them know of new behaviors. Management does not advise staff of the non pharmacological interventions to use, the staff had to figure those out. CNA #1 said Resident #33 had behaviors of yelling profanity at staff, refusing care, and throwing things at staff. She did not know care plan interventions or identified triggers for Resident #33. The SSD was interviewed with the social services consultant (SSC) on 10/11/23 at 1:29 p.m. She said the facility's process when a resident expressed suicidal ideations was to complete a suicide assessment with the resident to determine the severity of the risk. If a resident was sent out for psychiatric evaluation or hospitalizations related to suicide thoughts or actions, the resident's care plan was updated. Updates were made to care plans daily because the care plan was the road map to the resident's care and needs. After the psychiatric hospitalizations, Resident #33 and Resident #97 care plans should have been updated. After Resident #97 returned from his psychotic hospitalization, the SSD came up with a safety plan with him. The safety plan would include potential triggers, identified non pharmacological interventions, and support needed by the resident. She had not documented the safety plan in the care plan, behavior tracking, or educated the staff on the plan. SSD stated after Resident #33 returned from her psychiatric hospitalization on 7/21/23, no new interventions were put into place. The SSD stated when a resident had a behavior, the nurse made a behavior note including the specific behavior and the interventions tried. Interventions were put into the care plan and the staff were trained to look for a resident's individualized non pharmacological interventions in the care plan. Resident #97 had a behavior documented related to suicidal ideations on 10/11/23 with no further notes from the nurse. The SSD was not aware of what the behavior was and if the resident had made further remarks related to desiring suicide. She would provide documentation of staff training for behavior tracking and care plan interventions. The SSC stated management did a sweep of a resident's room for potential weapons with the resident's consent. If a resident had used a call light as a mode to attempt suicide in the past or expressed desire to use it, the call light would temporarily be removed and replaced with a bell. She stated she had done a suicide assessment and room sweep for Resident #97 on 10/10/23. He was determined to be at low risk and had expressed suicidal ideations related to feeling frustrated with staff not assisting him with getting out of bed for the day. She had not removed his call light because she was not aware he had used the call light in the past to attempt to hang himself. This was not identified in his care plan or his behavior tracking. The nursing home administrator (NHA) and DON were interviewed on 10/12/23 12:07 p.m. The NHA had not been able to locate staff training on how to complete a behavior tracking note, where to find interventions in the care plan or how to respond to resident's individual behaviors. The facility would start doing training with staff for residents with behaviors on individualized interventions, triggers and behaviors. The minimum data set coordinator (MDSC) was interviewed on 10/12/23 at 12:35 p.m. Resident behaviors were put in the care plan and flagged to show up in the CNA system (kardex). From there, the MDCS would add the resident's behaviors to the CNA tasks so the behaviors could be documented. The MDCS was unable to provide documentation Resident #97 and Resident #33 had behaviors and interventions from the care plan added to CNA tasks to monitor. The MDCS was interviewed again on 10/12/23 at 1:06 p.m. and stated she had entered the behavior monitoring in the CNA tasks.

Based on observation, record review and interviews, the facility failed to consistently provide appropriate treatment and services for dementia care for one (#99) of two residents with dementia out of 46 sample residents. Specifically, the facility failed to:-Provide a person-centered approach, individualized approach and treatment to Resident #99; and, -Have consistent, purposeful and meaningful activity for Resident #99. Findings include:I. Resident #99 A. Resident statusResident #91, age 65 was admitted on 3/9/23. According to the October 2023 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbances, major depressive disorder and anxiety disorder. According to the 9/23/23 minimum data set (MDS) assessment, the resident was cognitively severely impaired with a brief interview for mental status (BIMS) score of two out of 15. She required extensive assistance of two people with toileting, bed mobility and dressing. She required extensive assistance of one person with transferring, locomotion, eating and personal hygiene. The resident had no behavioral symptoms. The resident was on antidepresent and antipsychotics. II. Observations10/9/23 -At 10:14 a.m. the resident was in her bed. The room was dark and had no music or television (TV) on. The door was shut and the resident was yelling very loud and could be heard across the unit. Staff did not go into the resident's room. The resident did not have a weighted blanket or stuffed animals with her. -At 12:00 p.m. the resident continued to scream and can be heard across the floor unit. The resident remained in the same position. There was no music or TV on. The door remained shut. -At 2:45 p.m. the resident remained in the same position without music or television and continued to yell loudly. The door remained shut. A continuous observation on 10/10/23 beginning at 9:10 a.m. and ended at 2:47 p.m. revealed:-At 9:15 a.m. the resident was in her bed. The resident was yelling and could be heard when the door was shut. The resident did not have a weighted blanket or stuffed animals with her. There was no music or TV on in the resident's room. -At 9:22 a.m. an unknown certified nurse aide (CNA) entered the resident's room to grab her food tray. The CNA did not communicate with the resident and shut the door behind them. -At 9:32 a.m. the resident was screaming when two unknown staff members walked by her room but did not enter her room.