Every finding on record at VI at Silverstone, A VI and Plaza Companies Commun

Number of residents sampled: 2 Number of residents cited: 2 Based on observation, staff interviews, clinical record review, review of facility's documents and policy, the facility failed to ensure that its medication error rate was not greater than 5 percent. Observed 2 medication errors out of 25 which resulted in an 8 percent error rate. The deficient practice could result in residents receiving medications inappropriately and could place the residents at risk for health illnesses. Findings include: -Regarding Resident #1: Resident #1 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease, dementia, anxiety, atrial fibrillation (irregular heart rate), dysphagia, and cognitive communication deficit. The Resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3.0, indicating that the Resident was severely impaired. The assessment also revealed that the Resident did not have a swallowing disorder. A review of the Resident's care plan initiated on 07/17/2025, revealed a medication regimen for potential for adverse drug effects or interactions related to use of bronchodilator, anticoagulant, antihistamine, diuretic, antihypertensive, and laxative medications; and the Resident has a history of atrial fibrillation. The goal was for the Resident to take her medications as ordered and will be free of drug interactions daily. The interventions included to administer medications as ordered, notify the provider as needed, the pharmacist to review medications routinely and as needed, and observe for any potential side effects. A review of the physician orders revealed an order for: Metoprolol Succinate Extended Release 24 Hour 25 mg (milligram) take 1 tablet for atrial fibrillation and to hold for systolic blood pressure less than 100 and or heart rate 55, twice a day. Do not crush or chew. The order revealed that the medication had a start date of 05/28/2026. Regular diet with a puree consistency, nectar thick fluids, and no straws. A review of the May 2026 Medication Administration Record (MAR) revealed the following medications were transcribed in the MAR: An order for Metoprolol Succinate ER (Extended Release) 24 Hour 50 mg, take 1 tablet by mouth twice a day for atrial fibrillation, hold for a systolic blood pressure of less than 100 and or heart rate 55, and not to crush or chew. This medication had a start date of 03/04/2026, and was discontinued on 05/27/2026. An order for Metoprolol Succinate ER 24 Hour 25 mg, take 1 tablet by mouth twice a day for atrial fibrillation, hold for a systolic blood pressure of less than 100 and or heart rate 55, and not to crush or chew. This medication had a start date of 05/28/2026.The nursing progress note dated 05/27/2026, at 07:59 PM was reviewed and it revealed that the provider and hospice were notified of metoprolol was held due to the Resident's systolic blood pressure below parameters. Per progress notes, a new order was received to decrease the dose of metoprolol succinate from 50 mg to 25 mg and to continue with same instructions regarding the hold parameters and the medication administration schedule.On 05/28/2026, at 07:34 AM, a medication administration observation was conducted with a Licensed Practical Nurse (LPN/Staff #98) for Resident #1. One of the five medications observed being prepared from a bubble pack medication card was metoprolol succinate ER 50 mg, 1 tablet twice a day. At 7:39 AM, Staff #98 stated that all the medications were crushed except for the metoprolol because it is an extended release tablet. At 7:40 AM, Staff #98 entered the Resident's room, closed the door for the Resident's privacy, and administered the medications to Resident #1. At 7:43 AM, Staff #98 left the Resident's room to get Resident #1 a thickened liquid. At 7:44 AM, Staff #98 gave Resident #1 thickened liquid via a spoon. On 05/28/2026, at 08:26 AM, a review of the physician orders was conducted. The review revealed an order for metoprolol succinate tablet extended release 24-hour 25 mg for atrial fibrillation, hold for systolic blood pressure less than 100 and/or HR 55, and not to crush or chew. The start date of the medication was 05/28/2026. Additional review of the clinical record revealed that the Resident's blood pressure and heart rate was taken on 5/28/2026, at 6:31 AM. The Resident's blood pressure was 116/75 and the heart rate was 109 beats per minute. A review of the May 2026 MAR revealed a transcribed order for Metoprolol Succinate ER 24-Hour 25 mg, take 1 tablet by mouth twice a day for atrial fibrillation, hold for a systolic blood pressure of less than 100 and or heart rate 55, and not to crush or chew. The MAR also revealed that on May 28, 2026, at 8:00 AM time schedule, Staff #98 administered the medication. However, during the medication administration observation, on 05/28/2026, at 07:34 AM, Staff #98 was observed holding the bubble pack medication card for metoprolol succinate ER 50 mg and pushed out the pill from the bubble pack into a medication cup and then administered the medication along with the other prepared medications to Resident #1. Further, the MAR also revealed that the metoprolol succinate ER 50 mg order was discontinued on 05/27/2026 for Resident #1. A review of progress notes dated 05/28/2026, at 09:18 AM revealed a progress note for a medication variance related to Metoprolol Succinate ER. Per progress note, 50 mg was given instead of 25 mg as ordered. The Resident's vital signs was obtained. The Resident's blood pressure was 95/70, the heart rate was 91, the respiration was 18, the oxygen saturation was at 93% on room air, and the temperature was 97.6. The Assistant Director of Nursing (ADON), the provider and the resident's Power of Attorney (POA) were notified, and an order to continue monitoring the resident was received. -Regarding Resident #22: Resident #22 was admitted to the facility on [DATE], with diagnoses that included acute cystitis with hematuria, dementia, depression, hypertension, cognitive communication deficit, and weakness. A review of the Resident's care plan dated 03/12/2026, revealed a problem for potential for adverse drug effects and or interactions related to medication regimen. The Resident was on statin, anticoagulant, antidepressant, antibiotic, and laxative medications. The Resident was also at risk for malnutrition due to decreased appetite, dementia, cellulitis, osteopenia, and pulmonary embolism. The goal was for the Resident to take