Every finding on record at Algart Health Care

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memorandum QSO-22-09-ALL , review of the staff COVID-19 vaccination list, review of the COVID-19 Resident list, review of the nurse/nurse aide staff schedule, review of the facility policy, observation, and interview, the facility failed to ensure their employee COVID-19 vaccination policy matched with the CMS date for all staff to be vaccinated for COVID-19, the staff COVID-19 vaccination rate was 100%, and precautions were in place for staff who were not fully vaccinated. This affected all 70 residents who resided in the facility. The census was 70. Findings include: Review of the undated facility staff COVID-19 vaccination list revealed the facility had a total of 69 employees. There were 50 employees fully vaccinated for COVID-19, 12 employees had religious exemptions, two employees had delayed vaccinations, three employees were partially vaccinated for COVID-19 including State tested Nursing Assistant (STNA) #104, and two employees with pending religious exemptions including STNA # 117. The staff vaccination rate was 92.75%. Review of the nurse and nurse aide staff schedule for 03/23/22 revealed STNA #104 was assigned to the south hall from 3:00 P.M. to 11:00 P.M. Observation and interview on 03/28/22 at 12:56 P.M. with STNA #117 revealed she was wearing a surgical face mask. STNA #117 said she filed for a religious exemption and turned in the required documents. STNA #117 stated she was not sure of the date for requesting the exemption or the date the documents were submitted. Interview on 03/28/22 at 2:45 P.M. with the Director of Nursing (DON) verified the facility had two staff with pending religious exemptions and three staff that were partially vaccinated. STNA #104, who was partially vaccinated, was assigned to the south hall. STNA #117 submitted a religious exemption form which was returned to STNA #117 because it was not filled out correctly. The DON explained the pharmacy required five people to conduct a vaccine clinic and they had nine people signed up for a clinic later this week. Staff who were not fully vaccinated were tested weekly. Observation of the facility's testing logs with the DON confirmed staff who were not vaccinated or fully vaccinated were tested weekly. Observation and interview on 03/28/22 at 3:20 P.M. with STNA #104 revealed she was wearing a surgical mask. STNA #104 said she received the first dose of COVID-19 vaccine in February 2022 and was waiting for her second dose. STNA #104 stated scheduling the first dose was a process because she could not receive until there were five other people who also required the vaccine. Because there were not enough people several vaccination clinics were canceled. STNA #104 stated on 03/31/22 she would receive the second dose of the vaccine because there were five people signed up to receive the vaccine. STNA #104 revealed she was tested for COVID-19 on a weekly basis. Observation of STNA #104 on 03/28/22 at 3:40 P.M. revealed she was providing direct resident care on the south hall. Review of the facility's undated COVID-19 Resident list revealed no residents had been diagnosed with COVID-19 in the past four weeks. Review of the facility's Employee COVID-19 Vaccination policy, dated 11/08/21, revealed all staff were required to be vaccinated for Covid-19. The mandate states that all staff must have at least the first dose of the vaccine by 12/06/21 and be fully vaccinated by 01/04/22. The facility would provide an onsite clinic where staff could receive the vaccine on 11/18/21. The facility would provide instruction for staff to be able to receive the vaccine at their convenience offsite at a pharmacy of choice. There were two ways for staff to be exempt from this mandate. Staff could submit a medical or religious exemption request. Any staff member that obtained approval for a valid exemption would be required to submit to weekly testing. Review of Centers for Medicare & Medicaid Services (CMS) memorandum, QSO-22-09-ALL regarding COVID-19 health care staff vaccination, dated 01/14/22, revealed CMS expected all providers' and suppliers' staff to have received the appropriate number of doses by the time frames specified in the QSO-22-07 unless exempted as required by law, or delayed as recommended by the Centers for Disease Control (CDC). Facility staff vaccination rates under 100% constitute non-compliance under this rule. Within 60 days after issuance of this memorandum, 100% of staff have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple-dose vaccine series), or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is compliant under the rule; or less than 100% of all the staff received at lest one dose of a single doses of a multiple-dose vaccine series, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is non-compliant under the rule.

Based on the unprecedented global pandemic which resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of the Department of Health and Human Services, Center for Medicare and Medicaid Services information, the Centers for Disease Control and Prevention (CDC) guidelines, record review, observations, and interviews the facility failed to implement appropriate infection control practices related to quarantine/isolation and the use of appropriate personal protective equipment (PPE). This had the potential to affect all 72 residents in the facility. Findings include: Review of the Department of Health and Human Services, Centers for Medicare and Medicaid (CMS) Memo QSO 20-20-ALL dated 03/03/20 revealed CMS was committed to taking critical steps to ensure America's healthcare facilities were prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of infection control priorities during this time of crisis, and providers could perform a voluntary self-assessment of their ability to meet the priorities. The Quality, Safety and Oversite Group (QSO) Memo included additional instructions to nursing homes. We are disseminating the Infection Control survey developed by CMS and Centers for Disease Control (CDC) so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable diseases or infections should be reported (42 CFR 483.80 (a) (2) (i) and (ii). Observation was made on 10/26/20 at 11:10 A.M. of State tested Nursing Assistant (STNA) #500 wearing a cloth face mask. Observation was made on 10/26/20 at 11:15 A.M. of Licensed Practical Nurse (LPN) #501 wearing a cloth face mask. Observation was made on 10/26/20 at 11:40 A.M. of LPN #504 wearing a cloth face mask. Interview with the Director of Nursing (DON) on 10/26/20 at 12:20 P.M. stated the facility procedure for new admissions or readmissions was to complete a COVID-19 test at the time of admission using the facility Point of Care (POC) machine and to then quarantine the resident for 72 hours. The DON also verified the facility policy did not state this was the procedure and stated new admissions or readmissions would be quarantined for fourteen days. The DON stated this procedure was just implemented within the past few weeks (unable to give a specific date, but stated within the past month) and also stated it was done based on a decision in conjunction with the Administrator. The DON also verified the facility policy stated all staff were to wear surgical masks in all patient care and communal areas. The DON stated at the end of last week the facility had approximately 300 surgical masks and had received a shipment on the morning of 10/26/20 and now had approximately 1200 surgical masks. A facility tour was conducted with the DON on 10/26/20 at 12:35 P.M. and the following staff members were found to be wearing cloth masks: STNA #500, LPN #501, LPN #504, STNA #507, LPN #508, STNA #509, and Administrative Assistant #510. Interview with the Administrator on 10/26/20 at 12:48 P.M. stated the facility switched to the three day quarantine after consult with someone from the city of Cleveland, the Administrator was unable to provide evidence of this consult. The Administrator also stated the facility received the cloth face masks on approximately 08/31/20 from a state agency and allowed them to be used by staff as they were more comfortable. Review of the facility policy titled, COVID-19, dated 03/11/20, stated all new admissions/readmissions will be placed on quarantine/isolation for 14 days. The policy also stated all staff, vendors, essential personnel and residents will wear a surgical mask in all patient care areas and communal areas. Guidance from the CDC updated on 07/15/20, Interim Infection Prevention and Control for Healthcare Personnel during Coronavirus Disease (COVID-19) 2019 Pandemic, indicated healthcare personnel (HCP) should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. When available, facemasks are preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. HCP are defined by the CDC as all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. These HCP may include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the health care facility, and persons (e.g., clerical, dietary, environmental services, laundry, security, maintenance, engineering and facilities management, administrative, billing, and volunteer personnel) not directly involved in patient care but potentially exposed to infectious agents that can be transmitted among from HCP and patients. This information is located at https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/appendix/terminology.html.