-At 9:45 a.m. the resident continued to yell at three unknown staff members who walked by the resident's room without checking on her. -At 9:51 a.m. the resident was yelling her eyes were wide open and she had tears in her eyes. The door remained shut.-At 10:19 a.m. the resident continued to yell and was screeching. The resident was heard across the unit. Staff did not check on her.-At 10:22 a.m. licensed practical nurse (LPN) #5 went into the resident's room to give medications and treatments.-At 10:28 a.m. LPN #5 asked CNA #5 to change the resident. The resident continued to scream. CNA #5 left the room at 10:32 a.m.-At 10:35 a.m. there was a music activity going on in the common area. The resident remained in her bed with the door shut. The resident was screaming loudly. The resident could be heard over the music, no staff went into her room to check on her. -At 11:11 a.m. an unknown CNA was passing out water they went into the resident's room and set the water across the room and did not offer to help her drink. The resident could not reach the drink.-At 11:45 a.m. the resident continued to scream and staff did not check on her. -At 12:08 p.m. the resident was screaming the door was shut. An unknown nurse went into the resident's room to give her medications. The unknown nurse did not communicate with the resident.-At 12:15 p.m. the resident was yelling help and the staff did not check on her.-At 12:34 p.m. her representative went into the room and the resident continued to scream.-At 12:38 p.m. her representative came and asked about her supplements and lunch. The respresentative went into the resident's room and the resident stopped yelling. -At 1:30 p.m. the resident remained in the room with her respresentative. Her yelling had stopped. Staff did not enter the room.-At 2:45 p.m. the resident's representative remained in her room. Staff did not check on the resident or enter the room. The resident was no longer yelling. The representative asked an unknown CNA to reposition the resident. The resident's representative was interviewed on 10/10/23 at 2:50 p.m. She said the staff did not check on the resident often, allowed the resident to scream and gave the resident medications to calm her down. The representative said the resident had a decline within the last two months and she admitted to hospice care. The representative said she visited every day to ensure Resident #99's needs were met. III. Record review According to the communication care plan, revised on 3/29/23, documented the resident had communication issues due to a dementia diagnosis. Interventions included the following, anticipate the resident's needs. Allow adequate time to respond, repeat if necessary, do not rush. Monitor and document resident's ability to express and comprehend language, memory, reasoning ability, problem solving ability and ability to attend. Validate the resident's message by repeating aloud. According to the psychotropic/mood care plan, revised on 7/5/23 documented the resident was on medications to manage the symptoms of dementia with agitation. The interventions included the following, administered the medications as ordered. The resident or power of attorney could request a change in medications, frequent mood check ins and behavior monitoring. According to the behavior care plan, revised on 8/02/23, documented the resident yelled across the unit and speaks gibberish. The resident becomes irate and yells out more when redirected. The interventions included the following frequent mood checks, giving the resident a stuffed animal and weighted blanket and offering music to the resident. According to the psych progress note dated 9/8/23 documented the resident continued to have severe cognitive deficiencies with behavioral disturbances. According to the psychosocial note dated 9/12/23 documented during the care conference the interdiplinary team and the resprestative decided the resident should be placed on hospice. According to activity participation dated October 20223 the resident did not have one-to-one activity visits and did not participate in activities. IV. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 10/12/23 at 9:39 a.m. LPN #4 said when residents have behavioral issues staff should check on the resident and provide interventions to help them calm down. LPN #4 said medications could help but the staff should try other methods first. LPN #4 said Resident #99 was difficult to redirect. LPN #4 said the resident yelled a lot and could get aggressive with staff. LPN #4 said there were no specific interventions for the resident when she was screaming and yelling. LPN #4 said she knew the resident and was able to redirect her and calm her down. CNA #5 was interviewed on 10/12/23 at 9:53 a.m. CNA #5 said Resident #99 had behaviors that included screaming, yelling, agitated easily and hit staff. CNA #5 said the resident was not easy to redirect. CNA #5 said there were no interventions in place to help the resident. CNA #5 said the resident was not predictable and there was not many things that worked. CNA #5 said she would try to calmly talk to the resident. CNA #5 said there was nothing staff could do to stop the resident from yelling. The director of nursing (DON) was interviewed on 10/12/23 at 2:43 p.m. The DON said residents that have behavioral issues should have non-pharmaceutical interventions. The DON said non-pharmaceutical interventions should be offered first. The DON said there should be a dementia specific care plan for the resident that included interventions. The DON said Resident #99 was a unique case and she was very difficult to work with. The DON said Resident #99 was not predictable and the same intervention did not always work. The DON said the resident had declined in the last few months and was on hospice care. The DON said the resident would refuse care and had became more difficult to work with. The DON said there had been many recent medication changes for the resident.