her medications as ordered, would be free of drug interactions, and would meet estimated nutritional needs. The interventions included to administer the Resident's medications per physician's order, notify the provider as needed, the pharmacist to perform medication review routinely and as needed, observe for potential side effects, and provide supplement as ordered. A review of orders revealed an order for Slow Fe (ferrous sulfate) 137 mg (45 mg iron) ER orally, 1 tablet equals 137 mg once a day every day, created on 04/10/2026, and a diet order for regular diet with regular consistency, thin fluids, and the Resident preferred her food cut up. On 05/28/2026, at 7:47 AM, a medication administration observation was conducted with an LPN (LPN/Staff #98) for Resident #22. One of the medications observed being prepared was Slow FE (iron) 137 mg ER, 1 tablet daily. During the medication preparation at 7:50 AM, Staff #98 stated that the Resident's medications were crushed except for the probiotic capsule because she can open the capsule and mixed the medications in the apple sauce. On 05/28/2026, at 7:58 AM, a review of Resident #22's medication orders were conducted. The review revealed an order for Slow Fe 1-tablet extended release 137 mg orally every day. An interview was conducted on 05/28/2026, at 09:03 AM with LPN (Staff #98) at the nurses' station. Staff #98 opened her medication cart and looked at the bubble pack medication card for metoprolol succinate 50 mg Tablet ER 24-Hour twice a day for Resident #1. She stated that this was the medication Resident #1 received today. Then, Staff #98 opened Resident #1's electronic medical record and she stated that the order was for metoprolol succinate 25 mg Tablet ER 24-Hour twice a day but the medication card was for 50 mg. Staff #98 opened the progress notes and she said that the order was changed last night, with a decreased to 25 mg. Staff #98 stated that when administering medications to her residents, she would check their medications, follow the right dose, right time, and right route. She also stated that she gave an incorrect dose this morning, and she said that she would do a medication variance, notify the doctor, notify the resident's family, and report the incident. She would also check the resident's vital signs and do a 72- hour monitoring for Resident #1. An interview was conducted on 05/28/2026, at 0 9:11 AM with the Director of Nursing (DON/Staff #13) in her office. The DON stated that medication administration is done 1 hour before and 1 hour of the scheduled time, that the staff follows infection control by washing their hands, and by hand sanitizing in between task. The DON also stated for the staff to follow the electronic MAR; to follow the physician's order; to follow the medication rights which are the right dose, right route, right resident, right direction, right documentation, and the right for refusal. The DON stated that she expects her staff to knock on the door, use the picture in the electronic MAR to identify the resident, administer the resident's medications 1 hour before and 1 hour after, follow the orders in the electronic MAR, if there are parameters to follow the parameters, if the medications are not available, she expects the staff to call the doctor right away, and if the resident refused to take their medications, she expects the staff to disposed of the medications right away. Regarding physician orders, the DON stated that when the staff usually receives a telephone order, the staff writes the order in the resident's electronic medical record and the order automatically uploads in electronic medication administration record. Their pharmacy would then deliver the medication, or the staff could use the emergency drug kit. The DON stated that if there was a new order to decrease a dose such as for an order for metoprolol from 50 mg to 25 mg, the DON stated that she expects her staff to follow the order, and if the medication was not available, the staff can cut the pill in half. The DON stated that if the staff did not follow the order, the staff nurse should call the physician right away to let him know that the order was not followed. The DON stated that the risk to the resident if an order was not followed could cause an adverse effect such as a hypotensive episode. The DON stated that she would recheck the Resident's blood pressure and notify the doctor. Further, the DON also stated that the nurse should have check the electronic medication administration record with the medication card to ensure that the order matches the card and to ensure accurate dose would be administered. On 05/28/2026, at 10:20 AM, a call was placed to the Resident's pharmacy, and an interview was conducted with the pharmacy manager (Staff #102). Staff #102 stated that regarding receiving new orders from the facility, the facility staff directly uses their electronic computer system to place an order to the pharmacy. She said that once the pharmacy received the order, the pharmacy verifies the order, and then the new medications would get delivered at 11:00 AM for their first run, at 2:00 PM, and their last delivery schedule is at 8:00 PM. She stated that regarding the metoprolol ER with a decreased dose new order from 50 mg to 25 mg, the tablet can be cut in half because the 50 mg tablet is scored. She also stated that regarding the slow iron extended release tablet, she said that the tablet should not be crushed because it is an extended release medication. She said that if the medication was crushed, the Resident might get all the medication absorbed all at once. Staff #102 stated that iron comes in liquid form. She also said that the order for slow iron was to help the resident not to have stomach upset or would help minimized a stomach upset. A review of the nursing progress notes dated 05/28/2026, at 11:22 AM revealed a note to discontinue Slow Fe, and add Ferrous Sulfate 220 mg (44mg)/5 ml (milliliter) elixir, to give 5 ml daily. Review of facility policy titled Medication/Treatment Management Protocol-SN with a revision date of 10/2023, revealed a desired outcome that residents will have medications administered per orders from their healthcare provider with prescriptive authority. With a Changes in Medication/Treatment Orders, revealed that if the same medication with different dose or frequency is ordered, an Alert label is placed on the existing medication container indicating the changes until the new prescription label or medication arrives.

