Every finding on record at Vi at Grayhawk, a Vi and Plaza Companies Community

Based on closed record review, staff interviews, and the review of facility process and policy, the facility failed to ensure that a copy of the transfer/discharge notification was sent to the ombudsman prior to discharge of two out of four sampled residents (#7, & #35). The census was 33. The deficient practice could lead to notifications and pertinent information regarding the discharge/transfer not being provided.Findings include: Regarding Resident #7:-Resident # 7 was admitted to the facility on [DATE] with diagnoses of left humerus fracture and malaise.A Discharge Planning Note dated July 28, 2026 documented that the resident wished to discharge on [DATE] but understood she would have to be cleared by her provider.A Social Services note dated July 29, 2026 indicated that the resident had been cleared by her provider for discharge on [DATE] per resident's wishes.The resident's Notice of Discharge/Transfer Form documented that the resident would be discharged home on July, 29, 2026. Per the form, a copy of the notice was provided to the resident/responsible representative on the same day.The discharge Minimum Data Set (MDS) assessment with a reference date of July 30, 2026 documented a planned discharge to home/community. Per the MDS, the resident was discharged on July 30, 2026.The resident's Order History documented a physician order for the resident to discharge on [DATE].A Nursing note date dated July 30, 2026 documented that resident was discharged home with medication and belongings. The form indicated that a copy was provided to the resident. A Social Services note dated July 30, 2026 noted that the per the resident and her daughter's wishes, the resident successfully discharged . The note indicated that home health services was arranged. Per the note, the Ombudsman was provided with a discharge notice.An email correspondence between the Ombudsman (staff #53) and the facility documented that a copy of the resident's discharge notice was not sent until July 30, 2026, which was the day of the resident's discharge. An interview was conducted with the Social Services Manager (SS Manager/staff #137) on August 13, 2026 at 3:51 p.m. Staff #137 stated that the resident discharged home under the care of her daughter with home health services on July 30, 2026. Per the SS Manager, a copy of the discharge notification was given to the resident on July 29, 2026. However, a copy was not sent to the Ombudsman until July 30, 2026 which was the day of the resident's discharge. Regarding Resident # 35-Resident #35 was re-admitted to the facility on [DATE] with diagnoses of humerus fracture, left arm fracture, and diabetes mellitus with diabetic neuropathy.A Nursing note dated August 2, 2026 indicated that the resident and the family requested hospice consult for end-of-life care. Per the note, the physician was notified and an order was obtained.A subsequent Nursing note also dated August 2, 2026 revealed that resident's family panned for hospice admission the following morning.A Nursing note dated August 3, 2026 documented that an order was received to discharge the resident to an inpatient hospice facility.The Order History revealed a physician order dated August 3, 2026 to discharge the resident to an inpatient hospice facility. The resident's Notice of Discharge/Transfer Form indicated that the resident would be discharged to an inpatient hospice facility on August 3, 2026. Per the form, a copy of the notice was provided to the resident/responsible representative on August 3, 2026. A Nursing note dated August 3, 2026 documented that resident was discharged to the inpatient hospice facility via transport service. There was no indication if the Ombudsman was notified of the transfer.An email correspondence between the Ombudsman (staff #53) and the facility documented that a copy of the resident's discharge notice was not sent until August 10, 2026, which was seven days after the resident's discharge.A telephonic interview with the Ombudsman (staff #53) was conducted on August 11, 2026 at 10:21 a.m. Staff #53 stated that the facility had started sending her copies of the notice of discharge/transfer but would have to check to see if it was provided prior to discharge or on the day of discharge. Additionally, at the end of the month, she also received a discharge report.A follow-up, in-person interview with the Ombudsman (staff #53) was conducted on August 11, 2026 at 1:50 p.m. Staff #53 reiterated that she received a copy of the notice of discharge but would have to check when exactly she received it. She noted that it was important to receive the notice in order for her to be able to advocate for the residents should they need assistance.An email correspondence from the Ombudsman was received on August 11, 2026. The email documented that she normally received the notice of discharge the same day that they are issued to the residents. This had been per her office's request/preference. However, upon her review, she acknowledged that she had received some of the notification after the fact. She indicated that if the notice of discharge/transfer was presented to the resident over the weekend, the facility would not send her a copy until the next business day.An interview was conducted with the Social Services Manager (SS Manager/staff #137) on August 13, 2026 at 3:51 p.m. Staff #137 stated that the resident discharged /transferred to inpatient hospice facility on August 3, 2026. The email correspondence with the Ombudsman was reviewed regarding resident #35's discharge with the SS Manager. Staff #137 acknowledged that the notice was sent after the resident discharged . According to the SS Manager, the process with regards to discharge/transfer notification of the Ombudsman, a copy of the discharge notice is not sent to the Ombudsman until the day of the discharge. Staff #137 said that the it was important to provide a copy of the discharge notice to the resident/resident representative and the Ombudsman because it was part of resident rights, and the resident needed to know their rights to make an appeal. Additionally, the Ombudsman needed to be aware of residents discharging. Per the SS Manager, not providing a copy of the discharge notification was wrong and could impede the resident's right to appeal.An interview the Director of Nursing (DON/staff #106) was conducted on August 13, 2026 at 4:38 p.m. Staff #106 stated that her expectation was for the discharge/transfer notice to be provided 30-days prior to resident's discharge/transfer. The DON stated that timely notification was important to respect residents' rights, ensure the resident was informed, notify the ombudsman as as the resident's advocate, and ensure the discharge/transfer process was followed appropriately. The DON further stated that failure to provide timely notification could result in the resident not receiving needed assistance and, if the resident was not returning home, necessary resources and supports might not be arranged prior to discharge.The facility policy titled Discharge and Transfer of Residents revised October 2017 outlined the types of resident transfers and discharges within the facility. However, the policy did not cover the required information that a discharge/transfer notice must contain, who the written notice had to be provided to, and the timeline for when the notice is supposed to be provided.

Based on resident and staff interviews, facility documentation, and policy review, the facility failed to ensure it had sufficient staff to meet residents' needs. This deficient practice could result in residents not receiving the appropriate care and treatment they need.Findings include:A review of the resident council meeting minutes dated August, September, and October 2025 and June, July, and August 2026 revealed a comment that having 5 aides on the floor per shift would be ideal for the residents.A review of the grievance/concern log dated January 4, 2026, revealed that a resident reported that aides take an extended amount of time to respond to her call light. Further review of the June 2026 grievance/concern log revealed a grievance from a resident reporting that staff were slow to respond to requests for assistance. Additionally, the June 2026 grievance log documented a resident's concern that they were left on the commode for extended periods of time.During the initial screening conducted on August 11, 2026, at 11:02 a.m., Resident #16 reported experiencing wait times of up to one hour. She stated that staff would tell her they would be right back but would not return as stated.During initial screening conducted on August 11, 2026, at 11:46 a.m., Resident #2 stated that the facility used a lot of registry staff and that they tend to take longer since they were not familiar with the facility or its residents.During the initial screening conducted on August 11, 2026, at 9:55 a.m., a family member of Resident #31 expressed concern that the facility appeared to be short-staffed, stating that care and other tasks were not completed on time because staff were occupied elsewhere. The family member also expressed concern regarding the frequency with which staff check on the resident, stating that she often has to request staff assistance to ensure his care needs were addressed.During the initial screening conducted on August 11, 2026, at approximately 11:00 a.m., Resident #13 reported that staff took an extended amount of time to respond to his call light, sometimes 40 minutes or longer. He further stated that the facility used contracted staff whom he felt that they did not provide adequate attention to residents' needs.During initial screening conducted on August 11, 2026, at approximately 11:15 a.m., resident #41 stated he was not assisted to go to the dining room or to activities; he stated he was very lonely just being in his room. During initial screening conducted on August 11, 2026, at approximately 11:30 a.m., a family member of Resident #21 reported concerns regarding a delay in the administration of the resident's PRN pain medication. The family member stated that Resident #21 requested pain medication at approximately 5:00 a.m. and that the medication was not administered until approximately 11:00 a.m. The family member reported that a nurse came to the resident's room at approximately 11:00 a.m. and apologized, stating that the resident's pain medication had not been administered as requested at 5:00 a.m. The family member stated that the resident experienced pain while waiting for the medication and that it took some time after the medication was administered for the resident's pain to subside.During a Resident Council interview conducted on August 12, 2026, at 2:07 p.m., residents present expressed concerns regarding the adequacy of staffing to meet residents' needs. Residents stated that staffing levels affect response times to call lights, with the most significant delays occurring on weekends. Residents reported that call lights may remain unanswered for 30 to 60 minutes or longer on weekends. Residents stated that the facility did not appear to be fully staffed on weekends and that a significant portion of the weekend staff consisted of contracted staff. Residents reported that nurses generally did not assist with answering call lights and described weekends as a bit of a problem. Residents also stated that when staff calls off at the last minute, the facility had difficulty filling the vacant positions. Residents indicated that having only four CNAs available was insufficient to meet the needs of the resident population, particularly given the amount residents pay for their care. One resident stated, Things happen, and unfortunately we are the ones who suffer from it. Residents further expressed concern regarding the facility's reliance on contracted staff and whether those staff members were adequately capable and willing to assist residents. One resident stated, They just do not have enough or make sure that the contracted staff they bring in are capable of helping us or better yet, want to help us. Overall, residents expressed a consistent concern that staffing levels, particularly on weekends and when staff call off unexpectedly, contribute to delays in responding to call lights and meeting residents' care needs.Observations during the initial screening and duration of the survey did not reveal long call light wait times; however, the following observations were made;08/13/2026 8:34 AM male resident asked staff if he could be taken back to his room; staff said to give them a few minutes since they were still passing trays, and male resident said I guess so; 08/13/2026 8:36 AM male resident again asked another staff that was taking away his plate to go back to his room08/13/2026 8:37 AM another staff asked nurse if she could get someone to take male resident back to his room and said it might be until 9:15 until he could be taken back08/13/2026 8:39 AM staff asked the male resident if he wanted coffee while he was waiting to go back to his room08/13/2026 8:40 AM Staff told the resident that he would get his coffee in a bit08/13/2026 8:44 AM staff assisted resident at another table with feeding told another staff that male resident was ready to go08/13/2026 8:47 AM the staff from another table told the resident she would check on his coffee08/13/2026 8:49 AM staff brought his coffee to him08/13/2026 8:54 AM the resident is still waiting to be taken back to his room while other residents are taken back ahead of him08/13/2026 8:56 AM asked staff again that he needed someone to go back to his room08/13/2026 8:57 AM staff said, ok and got his walker, placed gait belt on resident08/13/2026 8:57 AM staff assisted resident and guided him in the direction of his room08/13/2026 8:58 AM the staff asked the resident if he wanted to be on the recliner, positioned the resident so he could maneuver to sit in his recliner in his room. Based on the observation, it took 24 minutes for the resident to receive assistance back to his room after asking multiple staff who went by his table. Then other residents were taken ahead of him at the 17-minute mark. An interview was conducted on August 13, 2026, at 2:21 p.m. with Registered Nurse (RN/Staff#118). They stated that there did not appear to be enough nursing staff to adequately care for the residents. She stated that the CNAs could sometimes run short-staffed, but staff all work together to help by answering call lights and assisting wherever needed. She further stated that the facility also brought in registry staff when necessary to supplement both the nursing and CNA staff.An interview was conducted on August 13, 2026, at 3:17 p.m. with Certified Nursing Assistant (CNA/Staff#66). During the interview, the CNA stated that the current census was approximately 35 residents, with five CNAs scheduled. The CNA stated that when there was no staff available to pick up an additional shift, staffing may decrease to four CNAs. The CNA stated that, in their opinion, five CNAs were needed consistently to provide adequate care to the residents. The CNA reported that staff sometimes have to rush while providing care and that residents have expressed concerns that they were not receiving the level of care they deserved, particularly given the amount they pay for their care. The CNA stated that during meal service, staff may be delayed in responding to residents who need assistance because they were passing meal trays. The CNA explained that residents may have to wait until tray service is completed so that their food did not become cold. The CNA stated that this was not because staff are unwilling to assist residents, but because staff must complete meal service. The CNA further stated that when there were residents on isolation precautions and residents requiring extensive assistance, staff may experience additional delays in responding to residents, although the CNA estimated these delays are generally less than 10 minutes. The CNA stated that staffing concerns were most noticeable in the morning. The CNA also identified concerns related to equipment. The CNA stated that the facility had only one Hoyer lift available for approximately 10 residents who required Hoyer-lift transfers. The CNA stated that the Hoyer lift provided by hospice was not very effective and described the equipment as somewhat frightening to use due to its instability.An informal interview was conducted on August 13, 2026, at 5:17 p.m. with the Administrator (Administrator/Staff #78) and Director of Nursing (DON/Staff #106). The Administrator and DON were informed of the concerns identified during initial screening and resident council interviews regarding staffing and residents' concerns that their needs were not being met.Review of the Facility Assessment indicated that the intent of the Facility Assessment is for Facility management to evaluate its resident population and identify the resources needed to provide appropriate care and services to the facility census. The assessment noted that the facility is licensed to provide care for 32 residents with the average daily census of 32.1 residents. The Staffing Plan portion of the assessment revealed the following:Staffing structure includes the following:- Licensed Nurses providing direct care:Director of Nursing (DON): 1 DON RN full-time, DaysAssistant Director of Nursing (ADON): 1 full-time RN, DaysDay shift (12-hour shifts) ratio: 3 LN Days, 2 LN EveningsDirect care staff: 4-5 -CNAs Day shifts; 1 Lead CNA overlapping 1st and second shift, 4-5 -CNAs Evening shift, 2-CNAs Night shift.