Based on observations and interviews, the facility failed to safely store and properly dispose of medications in a manner consistent with standards of practice for two of four medication storage rooms. Specifically, the facility failed to ensure:-Expired medications were discarded and removed from the medication storage room refrigerators in a timely manner; -All drugs and biologicals were kept safe and secure in locked compartments when not in direct line of sight of nurse; and,-All refrigerated drugs and biologicals were monitored daily for proper temperature controls in accordance with manufacturers specifications Findings include: I. Facility policy and procedureThe Medication Storage policy, revised October 2023, was provided by the nursing home administrator (NHA) provided on 10/12/23 at 4:33 p.m. it read in pertinent part: "The director of nursing (DON)/designee is responsible for drug storage per regulatory requirements to promote safety and security of medications and biologicals. Expired or discontinued non-narcotic medication will be stored in a locked area. Non-narcotic medication will be stored in a locked secure area. Medications requiring refrigeration or temperatures between 36-46 degrees Fahrenheit will be kept in a refrigerator with a thermometer to allow daily monitoring."II. Expired medication stored in refrigeratorThe second floor medication room was observed on 10/11/23 at 10:04 a.m. The refrigerator to contain the following expired medications: -Tuberculin purified protein derivative solution with an expiration date of 9/8/23;-Dulcolax laxative suppositories with an expiration date of 9/1/23; and,-Anasept topical gel (antimicrobial skin and wound cleanser) with an expiration date of 8/30/23. Registered nurse (RN) #2 was interviewed on 10/11/23 at 10:13 a.m. RN #2 said the nurse on the evening shift was responsible for checking the refrigerator for expired medication on a monthly basis. If a nurse forgot to check medication expiration dates it was up to the day nurse to complete the task. The fifth floor medication storage room was observed on 10/11/23 at 1:28 p.m., with licensed practical nurse (LPN) #1 The storage room ' s refrigerator contained a narcotic locked box and expired medication:-Diazepam suppositories with an expiration date of 7/12/23. LPN #1 was interviewed on 10/11/23 at 1:36 p.m. LPN #1 said nurses on the evening and night shifts were responsible for monitoring medication expiration dates and knew to remove the expired medication for disposal. LPN #1 said monitoring for expired medication was completed twice per month. III. Unsecured medication storage room On 10/11/23 at 1:48 p.m. the door to the fifth floor medication storage room was observed. The door to the medication storage room was slightly ajar and accessible to anyone walking by and without a nurse in direct line of sight. LPN #1 was observed removing personal belongings from the medication storage room leaving a book on the floor to hold the door open. LPN #1 had his back to the door for approximately three minutes. LPN #1 was interviewed on 10/11/23 at 1:52 p.m. LPN #1 said the lockers on the unit were too small for his backpack and did not have another space to put the backpack. LPN #1 said personal items were not supposed to be stored in the medication storage room nor should the door to the medication storage room remain open or ajar at any time. Registered nurse (RN) #2 was interviewed on 10/11/23 at 2:18 p.m. RN #2 said staff's personal items, non-medication items and food products should not be stored in the medication storage room. IV. Medication refrigerator temperature monitoringOn 10/11/23 at 10:40 a.m. the medication refrigerator on the fifth floor was observed with LPN #1. LPN #1 provided temperature logs that were in a binder. The temperature log was not consistently completed and there were days when the refrigerator ' s temperature was not monitored. The temperature logs for August, September, and October 2023 were reviewed. The temperature logs revealed inconsistent monitoring for daily temperature checks. The August 2023 refrigerator temperature log did not contain temperature checks for 8/3/23 through 8/8/23. The September 2023 refrigerator temperature log did not contain temperature checks for 9/12/23 through 9/15/23. The October 2023 refrigerator temperature log did not contain temperature checks for 10/3/23 through 10/6/23. -There was no way to know if the medications needing refrigeration were stored at the proper temperatures to maintain the stability and effectiveness of that medication on the dates when the staff failed to check the refrigerator temperatures. LPN #1 was interviewed on 10/11/23 at 1:41 p.m. LPN #1 said on the dates when the temperature checks were not conducted there were agency staff working the shift. LPN #1 said agency staff were provided an orientation to the unit and believed they received a