Number of residents sampled: facility staffNumber of residents cited: facility staff Based on staff interviews and review of facility documentation and policy, the facility failed to ensure that 3-staff members (#44, #168, #182) received training on emergency preparedness. The deficient practice could result in staff inappropriately trained regarding emergency preparedness and could place the residents and other individuals at risk for their health and safety.Findings include:On 5/28/2026, the training on emergency preparedness was requested for 3- staff members.-Regarding the Dietary Server (Staff #44):A review of the staffing list revealed that Staff #44 was hired on 12/16/2024.The transcript history document for the year 2025 for Staff #44 revealed that the training on emergency preparedness was not listed. Per the document, it is not known when Staff #44 took his emergency preparedness annual training.-Regarding the Physical Therapy Assistant (Staff #168):A review of the staffing list revealed that Staff #168 was hired on 08/01/2024.The transcript document for Staff #168 revealed that the training on emergency preparedness was not listed. Per the document, it is not known when Staff #168 took the emergency preparedness annual training.-Regarding the Speech Therapist (Staff #182):A review of the staffing list revealed that Staff #182 was hired on 01/05/2026.The transcript document for Staff #182 revealed that the training on emergency preparedness was not listed. Per the document, it is not known when Staff #182 took the emergency preparedness training.An interview was conducted on 05/28/2026, at 2:03 PM with the Director of Nursing (DON/Staff #13) in her office. The DON stated that regarding staff training, they have an eCampus for annual module training and a weekly meeting for additional topic discussion. She said that education is provided during meetings that focuses on compliance for infection control, resident rights, abuse and neglect, pressure ulcer in-services, and have a sign-in sheets. The DON said that all the nursing staff takes the abuse training, Elder Justice Act (EJA) training, resident right trainings, infection control training, emergency preparedness training done twice a year, and the dementia care training. The DON stated that the therapy team and the dietary staff takes the same training as the nursing staff. The DON stated that training is important to meet compliance, to be aware of resident rights, how to approach residents with dementia behaviors, and how to prevent the spread of infection. The DON stated that the annual training with staffs include abuse, infection control, EJA, resident rights, and emergency preparedness. She said that she expects her staff to complete their required training modules and complete their training. She also said that she has access to her staff modules to monitor their training completion.During the interview with the DON in her office, the Administrator (Staff #250) joined the interview regarding the rehabilitation therapy employee records. The administrator stated that the therapy employee files were not kept on site, and if their files were needed, he would contact their leadership team because it was part of their agreement with the therapy company.An interview was conducted on 05/28/2026, at 2:35 PM with Speech Therapist (ST/Staff #182). Staff #182 stated that she has been with the rehabilitation company since 01/2026. She also said that she had received training at the facility which included hand washing before and after her interaction with her residents for safety precaution. She said that during her orientation, she did her abuse training via a video format and that there should be some sort of transcript to show that she had completed it. She said that she received her infection control, Elder Justice Act, emergency preparedness, and resident rights training during her orientation and that there should be a transcript. However, a review of Staff #182's 2026 transcript revealed no list of abuse, infection control, Elder Justice Act, emergency preparedness, and resident rights training. Further, Staff #182's transcript revealed that she started her modules on other topics on 03/30/2026, 04/01/2026, 04/22/2026, 04/23/2026 and 05/06/2026.An interview was conducted on 05/28/2026, at 2:42 PM with a Licensed Practical Nurse (LPN/Staff #74). Staff #74 stated that she has her training all the time and during nurses' meeting to check her skills. She also stated that she takes her abuse training, infection control training, dementia care training, emergency preparedness training through their eCampus every year.An interview was conducted on 05/28/2026, at 2:58 PM with the Human Resources Director (HRD/Staff #200). The HRD stated that regarding their dietary server (Staff #44), he said that Staff #44 has a totally different learning plan than nursing and that Staff #44 was not required to have abuse training and infection control training. The HRD also stated that an active shooting and an armed intruder in their senior living communities are part of their emergency preparedness training to ensure that their employees are prepared during a work force emergency such as work place violence, and an active shooter situation.Regarding Staff #168's transcript document, the HRD stated that Staff #168 completed the abuse training in 12/2025 but he did not see Staff #168's Elder Justice Act training for 2025, infection control training for 2025, resident rights training for 2025, emergency preparedness training for 2025, and dementia care training for 2025.Regarding Staff #182's transcript, the HRD stated that he did not see in Staff #182's transcript document that she had the training for Elder Justice Act, infection control, resident rights, emergency preparedness, dementia care, and abuse training. The HRD stated that his expectation is that their contracted rehabilitation service company should provide their employees the same training as what his facility provides to their employees. The HRD also stated that training is introduced on day 1, and their abuse training, infection control training, Elder Justice Act training should be done within the first 60 days when they are hired. However, Staff #182 had a hire date of 01/05/2026 and the training for Elder Justice Act, infection control, resident rights, emergency preparedness, dementia care, and abuse training were not listed in her transcript document.Review of the facility policy titled Staff Development and Orientation-Resident Care with a revision date of 10/2023, revealed that orientation and staff development programs are intended to comply with federal and state regulations related to topics and frequency. (8). All new and existing staff, volunteers and contractor will receive training on the following topics, including but not limited to:Resident Right and Facility ResponsibilitiesAbuse, Neglect and Exploitation, dementia managementInfection Control

Based on staff interviews and review of facility documentation and policy, the facility failed to ensure that 3-staff members (#44, #168, #182) received annual training on resident rights. The deficient practice could result in staff inappropriately trained regarding resident rights and could place the residents at risk for their safety.Findings include:On 5/28/2026, the training on resident rights was requested for 3- staff members.-Regarding the Dietary Server (Staff #44):A review of the staffing list revealed that Staff #44 was hired on 12/16/2024.The transcript history document for the year 2025 for Staff #44 revealed that the training on resident rights was not listed. Per the document, it is not known when Staff #44 took his resident rights annual training.-Regarding the Physical Therapy Assistant (Staff #168):A review of the staffing list revealed that Staff #168 was hired on 08/01/2024.The transcript document for Staff #168 revealed that the training on resident rights was not listed. Per the document, it is not known when Staff #168 took the resident rights annual training.