Based on observation, facility documentation, staff interviews, and policy review, the facility failed to ensure nurse staffing information posted was accurate for actual hours worked by licensed and unlicensed direct care nursing staff and that the census was updated daily to reflect the actual number of residents. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information and census.Findings include:-Regarding May 25, 2026Review of the May 25, 2026 Staff Posting indicated the following:-The posting did not clearly identify which staff are Registered Nurse (RN) and Licensed Practical Nurse (LPN) for all shifts- It was unclear how many RNs and LPNs were on each shift-The posting did not reflect the total actual hours worked by the licensed and unlicensed nursing staff-The posting did not reflect the correct times for the evening shiftAdditionally, review of the Daily Assignment Sheet for May 25, 2026 revealed that a Certified Nursing Assistant (CNA) that picked up hours for the 9:45 p.m. - 6:15 a.m. shift was not reflected on the Staff Posting.-Regarding June 25, 2026Review of the June 25, 2026 Staff Posting indicated the following:-The posting did not clearly identify which staff are Registered Nurse (RN) and Licensed Practical Nurse (LPN) for all shifts- It was unclear how many RNs and LPNs were on each shift-The posting did not reflect the total actual hours worked by the licensed and unlicensed nursing staff-The posting did not reflect the correct times for the evening shift-Regarding July 4, 2026Review of the July 4, 2026 Staff Posting indicated the following:-The posting did not clearly identify which staff are Registered Nurse (RN) and Licensed Practical Nurse (LPN) for all shifts- It was unclear how many RNs and LPNs were on each shift-The posting did not reflect the total actual hours worked by the licensed and unlicensed nursing staff-The posting did not reflect the correct times for the evening shiftAdditionally, review of the Daily Assignment Sheet for July 4, 2026 revealed that the Staff Posting did not reflect the accurately number of CNAs indicated on the assignment sheet. Furthermore, the Staff Posting also did not account for the CNA's hours.The facility assessment updated January 15, 2026 revealed that the facility was licensed to care for 36 residents, and had an average daily census of 32.1. The Staffing plan included the following:- full time Director of Nursing- Up to 5 licensed nurses providing direct care (shifts not indicated on the plan)- Up to 5 CNAs during the day shift (5:45 a.m. - 2:15 p.m.)-1 lead CNA overlapping the first and second shift- Up to 5 CNAs during the evening shift (1:45 p.m. - 10:15 p.m.)-Up to 2 CNAs during the night shift (9:45 p.m. - 6:15 a.m.)During the initial screening walk through of the facility conducted on August 11, 2026 at 8:02 a.m., it was observed that the Daily Staff Posting located at the nurse's station across from the Activity Room did not clearly identify which staff are RNs and LPNs for all shifts. It was unclear how many RNs and LPNs were on shift. The census was noted as 33 for the day shift.However, review of the facility completed CMS-671 dated August 11, 2026 revealed that the census was 34.An interview with the Staffing Coordinator (staff #121) was conducted on August 13, 2026 at 2:36 p.m. Staff #121 stated that she was responsible for publishing the Daily Staff Posting. Additionally, the overnight CNAs was the one responsible for filling out the info for the next day's staffing and census. Per the Staffing Coordinator, the importance of posting an accurate Daily Staff Posting was to comply with BIPA (Benefits Improvement and Protection Act) and staff to know who was working. Staff #121 said that the impact of an inaccurate Daily Staff Posting was that it would mess up with the staff. The Staffing Coordinator, stated that to her knowledge the information that the posting should include are the date, staff names, hours worked and census. The selected Daily Staff Posting were reviewed with the Staffing Coordinator. During the review, she acknowledged that their current format of the posting did not easily identify the RNs and LPNs and their hours worked. Additionally, she agreed that the evening hours were wrong and admitted that she was probably on auto pilot in filling in out since she had not noticed that the hours were inaccurate. Furthermore, she concurred that for the May 25, 2026 night shift a CNA was not reflected on the Daily Staff Posting to match the Daily Assignment Sheet and that for the July 4, 2026 day shift a CNA was also not reflected on the Daily Staff Posting to match the Daily Assignment Sheet. Staff #121 explained that despite the inaccuracies, the residents could always ask staff who is on shift and that they had a board that showed pictures of who were on duty.During an interview with the Director of Nursing (DON/staff #106) conducted on August 13, 2026 at 4:38 p.m., staff #106 stated that her expectation with regards to the Daily Staff Posting was that it identified people working and staff were signing in to capture the hours. The DON said that this was important to show proper hours of care for resident care and that it matched what is reported the PBJ (Payroll-Based Journal). Per staff #106, the potential impact of an inaccurate Daily Staff Posting is that it would not match the time cards. However, if it was not aligned then they did not know what was real. The posting was for everyone to see, and for people to know what the staffing looked like.

Based on facility documentation, observations, staff interviews, and policy review, the facility failed to ensure that food items located in the refrigerator, freezer and dry storage areas were properly stored. The deficient practice could result in unsafe food storage, placing residents at risk for foodborne illnesses.Findings include:During the initial walk-through of the kitchen conducted on August 11, 2026, at 7:16 AM with the Executive Sous Chef (Staff #55), observations of the large refrigerator, freezer, and dry storage areas revealed the following: Refrigerator:- One half pan of mustard sauce with an expiration date of August 10, 2026.- One pan of demi-[NAME] with an expiration date of August 10, 2026.- One container of caramel sauce with an expiration date of August 10, 2026.-One container of Pastry Prep with an expiration of August 10, 2026.Freezer:- Three pounds of sliced potatoes with no opened date.- One pound of diced chicken that was opened and exposed to air.- One full box of turkey patties that was opened and exposed to air.- Ten pounds of frozen ground beef patties that was open and exposed to air.Dry Storage:-One bag of coconut flakes with no use-by date.-One package of dried cherries with no use-by date.An interview was conducted with Staff #55, following the observation, who stated the expectation was for the staff to label, date, and discard any expired food items. Staff #55 discarded all of the above identified food items and stated the risks of not properly labeling, dating, and storing food items could pose a potential risk for illness.An interview was conducted on August 13, 2026, at 4:46 PM with the Care Center Administrator (Staff #78). She stated she expected the facility staff would follow the policy of labeling and dating food and discarding any expired food items. She stated the risks were potential health concerns for the residents.