packet of information that included monitoring temperatures of the refrigerators in the medication storage room. LPN#1 said permanent staff always check the refrigerator temperature. RN #2 was interviewed on 10/11/23 at 2:05 p.m. RN #2 said the temperature logs should be monitored on a daily basis by the nurse on the evening or night shift. RN #2 said the temperature logs were picked up by the assistant director of nursing (ADON) and/or the weekend nurse for compliance purposes. RN #2 said he worked on the fifth floor every Thursday from 7:00 a.m. to 11:00 a.m. and relied on the evening shift nurse to check the fifth floor refrigerator temperature in the medication storage room. V. Administrative interviewThe director of nursing (DON) was interviewed on 10/12/23 at 2:56 p.m.. The DON said all agency staff who worked at the facility received a binder that covered their responsibility. The binder included instructions to monitor for expired medication in the medication storage refrigerators and monitoring refrigerator temperatures for proper medication storage on a daily basis while on shift. The DON said permanent facility staff know to monitor and remove expired medications and to check the refrigerator temperatures daily on the evening or night shift. VI. Unattended medication The fourth floor refrigerator medication cart was observed on 10/11/23 at 8:30 a.m. The fourth floor medication cart was left unattended with two medication cards continuing medications in the bubble pack cards. LPN #2 was interviewed on 10/11/23 at 8:55 a.m. She identified the two medications on her cart as fluoxetine (antidepressant) with two pills left in the card and myrbetriq (a medication that relaxes the bladder muscles to prevent urgency and frequency in overactive bladder) with four pills in the card. LPN #2 said medications should not be left on the cart unattended because a resident could take them and could lead to adverse reactions if the medication was not ordered for them or if they received too much of a prescribed medication.

Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in the kitchen. Specifically, the facility failed to:-Ensure proper hand hygiene and maintain a sanitary environment where food was being served; and, -Ensure the refrigerators on the units were cleaned properly. Findings include:I. Hand washing and use of hair netsA. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; "Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: Vigorous friction on the surfaces of the lathered fingers, finger tips, areas between the fingers, hands and arms for at least 15 seconds, followed by;Thorough rinsing under clean, running warm water; and Immediately follow the cleaning procedure with thorough drying of cleaned hands and arms with disposable or single use towels or a mechanical hand drying device. Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles. After handling soiled equipment or utensils; After engaging in any activities that contaminate the hands. Hand antiseptics may be used in addition to but not in place of proper handwashing. "Food employees engaged in food preparation shall wear hair restraints, such as hats, hair coverings, hair or beard nets, or other effective means, to effectively keep hair from contacting exposed food, clean equipment, utensils, and linens, and unwrapped single-service or single-use articles."B. Facility policies and proceduresThe Handwashing Dietary policy and procedure, revised 9/1/22, was provided by the nursing home administrator (NHA) on 10/12/23 at 4:45 p.m. It revealed in pertinent part, "Staff will wash hands frequently as needed throughout the day following proper handwashing procedures. Handwashing facilities should be readily accessible and equipped with paper towels and soap. Encourage handwashing instead of the use of chemical, sanitizing gel's or lotions. If chemical, sanitizing gel or use, staff must first wash hands as stated below. Clean hands and exposed portions of the arms immediately before engaging in food preparation, including working with exposed foods."When to wash hands, after touching bare human body parts, other than clean hands and clean, expose portions of arms after using the toilet room. During food preparation, as often as necessary to remove soil contamination prevent cross-contamination when changing tasks. Before donning gloves for working with food. After removing gloves. Before distributing meals to residents. After collecting soil, plates and food waste."C. ObservationsObservation on 10/10/23 at 12:00 p.m. on floor number four. Kitchen staff brought up lunch to serve, an unknown kitchen staff had a cart of plates that were not covered. The cart was not in the kitchen area and was in the nurses station area. An unknown RN was passing medications and had her backside leaning up against the cart touching the uncovered plates. Several staff walked by and they did not move the cart into the kitchen area. The kitchen staff used the plates to serve lunch. At 12:45 p.m. the kitchen staff ran out of plates the activities director went to a different floor and came back with a plate without it being covered and gave it to the kitchen staff to plate the food. Observations on 10/11/23 at 11:15 a.m. in the main kitchen area where the staff was preparing for lunch service. Dietary assistant (DA) #1 was preparing hotdogs and hamburgers for lunch service. DA #1 had gloves on and touched the handle to get the hotdogs and hamburgers out of the steam oven. DA #1 grabbed the hotdogs and hamburgers with gloved hands and touched the lettuce tomato and onion with the same gloves.