-Regarding the Speech Therapist (Staff #182):A review of the staffing list revealed that Staff #182 was hired on 01/05/2026.The transcript document for Staff #182 revealed that the training on resident rights was not listed. Per the document, it is not known when Staff #182 took the resident rights training.An interview was conducted on 05/28/2026, at 2:03 PM with the Director of Nursing (DON/Staff #13) in her office. The DON stated that regarding staff training, they have an eCampus for annual module training and a weekly meeting for additional topic discussion. She said that education is provided during meetings that focuses on compliance for infection control, resident rights, abuse and neglect, pressure ulcer in-services, and have a sign-in sheets. The DON said that all the nursing staff takes the abuse training, Elder Justice Act (EJA) training, resident right trainings, infection control training, emergency preparedness training done twice a year, and the dementia care training. The DON stated that the therapy team and the dietary staff takes the same training as the nursing staff. The DON stated that training is important to meet compliance, to be aware of resident rights, how to approach residents with dementia behaviors, and how to prevent the spread of infection. The DON stated that the annual training with staffs include abuse, infection control, EJA, resident rights, and emergency preparedness. She said that she expects her staff to complete their required training modules and complete their training. She also said that she has access to her staff modules to monitor their training completion.During the interview with the DON in her office, the Administrator (Staff #250) joined the interview regarding the rehabilitation therapy employee records. The administrator stated that the therapy employee files were not kept on site, and if their files were needed, he would contact their leadership team because it was part of their agreement with the therapy company.An interview was conducted on 05/28/2026, at 2:35 PM with Speech Therapist (ST/Staff #182). Staff #182 stated that she has been with the rehabilitation company since 01/2026. She also said that she had received training at the facility which included hand washing before and after her interaction with her residents for safety precaution. She said that during her orientation, she did her abuse training via a video format and that there should be some sort of transcript to show that she had completed it. She said that she received her infection control, Elder Justice Act, emergency preparedness, and resident rights training during her orientation and that there should be a transcript. However, a review of Staff #182's 2026 transcript revealed no list of abuse, infection control, Elder Justice Act, emergency preparedness, and resident rights training. Further, Staff #182's transcript revealed that she started her modules on other topics on 03/30/2026, 04/01/2026, 04/22/2026, 04/23/2026 and 05/06/2026.An interview was conducted on 05/28/2026, at 2:42 PM with a Licensed Practical Nurse (LPN/Staff #74). Staff #74 stated that she has her training all the time and during nurses' meeting to check her skills. She also stated that she takes her abuse training, infection control training, dementia care training, emergency preparedness training through their eCampus every year.An interview was conducted on 05/28/2026, at 2:58 PM with the Human Resources Director (HRD/Staff #200). The HRD stated that regarding their dietary server (Staff #44), he said that Staff #44 has a totally different learning plan than nursing and that Staff #44 was not required to have abuse training and infection control training. The HRD also stated that an active shooting and an armed intruder in their senior living communities is part of their emergency preparedness training to ensure that their employees are prepared during a work force emergency such as work place violence, and an active shooter situation.Regarding Staff #168's transcript document, the HRD stated that Staff #168 completed the abuse training in 12/2025 but he did not see Staff #168's Elder Justice Act training for 2025, infection control training for 2025, resident rights training for 2025, emergency preparedness training for 2025, and dementia care training for 2025.Regarding Staff #182's transcript, the HRD stated that he did not see in Staff #182's transcript document that she had the training for Elder Justice Act, infection control, resident rights, emergency preparedness, dementia care, and abuse training. The HRD stated that his expectation is that their contracted rehabilitation service company should provide their employees the same training as what his facility provides to his employees. The HRD also stated that training is introduced on day 1, and their abuse training, infection control training, Elder Justice Act training should be done within the first 60 days when they are hired. However, Staff #182 had a hire date of 01/05/2026 and the training for Elder Justice Act, infection control, resident rights, emergency preparedness, dementia care, and abuse training were not listed in her transcript document.Review of the facility policy titled Staff Development and Orientation-Resident Care with a revision date of 10/2023, revealed that orientation and staff development programs are intended to comply with federal and state regulations related to topics and frequency. (8). All new and existing staff, volunteers and contractor will receive training on the following topics, including but not limited to:Resident Right and Facility ResponsibilitiesAbuse, Neglect and Exploitation, dementia managementInfection Control

Based on staff interviews and review of facility documentation and policy, the facility failed to ensure that 2-staff members (#44, #182) received annual training on abuse, neglect and exploitation. The deficient practice could result in staff inappropriately trained regarding abuse, neglect and exploitation and could place the residents at risk for their safety.Findings include:On 5/28/2026, the training on abuse, neglect and exploitation was requested for 2- staff members.-Regarding the Dietary Server (Staff #44):A review of the staffing list revealed that Staff #44 was hired on 12/16/2024.The transcript history document for the year 2025 for Staff #44 revealed that the training on abuse, neglect and exploitation was not listed. Per the document, it is not known when Staff #44 took his abuse, neglect and exploitation annual training.-Regarding the Speech Therapist (Staff #182):A review of the staffing list revealed that Staff #182 was hired on 01/05/2026.The transcript document for Staff #182 revealed that the training on abuse, neglect and exploitation was not listed. Per the document, it is not known when Staff #182 took the abuse, neglect and exploitation training.An interview was conducted on 05/28/2026, at 2:03 PM with the Director of Nursing (DON/Staff #13) in her office. The DON stated that regarding staff training, they have an eCampus for annual module training and a weekly meeting for additional topic discussion. She said that education is provided during meetings that focuses on compliance for infection control, resident rights, abuse and neglect, pressure ulcer in-services, and have a sign-in sheets. The DON said that all the nursing staff takes the abuse training, Elder Justice Act (EJA) training, resident right trainings, infection control training, emergency preparedness training done twice a year, and the dementia care training. The DON stated that the therapy team and the dietary staff takes the same training as the nursing staff. The DON stated that training is important to meet compliance, to be aware of resident rights, how to approach residents with dementia behaviors, and how to prevent the spread of infection. The DON stated that the annual training with staffs include abuse, infection control, EJA, resident rights, and emergency preparedness. She said that she expects her staff to complete their required training modules and complete their training. She also said that she has access to her staff modules to monitor their training completion.During the interview with the DON in her office, the Administrator (Staff #250) joined the interview regarding the rehabilitation therapy employee records. The administrator stated that the therapy employee files were not kept on site, and if their files were needed, he would contact their leadership team because it was part of their agreement with the therapy company.An interview was conducted on 05/28/2026, at 2:35 PM with Speech Therapist (ST/Staff #182). Staff #182 stated that she has been with the rehabilitation company since 01/2026. She also said that she had received training at the facility which included hand washing before and after her interaction with her residents for safety precaution. She said that during her orientation, she did her abuse