Based on facility documentation, personnel record reviews, staff interviews, and facility policy review, the facility failed to ensure that two staff members (#50, & #66) have been screened for infectious tuberculosis (TB); failed to demonstrate that water management program assessed for the presence of Legionella; and failed to ensure that infection control and prevention policies/procedures were reviewed annually. The deficient practice could increase the risk for infectious TB, Legionella, and other diseases/infections, and staff would not have the guidelines/practices that meets current standards for the provision of infection prevention and control.Findings include:-Regarding TB Screening- Regarding Staff #50Review of the personnel record for a Registered Nurse (RN/staff #50) revealed a hire date of October 14, 2025. The record included a radiology interpretation report for a chest x-ray that indicated an exam date of January 15, 2025. The result noted that there was no evidence of active pulmonary TB.A Tuberculosis (TB) Screening and Risk Assessment form dated October 14, 2025 revealed that the screening was signed by staff #50. However, the screening was missing an Infection Control or Health Nurse review/signature.The 90-day punch detail report revealed that staff #50 was on shift as recent as August 9, 2026.The Daily Assignment Sheet indicated that staff #50 was scheduled to work on August 14, 2026.-Regarding Staff #66Review of the personnel record for a Licensed Nursing Assistant (LNA/staff #66) revealed a hire date of February 14, 2022. The record included a radiology interpretation report for a chest x-ray from 2021. The report noted that there was no evidence for manifestation of pulmonary tuberculosis.A Tuberculosis (TB) Screening and Risk Assessment form dated February 6, 2026 revealed that staff #66 answered Yes to the question Have you ever been diagnosed with active TB disease? Although, the form was signed by both staff #66 and the IP/RN (staff #140), the IP did not complete the screening as she did not complete the section marked as For Office Use Only where it asked the following screening questions for the IP/RN:Was this employee referred for further evaluation?If yes, to whom?Chest x-ray?Medication?Work restrictions?If yes, describe:The 90-day punch detail report revealed that staff #66 was on shift as recent as August 11, 2026.The Daily Assignment Sheet indicated that staff #66 was schedule for work August 12 thru August 13, 2026.During an interview the Director of Nursing (DON)/Acting Infection Preventionist (IP) (staff #106) conducted on August 13, 2026 at 2:05 p.m., staff #106 stated that for established employees, they undergo an annual screening and education for TB. Per the DON, this was important because TB is highly contagious, airborne, and there are no means to control it. The impact of not screening for TB is that there is a risk of someone with symptoms being allowed to work and exposing other people. The acting IP said that the screening questionnaire should be reviewed, signed, and the For Office Use Only section completed by the IP or a nurse if the employee answered yes to any of the questions. Otherwise, the screening was not considered complete. Staff #106 said that if the employee did not answer yes to any questions then the IP/nurse signature would suffice and indicate that the screening questionnaire had been reviewed/completed.An interview with the Staffing Coordinator (staff #121) was conducted on August 13, 2026 at 2:36 p.m. Staff #121 stated that she was no longer involved in staff's TB screening. Per the Staffing Coordinator, TB screening was important because if someone has TB they could spread it. The impact of not screening for TB is that if someone does not know that they have TB, they could spread it to others. The facility policy titled Tuberculosis Screening: Residents and Employees - Infection Control revised December 2017 indicated that employees, contract workers, and volunteers are required to have an entry 2-step tuberculin skin test prior to starting work and an annual tuberculosis reevaluation. Per the policy, TB reevaluation are administered annually. The policy noted that individuals who have not previously tested positive are administered a single tuberculin skin test. Individuals that had previously tested positive but found to be free of TB based on chest x-ray and medical exam are screened for symptoms consistent with pulmonary TB at the time of the annual TB test. If symptoms consistent with pulmonary TB are present, a standard chest x-ray is required.-Regarding Water Management Testing for LegionellaReview of an Analytical Report provided by the facility for their third-party Water Management testing for Legionella revealed that the last recorded report the facility has on file was from September 19, 2024. Per the report, the sample was taken on September 18, 2024 from Domestic Water Systems Main Portable Hot - Supply - SNF. The report noted that the test method used as EM-BT-S-1045 (an internal laboratory tracking code used by environmental testing facilities). The report documented the total Legionella detected as 6 CFU/ml. Additionally, the report noted that the species of bacteria detected was Legionella pneumophila SG 1 which is the primary bacterium responsible for human Legionnaires' disease cases worldwide. The report did not indicate what actions if any was recommended.Review of the invoice provide by the facility for their third-party Water Management verified that the facility is paying for a water program. The invoices were for the following billing period:November 1, 2025 thru January 31, 2026February 1, 2026 thru April 30, 2026May 1, 2026 thru July 31, 2026August 1, 2026 thru October 31, 2026However, the invoice did not indicate what services were included or provided during the billing period.A sit-down interview with the Director of Engineering (staff # 54) was attempted on August 12, 2026 at approximately 4:00 p.m. Staff #55 (Assistant Director of Engineering) stated that staff #54 had left for the day and will be back tomorrow. Staff #55 said that he was not familiar with the water management/testing for Legionella since it was staff #54 that oversaw it. Staff #55 indicated to speak with staff #54 regarding the program for detailed information. During an interview with the Assistant Director of Engineering (staff #55) conducted on August 13, 2026 at 10:05 a.m., he stated that staff #55 was off and would not be in the office. Staff #55 said that they have a third party under contract that did the testing to ensure that they did not have Legionella. Documentation regarding the water management program/Legionella was requested for review and staff #55 said that he would try to obtain them but that they have had a hard time getting that information from the company.An extension to provide the requested proof of water management testing for Legionella was granted until August 14, 2026 at 1:00 p.m. was documented on a request form dated August 13, 2026.An email correspondence from the Administrator (staff #78) sent August 14, 2026 at 3:17 p.m. documented that the facility was unable to obtain/send reports to indicate that the facility tested its water system for Legionella. The facility policy titled Infection Control Program and Committee revised June 2020 indicated that it is the objective of the infection control program to control healthcare and community acquired infections.-Regarding Annual Review of Policies/ProceduresThe facility provided the following as infection prevention and control policies/procedures: Surveillance System - Infection Control with an effective date of June 2010 indicated that it was last revised on December 2017. The policy serves as a guide for the provision of accurate statistics of infection rates in the care venue. There was no indication that the policy had been reviewed since it was last revised. Infection Control Program and Committee with an effective date of June 2010 documented that it was last revised on June 2020. The policy describes the Infection Control Program and the Infection Control Committee in the SNF (Skilled Nursing Facility). There was no indication that the policy had been reviewed since it was last revised. Immunization Program with an effective date of May 2016 indicated that it was last revised on September 2023. The policy is a guideline for the implementation of the immunization program. There was no indication that the policy had been reviewed since it was last revised. Immunization Documentation Guidelines - Resident Care revised December 2020. The policy is the protocol for the process of documentation of immunization and supplements the policy/procedure related to the immunization program. There was no indication that the policy had been reviewed since it was last revised. Antibiotic Stewardship with an effective date of November 28, 2017 indicated it was last revised on March 2021. The policy established directives for antibiotic stewardship to develop antibiotic use protocols and a system to monitor antibiotic use. There was no indication that the policy had been reviewed since it was last revised. Minimum Criteria for Antibiotic Use Protocol which was undated serves as the protocol to improve appropriate antibiotic use and establish minimum criteria/clinical guidelines for the use on antibiotics. There was not indication of when the policy was last revised/reviewed.The following policies were additionally requested for specific programs that fall under infection prevention and control: Tuberculosis Screening: Residents and Employees - Infection Control with an effective date of October 2009 indicated it was last revised on December 2017. The policy outlines measures taken for compliance with state regulations regarding tuberculosis screening. The policy did not indicate when it was last reviewed. Respiratory Therapy - Infection Control with an effective date of June 2010 indicated it was last revised on December 2017. The policy provides guidelines to the infection control measures associated with the use of respiratory therapy equipment in the licensed care venues. There was no indication that the policy had been reviewed since it was last revised.The facility's Annual Survey Cycle 2026 SNF and Medicare Policy Change Index indicated that the following policies had new policies, significant edits and updated language briefed on January 15, 2026: Enhanced Barrier Precautions - marked as new policy. Tuberculosis Program Management - indicated to follow state or local requirements regarding TB screening and testing of employees. Tuberculosis Screening: Residents and Employees - Infection Control indicated to follow state or local requirements regarding TB screening and testing of employees.An interview with the DON/Acting IP (staff #106) was conducted on August 13, 2026 at 2:05 p.m. Staff #106 said that policies for infection control are reviewed thru QAPI (Quality Assurance and Performance Improvement) meetings then the team signs off on policy. The acting IP said that she is unsure whether it is straight up review only or if updates are discussed in QAPI. Staff #106 stated that policy are updated by their corporate office and is it sent thru QAPI. Per the DON, the importance of having reviewed current infection control policies is that practices change and staff need to be aware of those updates. Staff #106 stated that the impact of infection control policies not being reviewed/current is that regular practice could be affected such as testing/screening. People need to know that policies are updated so that they would know that what is being done is current practice.During a follow-up interview with the DON conducted on August 13, 2026 at 3:12 p.m., the DON said that per their current practice they are unable to prove that infection control policies were reviewed annually if they were not revised.The facility policy titled Infection Control Program and Committee revised June 2020 indicated that objectives/duties of the Infection Control Team are to:Develop, review, monitor, and approve written policies and procedures for investigating, controlling, and preventing infections among residents, visitors and personnel;Review policies and procedures for the surveillance and monitoring of infection control practices;Conduct and annual Infection Control Risk Assessment.