Based on observation, spread sheet review and interview the facility failed to serve meals according to the spread sheet during the lunch meal on 10/16/19. This affected seven residents (#5, #27, #39, #45, #49, #62 and #68) of seven who were ordered a pureed diet. The facility census was 71. Findings include: On 10/16/19 at 11:50 [NAME]M. observation of the lunch meal revealed residents who were ordered pureed diets received pureed chicken, pureed mashed potatoes and pureed vegetable for lunch. Review of the lunch meal rotating spread sheet for Week 3 on Wednesday revealed residents with pureed diets would receive pureed lasagna with tomato sauce, pureed Italian vegetable with a half of cup of bread for lunch. Interview on 10/16/19 at 12:05 P.M. with the Dietary Manager verified residents who were to receive pureed diets did not receive what was on the planned menu/spreadsheet. Interview on 10/18/19 at 12:26 PM with the Dietitian revealed she reviewed the spreadsheets biannually. The facility identified seven residents, Resident #5, #27, #39, #45, #49, #62 and #68 who were ordered a pureed diet.

Based on observation, record review and interview the facility failed to ensure Resident #34's call light was within reach for the resident to use to call for assistance. This affected one resident (#34) of 71 residents who resided in the facility. Findings Include: Record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/05/19 revealed Resident #34 was cognitively intact and required supervision with physical assistance of one person for activities of daily living (ADLs). Review of Resident #34's current care plan for falls revealed the resident's call light should be within reach at all times. Observation of and interview with Resident #34 on 10/16/19 at 10:21 [NAME]M. revealed Resident #34 was sitting in his chair and stated to this surveyor that he was supposed to use his call light when he felt he was having a [MEDICAL CONDITION] and thinks he was having a [MEDICAL CONDITION] at the time of the interview. The call light was observed to be clipped to the bed sheet approximately 24 inches from the chair and out of the resident's reach. This surveyor activated the call light for the resident and Activities Assistant #5 answered the call light, got a nurse and verified the call light was not within reach on 10/16/19 at 10:22 [NAME]M.

Based on observation, record review and interview the facility failed to ensure Resident #37 received oxygen according to the physician's order. This affected one resident (#37) of nine residents who were ordered oxygen. Findings Include: Record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 was cognitively intact and required extensive assistance from staff for most activities of daily living including toileting and personal hygiene. Review of the physician's orders, dated (MONTH) 2019 revealed an order for [REDACTED]. On 10/17/19 at 9:10 [NAME]M. Resident #37 was observed being wheeled back from the dining room into his room. The resident was observed with oxygen tubing in place in his nose. However, observation of the resident's oxygen tank revealed the tank was empty and the resident was not receiving any oxygen at this time. Interview with Stated tested Nursing Assistant (STNA) #72 on 10/17/19 at 9:22 [NAME]M. verified the resident's oxygen tank was empty and he was not receiving any oxygen via nasal cannula.

Based on observation, record review and interview the facility failed to provide routine medications to Resident #64 as ordered by the physician. This affected one resident (#64) of three sampled residents. Findings Include: Review of Resident #64's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/25/19 revealed the resident was cognitively intact and she required extensive assistance from staff for bed mobility, dressing and personal hygiene. Resident #64 was totally dependent on staff for transfers and toileting. Review of the physician's orders [REDACTED].#64 had an order for [REDACTED]. Review of Resident #64's record revealed Resident #64 did have an assessment for self -administering medications on 03/01/16 which sated the resident had no interest in self-administering her medications. On 10/16/19 another assessment for self-administering of medication was completed which showed again the resident was not interested in self-administering her medications. Observation of and interview with Resident #64 on 10/17/19 at 7:00 [NAME]M. revealed Resident #64 was asleep in bed with her bedside tray positioned in front of her. On her bedside tray was a glass of water, three magazines, a notebook and a medication cup with one gray and purple capsule in it. Registered Nurse (RN) #20 who was also at the bedside, asked the resident what the pill was from. Resident #64 stated the night shift nurse told her to take the pill. Resident #64 stated she fell asleep and forgot to take it. Interview with RN #20 on 10/17/19 at 7:30 [NAME]M. verified the resident had her morning dose of [MEDICATION NAME] sitting at her bedside. Review of the policy titled Medication Administration, dated 03/2016 revealed self-administration of medications were typically not permitted. The exception to this would be written orders by the physician/nurse practitioner, as the resident was educated and demonstrated the ability to self-administer medications safely per order.