training via a video format and that there should be some sort of transcript to show that she had completed it. She said that she received her infection control, Elder Justice Act, emergency preparedness, and resident rights training during her orientation and that there should be a transcript. However, a review of Staff #182's 2026 transcript revealed no list of abuse, infection control, Elder Justice Act, emergency preparedness, and resident rights training. Further, Staff #182's transcript revealed that she started her modules on other topics on 03/30/2026, 04/01/2026, 04/22/2026, 04/23/2026 and 05/06/2026.An interview was conducted on 05/28/2026, at 2:42 PM with a Licensed Practical Nurse (LPN/Staff #74). Staff #74 stated that she has her training all the time and during nurses' meeting to check her skills. She also stated that she takes her abuse training, infection control training, dementia care training, emergency preparedness training through their eCampus every year.An interview was conducted on 05/28/2026, at 2:58 PM with the Human Resources Director (HRD/Staff #200). The HRD stated that regarding their dietary server (Staff #44), he said that Staff #44 has a totally different learning plan than nursing and that Staff #44 was not required to have abuse training and infection control training. The HRD also stated that an active shooting and an armed intruder in their senior living communities is part of their emergency preparedness training to ensure that their employees are prepared during a work force emergency such as work place violence, and an active shooter situation.Regarding Staff #182's transcript, the HRD stated that he did not see in Staff #182's transcript document that she had the training for Elder Justice Act, infection control, resident rights, emergency preparedness, dementia care, and abuse training. The HRD stated that his expectation is that their contracted rehabilitation service company should provide their employees the same training as what his facility provides to his employees. The HRD also stated that training is introduced on day 1, and their abuse training, infection control training, Elder Justice Act training should be done within the first 60 days when they are hired. However, Staff #182 had a hire date of 01/05/2026 and the training for Elder Justice Act, infection control, resident rights, emergency preparedness, dementia care, and abuse training were not listed in her transcript document.Review of the facility policy titled Staff Development and Orientation-Resident Care with a revision date of 10/2023, revealed that orientation and staff development programs are intended to comply with federal and state regulations related to topics and frequency. (8). All new and existing staff, volunteers and contractor will receive training on the following topics, including but not limited to:Resident Right and Facility ResponsibilitiesAbuse, Neglect and Exploitation, dementia managementInfection Control

Based on staff interviews and review of facility documentation and policy, the facility failed to ensure that 4-staff members (#44, #92, #168, #182) received annual training on infection control. The deficient practice could result in staff inappropriately trained and could place the residents at risk for infection.Findings include:On 5/28/2026, the training on infection control was requested for 4- staff members.-Regarding the Dietary Server (Staff #44):A review of the staffing list revealed that Staff #44 was hired on 12/16/2024.The transcript history document for the year 2025 for Staff #44 revealed that the training on infection control was not listed. Per the document, it is not known when Staff #44 took his infection control annual training.-Regarding the Lifestyle Manager (Staff #92):A review of the staffing list revealed that Staff #92 was hired on 03/23/2022.The transcript history document for the year 2024 for Staff #92 revealed that her training on infection control was completed on 12/31/2024. Further, Staff #92's 2025 transcript revealed that her training on infection control was not listed. Per the 2025 transcript document, it is not known when Staff #92 took her infection control annual training in 2025.On 05/28/2026, around 4:45 PM, the survey team completed the survey onsite and exited the facility. At 7:56 PM, the Administrator (Staff #250) sent an email and attached a document to the State Agency (SA). Per the document, Staff #92's missing annual education was attached to the email.After reviewing the emailed additional annual education document for Staff #92, the document revealed that Staff #92's infection control training had a registration date of 01/04/2025, and per Staff #92's transcript, the infection control training was completed on 05/06/2025. The document also revealed that there was no infection control training for 05/2026.-Regarding the Physical Therapy Assistant (Staff #168):A review of the staffing list revealed that Staff #168 was hired on 08/01/2024.The transcript document for Staff #168 revealed that the training on infection control was not listed. Per the document, it is not known when Staff #168 took the infection control annual training.-Regarding the Speech Therapist (Staff #182):A review of the staffing list revealed that Staff #182 was hired on 01/05/2026.The transcript document for Staff #182 revealed that the training on infection control was not listed. Per the document, it is not known when Staff #182 took the infection control training.An interview was conducted on 05/28/2026, at 2:03 PM with the Director of Nursing (DON/Staff #13) in her office. The DON stated that regarding staff training, they have an eCampus for annual module training and a weekly meeting for additional topic discussion. She said that education is provided during meetings that focuses on compliance for infection control, resident rights, abuse and neglect, pressure ulcer in-services, and have a sign-in sheets. The DON said that all the nursing staff takes the abuse training, Elder Justice Act (EJA) training, resident right trainings, infection control training, emergency preparedness training done twice a year, and the dementia care training. The DON stated that the therapy team and the dietary staff takes the same training as the nursing staff. The DON stated that training is important to meet compliance, to be aware of resident rights, how to approach residents with dementia behaviors, and how to prevent the spread of infection. The DON stated that the annual training with staffs include abuse, infection control, EJA, resident rights, and emergency preparedness. She said that she expects her staff to complete their required training modules and complete their training. She also said that she has access to her staff modules to monitor their training completion.During the interview with the DON in her office, the Administrator (Staff #250) joined the interview regarding the rehabilitation therapy employee records. The administrator stated that the therapy employee files were not kept on site, and if their files were needed, he would contact their leadership team because it was part of their agreement with the therapy company.An interview was conducted on 05/28/2026, at 2:35 PM with Speech Therapist (ST/Staff #182). Staff #182 stated that she has been with the rehabilitation company since 01/2026. She also said that she had received training at the facility which included hand washing before and after her interaction with her residents for safety precaution. She said that during her orientation, she did her abuse training via a video format and that there should be some sort of transcript to show that she had completed it. She said that she received her infection control, Elder Justice Act, emergency preparedness, and resident rights training during her orientation and that there should be a transcript. However, a review of Staff #182's 2026 transcript revealed no list of abuse, infection control, Elder Justice Act, emergency preparedness, and resident rights training. Further, Staff #182's transcript revealed that she started her modules on other topics on 03/30/2026, 04/01/2026, 04/22/2026, 04/23/2026 and 05/06/2026.An interview was conducted on 05/28/2026, at 2:42 PM with a Licensed Practical Nurse (LPN/Staff #74). Staff #74 stated that she has her training all the time and during nurses' meeting to check her skills. She also stated that she takes her abuse training, infection control training, dementia care training, emergency