Based on documentation, staff interviews, and facility policies the facility failed to ensure that four staff members (#68, #66, #67, & #71) received Disaster training. The deficient practice could result in staff not being familiar with the procedures to follow in the event of an emergency and/or disaster.Findings include:-Regarding Staff #68Review of a personnel record for a Certified Nursing Assistant (CNA/staff #68) revealed signed job description dated June 24, 2024 which indicated that part of the employee's essential job function was to attend/comply with meetings, mandatory in-services and committee meetings.The training transcript for staff #68 provided via email revealed that she last completed Disaster training on May 31, 2025.Review of the facility's Care Center Completions 2025 PDF (Portable Document Format) file provided via email revealed no evidence that staff #68 had current Disaster training.-Regarding Staff #66Review of a personnel record for a Licensed Nursing Assistant (LNA/staff #66) revealed a hire date of February 14, 2022. A signed job description dated February 25, 2022 indicted that part of the employee's essential job function is to attend/comply with meetings, mandatory in-services, and committee meetings.The training transcript for staff #66 provided via email revealed that she last completed Disaster training on January 17, 2025.Review of the facility's Care Completions 2025 PDF file provided via email revealed no evidence that staff #68 had current Disaster training.-Regarding Staff #67Review of a personnel record for a Licensed Practical Nurse (LPN/staff #67) revealed a hire date of February 12, 2024.A signed job description dated February 12, 2024 indicated that part of the employee's essential job function is to attend/participate in department meetings, in-services, committee meetings, and adhere to policies and guidelines of regulatory agencies.The training transcript for staff #67 provided via email revealed that he last completed Disaster training on March 18, 2025.Review of the facility's Care Completions 2025 PDF file provided via email revealed no evidence that staff #67 had current Disaster training.Regarding Staff #71Review of personnel record for an LPN (staff #71) revealed a hire date of October 9, 2017.A signed job description dated June 8, 2018 indicated that part of the employee's essential job function is to adhere to policies and guidelines of regulatory agencies.The training transcript for staff #71 provided via email revealed that she last completed Disaster training on February 13, 2025.Review of the facility's Care Completions 2025 PDF file provided via email revealed no evidence that staff #71 had current Disaster training.An interview with the Staffing Coordinator (staff #121) was conducted on August 13, 2026 at 2:36 p.m. Staff #121 stated that employees received training via their online training portal and thru in-service. Per the Staffing Coordinator, it is important for staff to complete Disaster training so that they would know how to evacuate, what to do, and where to go depending on the situation. The impact of not completing Disaster training is that without the knowledge/familiarity staff would just be running around and screaming and only think about themselves-staff will not be able to process properly if they have no familiarity with what to do.During an interview with a Licensed Nursing Assistant (LNA/staff #66) conducted on August 13, 2026 at 3:17 p.m., staff #66 stated that staff receive training via an online training portal and via videos. Staff #66 said that it is important for staff to complete Disaster training so that they will know how to act and ensure their and the resident's safety. The impact of not completing the training is that they would not know what to do and might not be able to rescue residents, especially those needing Hoyer lift to transfer.An interview with the Director of Nursing (DON/staff #106) was conducted on August 13, 2026 at 4:38 p.m. Staff #106 stated that her expectation with regards to training is that staff takes the opportunity to get impromptu coaching, be informed, and have the resources to do the job such as staff meetings, huddles. The DON said that Disaster training is important because there is a possibility that staff have to respond to a disaster/fire and they would need to know what to do. These situations are scary so training and practice is important so they do not freeze. The impact of not completing Disaster training is that if the staff is not prepared then residents are in danger and not able to quickly respond.The facility policy titled Staff Development and Orientation - Resident Care revised October 2023 outlined the orientation plan, training requirements, and development initiatives for resident care employees. Per the policy, orientation and staff development programs are intended to comply with federal and state regulations related to topics and frequency. The policy noted that new employee receive orientation on environment of care/safety. However, the policy did not mention Disaster/Fire Safety training for new and existing staff.

Based on documentation, staff interviews, and facility policies the facility failed to ensure that four staff members (#72, #68, #66 & # 71) are educated on the rights of the resident and the responsibilities of a facility to care for its residents. The deficient practice could result in staff not being familiar with residents' rights.Findings include:-Regarding Staff #72Review of a personnel record for a Maintenance Technician (Maint Tech/staff #72) revealed a hire date of July 23, 2008.The undated training transcript for staff #72 provided via email revealed that his Resident Rights training had not been completed and is currently in progress.Review of the facility's Care Center Completions 2025 PDF (Portable Document Format) file provided via email revealed no evidence that staff #72 had current Resident Rights training.-Regarding Staff #68Review of a personnel record for a Certified Nursing Assistant (CNA/staff #68) revealed signed job description dated June 24, 2024 which indicated that part of the employee's essential job function was to attend/comply with meetings, mandatory in-services and committee meetings.The training transcript for staff #68 provided via email revealed that she last completed Resident Rights training on May 31, 2025Review of the facility's Care Center Completions 2025 PDF (Portable Document Format) file provided via email revealed no evidence that staff #68 had current Resident Rights training.-Regarding Staff #66Review of a personnel record for a Licensed Nursing Assistant (LNA/staff #66) revealed a hire date of February 14, 2022. A signed job description dated February 25, 2022 indicted that part of the employee's essential job function is to attend/comply with meetings, mandatory in-services, and committee meetings.The training transcript for staff #66 provided via email revealed that she last completed Resident Rights training on January 23, 2025.Review of the facility's Care Completions 2025 PDF file provided via email revealed no evidence that staff #66 had current Resident Rights training.-Regarding Staff #71Review of personnel record for an LPN (staff #71) revealed a hire date of October 9, 2017.A signed job description dated June 8, 2018 indicated that part of the employee's essential job function is to adhere to policies and guidelines of regulatory agencies.The training transcript for staff #71 provided via email revealed that she last completed Resident Rights training on February 13, 2025.Review of the facility's Care Completions 2025 PDF file provided via email revealed no evidence that staff #71 had current Resident Rights training.An interview with the Staffing Coordinator (staff #121) was conducted on August 13, 2026 at 2:36 p.m. Staff #121 stated that employees received training via their online training portal and thru in-service. The Staffing Coordinator said that it is important for staff to complete Resident Rights training so they can be familiar with the rights because staff need to know that it is their job to respect the residents' rights and remember that the facility is the resident's home. The impact of not knowing/being familiar with the resident's rights is that they might end up not respecting the resident's wishes/choices.During an interview with a Licensed Nursing Assistant (LNA/staff #66) conducted on August 13, 2026 at 3:17 p.m., staff #66 stated that staff receive training via an online training portal and via videos. The LNA said that it is important for staff to complete Resident Rights training in order for them to be familiar with those rights and respect them. Staff #66 noted that if the staff member is not trained on resident rights then the staff member could be put in a situation in which the resident refused care/services and the staff member ends up telling the resident that he/she has to do it then force the resident and this would be not respecting the resident's right to refuse.An interview with the Director of Nursing (DON/staff #106) was conducted on August 13, 2026 at 4:38 p.m. Staff #106 stated that her expectation with regards to training is that staff takes the opportunity to get impromptu coaching, be informed, and have the resources to do the job such as staff meetings, huddles. The DON said that it is important for staff to be trained on resident rights so that they can understand that residents have a voice and just because they are healthcare providers does not mean that the resident cannot refuse. That is why staff have to be educated that residents can choose, need to be treated with dignity, and that the staff are there to serve the residents and not tell them what to do. The impact of staff not being educated on resident rights is that it can possibly impact the staff's interaction with residents. If the staff is rusty on what resident rights are,t hey might need a reminder and not realize that it is a resident's right - for example, the use of clothing protector is a choice.The facility policy titled Staff Development and Orientation - Resident Care revised October 2023 outlined the orientation plan, training requirements, and development initiatives for resident care employees. Per the policy, orientation and staff development programs are intended to comply with federal and state regulations related to topics and frequency. The policy indicated that all new and existing staff will receive training on Resident Right and Facility Responsibilities.

Based on documentation, staff interviews, and facility policies the facility failed to ensure that four staff members (#72, #68, #66, & #71) were educated on abuse, neglect, and exploitation and that seven staff members (#73, #72, #68, #67 #66, #71, & #52) received Elder Justice Act (EJA) training. The deficient practice could result in staff not being familiar with the detection, prevention and reporting of abuse, neglect, and exploitation of property.Findings include: -Regarding Staff #72Review of a personnel record for a Maintenance Technician (Maint Tech/staff #72) revealed a hire date of July 23, 2008.The undated training transcript for staff #72 provided via email revealed that he had not completed Abuse, Neglect, and Exploitation training or EJA training. The transcript indicated that he was registered for both training.Review of the facility's Care Center Completions 2025 PDF (Portable Document Format) file provided via email revealed no evidence that staff #72 had current Abuse training and/or EJA training.-Regarding Staff #68Review of a personnel record for a Certified Nursing Assistant (CNA/staff #68) revealed signed job description dated June 24, 2024 which indicated that part of the employee's essential job function was to attend/comply with meetings, mandatory in-services and committee meetings.The training transcript for staff #68 provided via email revealed that she last completed EJA training on July 25, 2024. Per the transcript, she last completed Abuse, Neglect, and Exploitation training on June 4.2025 Review of the facility's Care Center Completions 2025 PDF (Portable Document Format) file provided via email revealed no evidence that staff #68 had current Abuse, Neglect, and Exploitation training and/or EJA training.-Regarding Staff #66Review of a personnel record for a Licensed Nursing Assistant (LNA/staff #66) revealed a hire date of February 14, 2022. A signed job description dated February 25, 2022 indicted that part of the employee's essential job function is to attend/comply with meetings, mandatory in-services, and committee meetings.The training transcript for staff #66 provided via email revealed that she last completed EJA training on January 11, 2025. The transcript also documented that she last completed Abuse, Neglect, and Exploitation training on March 2, 2025.Review of the facility's Care Completions 2025 PDF file provided via email revealed no evidence that staff #66 had current Abuse, Neglect, and Exploitation training and/or EJA training.-Regarding Staff #71Review of a personnel record for an LPN (staff #71) revealed a hire date of October 9, 2017.A signed job description dated June 8, 2018 indicated that part of the employee's essential job function is to adhere to policies and guidelines of regulatory agencies.The training transcript for staff #71 provided via email revealed that she last completed EJA training on January 16, 2025 and Abuse, Neglect, and Exploitation training on March 4, 2025. Review of the facility's Care Completions 2025 PDF file provided via email revealed no evidence that staff #71 had current Abuse, Neglect, and Exploitation training and/or EJA training.-Regarding Staff #73Review of a personnel record for a Rehabilitation Technician revealed a hire date of September 11, 2024.The training transcript for staff #73 provided via email revealed no evidence that staff #73 had completed EJA training.Review of the facility's Care Completions 2025 PDF file provided via email revealed no evidence that staff #73 had current EJA training.-Regarding Staff #67Review of a personnel record for a Licensed Practical Nurse (LPN/staff #67) revealed a hire date of February 12, 2024.A signed job description dated February 12, 2024 indicated that part of the employee's essential job function is to adhere to policies and guidelines of regulatory agencies. Additionally, it noted that employees attends/participates in department meetings, in-services, and committee meetings.The training transcript for staff #67 provided via email revealed that he last completed EJA training on March 2, 2025.Review of the facility's Care Completions 2025 PDF file provided via email revealed no evidence that staff #67 had current EJA training.-Regarding Staff #52Review of personnel record for a Registered Nurse (RN/staff #52) revealed a hire date of July 4, 2023.A signed job description dated July 7, 2023 indicated that part of the employee's essential job function is to attend/participate in meetings, in-services, and committee meetings. The training transcript for staff #52 provided via email revealed that she last completed EJA training on July 24, 2025.Review of the facility's Care Completions 2025 PDF file provided revealed no evidence that staff #52 had current EJA training.An interview with the Staffing Coordinator (staff #121) was conducted on August 13, 2026 at 2:36 p.m. Staff #121 stated that employees received training via their online training portal and thru in-service. The Staffing Coordinator said that it is important for staff to be educated on abuse because this is a huge issue-needs have to be met in the SNF (Skilled Nursing Facility) setting so it is vital to know not to hurt anyone and be reminded about what abuse can look like. The impact of staff not being educated on abuse is that the staff would not be able to show understanding and something could happen that could lead to an allegation which impacts employee and affect the care the residents receive. Staff #121 said that with regards to EJA, staff needs to be educated on it to know how to take care of the elder, their rights, feelings, and be respectful as if these residents are your family members.During an interview with a Licensed Nursing Assistant (LNA/staff #66) conducted on August 13, 2026 at 3:17 p.m., staff #66 stated that staff receive training via an online training portal and via videos. The LNA said that it is important for staff to be educated on abuse because you never know if an allegation is true or not so it is good to get training so you are more educated about it and what signs to look for. Staff #66 said that she is unsure of what an impact could be for not being educated on abuse because for the most part if someone does not know, they can ask someone else. Regarding EJA, she said that staff should be educated on it so that they know what to do and not do and be educated on when abuse happens to report immediately.An interview with the Director of Nursing (DON/staff #106) was conducted on August 13, 2026 at 4:38 p.m. Staff #106 stated that her expectation with regards to training is that staff takes the opportunity to get impromptu coaching, be informed, and have the resources to do the job such as staff meetings, huddles. The DON said that staff should be educated on abuse because they are in a role that is demanding emotionally and physically. Therefore, if they are feeling stressed, they need to know that they cannot respond in a way that is reciprocal to how the resident might be acting. It is also important to be able to recognize abuse in others so they can determine when to report, and ensure that everyone is safe. Staff #106 said that the impact of staff not being educated on abuse is that they could not recognize when they need to say something or not recognize that something is offensive or not appropriate. The DON stated that it is important for staff to be educated on EJA because they are mandatory reporters of abuse, neglect, and misappropriation. Therefore, they need to know what to do to protect the residents who are considered a vulnerable population. The impact of staff not being educated on EJA is that there is a risk that a report is made and it not be followed-up leading to the resident not feeling protected.The facility policy titled Staff Development and Orientation - Resident Care revised October 2023 outlined the orientation plan, training requirements, and development initiatives for resident care employees. Per the policy, orientation and staff development programs are intended to comply with federal and state regulations related to topics and frequency. The policy noted that all new and existing staff will be trained on Abuse, Neglect, and Exploitation, including activities that constitute abuse, neglect, exploitation, and misappropriation of property, reporting of incidents, dementia management, and abuse prevention.