-At 11:25 a.m. cook (CK) #1 was pureeing dessert and grits. CK #1 put gloves on before starting this task. CK #1 put the dessert in the blender and needed to add more dessert and went to the steam oven and kept the same gloves on. CK #1 dished the dessert into a cup and touched the lip of the cup and the lid with the same gloves. CK #1 changed gloves and did not preform hand hygiene. CK #1 was pureeing grits and had to add more grits to it. CK #1 touched the handle of the steam oven. CK #1 touched the top of the cup and lid while putting the grits into the cup.-At 12:11 p.m. on the third floor kitchen. CK #2 had started serving the residents. CK #2 had the cart with uncovered clean plates and plates with food on them. CK #2 had the dishes of food uncovered on the steam table and on the steam table without coverings and staff were coming into the kitchen with hair coverings (see below). Certified nurse aide (CNA) #3 entered the kitchen without a hair net and performed hand hygiene. CNA #3 opened the refrigerator to get drinks. CNA #3 went to the dining area and touched a resident's shoulder then came back into the kitchen performing hand hygiene. CNA #3 rubbed up against the counter where the dessert was being served. CNA #3 went into the refrigerator and got drinks, went into the dining room and came back into the kitchen. CNA #4 came into the kitchen. CNA #4 did not have a hairnet on. CNA #4 did not perform hand hygiene and came into the kitchen. CNA #4 had delivered food to the dining area and came into the kitchen to get drinks. She opened the refrigerator. CNA #3 went into the kitchen without performing hand hygiene. CNA #3 went to the dining area to deliver a drink. CNA #3 came back into the kitchen without performing had hygiene. CNA #3 used the microwave that was above the counter. The cart with the uncovered dishes and plates of food that had plastic on them was under the microwave. CNA #3 reached to put the food in the microwave. CNA #3 touched the front of her body onto the cart. D. Staff interviewCK #2 was interviewed on 10/11/23 at 12:53 p.m. CK #2 said before entering the kitchen area staff should wash their hands and have hair nets on. CK #2 said nursing staff would come into the kitchen whenever they want. The infection preventionist (IP) was interviewed on 10/11/23 at 3:08 p.m. The IP said nursing staff should not be in areas that have food products in it. The IP said nursing staff should wash their hands and wear an apron if they went into the kitchens when food was present. The IP said nursing staff work directly with residents. The IP said there was a risk of contaminating food and spreading infections when nursing staff was in the kitchens while serving food. CNA #5 was interviewed on 10/12/23 at 9:53 a.m. CNA #5 said CNAs should not go into the kitchen area during food service. CNA #5 said staff that go into the kitchen area needed a hair net and should perform hand hygiene before entering the kitchen if they need to. The nutrition service director (NSD) was interviewed on 10/12/23 at 9:22 a.m. The NSD said she saw her kitchen staff using gloves and touching multiple things before touching the food and bowls that food went into. The NSD said she had already started to inservice her staff on proper hand hygiene. The NSD said kitchen staff should make sure the cart with the plates on it were in the kitchen area. The NSD said nursing staff should not lean against the counters or carts that have plates or food on them because their clothing was not sanitary. The NSD said nursing staff should not enter the kitchens while kitchen staff was serving. The NSD said hair nets and hand washing were required to enter kitchens that have food being served. The NSD said nursing staffshould be patient and wait for the server to assist them. The NSD said she had educated CNAs in the past and will re-educate them about going into the kitchen areas. The director of nursing (DON) was interviewed on 10/12/23 at 2:43 p.m. The DON said nursing staff should not enter the kitchens. The DON said the way the refrigerators were set up made it hard for the CNAs to help with food service. The DON said staff should wash their hands before entering the kitchen