preparedness training through their eCampus every year.An interview was conducted on 05/28/2026, at 2:58 PM with the Human Resources Director (HRD/Staff #200). The HRD stated that regarding their dietary server (Staff #44), he said that Staff #44 has a totally different learning plan than nursing and that Staff #44 was not required to have abuse training and infection control training. The HRD also stated that an active shooting and an armed intruder in their senior living communities is part of their emergency preparedness training to ensure that their employees are prepared during a work force emergency such as work place violence, and an active shooter situation.During the interview, the HRD was also looking at Staff #92's transcript document. He said that Staff #92's role was not nursing. The HRD stated that Staff #92's training was completed on 12/2024 which included dementia care, resident rights, workplace emergencies, abuse, and infection control. He said that Staff #92's Elder Justice Act was completed in 12/2025, and he said that he did not see in the transcript Staff #92's workplace violence emergency preparedness training for 2025, abuse training for 2025, infection control training for 2025, and resident rights training for 2025.Regarding Staff #168's transcript document, the HRD stated that Staff #168 completed the abuse training in 12/2025 but he did not see Staff #168's Elder Justice Act training for 2025, infection control training for 2025, resident rights training for 2025, emergency preparedness training for 2025, and dementia care training for 2025.Regarding Staff #182's transcript, the HRD stated that he did not see in Staff #182's transcript document that she had the training for Elder Justice Act, infection control, resident rights, emergency preparedness, dementia care, and abuse training. The HRD stated that his expectation is that their contracted rehabilitation service company should provide their employees the same training as what his facility provides to his employees. The HRD also stated that training is introduced on day 1, and their abuse training, infection control training, Elder Justice Act training should be done within the first 60 days when they are hired. However, Staff #182 had a hire date of 01/05/2026 and the training for Elder Justice Act, infection control, resident rights, emergency preparedness, dementia care, and abuse training were not listed in her transcript document.Review of the facility policy titled Staff Development and Orientation-Resident Care with a revision date of 10/2023, revealed that orientation and staff development programs are intended to comply with federal and state regulations related to topics and frequency. (8). All new and existing staff, volunteers and contractor will receive training on the following topics, including but not limited to:Resident Right and Facility ResponsibilitiesAbuse, Neglect and Exploitation, dementia managementInfection Control

Based on staff interviews and review of facility documentation and policy, the facility failed to ensure that 3-staff members (#44, #168, #182) received annual training on behavioral health training related to dementia care. The deficient practice could result in staff inappropriately trained regarding behavioral health training related to dementia care and could place the residents at risk for their health and safety.Findings include:On 5/28/2026, the training on behavioral health training related to dementia care was requested for 3- staff members.-Regarding the Dietary Server (Staff #44):A review of the staffing list revealed that Staff #44 was hired on 12/16/2024.The transcript history document for the year 2025 for Staff #44 revealed that the training on behavioral health training related to dementia care was not listed. Per the document, it is not known when Staff #44 took his behavioral health training related to dementia care annual training.-Regarding the Physical Therapy Assistant (Staff #168):A review of the staffing list revealed that Staff #168 was hired on 08/01/2024.The transcript document for Staff #168 revealed that the training on behavioral health training related to dementia care was not listed. Per the document, it is not known when Staff #168 took the behavioral health training related to dementia care annual training.-Regarding the Speech Therapist (Staff #182):A review of the staffing list revealed that Staff #182 was hired on 01/05/2026.The transcript document for Staff #182 revealed that the training on behavioral health training related to dementia care was not listed. Per the document, it is not known when Staff #182 took the behavioral health training related to dementia care training.An interview was conducted on 05/28/2026, at 2:03 PM with the Director of Nursing (DON/Staff #13) in her office. The DON stated that regarding staff training, they have an eCampus for annual module training and a weekly meeting for additional topic discussion. She said that education is provided during meetings that focuses on compliance for infection control, resident rights, abuse and neglect, pressure ulcer in-services, and have a sign-in sheets. The DON said that all the nursing staff takes the abuse training, Elder Justice Act (EJA) training, resident right trainings, infection control training, emergency preparedness training done twice a year, and the dementia care training. The DON stated that the therapy team and the dietary staff takes the same training as the nursing staff. The DON stated that training is important to meet compliance, to be aware of resident rights, how to approach residents with dementia behaviors, and how to prevent the spread of infection. The DON stated that the annual training with staffs include abuse, infection control, EJA, resident rights, and emergency preparedness. She said that she expects her staff to complete their required training modules and complete their training. She also said that she has access to her staff modules to monitor their training completion.During the interview with the DON in her office, the Administrator (Staff #250) joined the interview regarding the rehabilitation therapy employee records. The administrator stated that the therapy employee files were not kept on site, and if their files were needed, he would contact their leadership team because it was part of their agreement with the therapy company.An interview was conducted on 05/28/2026, at 2:35 PM with Speech Therapist (ST/Staff #182). Staff #182 stated that she has been with the rehabilitation company since 01/2026. She also said that she had received training at the facility which included hand washing before and after her interaction with her residents for safety precaution. She said that during her orientation, she did her abuse training via a video format and that there should be some sort of transcript to show that she had completed it. She said that she received her infection control, Elder Justice Act, emergency preparedness, and resident rights training during her orientation and that there should be a transcript. However, a review of Staff #182's 2026 transcript revealed no list of abuse, infection control, Elder Justice Act, emergency preparedness, and resident rights training. Further, Staff #182's transcript revealed that she started her modules on other topics on 03/30/2026, 04/01/2026, 04/22/2026, 04/23/2026 and 05/06/2026.An interview was conducted on 05/28/2026, at 2:42 PM with a Licensed Practical Nurse (LPN/Staff #74). Staff #74 stated that she has her training all the time and during nurses' meeting to check her skills. She also stated that she takes her abuse training, infection control training, dementia care training, emergency preparedness training through their eCampus every year.An interview was conducted on 05/28/2026, at 2:58 PM with the Human Resources Director (HRD/Staff #200). The HRD stated that regarding their dietary server (Staff #44), he said that Staff #44 has a totally different learning plan than nursing and that Staff #44 was not required to have abuse training and infection control training. The HRD also stated that an active shooting and an armed intruder in their senior living communities is part of their emergency preparedness training to ensure that their employees are prepared during a work force emergency such as work place violence, and an active shooter situation.Regarding Staff #168's transcript document, the HRD stated that Staff #168 completed the abuse training in 12/2025 but he did not see