Based on record review and interview the facility failed to ensure an as needed order for an anti anxiety medication for Resident #37 was limited to 14 days or was evaluated for the needed continuation of the medication. This affected one resident (#37) of five residents reviewed for unnecessary medication use. Findings Include: Record review revealed Resident #37 was admitted to this facility on 04/25/19 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/08/19 revealed Resident #37 was cognitively intact. The assessment revealed the resident receive any antianxiety medication during the assessment reference period. Review of the physician's orders [REDACTED]. This order was good for 14 days which was until 09/24/19. Review of the resident's Medication Administration Record [REDACTED]. Interview with Licensed Practical Nurse (LPN) #78 on 10/17/19 at 2:30 P.M. verified the [MEDICATION NAME] medication was ordered on [DATE] and was not reordered or re-evaluated for the continued need for the medication. She also verified the resident received three doses of the medication in (MONTH) 2019 after the 14th day of the prescription.

Based on observation, record review, and interview, the facility failed to ensure residents remained free from abuse. This resulted in actual harm when Resident #32 was physically abused by a staff member (State tested Nurse Aide (STNA) #203) on an undetermined date and transferred to the emergency roiagnom on [DATE], where she was diagnosed with [REDACTED]. This affected one of five residents reviewed for abuse prohibition. The facility census was 72 residents. Findings include: Interview with Resident #28 on 03/28/19 at 11:02 A.M. revealed staff members once attacked and broke the hand of her roommate (Resident #32). Resident #28 could not see the event because the privacy curtain was pulled between her bed and Resident #32's bed, but she could hear the event. The staff members were yelling at Resident #32 as well. Resident #28 could not identify who the staff members were, how many staff members participated, or when the event occurred. Observation of Resident #32 on 03/28/19 at 12:42 P.M. revealed she had a pink cast on her right hand and wrist. Interview with Resident #32 at this time revealed STNA #203 had thrown her into the bed and broke her wrist. She also said STNA #203 hit her. Resident #32 said this event occurred after dinner, and could not identify the date this occurred. She said no other staff members were present during this event. She was unable to verify when she informed staff of the abuse. Review of Resident #32's medical record revealed she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. She was assessed by her most recent full Minimum Data Set 3.0 assessment on 01/01/19 as having mild cognitive impairment and requiring extensive assistance for toileting and transfers. Her progress notes revealed that a bruise was identified on her hand on 03/14/19, which was X-rayed and found to have a fracture. The resident was sent to the emergency room and returned on 03/15/19 with a splint on her hand. Her hand was placed in a cast on 03/20/19. Review of Resident #32's care summary provided by the hospital dated 03/14/19 revealed Resident #32 was treated for [REDACTED]. She was also treated for [REDACTED]. Resident #32 reported to the hospital nurses that STNA #203 grabbed her hand and squeezed very hard two days ago (roughly 03/12/19). She was assessed by the hospital as being alert and oriented. Record review of the facility Self-Reported Incident (SRI) revealed it concerned an allegation by Resident #32 that STNA #203 had abused her. The facility launched an investigation, including interviews with Resident #32 and Resident #28 that were consistent with what these residents had told the surveyor. The review revealed no evidence STNA #203 was directly questioned regarding her alleged abuse of Resident #32. The facility found the allegation to be substantiated, terminated STNA #203 from employment, and reported her to the nurse aide registry. Interview with the Administrator on 03/28/19 at 4:39 P.M. verified these findings. Review of the facility abuse policy dated 09/2018 revealed all staff were responsible to ensure every resident was free from abuse. Abuse was not to be tolerated, and any suspected occurrence was to be thoroughly investigated and appropriately acted upon. The policy defined Resident abuse as an intentional act or omission which causes or could cause physical harm or mental anguish to a resident. This deficiency substantiates Self-Reported Incident Control Number OH 290.

Based on observation, record review, and interview, the facility failed to prevent, appropriately investigate, and report an alleged abuse event involving Resident #32. The facility failed to contact the police regarding the alleged abuse, and failed to specifically question the alleged perpetrator regarding their potential role in the resident's abuse. Staff members failed to report the alleged abuse to the abuse coordinator in a timely fashion. This affected one (Resident #32) of five residents reviewed for abuse prohibition. The facility census was 72 residents. Findings include: Interview with Resident #28 on 03/28/19 at 11:02 A.M. revealed staff members once attacked and broke the hand of her roommate (Resident #32). Resident #28 could not see the event because the privacy curtain was pulled between her bed and Resident #32's bed, but she could hear the event. The staff members were yelling at Resident #32 as well. Resident #28 could not identify who the staff members were, how many staff members participated, or when the event occurred. Observation of Resident #32 on 03/28/19 at 12:42 P.M. revealed she had a pink cast on her right hand and wrist. Interview with Resident #32 at this time revealed State tested Nursing Aide (STNA) #203 had thrown her into the bed and broke her wrist. She also said STNA #203 hit her. Resident #32 said this event occurred after dinner, and could not identify the date this occurred. She said no other staff members were present during this event. She was unable to verify when she informed staff of the abuse. Review of Resident #32's medical record revealed she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. She was assessed by her most recent full Minimum Data Set 3.0 assessment on 01/01/19 as having mild cognitive impairment and requiring extensive assistance for toileting and transfers. Her progress notes revealed that a bruise was identified on her hand on 03/14/19, which was X-rayed and found to have a fracture. The resident was sent to the emergency room and returned on 03/15/19 with a splint on her hand. Her hand was placed in a cast on 03/20/19. An assessment by the resident's Clinical Nurse Practitioner dated 03/14/19 revealed the resident claimed a lady beat me up. The time of their assessment was not identified, and it had no evidence the allegation was reported at the time it was made. Review of Resident #32's care summary provided by the hospital on [DATE] revealed she was treated for [REDACTED]. She was also treated for [REDACTED]. Resident #32 reported to the hospital nurses that STNA #203 grabbed her hand and squeezed very hard two days ago. She was assessed by the hospital as being alert and oriented. Record review of a facility Self-Reported Incident (SRI) revealed it concerned an allegation by Resident #32 that STNA #203 had abused her. The facility launched an investigation, including interviews with Resident #32 and Resident #28 that were consistent with what these residents had told the surveyor. The review revealed no evidence STNA #203 was directly questioned regarding her alleged abuse of Resident #32, or that any other staff members were questioned regarding STNA #203's treatment of [REDACTED].#203 from employment, and reported her to the nurse aide registry. No evidence was found indicating the police were informed. The SRI timeline revealed the resident's clinical nurse practitioner assessed the resident at 5:37 A.M. A witness statement from Registered Nurse #401 revealed the resident complaint of hand pain around 2:00 A.M. on 03/14/19 and alleged someone beat her up. A witness statement from STNA #203 revealed she identified a bruise on 03/13/19 and the resident claimed a lot of girls beat her up. Neither staff member documented any communication with the Director of Nursing or Administrator about the allegations. There was no evidence of management awareness of an abuse allegation until 7:15 P.M. on 03/14/19, when the timeline identified that Resident #32 said a staff member threw her into the bed and hit her. Interviews with the Administrator on 03/28/19 at 1:25 P.M. and at 4:39 P.M. revealed he was the facility's abuse coordinator. The alleged abuse event involving Resident #32 was brought to his attention the evening of 03/14/19. He confirmed the police were not contacted by the facility regarding the alleged event. He verified the above findings. Review of the facility abuse policy dated 09/2018 revealed all staff was responsible to ensure every resident was free from abuse. Abuse was not to be tolerated, and any suspected occurrence was to be thoroughly investigated and appropriately acted upon. The policy defined Resident abuse as an intentional act or omission which causes or could cause physical harm or mental anguish to a resident. The policy contained no requirement that the police be informed. This deficiency substantiates Self-Reported Incident Control Number OH 290.