areas. The DON said the staff entering the kitchen should wear hair nets. The DON said the nursing staff should be careful and not let their bodies touch the counters or plates in the kitchens. The DON said there was an infection control risk if nursing staff went into the kitchens without proper hand hygiene. II. Refrigerator cleanlinessA. ObservationsObservations on 10/11/23 at 12:00 p.m. on the third floor kitchen the refrigerator had crumbs on the bottom of it. The door handle had a film of a dark brown tacky substance that had built up it was a dark color and appeared to not have been cleaned for a long time. Observations on 10/12/23 at 11:17 a.m. the refrigerator on the fourth floor had dark streaks on the inside of the refrigerator and crumbs throughout the refrigerator. The handle had a buildup film that was dark and tacky. -At 11:20 p.m. the refrigerator on the fifth floor had crumbs throughout and the handle had a thick buildup of dark tacky substance. B. Staff interviews CK #2 was interviewed on 10/11/23 at 12:53 p.m. CK #2 said nursing staff cleaned the kitchens when they were done with food service. CK #2 said nursing and housekeeping staff made sure the refrigerators were cleaned. CNA #5 was interviewed on 10/12/23 at 9:53 a.m. CNA #5 said kitchen staff were required to clean the kitchens in between services. CNA #5 said the kitchen staff were required to keep the refrigerators clean. The NSD was interviewed on 10/12/23 at 9:22 a.m. The NSD said that housekeeping, kitchen and nursing staff made sure the kitchens were clean. The NSD said it was a group effort to ensure the refrigerator were clean. The NSD said they did not have a schedule of when they cleaned refrigerators. The director of nursing (DON) was interviewed on 10/12/23 at 2:43 p.m. The DON said cleaning the kitchens including the refrigerators was a group effort with the kitchen staff, housekeeping and nursing staff. The DON said they did not have a schedule for cleaning the refrigerators. The DON said the refrigerators including the handle should be cleaned. The DON said keeping the kitchens areas clean was to ensure infection control.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection. Specifically, the facility failed to:-Ensure continuous positive airway pressure (CPAP) masks were stored off the floor, in a clean bag and replaced when contaminated; -Ensure staff performed hand hygiene during medication administration; and, -Ensure staff disposed of needles appropriately. Findings include:I. Facility policy and procedureThe Infection Control policy and procedure, revised 5/7/23, was provided by the nursing home administrator (NHA) on 10/9/23 at 10:15 a.m. It read in pertinent part,"Standard precautions include:"A group of infection prevention practices that apply to all resident's environments, regardless of suspected or confirmed infection status, in any setting where healthcare is delivered. Includes: resident care equipment likely to have been contaminated by bodily fluids must be handled in a manner to prevent the transmission of infectious disease." II. Continuous positive airway pressure (CPAP) maskA. ObservationOn 10/9/23 at 10:15 a.m. Resident #97 CPAP mask was observed hanging in an unsanitary manner on the floor next to the resident's foley bag with urine. On 10/10/23 at 11:30 a.m. Resident #97 CPAP mask was observed under his upper body while he was lying in bed. B. Resident interview Resident #97 was interviewed on 10/9/23 at 10:15 a.m. He stated the staff care for his CPAP mask and clean it for him. He was not able to get out of his bed independently and clean his CPAP. He also had contractures in his hands and this prevented him from being able to clean his CPAP mask or take care of it without the staff's assistance. C. Staff interviewsRegistered nurse (RN) #1 was interviewed on 10/10/23 at 10:35 a.m. Resident #97 had a CPAP and when he was not using it, the staff had to clean it and keep it in a bag on his dresser. RN #1 did not know how many times a week it needed to be cleaned. He said the nurse is responsible for the cleaning and maintenance of Resident #97's CPAP mask. RN #1 said the CPAP mask should never be on the resident's floor next to his foley bag. This could cause the spread of bacteria. The CPAP mask should not be kept in the resident's bed under his body because it could damage the mask. The infection preventionist (IP) was interviewed on 10/11/23 at 2:58 p.m. She was not sure of Resident 97's CPAP mask cleaning schedule but stated the mask should not be on his floor next to a foley bag. The mask should be on his dresser or in a drawer. The risk of having his CPAP mask on the floor, especially next a foley bag with urine, was contamination and the spread of bacteria. III. Hand hygiene with medication administrationA. Facility policy and proceduresThe Medication Administration General Guidelines policy and procedure, dated 10/15/10, was