Staff #168's Elder Justice Act training for 2025, infection control training for 2025, resident rights training for 2025, emergency preparedness training for 2025, and dementia care training for 2025.Regarding Staff #182's transcript, the HRD stated that he did not see in Staff #182's transcript document that she had the training for Elder Justice Act, infection control, resident rights, emergency preparedness, dementia care, and abuse training. The HRD stated that his expectation is that their contracted rehabilitation service company should provide their employees the same training as what his facility provides to his employees. The HRD also stated that training is introduced on day 1, and their abuse training, infection control training, Elder Justice Act training should be done within the first 60 days when they are hired. However, Staff #182 had a hire date of 01/05/2026 and the training for Elder Justice Act, infection control, resident rights, emergency preparedness, dementia care, and abuse training were not listed in her transcript document.Review of the facility policy titled Staff Development and Orientation-Resident Care with a revision date of 10/2023, revealed that orientation and staff development programs are intended to comply with federal and state regulations related to topics and frequency. (8). All new and existing staff, volunteers and contractor will receive training on the following topics, including but not limited to:Resident Right and Facility ResponsibilitiesAbuse, Neglect and Exploitation, dementia managementInfection Control

Based on observations, resident and staff interviews, clinical record review, facility documentation, and policies and procedures, the facility failed to develop and implement a care plan for one resident (#5) regarding rehabilitation services. The deficient practice could result in the residents' care and services not being met according to their assessed needs so that the resident can attain or maintain his or her highest practicable physical, mental and psychosocial well-being. The universe was 18 and the sample size was 1.Findings include: Resident #5 was admitted on [DATE] with diagnoses including hemiplegia, hemiparesis, muscle weakness, and abnormalities of mobility and gait. A physician order with a start date for February 5, 2026 revealed a Physical Therapy (PT) and Occupational Therapy (OT) order to evaluate and treat. No frequency or end date were included in the order.A care plan dated March 30, 2026 identified a problem area for Activities of Daily Living (ADL) self-care deficit related to impaired mobility. Approaches included PT and OT consultation and treatment per physician orders. The care plan did not include interventions related to contracture prevention, management, or OT recommendations.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Further review of the MDS revealed impairment of the resident's upper and lower extremities on one side, and substantial or maximal assistance required for bed mobility and transfers. The MDS further indicated that during the lookback period, the resident was not receiving PT or OT services.An interview was conducted, during an initial screening on May 26, 2026 at 9:24 AM with resident #5. She was observed lying in bed with the left hand contracted and fingers tightly curled into the palm of her hand. The resident stated she was supposed to receive therapy, but had not received therapy for a period of time and could not recall the length of time. She further stated she was unable to get out of bed, unable to move, and had pain on the left side of her body, including her left hand.On May 27, 2026 at 10:36 AM, an observation was conducted of resident #5. The resident was observed lying in bed with the left hand curved at the wrist inward toward her body and the fingers were tightly clenched in a contracted position. The left hand was observed to have a strong foul odor and without a hand roll, splint, carrot, or brace. Further observation revealed dark debris underneath the resident's fingernails, which were indenting into the palm of her left hand. The resident stated she had not received therapy or restorative services for her left hand.An interview was conducted on May 27, 2026 at 1:08 PM with Licensed Practical Nurse (LPN/staff #98). Staff #98 reviewed the resident's progress notes stating the resident had previously received PT services, but that the PT services had been discontinued on April 15, 2026. She stated there was no documentation regarding an OT evaluation or treatment plan, but that the OT treatment order remained active in the resident's Electronic Health Record (EHR) and had not been discontinued.An interview was conducted on May 27, 2026 at 1:18 PM with Restorative Nursing Assistant (RNA/staff #3). Staff #3 stated she provided resident #5 with passive range of motion (PROM) exercises for the resident's lower extremities. She stated she rarely worked with the resident's left upper extremity due to the resident's complaints of pain to her contracted left hand. Staff #3 stated in December 2025, a washcloth had been placed in the resident's left hand for further contracture prevention. The RNA stated that she discontinued placement of the washcloth due to the resident's complaints of pain, but she had never communicated this information to nursing staff or to the Director of Nursing (DON). She stated that all recommendations regarding use of braces and carrots for contractures must be provided by therapy. She further stated there were no orders for a hand roll or carrot. The RNA stated she had been directed by the DON to use the rolled washcloth to prevent further contracture. An interview was conducted on May 27, 2026 at 3:09 PM with Physical Therapist (staff #167). Staff #167 confirmed resident #5 had received PT services with a focus on bed mobility and lower extremity function. He stated it didn't come to my attention at the time that the resident had any contractures and he had not received any communication regarding the contracture from nursing or other PT staff. He further stated that PT focuses on treating and making recommendations for the lower extremities, while OT addresses upper extremity function and contracture-related interventions. Staff #167 stated splints and carrots are typically interventions recommended for contractures by OT and stated no PT interventions had been implemented for the resident's contracted left hand. He further stated orders are required for carrots or rolled up washcloths following the OT evaluation and that they are placed in the hands to keep them open. He stated the risk for not implementing interventions for a contracted hand are skin breakdown as a result of moisture trapped in the hands, and potential infection as a result of bacteria buildup.An interview was conducted on May 28, 2026 at 1:14 PM with the DON (staff #13). The DON stated once orders are placed, the expectation is that they will be implemented by any of the disciplines providing their service. She further stated resident #5 was admitted with the contracture and should have received an OT evaluation and contracture screening. Staff #13 conducted a review of the resident's EHR and stated that PT and OT evaluations and treatments were ordered, but no OT evaluation had been conducted. She further stated there were no contracture monitoring sheets or contracture prevention interventions within the care plan for resident #5. The DON stated the risks for not providing an OT evaluation and implementing a care plan for contractures could result in decline in ADLs, delay in resident care, and risk for infection.Review of the facility policy titled Plan of Care, with a revision date of October 2023 states skilled nursing (SN) develops a plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, cognitive and psychosocial needs identified in the comprehensive assessments performed.Review of the facility policy titled Medical, Nursing, and Personal Care, with a revision date of October 2017 revealed that skilled nursing provides the necessary care and services in order to obtain or maintain the highest practicable, physical, mental, and psychological well-being of the residents in accordance with each resident's assessment and plan of care. Nursing care and personal care are provided to meet the needs of each resident.1.1 Residents who have limited ROM will receive appropriate treatment and services to promote an increase in ROM and/or prevent further decrease in ROM.