Based on record review and interview, the facility failed to report reasonable suspicion of staff to resident physical abuse to the police. This affected one resident (Resident #32) of five residents reviewed for abuse prohibition. The facility census was 72 residents. Findings include: Record review of facility Self-Reported Incident (SRI) revealed it concerned an allegation by Resident #32 that State tested Nursing Aide #203 had abused her. The resident was sent to the emergency roiagnom on [DATE] for a wrist fracture she claimed to be related to the abuse. While there she was diagnosed with [REDACTED]. The facility investigated the allegation and found it to be substantiated. No evidence could be found indicating the facility informed the police of the alleged crime. Interviews with the Administrator on 03/28/19 at 1:25 P.M. and at 4:39 P.M. revealed he was the facility's abuse coordinator. He confirmed the police were not contacted by the facility regarding the alleged abuse of Resident #32. Review of the facility abuse policy, dated (MONTH) (YEAR), revealed all staff was responsible to ensure every resident was free from abuse. Abuse was not to be tolerated, and any suspected occurrence was to be thoroughly investigated and appropriately acted upon. The policy contained no requirement that the police be informed. This deficiency substantiates Self-Reported Incident Control Number OH 290.

Based on observation, record review and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, milk was stored to prevent contamination and food products were dated when opened. This had the potential to affect 72 out of 72 residents who ate meals in the facility's kitchen. Findings include: Observations during the initial tour of the kitchen on 09/04/18 from 8:37 A.M. through 9:00 A.M. with Dietary Manager (DM) #10 revealed the ice machine had mold around the edge where the door closed, the wall behind the stove had grease drippings on it, the shelf above the range had food residue and dried gravy on it, the microwave had food splatter on the inside walls and the door, the walk-in refrigerator had full milk crates with containers of milk directly on the floor, and tartar sauce and ranch dressing were not dated as to when they were opened. Interview with DM #10 on 09/04/18 at 9:003 A.M. verified the observations and he said the kitchen could be cleaner. DM #10 said the dietary department had recently been short staffed. Review of the undated sanitation policy revealed that all work surfaces would be cleaned and sanitized after use and all food would be stored six inches above the floor.

Based on interview and record review, the facility failed to ensure mail was delivered to residents on Saturday. This affected five residents (Residents #3, #36, #40, #43 and #48) and had the potential to affect all 72 residents that resided in the facility. Findings include: During a resident council meeting on 09/05/18 at 2:00 P.M., Residents #35, #36, #40, #43, and #48, stated that the facility did not deliver mail on Saturdays. Interview with Activity Director #112 on 09/05/18 at 3:33 P.M. confirmed the mail was not delivered on weekends. Interview with Administrator #102 on 09/05/18 at 3:28 P.M. revealed the previous administration canceled mail delivery on Saturdays because there was no one working in the front office. The weekend mail was getting lost, so it was decided no mail would be delivered. A review of the admission packet revealed an addendum titled Algart Healthcare Special Note which indicated mail would be delivered to the residents daily.

Based on observations, interviews and record review, the facility failed to ensure adequate pest control related to flies in the south wing including the dining room. This affected four (Resident #12, Resident #19, Resident #6 and Resident #2) of thirty residents residing and eating in the south wing. Findings include: Observations on 09/04/18 of the south wing resident rooms and dining room from 9:46 A.M. until 12:22 P.M. revealed flies were present in four resident rooms and in the dining room during the lunch meal. This was verified by Licensed Practical Nurse (LPN) #107, Occupational Therapist #106, State tested Nursing Assistant (STNA) #105, LPN #103 and STNA #104. An interview on 09/04/18 at 9:46 A.M. with Resident #12 revealed there were always at least two flies in her room. An interview on 09/04/18 at 10:02 A.M. with Resident #19 revealed there were all kinds of flies in the resident's room. An interview on 09/04/18 at 10:12 A.M. with Resident #6 revealed he was tired of always having flies in his room and in the dining room. An interview on 09/04/18 at 10:31 A.M. with Resident #2 revealed flies were all over the place. An interview on 09/04/18 at 11:10 A.M. with the Maintenance Director #100 revealed they had an exterminator who would spray once a month for bugs. He relayed he did not know what else to do. He confirmed he observed flies on the south wing. Review of the Pest Control Policy dated revised 2010 revealed a professional pest control services would be called to perform thorough inspections and subsequent extermination. The housekeeping department was to perform regular inspections.