Based on documentation, staff interviews, and facility policies the facility failed to ensure that four staff members (#68, #66, #67, & #71) received Dementia (behavioral health) training. The deficient practice could result in staff not being familiar with and prepared to care for residents exhibiting behavioral symptoms.Findings include:-Regarding Staff #68Review of a personnel record for a Certified Nursing Assistant (CNA/staff #68) revealed signed job description dated June 24, 2024 which indicated that part of the employee's essential job function was to attend/comply with meetings, mandatory in-services and committee meetings.The training transcript for staff #68 provided via email revealed that she last completed Dementia training on June 10, 2025.Review of the facility's Care Center Completions 2025 PDF (Portable Document Format) file provided via email revealed no evidence that staff #68 had current Dementia training.-Regarding Staff #66Review of a personnel record for a Licensed Nursing Assistant (LNA/staff #66) revealed a hire date of February 14, 2022. A signed job description dated February 25, 2022 indicted that part of the employee's essential job function is to attend/comply with meetings, mandatory in-services, and committee meetings.The training transcript for staff #66 provided via email revealed that she last completed Dementia training on January 15, 2025.Review of the facility's Care Completions 2025 PDF file provided via email revealed no evidence that staff #66 had current Dementia training.-Regarding Staff #67Review of a personnel record for a Licensed Practical Nurse (LPN/staff #67) revealed a hire date of February 12, 2024.A signed job description dated February 12, 2024 indicated that part of the employee's essential job function is to adhere to policies and guidelines of regulatory agencies. Additionally, it noted that employees attends/participates in department meetings, in-services, and committee meetings.The training transcript for staff #67 provided via email revealed that he last completed Dementia training on April 15, 2025.Review of the facility's Care Completions 2025 PDF file provided via email revealed no evidence that staff #67 had current Dementia training.-Regarding Staff #71Review of personnel record for an LPN (staff #71) revealed a hire date of October 9, 2017.A signed job description dated June 8, 2018 indicated that part of the employee's essential job function is to adhere to policies and guidelines of regulatory agencies.The training transcript for staff #71 provided via email revealed that she last completed Dementia training on March 4, 2025.Review of the facility's Care Completions 2025 PDF file provided via email revealed no evidence that staff #71 had current Dementia training.An interview with the Staffing Coordinator (staff #121) was conducted on August 13, 2026 at 2:36 p.m. Staff #121 stated that employees received training via their online training portal and thru in-service. The Staffing Coordinator said that it is important for staff to be educated on dementia so that they can learn the difference in behavior of a resident that is sundowning, why residents get upset, and that they resident can confuse you for their child. The impact of not being educated on dementia is that the staff could go in blink talking to a resident and not know how to communicate with him/her.During an interview with a Licensed Nursing Assistant (LNA/staff #66) conducted on August 13, 2026 at 3:17 p.m., staff #66 stated that staff receive training via an online training portal and via videos. The LNA said that it is important for staff to be educated on dementia because some of their residents have dementia and you need to know how to talk to them. The impact of staff not being educated on dementia is that the staff can say something and it not be taken the right way. For example, you go to a resident's room super happy or loud and that resident might not like it. But if you give the resident attitude or with a look on your face the situation could escalate.An interview with the Director of Nursing (DON/staff #106) was conducted on August 13, 2026 at 4:38 p.m. Staff #106 stated that her expectation with regards to training is that staff takes the opportunity to get impromptu coaching, be informed, and have the resources to do the job such as staff meetings, huddles. The DON said that it is important for staff to be educated on behavior health (dementia) because some people have dementia with behaviors so it takes a special person to handle that well. Staff need to have training because everyone is human. However, you cannot be offended and respond in a way that is reciprocal-you have to stay calm and not argue even though the arguing is what is human nature. The impact of staff not being educated on behavioral health is that the staff member will not understand and follow plan of care to meet the needs of the resident who is already anxious and instead made the resident feel worst.The facility policy titled Staff Development and Orientation - Resident Care revised October 2023 outlined the orientation plan, training requirements, and development initiatives for resident care employees. Per the policy, orientation and staff development programs are intended to comply with federal and state regulations related to topics and frequency. The policy indicated that employees receive staff development routinely on dementia and dementia care.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that advance directives were completed and maintained for one sampled resident (#11). The deficient practice could result in residents not receiving proper care according to their preferences or potential harm to the resident's life. Findings include:Resident #11 was admitted to the facility on [DATE], with a diagnosis that included Lymphocytic colitis, abnormalities of gait and mobility, and dementia.An active physician's order dated February 17, 2026, indicated the resident's Code Status as Do Not Resuscitate (DNR) without a hold or end date.A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment.A Care Plan date revised August 10, 2026, revealed a full code status. Interventions included reviewing advanced directives at the care conference or as needed and updating the face sheet and Interdisciplinary team with changes to advanced directives.An observation was made on August 11, 2026, at 2:42 pm of the resident medical chart, revealing a Pre-Hospital Do Not Resuscitate (DNR) form, with a line drawn across the document and above the line was written the term Full Code.Review of the resident face sheet stated resident #11's directive was Do Not Resuscitate (DNR) and that the copy was on file.A State of Arizona Durable Health Care Power of Attorney (POA) form dated July 2, 2018, revealed the resident indicated, I do not want my representative to make the following health care decisions for me: level one behavioral health facility; cardiopulmonary resuscitation CPR; ventilator; artificially administered food or fluids. Further review of the POA form revealed a checked mark indicating that the resident had not signed a prehospital medical care directive or Do Not Resuscitate Directive. An interview was conducted on August 13, 2026, at 2:21 p.m. with Registered Nurse (RN/Staff #118). Staff #118 stated the facility process for confirming a resident's code status is to look in the resident's chart and in the resident's electronic health record for the orange copy that would be in the advance directives. Staff #118 stated that if they did not have proof that the resident is a DNR the they would have no choice but to initiate a full code. Staff #118 stated the risks of having inaccurate documentation regarding a resident's code status is the resident's wishes would not be honored and would go against what they had in place, but with no proof, staff would have no choice but to initiate a full code.An interview was conducted on August 13, 2026, at 2:58 p.m. with contracted staff Licensed Practical Nurse (Staff/LPN #56). The LPN stated that to confirm a resident's code status, she would first look in the medication administration record and the physician's orders in the resident's chart. She stated she would also need to confirm with a signed and dated orange form. The LPN reviewed the resident's electronic chart stating the resident had DNR orders effective February 17, 2026. She further reviewed the EHR for the resident's prehospital medical care directive. Staff #56 stated, I am observing a crossed-out form that says full code. She stated that she would have to go off the form that says full code because that is what it says, and stated there were no additional advance directives in the resident's chart. Staff #56 stated it was a major risk to go against the resident's wishes and stated. You are saving someone that does not want to be saved. An interview was conducted on August 13, 2026, at 3:10 p.m. with Registered Nurse (RN/Staff #85). Staff# 85 stated the facility keeps copies of the resident's code status in their physical chart, and a copy is also in the resident's electronic chart for easy access. Staff#85 retrieved the physical chart, which had several copies of the resident's prehospital form for his DNR status. She further reviewed the resident's electronic chart, observing the prehospital form that was crossed out with the term full code written across the form. She stated the form was incorrect and presented faulty information. She stated the risk of having incorrect information in the resident's chart is that staff may perform CPR on a resident who did not want it. An interview was conducted on August 13, 2026, at 3:22 p.m. with the Director of Nursing (DON/Staff #106). The DON stated the DNR forms are kept in both the resident's physical and electronic charts under the advanced directives tab. She stated a DNR required a signed advance directive and a physician's order and ideally have them readily available. The DON reviewed resident #11's electronic chart, noting the crossed-out prehospital medical care directive form with 'Full Code written across the form. She stated it was poor documentation and could place the resident at risk by providing care that is not desired. She stated the nurses are responsible for updating the resident's code status if there is a change in status. She stated they would scan the new form and it would be uploaded in the electronic chart. A review of the facility policy titled DNR - Do Not Resuscitate Protocol Revised: November 2011 states 2.2. Do Not Resuscitate or advance directive status will be documented in writing for patients that meet the criteria for this decision.