received from the NHA on 10/12/23 at 4:45 p.m. revealed in pertinent part "Procedure: wash or sanitize hands before and after administration of medications."B. Observation On 10/11/23 at 7:54 a.m. licensed practical nurse (LPN) #1 was observed preparing medications to Resident #39, he did not perform hand hygiene prior to preparing the medication. LPN #1 then knocked on her door when entering the room, passed the medication cup to the resident and grabbed the resident's personal water cup and handed it to her. LPN #1 then exited the room, returned to the medication cart and began charting the medications administration. LPN #1 failed to perform hand hygiene on exit of Resident #39's room. At 8:04 a.m. LPN #1 began preparing medications for Resident #25. LPN #1 knocked on Resident #25 door, assisted the resident to sit up in bed using the bed control and took the resident's blood pressure. LPN #1 then handed the medications to Resident #25, then washed his hands with soap and water. LPN #1 then applied gloves to administer eye drops to the resident. LPN #1 then washed his hands upon removal of gloves. LPN #1 took the empty bottle of Boost (supplement drink) tossed it into the trash, touching the trash bag as it fell into the trash bin, he then adjusted the bedside table and the bed position for Resident #25. LPN #1 then exited the residents room returning to the medication cart, placed eye drops back in the cart and charted the administration of medications. LPN #1 failed to perform hand hygiene after leaving Resident #25's room. At 8:23 a.m. LPN #1 began preparing medications for Resident #64. Resident #64 was in the dining room when he administered the medications to her. LPN #1 returned to his medication cart and charted the administration. LPN #1 failed to perform hand hygiene after medication administration to Resident #64. C. Staff interviewsLPN #1 was interviewed on 10/11/23 at 3:39 p.m. He said nurses were to wash with soap and water or use sanitizer on their hands if they administer eye drops, insulin (medication for abnormal glucose) or if they touch any of the resident's personal items. LPN #1 said if residents were only receiving medication in pill forms he did not have to wash his hands. The director of nursing (DON) was interviewed on 10/12/23 at 2:41 p.m. She said the nursing staff were to sanitize their hands before dispensing medications and again after the resident took the medication. The DON said nurses should perform hand hygiene to prevent infections. IV. Proper disposal of needles A. Facility policy and procedureThe Sharps Storage and Disposal policy and procedure, dated 10/15/10, was received from the NHA on 10/12/23 at 4:45 p.m. revealed in pertinent part, "Sharps such as syringe, needles, lancets, razors will be secured out of residents reach. After use, sharps will be placed into an approved designated sharps container and disposed of in accordance with applicable laws and safety regulations. Immediately after use syringe, needles, or lancets will be placed in a puncture resistant, one way container with a lid that prohibits reaching into the container."B. ObservationsOn 10/11/23 at 8:31 a.m. LPN #2 was observed passing medications to Resident #57. LPN #2 administered Insulin (glucose control) via injection into the Resident #57's right arm. LPN #2 then placed the safety sleeve over the needle and placed the syringe and needle into an empty water cup along with trash from two alcohol swabs and her used gloves. She returned to the medication cart. LPN #2 placed the cup and its contents into a trash bag hanging over the sharps container on the medication cart and then sanitized her hands and charted the medication administration. LPN#2 failed to properly dispose of a sharps. C. Staff interviewsLPN #2 was interviewed on 10/11/23 at 8:37 a.m. She said the needle and syringe were to be disposed of into the sharps container not the trash when asked about where the needle was disposed of. LPN #2 then proceeded to dig through the trash bag with no gloves on to retrieve the syringe and needle. LPN #2 found the syringe and needle and moved the trash bag to access the sharps container on her medication cart where she then properly disposed of the syringe and needle. She then re-hung the trash bag over the sharps container. The director of nursing (DON) was interviewed on 10/12/23 at 2:41 p.m. She said needles were to be disposed of in the sharps container to reduce the risk of contamination or a needle stick which could lead to blood borne disease transmission. The DON said the nurse should not have dug through the trash to retieve the syringe and needle because it increased the risk of being struck by the needle.

A revisit survey was completed on 8/23/23 for all previous deficiencies cited on 6/1/23. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO32349 was conducted from 5/31/23 to 6/1/23. One deficiency was cited.