Based on record review and interview, the facility failed to conduct a thorough investigation in regard to an allegation of abuse involving Resident #66. The affected one of one resident reviewed for facility self reported incidents. The census was 72. Findings include: Review of a self-reported incident (tracking number 1) dated 05/30/18 revealed on 05/30/18 at approximately 6:00 A.M., Resident #66 reported to the nurse on duty the State tested Nursing Assistant (STNA) taking care of her was mean. She revealed she was scared of her, did not want her to take care of her, and she did not want the STNA in her room. Resident #66 was visibly upset and crying. She revealed she did not hit me very hard and demonstrated on the nurse by pushing on her. She was being helped in the bathroom by the STNA. Resident #66 claimed to had been hit by the STNA and that the STNA was nasty and not very nice. The STNA involved and the nurse on duty who took the complaint/allegation were interviewed. No other residents or staff were interviewed. An interview on 09/06/18 at 3:02 P.M. with the Director of Nursing (DON) revealed they interviewed the involved resident, the accused staff person and one nurse. The DON stated they should have talked to other people but they were going to fire the STNA anyway due to other circumstances.

Based on interviews and record review, the facility failed to ensure restorative services were provided to Residents #19 and #22 after being referred from physical and/or occupational therapy. This affected two of 18 residents referred for restorative services. Findings include: Medical record review revealed Resident #19 was cognitively intact with [DIAGNOSES REDACTED]. Review of the discharge summary for physical therapy dated 06/08/18 to 08/14/18 revealed Resident #19 would be referred to the restorative nursing program for physical therapy. Review of the occupational therapy discharge summary dated 06/14/18 to 08/07/18 revealed Resident #19 was referred to the restorative nursing program for occupational therapy. Review of the referral sheets for the restorative program revealed Resident #19 was to begin receiving restorative occupational therapy on 08/08/18 to include range of motion in functional planes. She was to begin restorative physical therapy beginning on 08/15/18 for basic therapeutic exercises of the lower extremities. An interview on 09/04/18 at 10:02 A.M. with Resident #19 revealed she had been in therapy and it was discontinued. She stated that they had not done anything for her regarding exercise, walking, or range of motion since she left therapy. An interview on 09/05/18 at 11:13 A.M. with Restorative Nurse #109 revealed she approached residents about restorative therapy and if they refused she did not re-approach them. Review of typed restorative therapy notes dated 08/13/18 which were not a part of the medical record, authored by Restorative Nurse #109, revealed a referral was received from occupational therapy and it was recommended Resident #19 receive active range of motion exercises to bilateral upper shoulders, elbows, wrist and hand/fingers. Exercises were reviewed with Resident #19 and she did not wish to continue doing exercises. The resident would not be added to restorative exercises and would be referred to occupational therapy as needed. An interview on 09/05/18 at 2:05 P.M. with Therapy program manager #110 revealed Resident #19 had come off occupational therapy on 08/07/18 and physical therapy on 08/14/18. Referrals for restorative programs were sent to Restorative Nurse #109. The referral forms specified what was needed to maintain function. They assumed the programs were being implemented unless they were notified of problems. They had not heard of any problems regarding Resident #19. A follow up interview on 09/06/18 at 10:52 A.M. with Resident #19 revealed she had never been approached by anyone regarding a restorative program and had never refused any services related to therapy. Review of the care plan dated 06/28/18 Resident #19 had been working with physical therapy and should improve her mobility status after working with therapy. 2. Review of the medical record of Resident #22 revealed the resident had moderate cognitive impairment. [DIAGNOSES REDACTED]. Review of the referral sheet for restorative occupational therapy dated 07/05/18 revealed Resident #22 was referred for range of motion exercises in functional planes, 20 repetitions two times daily. Review of the occupational therapy discharge summary dated 05/28/18 to 07/04/18 revealed Resident #22 was referred to the restorative nursing program on 07/04/18 and restorative therapy was to begin on 07/05/18. An interview and observation on 09/04/18 at 11:40 A.M. with Resident #22 revealed he had a contracture of the right hand from a stroke. He indicated he used to have a palm protector but it had been discontinued and he did not want to wear it. He stated staff did not do anything with the hand other than clean it sometimes. An interview on 09/05/18 at 9:57 A.M. with Licensed Practical Nurse (LPN) #108 revealed they cleaned the hands of Resident #22 when they could. An interview on 09/05/18 at 10:21 A.M. with State tested Nursing Assistant (STNA) #105 revealed she did not know if they had to do anything for the hand of Resident #22. They were not told to do exercises. An interview on 09/05/18 at 10:32 A.M. with Occupational Therapist #106 revealed she believed restorative was doing range of motion with Resident #22. She stated that something needed to be done with the contacted hand. An interview with Restorative Nurse #109 on 09/05/18 at 11:13 A.M. regarding Resident #22 revealed all she could remember was he had a cane. She said she would look for any notes. She said she tried to check the folder with referrals every day but she had not lately. Review of Restorative Nurse #109's notes dated 07/13/18 revealed she had received restorative recommendations from occupational therapy for Resident #22 and they included active and passive range of motion to bilateral upper extremities to include the hands. She had discussed this with Resident #22 and he did not want to continue with exercises at that time. She would refer him to occupational therapy as needed. An interview on 09/05/18 at 1:44 P.M. with STNA #104 revealed there would be something in the point of care (STNA electronic documentation) for Resident #22 if they were supposed to do anything. Review of the STNA's electronic documentation revealed an entry indicating they were not to provide any range of motion with care or otherwise. An interview on 09/05/18 at 2:05 P.M. with Therapy program manager #110 revealed Resident #22 came off occupational therapy on 07/04/18. After discontinuation of therapy they referred to restorative services and specified what was needed to maintain function. The referral forms went to Restorative Nurse #109. They assumed the programs were being implemented unless they heard there was a problem. They had not heard of any problem regarding Resident #22. Their expectation was restorative therapy would begin the day after the referral was made. Review of the Restorative Maintenance Program policy dated 03/2015 revealed the facility had a comprehensive restorative program to maintain a resident's highest practical range of motion. Residents would be placed in the restorative program from referrals from the therapy department, from staff members reporting declines, from resident requests or responsible party requests. Once the referral was made a Registered Nurse would develop an individualized program for the resident. Discharge protocol would occur if a resident refused the restorative program after several attempts.