Based on observations, staff and resident interviews, and policy review, the facility failed to provide safe and secure medication storage for one resident (#4), whose medications were left at the bedside. The deficient practice could result in harm to the residents and/or visitors who have access to medications.Findings include:Resident #4 was admitted to the facility on [DATE], with diagnoses that included primary open-angle glaucoma, right eye, right eye corneal transplant status, lack of coordination, and muscle weakness. An active physician order, start date July 15, 2026 written for prednisolone acetate drops, suspension; 1 %, 1 drop, ophthalmic (eye). A care plan revised on July 16, 2026 revealed a problem area for impaired vision related to Glaucoma. Interventions included administering drugs as ordered at appropriate times and in appropriate order.A Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13, which indicated the resident's cognition was intact. The resident's electronic health record (EHR) revealed no assessments for self-administration.During initial screening and observation conducted on August 11, 2026, at 11:15 a.m. in resident #4's room, a small bottle of Prednisolone acetate sterile ophthalmic suspension 1%, 5ml was observed on the resident's bedside table. An interview was conducted on August 11, 2026, at 11:15 a.m. with resident #4. She stated she took her own eye drops as needed and that the staff also gave her eye drops from a bottle with a pink cap. The resident stated she liked to keep them on her table where she can reach them and has had the eye drops for a while. An interview was conducted on August 11, 2026, at 11:35 a.m. with Registered Nurse (RN/Staff#52). She stated that one of the nurses had informed her that the resident was particular about the use of her eye drops and prefered to use eye drops from Walgreens, which were the same eye drops that were prescribed for her at the facility. She stated she was unaware that the resident had the medicated eye drops at her bedside. The risk of having them at her bedside could lead to double-dosing her medication and overdose on the prednisone contained in the eye drops. Staff #52 stated all medications should be locked on the medication cart and administered as ordered. She then educated the resident regarding medications in her room and informed the resident she would be removing the medications and placing them in her med cart.An interview was conducted on August 11, 2026, at 3:32 p.m. with the Director of Nursing (DON/Staff#106). She stated that no resident should have any medications at the bedside and that the facility has a process for self-administration. She stated a resident must be assessed to determine if a resident is capable of self-administering their own medications, proper storage of the medications, and that resident #4 had not been assessed for medication self-administration. She stated the risks of having medications at the bedside is the resident was not monitored and could take the wrong dosage, or another resident could take the medication. Review of the facility policy titled Medication/Treatment Management Protocol - SN, Revised: October 2023. States Residents will have medications administered per orders from their healthcare provider with prescriptive authority.1. If a resident verbalizes the desire to self-administer medication, the resident is assessed using the Self-Administration of Medication assessment tool upon admission or when the request for self-administration is made.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure resident safety was provided in accordance with professional standards of practice regarding the use of a gait belt during transfer of one resident #23. The deficient practice could result in further injury of residents based on their physical needs. Findings Include: Resident #23 was admitted on [DATE] with diagnosis including displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, adult failure to thrive, anxiety disorder, unspecified, muscle weakness (generalized), difficulty in walking, not elsewhere classified. The MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview for mental status) score of 15, suggesting intact cognitive abilities, no indicators for mood or behaviors were identified. Further review of the MDS identified substantial to maximal assistance for toileting, partial to moderate assistance rolling left to right, sit to lying, bed to chair to bed transfers and lying to sitting on side of the bed. A review of the physician's orders dated April 2, 2024 included an order for use of siderails as enablers for assistance with transfers, bed mobility and aid in positioning related to diagnosis of weakness related to femur fracture. Review of the care plan-initiated on August 5, 2024 included that resident #23 had a right femur fracture this year that still caused her some discomfort and she has chronic pain and was at risk for fall due to debility from recent illness, new surroundings, advancing age with comorbidities, polypharmacy, poor balance, impaired gait, and weakness. Interventions included to handle gently and try to eliminate any environmental stimuli, position for comfort with physical support as necessary and staff to cares in pairs whenever possible. A review of the physician progress notes dated August 12, 2024 revealed that the resident #23 felt tired that day and was visited by her son. The note further stated that per the staff and son, there had been issues with the resident's care by CNA (Certified Nursing Assistant). The note stated that was being further evaluated by the team, supportive measures were being provided, escalation of opiate dosing was offered and the resident stated she will discuss further with her son. The social services progress note revealed resident #23's son informed social services of a claim presented to him by his mother's caregiver that the facility's nurse's aide was rough when helping his mother back to bed on 8/11/24 and his mother referred to the aide as aggressive. An interview was conducted on July 21, 2023 at 1:33 p.m. with resident # 23 who stated CNA (Staff #198) had assisted her to the bathroom and to bed. Resident stated while transferring her to bed Staff#198 caused her pain in both her upper legs and to her right hip. The resident stated staff #198 had placed her wheelchair by the side of her bed and had the resident place her arms around her waist lifting her and sitting her on the side of the bed. The resident stated when the staff then raised both her legs and swung her into the bed real fast and abrupt. The resident stated the move caused her pain in both her legs and hip and caused her to fall backwards on the bed. Resident #23 stated she did not know staff#198 was going to swing her legs on to the bed without warning. The resident denied being grabbed by the wrist at any time, but did state no gait belt was used with either transfer to the bathroom or while placing in bed. An interview was conducted with the CNA (Staff #198) on August 20, 2024 at 12:45 p.m. Staff #198 stated she has been employed with the facility for three years and stated she had received abuse training approximately one year ago. Staff #198 stated she worked the night shift on August 11, 2024 and was assigned to resident #23. She stated the resident had her call light on and went to her room to assist her to the bathroom. She stated the resident's personal caregiver was in the room with the resident and went into the bathroom while assisting the resident to the toilet. She stated the resident pulled herself up to the side rails and she assisted with pulling down her brief. Staff #198 stated when the resident was done, she changed her brief and assisted her with incontinence care. She said she then had the resident sit back in the wheelchair and parked it beside her bed. She stated she had the resident place her arms around her waist, because she did not have a gait belt with her. She said she stood the resident and had her sit on the side of the bed. She stated the resident was taller and heavier than her and found it difficult. She stated she lifted both of the resident's legs into the bed. She again stated she struggled because she found the residents legs to be heavy. She stated she was unable to support the resident's back when placing the resident's legs in the bed, because she is shorter than the resident. Staff # 198 stated she did not ask for help with transferring the resident because we were short staffed. She stated she then placed pillows under the resident's legs and the resident was able to position her upper body herself with no complaints of pain from the resident following the transfer. An interview was conducted on August 20, 2024 at 1:44 p.m. with the Director of Nursing (DON/staff #87). Staff #87 stated it is her expectation that for proper transferring, staff always use a gait belt for safety, and follow therapy recommendations. Staff #87 stated she is aware that resident #23 is care planned for safety and impulsivity due to what appears to be sundowning and has a personal caregiver from 7pm to 7am daily. Review of the facility policy revised October 2017 titled Gait Belts states This policy defines when gait belts are used in the care of residents in the licensed care venue. A gait belt is used to facilitate safety in transferrin or ambulating residents who have difficulty with mobility, unless its use is contraindicated.

Based on observation, staff interviews, and review of facility documentation, the facility failed to ensure one resident's (#27) oxygen tubing was safely secured. The deficient practice could result in a preventable accident. Findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia, gastro-esophageal reflux disease without esophagitis, and chronic obstructive pulmonary disease. Review of the MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 11 indicating moderate cognitive impairment. A care plan dated 09/28/2023 revealed resident was at risk for incontinence due to advanced aging process, new surroundings, debility related to activity intolerance and weakness complicated by acute on chronic respiratory failure. Interventions included to assist and offer to toilet frequently and as needed and encourage independence. The care plan also revealed resident was in need of assistance with self-mobility and functional tasks due to debility from recent illness, advancing age with comorbidities and interventions included 1/4 side rails to bedside as appropriate to encourage/foster mobility independence. The physician order report revealed an order dated 11/15/2023 for oxygen at 2 liters (L) to 4 L via nasal cannula for diagnosis of chronic obstructive pulmonary disease. An observation was conducted on 02/21/2024 at 10:13 A.M. The oxygen concentrator inside the resident's room was located between the door to the hallway and the door to the bathroom. The bathroom was located between the concentrator and the resident's bed. The resident was observed wearing the nasal cannula and the oxygen tubing connected to the oxygen concentrator was placed above the bathroom door frame with the bathroom door open. A follow up observation on 02/22/2024 at 11:37 A.M. revealed the oxygen tubing connected to an oxygen concentrator remained above the door frame of the bathroom door. Review of the progress note dated 01/20/2024 revealed resident was on continuous oxygen via nasal cannula at 3 L and displayed shortness of breath with minimal exertion. The note on 2/14/2024 revealed resident reported feeling like he can't get air. On 2/20/2024 in was noted that resident reported increased dyspnea. An interview was conducted with Licensed Practical Nurse (LPN\staff #280) on 02/23/2024 at 9:47 A.M. at which time she observed the oxygen tubing over the resident's bathroom door, staff #280 stated that maintenance/engineering fixed it that way to prevent resident from tripping and keeping it out of the way. Staff #280 stated it needed a top right corner bracket to keep the door from closing and clamping the tubing. During the interview, staff #280 opened and closed the door several times and the tubing fell in between the door and the door frame. The LPN started to close the door but stopped just before the door clamped the tubing which she acknowledged would prevent the resident from receiving oxygen. In an interview with the Director of Nursing (DON) on 02/23/2024 at 10:05 A.M. she stated that the facility used oxygen tubing clips above the doorway, that it was standard procedure so residents do not trip over their door. When the DON was informed of resident #27's oxygen tubing she stated she did not see it because maintenance had already added another bracket to secure the tubing.