Based on record review and staff interviews the facility failed to provide advance beneficiary protection notification (ABN) for three (#7, #8 and #9) out of three residents reviewed out of nine sample residents. Specifically, the facility failed to ensure Resident #7, #8 and #9 were provided a description of the type of Medicare part A services that were ending, given an estimated cost of services if the resident wanted to pay privately, the reason why Medicare would not continue to pay for the service and the resident's option to appeal. Findings include:I. Facility policy and procedureThe facility policy for Advance Beneficiary Notice of Non Coverage (ABN) was requested from the nursing home administrator (NHA) on 6/1/23 at 10:18 a.m. -The NHA said the facility did not have an ABN policy, but the facility followed Medicare guidelines for beneficiary notices. According to the Center for Medicare and Medicaid Services (CMS) website: https://www.cms.gov/search/cms?keys=ABN+nursing+home+regulation:The Medicare Advance Written Notice of Noncoverage February 2020, retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ABN_Booklet_ICN006266.pdf page 3, read and revealed in pertinent part: "All health care providers and suppliers must deliver an Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 when they expect a Medicare payment denial that transfers financial liability to the beneficiary. This includes skilled nursing facilities (SNFs). The ABN helps the beneficiary decide whether to get the item or service Medicare may not cover and accept financial responsibility for it."II. Record review A list of residents discharged from Medicare A services, with benefit days remaining, in the last six months, was received from the NHA on 5/31/23 at 3:00 p.m. There were 13 resident names listed. The form indicated 11 of the residents remained in the facility after Medicare A services were discontinued. Resident #7's discharge date, from Medicare part A skilled services, was documented as 2/3/23. The facility initiated the discharge from part A services, however the resident's benefit days were not exhausted. The resident remained in the facility. Resident #8's discharge date, from Medicare part A skilled services, was documented as 2/22/23. The facility initiated the discharge from part A services, however the resident's benefit days were not exhausted. The resident remained in the facility. Resident #9's discharge date, from Medicare part A skilled services, was documented as 4/7/23. The facility initiated the discharge from part A services, however the resident's benefit days were not exhausted. The resident remained in the facility. III. InterviewsThe social service coordinator (SSC) was interviewed with the NHA on 6/1/23 at 10:18 a.m. The Advance Beneficiary Notice of Non Coverage (ABN) was requested on 6/1/23 at 10:18 a.m. for Residents #7, #8 and #9 from the SSC and the NHA. The SSC said she did not complete ABN forms and was unsure what the ABN was used for. The NHA said there was a communication failure, and the ABN forms had not been completed. She said the facility did not have an ABN form for any of the 11 residents who were discharged from Medicare A services, with benefits remaining and remained in the facility. The NHA said the facility's financial coordinator would be issuing the ABN forms in the future. She said the facility had received education on the ABN requirement and she would provide a copy of the education. The NHA said she had not been previously aware that the ABN forms had not been issued. IV. Facility follow-upOn 6/1/23 at 2:00 p.m., the NHA provided a document, dated September 2022, titled, SNF (skilled nursing facility) ABN, NOMNC (Notice of Medicare Non Coverage). Education for Leadership and Social Service Staff. There were no signatures of those receiving the education, on or attached to the form. The form documented in pertinent part, "Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNF ABN) It is important to note that the SNF ABN, CMS-10055, is only issued if the beneficiary intends to continue services and the SNF believes the services may not be covered under Medicare. It is the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. Per Ch. 30, section 70.2 of the Medicare Claims Processing Manual (IOM Pub. 100-04), a SNF ABN must be given to a beneficiary for the following triggering events: -Initiation -In the situation in which a SNF believes Medicare will not pay for extended care items or services that a physician has ordered, the SNF must provide a SNF ABN to the beneficiary before it furnishes those non-covered extended care items or services to the beneficiary. -Reduction -In the situation in which a SNF proposes to reduce a beneficiary's extended care items or services because it expects that Medicare will not pay for a subset of extended care items or services, or for any items or services at the current level and/or frequency of care that a physician has ordered, the SNF must provide a SNF ABN to the beneficiary before it reduces items or services to the beneficiary.-Termination -In the situation in which a SNF proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF must provide a SNF ABN to the beneficiary before it terminates such extended care items or services."

A complaint survey, prompted by #CO30580 was conducted on 1/17/23. No deficiencies were cited.