Based on observation and interviews the facility failed to ensure appropriate procedures were followed to reduce the risk of falls or injury during Hoyer (mechanical) transfers. This affected one of one (Resident #27) resident observed transferring via a Hoyer lift. Findings include: Observations with Resident #27 and State tested Nurse Assistant (STNA) #50 on 09/04/18 at 12:06 P.M. revealed STNA #52 standing alone in the middle of the resident room with Resident #27 in the Hoyer lift. STNA #52 pointed to the bathroom and stated that another staff member was in the bathroom assisting another resident. An interview with STNA #50 on 09/04/18 at 12:12 P.M. revealed another staff was in the bathroom during the transfer. STNA #50 stated the facility policy indicated we just need to have another staff member in the room during transfers. Interviews with STNAs #51, #52 and #53 on 09/05/18 between 9:24 A.M. and 9:30 A.M., revealed two staff were to stay with the resident until the Hoyer lift was completed. An interview with Director of Nursing (DON) on 09/05/18 at 9:49 A.M. revealed two staff were to have hands on the Hoyer lift during the entire transfer to assist and prevent falls/injuries. A review of Hoyer Lift/ Stand Lift policy dated (YEAR) revealed two staff were to have hands-on assist during all Hoyer (mechanical) transfers.

Based on interview and record review, the facility failed to ensure a comprehensive restorative program was in place to maintain residents' (Residents #13, #9, #53, #6, #46, #21, #5, #22, #69, #54, #4, #66, #52, #18, #70 and #7) highest practical range of motion. This affected 16 of 16 residents who were referred by skilled therapy to receive range of motion from the facility. The facility census was 71. Findings include: 1. Review of Resident #18's restorative rehabilitation program recommendations dated 02/18/15 revealed the resident was discharged from physical therapy (PT) on 02/18/15 and referred to restorative therapy for range of motion (ROM) to both arms and legs. Review of the mobility plan of care did not indicate the resident was to receive ROM. Review of the State tested Nurse Aides (STNAs) Tasks form, that listed each resident's required care needs, revealed there was no documented evidence the resident was to receive ROM. 2. Review of Resident #70's restorative rehabilitation program recommendations dated 02/11/15 revealed the resident was discharged from PT on 02/11/15 and referred to restorative therapy for ROM to both legs. Review of the mobility plan of care did not indicate the resident was to receive ROM. Review of the STNAs Tasks form revealed there was no documented evidence the resident was to receive ROM. 3. Review of Resident #52's restorative rehabilitation program recommendations dated 02/04/15 revealed the resident was discharged from occupational therapy (OT) on 02/04/15 and referred to restorative therapy for ROM to the right thumb. Review of the mobility plan of care did not indicate the resident was to receive ROM. Review of the STNAs Tasks form revealed there was no documented evidence the resident was to receive ROM. 4. Review of Resident #4's restorative rehabilitation program recommendations dated 01/09/15 revealed the resident was discharged from OT on 01/09/15 and referred to restorative therapy for ROM to both arms and hands for contracture management. Review of the mobility plan of care did not indicate the resident was to receive ROM. Review of the STNAs Tasks form revealed there was no documented evidence the resident was to receive ROM. 5. Review of Resident #66's restorative rehabilitation program recommendations dated 01/07/15 revealed the resident was discharged from OT on 01/07/15 and referred to restorative therapy for ROM to both arms and hands for contracture management. Review of the mobility plan of care did not indicate the resident was to receive ROM. Review of the STNAs Tasks form revealed there was no documented evidence the resident was to receive ROM. 6. Review of Resident #13's facility in house exercise programs revealed the resident was discharged from OT on 09/10/14 and referred to restorative therapy for active (A) ROM exercise for the right wrist. Other suggestions included a wrist extension splinting schedule for the right wrist to decrease pain. Review of Resident #13's facility in house exercise programs revealed the resident was discharged from OT on 04/11/14 and referred to restorative therapy for AROM for both arms and hands and back to increase proper positioning and strength. Review of the mobility plan of care did not indicate the resident was to receive AROM. Review of the STNAs Tasks form revealed there was no documented evidence the resident was to receive AROM. 7. Review of Resident #9's facility in house exercise programs revealed the resident was discharged from OT on 06/09/14 and referred to restorative therapy for active participation in general AROM in all planes of motion. Review of the current mobility plan of care did not indicate the resident was to receive AROM. Review of the STNAs Tasks form revealed there was no documented evidence the resident was to receive AROM. 8. Review of Resident #53's facility in house exercise programs revealed the resident was discharged from PT on 06/07/14 and referred to restorative therapy for active ROM in both legs. Review of the current mobility plan of care did not indicate the resident was to receive AROM. Review of the STNAs Tasks form revealed there was no documented evidence the resident was to receive AROM. 9. Review of Resident #6's facility in house exercise programs revealed the resident was discharged from OT on 06/03/14 and referred to restorative therapy for active ROM in all planes of motion. Review of the current mobility plan of care did not indicate the resident was to receive AROM. Review of the STNAs Tasks form revealed there was no documented evidence the resident was to receive AROM. 10. Review of Resident #46's facility in house exercise programs revealed the resident was discharged from OT on 05/16/14 and referred to restorative therapy for active and passive ROM to both arms and hands. Review of the current mobility plan of care did not indicate the resident was to receive AROM or PROM. Review of the STNAs Tasks form revealed there was no documented evidence the resident was to receive AROM or PROM. 11. Review of Resident #21's facility in house exercise programs revealed the resident was discharged from PT on 05/15/14 and