Based on observations, clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure one sampled resident (#25) received treatment and care in accordance with professional standards of practice, by failing to ensure interventions were implemented as ordered by the physician. The deficient practice could result in skin breakdown. Findings include: Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated on March 30, 2021 revealed the resident was at risk for skin breakdown related to impaired mobility from a history of a right ankle fracture. The goal was that the resident's skin would remain intact. Interventions included an APP (Alternating Pressure Pad) mattress to the bed to maintain skin integrity. Review of the physician order dated April 8, 2021 revealed for an APP mattress for skin integrity, check proper functioning every shift related to skin integrity. A physician order dated May 25, 2021 included for a heel protector to the right heel when in bed related to the wound to the right heel. A skin integrity care plan initiated on September 2, 2021 revealed the resident had infection to a right ankle wound. Interventions included antibiotic as ordered and daily dressing change to the wound on the right ankle. Review of a quarterly Minimum Data Set assessment dated [DATE], included a Brief Interview for Mental Status score of 00, indicating the resident had severe cognitive impairment. The assessment included the resident was at risk of developing pressure ulcers, had a surgical wound, surgical wound care, and a pressure relieving device for the bed. Review of the Treatment Assessment Record (TAR) for November 2021 revealed nursing documentation that the APP had been checked for proper functioning every shift on November 8 and 9, 2021 between 7:00 AM and 11:00 AM. Further review of the November 2021 TAR revealed documentation that the heel protector had been applied to the right heel when the resident was in bed on November 8, 2021 from 7:00 AM to 11:00 AM. An observation was conducted on November 8, 2021 at 9:12 AM. The resident was observed sitting in a wheelchair, and an APP mattress was on the bed that was not plugged into the wall outlet and one black wire was hanging off the APP console. Further observations were conducted on November 8, 2021 at 11:41 AM and 2:33 PM, in which the resident was observed lying in bed with no heel protector applied to the right foot, and the APP mattress was not plugged into the wall outlet, with one black wire hanging from the APP console. Several observations were conducted on November 9, 2021 at 9:20 AM, 1:14 PM and 1:25 PM, which the resident was observed to be lying in bed with the APP not plugged into the wall outlet, with a black wire hanging loose from the APP console, and the heel protector not applied to the right heel. An interview was conducted on November 9, 2021 at 10:10 AM with a Certified Nursing Assistant (CNA/staff #51), who stated that when the resident is lying in bed, she needs to make sure the bed is low and fall mats are in place. She also stated that nothing needs to be placed on the resident's feet when the resident is in bed. She stated that the resident used to wear a bootie, but that was discontinued. The CNA further stated that right now the resident has a regular mattress on the bed and does not have a mechanical mattress. An interview was conducted on November 9, 2021 at 11:00 AM with a Registered Nurse (RN/staff #59), who stated that the air mattress is on the care plan and should be operational when the resident is in bed. She also stated that the resident should wear a boot during the day, but she has not seen it lately. An interview was conducted on November 9, 2021 at 1:37 PM with an RN (staff #53), who stated that the facility policy is to follow the physician orders as written, including pressure relieving devices. She reviewed the physician's orders and stated that there is a current order for APP mattress check, to make sure that it is working properly on each shift. She further reviewed the physician's orders and stated there is also a current order for a heel protector to the right heel while in bed. The RN stated that per facility policy, she would expect that the resident would have a heel protector applied and an APP mattress while in bed. The RN then reviewed the progress notes dated November 1, 2021 and November 8, 2021 and did not see any documentation that the resident had refused application of the heel protector or APP mattress. Immediately after the interview, an observation was conducted with the RN (staff #53) of the resident in her room. The RN stated that the resident was lying in the bed and was not wearing the heel protector, that the APP mattress was not plugged into the wall outlet, and that this did not meet physician's orders. The RN then plugged the APP plug into the wall outlet, and the device did not start, she then stated that there was a black wire loose from the connector. She further stated that the APP mattress is non-operational at this time. The RN reported status of the non-operational APP mattress to maintenance. An interview was conducted on November 9, 2021 at 1:59 PM with the Lead CNA (staff #47), who stated that the CNAs should report to him or the nurse if an APP mattress is not operating. He also stated that no one had reported that the resident's APP mattress was not working. He then checked the APP mattress and stated that it was non-operational and that he will make a call to replace the mattress. An interview was conducted on November 10, 2021 at 9:04 AM with the Director of Nursing (DON/staff #18), who stated that if there is an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated that this would also include heel protectors. The DON stated that she had reviewed the medical record and that there were physician's orders for a heel protector and APP mattress. She further stated that the order for a heel protector has now been discontinued. The DON also stated that the risk of not utilizing pressure relief as ordered could result in the development of an injury. A review of the facility policy titled, Medication/Treatment Management Protocol, revealed that residents will have medications administered per orders from their healthcare provider with prescriptive authority. The Treatment Administration Record (TAR) is also a component of the electronic documentation system. When a medication/treatment is not given as ordered, the following items are documented in the medical record: Reason medication/treatment was not given as ordered; Notification of prescribing healthcare provider with prescriptive authority (if needed) and his or her response; and any outcome related to the medication/treatment not being given as prescribed. Treatments are documented in the electronic Treatment Administration Record (TAR) in eMAR by the person administering the treatment. A review of the facility policy titled, Pressure Injury Prevention & Treatment Protocol, revealed risk factors that increase the resident's susceptibility to develop pressure injuries that included impaired/decreased mobility, co-morbid conditions, and cognitive impairment. Document treatment type and frequency in the Treatment Administration Record (TAR). Utilize heel protectors, special positioning devices and specialty beds, as appropriate. Monitor that medical devices being used do not cause impairment of circulation to surrounding tissues. Create and implement a care plan for the resident, reevaluate the plan of care at least quarterly and as needed.

Based on observation, staff interviews, and policy and procedures, the facility failed to ensure infection control standards were maintained regarding glucometers. The facility census was 33. The deficient practice could result in transmission of infection. Findings include: A medication administration observation was conducted on November 9, 2021 at 7:00 AM with a Licensed Practical Nurse (LPN/staff #57). Two glucometers were observed sitting on a paper towel, on the top of the medication cart. The LPN was observed to check a resident's blood glucose level and place the glucometer back into the medication cart without disinfecting the glucometer. The nurse was then observed to take the second glucometer into another resident room and check the resident's blood glucose level. After this procedure she placed the glucometer in the medication cart, without disinfecting it. An interview was immediately conducted with staff #57 who stated that she had used both glucometers and that she did not disinfect them after use. She further stated that she thought the facility policy was to clean glucometers prior to use for blood glucose checks, not after use. An interview was conducted with the Assistant Director of Nursing (ADON/staff #17) on November 9, 2021 at 11:35 AM, who stated that the process for glucometer cleaning is to disinfect after each use, not before. She stated that she had just used the glucometer and did not clean it prior to use, and that she had disinfected it after use with an alcohol wipe. An interview was conducted on November 10, 2021 at 9:04 AM with the Director of Nursing (DON/staff #18), who stated that the facility policy for glucometer care is to clean the glucometer after each use. She stated that if a glucometer is not disinfected after use, it would not be following facility expectations. The DON further stated that the facility policy is to clean all glucometers with disinfectant wipes, not alcohol wipes. She stated that if the glucometers were not cleaned after each use, or with approved disinfectants, it could result in the risk for infection. A review of the facility policy titled, Glucometer Quality Control Testing and Cleaning, revealed that cleansing the glucometer routinely is completed for infection control purposes. The glucometer and fingerstick device are disinfected after each use using the PDI Super Sani Cloth or Sani Cloth Plus or other approved cleaner noted in the manufacturer's guidelines.

Based on observations, staff interviews, facility documentation, and policy review, the facility failed to ensure that food stored in one refrigerator was in accordance with professional standards for food service safety. The deficient practice could place residents at risk for foodborne illness. Findings include: During an initial observation of the kitchen conducted on 8/26/2019 at 7:30 AM with a cook (staff #100), the thermometer on the outside of the refrigerator displayed 54 degrees Fahrenheit (F). Inside the refrigerator were various food items including milk, yogurt, and juice. No internal thermometer was located inside of the refrigerator and staff #100 was also unable to locate a thermometer inside the refrigerator. Staff #100 stated that the refrigerator temperature for that morning is recorded on the Monthly Temperature Log. Review of the Monthly Temperature Log for (MONTH) 2019 revealed the refrigerator temperature on 8/26/2019 at 7:15 AM was 45 degrees F. The log included the Critical Limit (CL) for refrigerators were up to 41 degrees F and that if the temperature registers above the CL, retake the temperature in one hour. The log also included that if the temperature again registers above the CL, immediately notify the manager, assess product integrity by taking temperatures, and initiate product removal/relocation procedure. No corrective action was recorded on the log for the 45 degree F refrigerator temperature. During an observation conducted on 8/28/19 at 11:45 AM of the same refrigerator, the external thermometer had a reading of 55 degrees F. This time, a thermometer inside of the refrigerator was observed and had a reading of 44 degrees F. The refrigerator contained various food items including milk and yogurt. The Registered Dietary Consultant (staff #117) removed two random milk cartons from the refrigerator and took the temperature of the milk. The milk temperature was 48 degrees F. The Nutrition Services Manager (Staff #95) removed one container of yogurt and checked the yogurt temperature. The yogurt temperature was 53 degrees F. The Monthly Temperature Log for (MONTH) 2019 revealed the refrigerator temperature on 8/28/2019 at 6:30 AM was 35 degrees F. Continued review of the log revealed the temperature of 45 degrees F on 8/26/2019 at 7:15 AM, now had a zero written over the 5. The log now reflects a temperature of 40 degrees F at 7:15 AM on 8/26/2019 instead of 45 degrees F. An Interview was conducted on 8/28/2019 at 12:58 PM with staff #117 and staff #95. Staff #95 stated the temperatures for the refrigerators are recorded twice a day. She stated that she checks the logs a couple of times a day. Staff #95 stated that if a temperature is out of range, she shuts the door for 30 minutes and rechecks the temperature. She said if it is still out of range, the door is kept shut for another 30 minutes. She stated that if the temperature is still out of range after an hour, the refrigerator is shut down and all services out of that refrigerator are stopped. Staff #95 stated that if the refrigerator still did not hold the correct temperature she would put a work order in, remove all products, and use everything out of main kitchen refrigerator. After the refrigerator has been repaired, she stated that she would ensure the temperature is back in range for 24 hours before using the refrigerator. She also stated that she looks at the refrigerator outside temperature reading to see if it matches with the internal temperature reading. Staff #95 stated that the changes to the (MONTH) 2019 Monthly Temperature Log for (MONTH) 26, 2019 at 7: 15 AM was made after the staff rechecked the refrigerator and that they should have documented what corrective action was taken. Review of facility's policy regarding Refrigerator Management revealed refrigerator temperatures are maintained at 41 degrees Fahrenheit or less. Temperatures are documented on the Hazard Analysis and Critical Control Points (HACCP) Temperature Log. If the temperatures fall out of recommended range, adjust the thermostat slightly and re-check every 30 minutes for one hour until temperature is within range. If unable to reach/maintain recommended temperature, a work request for repair is filled out and the Supervisor is notified. If temperature cannot be reached and/or maintained, items should be removed from the refrigerator and placed in a properly functioning refrigerator.