referred to restorative therapy for PROM to both legs according to the diagram provided. Review of the current mobility plan of care did not indicate the resident was to receive PROM. Review of the STNAs Tasks form revealed there was no documented evidence the resident was to receive PROM. 12. Review of Resident #7's facility in house exercise programs revealed the resident was discharged from PT on 05/01/14 and referred to restorative therapy for ROM to both knees. Review of the current mobility plan of care did not indicate the resident was to receive ROM. Review of the STNAs Tasks form revealed there was no documented evidence the resident was to receive ROM. 13. Review of Resident #5's facility in house exercise programs revealed the resident was discharged from PT on 04/28/14 and referred to restorative therapy for AROM to both legs. Review of the current mobility plan of care did not indicate the resident was to receive AROM. Review of the STNAs Tasks form revealed there was no documented evidence the resident was to receive AROM. 14. Review of Resident #22's facility in house exercise programs revealed the resident was discharged from OT on 04/25/14 and referred to restorative therapy for A/PROM to left arm and hand prior to application of wrist extension splint. Review of the current mobility plan of care did not indicate the resident was to receive A/PROM. Review of the STNAs Tasks form revealed there was no documented evidence the resident was to receive A/PROM. 15. Review of Resident #69's facility in house exercise programs revealed the resident was discharged from OT on 04/21/14 and referred to restorative therapy for A/PROM and strengthening for both arms and hands. Review of the current mobility plan of care did not indicate the resident was to receive A/PROM. Review of the STNAs Tasks form revealed there was no documented evidence the resident was to receive A/PROM. 16. Review of Resident #54's facility in house exercise programs revealed the resident was discharged from OT on 04/21/14 and referred to restorative therapy for AROM and strengthening for both arms and hands. Review of the current mobility plan of care did not indicate the resident was to receive AROM. Review of the STNAs Tasks form revealed there was no documented evidence the resident was to receive AROM. On 03/18/15 at 5:00 P.M., interview with the director of nursing (DON) revealed she was new to the facility in the fall of 2014 and verified she recently became aware the facility did not have a restorative program. She had been working on creating a system to ensure residents who were discharged from skilled therapy received restorative therapy if required. The DON verified she had found referrals dated June 2014 from skilled therapy for range of motion (ROM) and verified it ended there. The restorative therapy was never provided to the residents. The DON verified no residents had received restorative ROM as recommended by skilled therapy since at least June 2014. On 03/19/15 at 11:30 A.M., interview with Minimum Data Set (MDS)Licensed Practical Nurse (LPN) #101 verified the care plans were directed from the documentation she submitted on the MDS assessment. When a care plan was created it automatically imported the resident's specific care needs to the STNAs electronic Tasks form so the STNAs knew the specific care to provide to each resident. LPN #101 verified there was no care plan generated from the documentation she submitted in the MDS asssessment because the facility did not have a system to ensure residents who were referred from skilled therapy received the range of motion (ROM) as recommended. LPN #101 verified since no care plan was generated no STNA Tasks form was generated. LPN #101 verified there were no assessments completed to identify if any residents had declined in ROM because no one assessed ROM. LPN #101 verified she continued to input the MDS assessment information based on the previous MDS assessment because she did not have any documented evidence to suggest otherwise. LPN #101 verified the facility currently did not have a restorative nurse. On 03/19/15 at 12:20 P.M., interview with STNA #102 revealed she was not providing any active or passive ROM to any of her residents. On 03/19/15 at 12:25 P.M., interview with STNA #103 verified she conducted ROM on residents who were listed on the Task form to complete ROM. STNA #103 verified she was not aware of any residents currently assigned to receive restorative ROM. STNA #103 indicated the floor staff were responsible for completing ROM as assigned. On 03/19/15 at 4:50 P.M., interview with STNA #2 verified the floor STNAs were responsible for providing restorative ROM if listed on the Task form. STNA #2 verified she currently had no residents receiving restorative ROM. STNA #2 said if restorative ROM was ordered the STNAs would have to document when ROM was given and it would be done in the morning with A.M. care. On 03/19/15 at 5:00 P.M., interview with STNA #3 verified she did not have any resident that received ROM services at this time. STNA #3 stated if a resident was on restorative ROM it would be completed at bed time and documented in the Task record. On 03/19/15 at 5:00 P.M., interview with Registered Nurse (RN) #104 verified after a resident completed skilled therapy, if any further services were needed, therapy would write an order. RN #104 was not aware of any residents currently receiving restorative therapy. RN #104 said the facility currently did not have any specific restorative therapy staff. On 03/19/15 at 5:15 P.M., interview with Skilled Therapy Manager (STM) #105 revealed there had not been a system in place to ensure residents who were discharged from skilled therapy received restorative therapy as needed until a couple weeks ago when the DON identified the system problem. STM #105 verified the skilled therapy department did not conduct quarterly screens on residents but worked based on referrals from the facility staff. On 3/19/15 at 5:24 P.M., interview with LPN #105 revealed if she noticed a resident had a decline she would inform therapy so they could evaluate the resident. She verified there was no documented evidence related to ROM to be able to tell if the resident had a decline. LPN #105 verified when a resident was discharged from skilled therapy, no further interventions were needed unless therapy wrote an order. LPN #105 said the facility currently did not have any specific restorative therapy staff.