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#19) was treated with dignity and respect. The deficient practice could result in residents experiencing a negative psychosocial outcome and decrease in quality of life. Findings include: Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the care plan with a start date 5/13/2019 revealed the resident had a self-care and mobility deficit. The goal was that the resident will maintain/improve functional level. Intervention included assisting as needed and that the resident bed is placed against the wall per his choice for a sense of space. A nursing progress noted dated 5/14/2019 stated the resident has private caregiver(s) at bedside at all times. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) assessment had a summary score of 2, indicating the resident had severely impaired cognition. The assessment also included the resident was totally dependent for bed mobility and personal hygiene. An observation was conducted of the resident's room on 8/26/2019 at 7:40 AM from the hallway. The resident's room door was open and the bed was observed close to the center of the room. A private caregiver was providing care. The resident was observed lying on his left side with his backside towards the room entrance wearing a brief. During an observation conducted on 8/26/2019 at 10:38 AM across the hall from the resident's room, multiple staff members and visitors were observed passing by the resident's room. The resident's room door was opened and the resident was observed uncovered wearing a brief. Another observation was conducted of the resident's room from the hallway on 8/26/2019 at 11:45 AM. The resident's room door was ajar. The resident was observed lying in bed, exposed from his hips to his lower legs wearing a brief. A caregiver was observed inside the room assisting the resident. An interview was conducted on 08/27/19 at 9:45 AM with a Certified Nursing Assistant (CNA/staff #41). The CNA stated that he always provides privacy during private care, including shutting the door if the resident is exposed. An interview was conducted on 08/27/19 at 10:05 AM with a Registered Nurse (RN/staff #77). The RN stated that she shuts a resident's room door when providing private care. She stated that if she sees a caregiver or staff member not providing privacy for a resident, she pulls them aside and explains how to provide dignity to the resident. The RN stated dignity includes having the door shut to protect the resident's privacy which keeps other residents and guests from looking into the room. During an interview conducted with the Director of Nursing (DON/staff #91) on 8/28/2019 at 7:55 AM, she stated that resident #19 has a private caregiver 24 hours a day. The DON stated the resident's dignity and privacy is 100% the responsibility of the facility. She also stated that she had never seen the resident exposed. An interview was conducted on 8/28/2019 at 2:07 PM with the resident's family member, the DON, and the CNA (staff #41). Both the family member and CNA stated that the resident's room door was open and the resident was exposed because he was very hot. The CNA #41 stated that the resident is hot and then cold and that family and staff remove and add sheets or blankets as needed. The resident's family member confirmed that on 8/26/2019, the sheets had been removed because the resident was hot. The DON stated that with the bed in the middle of the room and the door open, she observed that the resident can be observed exposed from the hallway. Review of the facility's policy regarding Residents' Privacy and Confidentiality revised (MONTH) 2014, revealed the facility protects the rights of all residents, and is committed to treating residents with respect, [MEDICATION NAME], and dignity. The policy included that consistent with applicable laws and regulations, the facility expects each employee to protect residents' rights to privacy and confidentiality at all times.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one of two sampled residents (#4) was free from unnecessary drugs, by failing to administer drugs according to the physician ordered parameters. The deficient practice could result in low blood pressures and residents receiving drugs which may not be necessary. Findings include: Resident #4 was admitted to the facility on (MONTH) 6, 2019, with [DIAGNOSES REDACTED]. Review of the care plan dated (MONTH) 10, 2019 for Activities of Daily Living Function/Rehabilitation revealed the resident was at risk for decreased cardiac output related to increase blood pressure. The goal was that the resident's blood pressure will be maintained within acceptable range. Interventions included administering medications as ordered, and monitoring vital signs per orders and as needed. A physician's orders [REDACTED]. The Medication Administration Record [REDACTED] - on (MONTH) 11: The resident had a pulse of 53 - on (MONTH) 25: The resident had a pulse of 52 - on (MONTH) 3: The resident had a pulse of 52 - on (MONTH) 4: The resident had a pulse of 50 - on (MONTH) 27: The resident had a pulse of 50 An interview was conducted on (MONTH) 28, 2019 at 12:09 PM with a Registered Nurse (RN/staff #77). The RN stated that when giving hypertensive medications, parameters are checked before the medication is given. She stated that with parameters to hold [MEDICATION NAME] for systolic blood pressure under 110, a diastolic blood pressure under 55, and a pulse under 55, the medication should be held for any one of the three parameters. After reviewing the MAR, staff #77 stated that this medication was given in error. An interview was conducted on (MONTH) 28, 2019 at 02:05 PM with the Director of Nursing (DON/staff #91). The DON stated that for all medications, she would expect the nurses to follow the orders including any parameters ordered. She stated that she would expect the nurses to hold the medication [MEDICATION NAME] for any one of the three ordered parameters. After reviewing the clinical record, the DON stated that this medication was given in error. Review of the facility's policy for Medication/Treatment Management revealed that medications require an order from a healthcare provider with prescriptive authority. Documentation and monitored parameters, e.g., taking of vital signs, documenting that a medication has been given or held, or any other documentation regarding medication administration is completed in a timely manner prior to or after the medication or treatment has been provided (depending on the type of documentation). It also stated that if for any reason a medication/treatment order cannot be followed or the resident refuses a medication or treatment that has been prescribed, the healthcare provider with the prescriptive authority is notified as soon as is reasonable, depending on the situation. The policy included the reason the medication/treatment order was not carried out is documented in their eMAR record.

Based on clinical record reviews, staff interviews and review of policy and procedures, the facility failed to ensure that as needed pain medications were administered per the physician orders [REDACTED].#15 and #223). Findings include: -Resident #223 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. According to the (MONTH) and (MONTH) (YEAR) Medication Administration Records (MAR) revealed the above orders. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The MAR indicated [REDACTED]. -Resident #15 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A baseline care plan dated (MONTH) 21, (YEAR) identified the resident had a potential for pain. An intervention included to administer medications as ordered. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. An interview was conducted with two Licensed Practical Nurses (staff #54 and staff #104) on (MONTH) 10, (YEAR) at 10:40 AM. Both nurses stated they would administer pain medication based on what was ordered for the resident's level of pain. An interview was conducted with the Assistant Director of Nursing (staff #16) on (MONTH) 10, (YEAR) at 12:10 PM. She stated that PRN pain medication should be administered based on what was ordered by the physician for the specific level of pain. A review of the facility's pain management protocol revealed that pain medications should be administered as ordered, according to the 0-10 pain scale.

Based on clinical record review, staff interviews and review of the RAI (Resident Assessment Instrument) manual, the facility failed to ensure that a Significant Change in Status MDS (Minimum Data Set) assessment was completed for one resident (#6), within the required timeframe. Findings include: Resident #6 was readmitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. An occupational therapy note dated (MONTH) 16, (YEAR) included the resident had been on hospice previously, and was now on Medicare A services. A nursing progress note dated (MONTH) 18, (YEAR) included the resident returned to the facility without hospice services and was on Medicare A benefit. Review of an admission MDS assessment dated (MONTH) 22, (YEAR), revealed in Section O-Special Treatments, Procedures and Programs that hospice was coded, while not a resident of the facility. A social services note dated (MONTH) 31, (YEAR) stated the physician was contacted related to a review for the resident's return to hospice services. Per the documentation, the last covered day would be (MONTH) 4, (YEAR) and hospice will evaluate and treat as soon as (MONTH) 5, (YEAR). Review of a physician's progress note dated (MONTH) 31, (YEAR) revealed the resident's family opted for comfort care and a referral to hospice was initiated. A physician's orders [REDACTED]. A nursing note dated (MONTH) 6, (YEAR) revealed that the resident was evaluated and will be followed by hospice. A nursing note dated (MONTH) 10, (YEAR) included the resident was recently readmitted to hospice services. A care plan was initiated on (MONTH) 10, (YEAR) and included that the resident was currently receiving hospice services. A physician's note dated (MONTH) 22, (YEAR) included the resident was back on hospice after a gap to care for the resident's [MEDICAL CONDITION]. The note included that the plan was for the resident to remain on hospice for supportive care. Despite documentation that the resident was receiving hospice services, there was no evidence that a Significant Change in Status Assessment (SCSA) was completed within 14 calendar days, after determination that a significant change in the resident's status occurred. In an interview with the MDS Coordinator (staff #71) conducted on (MONTH) 10, (YEAR) at 11:48 a.m., she stated when a hospice order is written, a Significant Change MDS assessment will be triggered and completed, within 14 days of when the resident signed on hospice. She stated that she had missed the physician's orders [REDACTED]. Further, she stated that she uses the RAI manual for guidance in coding the MDS. During an interview with the Assistant Director of Nursing (ADON/staff #16) conducted on (MONTH) 10, (YEAR) at 12:10 p.m., she stated that the MDS coordinator (staff #71) is to ensure that resident assessments are accurate. Review of the RAI manual revealed to code residents as being in a hospice program for the palliation and management of terminal illness and related conditions. The manual also included that it is a CMS requirement to have a SCSA completed every time the hospice benefit has been elected, even if a recent MDS was done and the only change is the election of the hospice benefit. Further, the RAI manual included that a SCSA must be completed on the 14th calendar day after determination that a significant change in resident's status occurred.