Based on observation, policy review and interview, the facility failed to ensure medications were secured and inaccessible to residents. This affected seven cognitively impaired, independently mobile residents out of 31 residents residing in the Buckeye unit. Findings include: On 3/19/15 at 11:35 A.M. Registered Nurse (RN) #1was observed during a medication pass. During the medication pass the medication cart was located at the top of the south hall right outside the dining room. RN #1 left the medication cart unlocked with drawers facing outward when she walked down the hall to room [ROOM NUMBER] to do a fingerstick blood sugar on Resident #72. Upon returning to the medication cart, RN #1 verified the medication cart was left unlocked and stated "I did not leave the hall that's why I didn't lock it." She revealed she did not think it was a concern that she left the medication cart unlocked and unattended because she came right back. Residents were observed coming in and out of the dining room and resident rooms on the south hall at the time of the medication pass. Review of the facility's undated Medication Administration Procedures policy revealed during the medication administration process, the medication cart must always be locked.

Based on observation, interview and record review, the facility failed to ensure Resident #62 received range of motion (ROM) services or was assessed for the use of splinting devices to ensure the resident did not have further decline in ROM. This affected one of one residents reviewed for ROM services. Findings include: Review of the medical record revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the ROM assessment dated [DATE] revealed the resident had contractures of the left fingers up to the shoulder. No other contractures or limits in ROM were noted. Review of the occupation therapy discharge summary dated 06/10/14 revealed the right arm and hand were within functional limits but the left arm and hand had severe joint contracture throughout with a flexor [MEDICATION NAME] pattern. Home exercise program was recommended which included right arm and hand ROM. The left arm and hand were not assessed for contracture or need for splinting. Review of the physical therapy discharge summary dated 06/26/14 revealed the resident's goal was to be able to walk to the dining room again without any assistive devices. The resident had tight bilateral hamstrings limited by 45 degrees extension from neutral baseline. The goal was to prevent decline with active ROM and ambulation programs. Review of the facility in house exercise programs for physical therapy dated 06/25/14 revealed ambulate with pyramid cane to and from dining room with stand by assist of staff. Review of the 10/03/14 Minimum Data Set (MDS) 3.0 assessment revealed the resident had intact mental status. The resident displayed no behaviors, had functional limitations of ROM on one side - both arm and leg, and had orthotic shoes since 10/25/09. The resident used a walker for ambulation. No restorative or splinting devices were in place. Review of the MDS 3.0 assessment dated [DATE] revealed the resident had intact mental status. The resident displayed no behaviors and was discharged from physical therapy on 06/26/14 and occupational therapy on 06/10/14 with functional limitations in ROM of the arm and leg on one side and used a walker for mobility. No restorative or splinting devices were in place. Review of the mobility plan of care initiated 06/24/09 and current through 06/11/15 revealed there was no evidence the resident received any restorative therapy to either arms or legs. Review of the state tested nurse aide (STNA) Task record for March 2015 verified there was no evidence the resident was to receive any restorative therapy to the arms or legs. Review of the physicians orders revealed there was no evidence the restorative therapy the skilled therapy department recommended was put into place. On 03/17/15 at 1:56 P.M., Resident #62 was observed with left arm and wrist contracture. On 03/17/15 at 11:10 A.M., during stage one unidentified staff interview revealed the resident had a congenital deficit and did not receive any ROM services nor any splinting devices. On 03/18/15 at 5:00 P.M., interview with the director of nursing (DON) revealed she spoke with the occupational therapy (OT) who stated the resident was most recently discharged from OT on 06/10/14 with severely contracted left hand and left leg. The DON was not sure why the resident was not on any ROM programs or why the resident had no splinting devices. On 03/18/15 at 5:30 P.M., the resident was observed walking back from the dining room, without any staff assistance, using his walker with his right hand. The left arm and leg were contracted. The resident ambulated with a significant limp. On 03/19/15 at 11:30 A.M., interview with Licensed Practical Nurse (LPN) #101 verified the resident was admitted with contractures of the left arm and leg due to a stroke when the resident was very young. LPN #101 was not able to verify if either of the contractures had worsened because there had not been any assessments indicating the degree of contractures by the facility or the skilled therapy department since the resident had been admitted to the facility. On 03/19/15 at 12:05 P.M., the resident was observed in the dining room feeding himself a sandwich with his right hand. The surveyor was not able to see the left arm because it was under the clothing protector. A narrow pyramid walker (with four legs about half the size of a standard walker) was at the resident's side. On 03/19/15 at 12:20 P.M., interview with STNA #102 verified the resident was very pleasant and was able to state his needs. STNA #102 verified she had been here over five years and the resident did not have any splinting or any ROM that she knew of. On 03/19/15 at 12:25 P.M., interview with STNA #103 verified she had worked at the facility for about three years and had not seen any splinting devices on Resident #62 nor was she aware of any ROM programs. STNA #103 stated the resident was very nice and would do what they asked. On 03/19/15 at 12:30 P.M., Resident #62 remained in the dining room for lunch but had asked staff to assist him back to his room. STNA #102 assisted the resident out of his chair and handed him the walker. STNA #102 stated he could walk back to his room by himself after they helped him out of the chair but sometimes they walked him back. STNA #102 said his room was right around the corner and he just needed pointed in the right direction because he was blind. On 03/19/15 at 12:45 P.M., interview with Resident #62 verified he had a stroke when he was 11 months old. He stated his arm had been contracted but had gotten worse over time. He said he use to have a splint prior to coming to the facility but had not had one since admission. The resident stated he use to be able to walk independently until he had a fall and now he needed to use the walker. The resident stated he wanted to be able to walk independently again without the walker. The resident stated no one did exercises with him. On 03/19/15 at 2:15 P.M., interview with Skilled Therapy Manager (STM) #105 verified Resident #62 was to be on a restorative therapy program for ROM and ambulation. On 03/19/15 at 5:15 P.M., interview with STM #105 verified the documentation indicated Resident #62 did not have any concerns with the right arm or leg on admission. STM #105 verified none of the occupational or physical therapy documentation since admission had assessed the degree of contractions of the left arm and leg. The physician therapy assessment dated [DATE] indicated moderate assist for ambulation which was hand held assist by staff but prior to that the resident was modified independent without an assistance device. The resident was evaluated by physical therapy after a fall. The interventions included the use of the pyramid cane. The occupational evaluation dated 04/14/14 after a fall indicated the right arm was within function limits and the left arm was severely impaired but no degree of the contracture was documented. There was no documented evidence the resident was offered or refused ROM or splinting. STM #105 verified the documentation on 06/12/14 indicated the resident had problems with his left ankle but the degree of contracture was not rated. The discharge goal on 6/12/14 was to be negative 15 degrees from neutral bilaterally to both legs. No ROM for the legs was recommended but an ambulation program was recommended and there was no documented evidence this program was put into place. The discharge summary from occupational therapy dated 06/10/14 referred the resident to restorative ROM for right arm and hand strengthening.

Based on observation and interview the facility failed to ensure the daily nursing staffing hours was posted in the facility. This had potential to affect all 71 residents residing in the facility. Findings include: Observations conducted on 03/16/15 at 9:50 A.M. during the facility tour revealed no evidence that the facility posted the nursing staffing hours for resident and visitor review. Observations on 03/16/15 at 3:00 P.M. revealed no evidence of staffing posted. Interview with the facility Director of Nursing (DON) on 03/17/15 at 3:20 P.M. revealed she had been employed in the facility for six months and was unaware no one was posting the staffing hours. The DON confirmed the facility did not post the required information.