Based on review of the clinical record, resident and staff interviews, observations, facility documentation, and policy and procedure, the facility failed to ensure the comprehensive care plan for one resident (#5) was reviewed and revised to meet the resident's needs regarding occupational therapy services. The deficient practice could result in care or services that do not meet residents' needs. The universe was 18 and the sample size was 1. Findings include:Resident #5 was admitted on [DATE], with diagnoses including hemiplegia, hemiparesis, muscle weakness, and abnormalities in mobility and gait. A physician's order dated February 05, 2026 revealed a physical therapy (PT) and occupational therapy (OT) order to evaluate and treat. The order did not specify the frequency of therapy services. A care plan dated March 30th, 2026 revealed a problem area for activities of daily living (ADLs) due to impaired mobility and left sided weakness. Approaches included physical assistance as needed and PT and OT consultation and treatment per orders.A Quarterly Minimum Data Set (MDS) assessment dated [DATE]TH, 2026, included a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition, no indicators for mood or behavior. Further review of the MDS revealed impairment of the resident's upper and lower extremities on one side, dependent for bathing and showers, and required substantial or maximal assistance with personal hygiene. During the look back period, the resident was not receiving OT services. An interview was conducted during initial screening on May 26th, 2026 at 9:24 am with resident #5. She stated she was unable to move her left side, and was no longer able to attend activities or able to get out of bed. The resident stated that she had not received therapy services for a long period of time, but she could not recall for how long. Observation of the resident's left hand revealed an inward curve at the wrist toward her body and the fingers were tightly clenched in a contracted position. A strong foul odor was noted from the left hand. The nails on both hands had dark brown debris under the fingernails. Further observation revealed no carrot, brace, or washcloth to prevent contracture to the resident's left hand. An interview was conducted on May 27TH, 2026 at 1:08 pm with Licensed Practical Nurse (LPN/staff #98), during which she reviewed the resident's progress notes and care plan. She stated that an open ended order for occupational therapy (OT) to evaluate and treat was dated for February 5th, 2026. However, further review of the progress notes revealed the order had not been completed. Staff #98 stated there were no notes for OT in the progress notes nor in the care plan. An interview was conducted on May 28th, 2026 at 1:14pm with Director of Nursing (DON/staff #13). The DON stated therapy orders should be implemented once written, and nursing must notify therapy of new orders. She reviewed the care plan and progress notes and stated the evaluation for OT had not been completed nor had it been updated in the care plan. The DON stated the resident was admitted to the facility with a contracture to the left hand and she had missed identifying the contracture by not implementing the interventions into the care plan. She stated that not updating or revising the care plan to include the new orders for OT services placed the resident at risk for infections, decline in ADLS and delay of care. Review of the facility policy titled Plan of Care, revision date October of 2023. The policy establishes the process for initiation, revision, maintenance, and evaluation of the plan of care for the resident in skilled nursing (SN).4.2 The comprehensive care plan is prepared by the interdisciplinary team that includes but is not limited to the following disciplines and participants: the attending physician, a registered nurse, a nurse aide, a member of food and nutrition staff, resident and/or a resident's representative, and other staff determined by the resident's needs or as requested. All disciplines involved in the resident's care should be included in developing the comprehensive care plan.

Based on record review, resident and staff interviews and observations, the facility failed ensure proper nail care was provided for one resident (5). The deficient practice could result in grooming and hygiene needs not being met. The universe was 18, and the sample size was 1.Findings include: Resident #5 was admitted to the facility on [DATE] with diagnosis including hemiplegia, hemiparesis, muscle weakness, abnormalities of mobility and gait.Review of care plan dated March 30, 2026 revealed activities of daily living (ADL) self-care deficit related to impaired independence of functional mobility, and requires assistance with ADLs. Interventions include physical assist as needed.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Further review of the MDS revealed impairment for the resident's upper and lower extremities on one side, dependent for bathing and showers, and required substantial or maximal assistance with personal hygiene.Resident #5 was observed on May 26, 2026 at 9:20 AM with long fingernails and dark, brown debris underneath them. Resident stated she had only received a bed bath and no showers, which were supposed to be on Mondays and Wednesdays. The resident had a strong odor of feces, hair was disheveled and oily.A second observation was conducted on May 27, 2026 at 10:36 AM. Resident #5 was observed resting in bed. Observation revealed the resident's left hand was contracted, and a strong odor was noted on the left hand and the middle fingernail was observed indenting the palm of her left hand. The fingernails on the left hand were long with dark, brown debris underneath them. The right hand still had long fingernails with dark, brown debris underneath them. Some of the fingernails were chipped. The resident stated that she did not like her nails this way, but that she was unable to get to the beauty shop, and that staff had not provided nail care during her bed baths.An observation was conducted on May 27, 2026 at 1:37 PM by certified nursing assistant (CNA/Staff #3) of resident #5's fingernails. She stated that she observed long fingernails digging into the resident's left hand, stating it's really stinky like it usually is. Staff #3 stated she could smell the hand's odor when she conducts the resident's range of motion (ROM), and would use a dry towel or something like a wipe to remove the sweat. Staff #3 stated that she had informed registered nurse (RN/Staff #85) that the resident's hand was really starting to smell. Staff #3 stated the risks of not providing nail and hand care are that the resident can develop a pressure sore caused by digging into the palm of her hand, could become sick from food or something from beneath the fingernails, and that staff should be cleaning the resident's hands and fingernails after she eats.An interview was conducted on May 27, 2026 at 12:52 PM with licensed practical nurse (LPN/Staff #98). Staff #98 stated that the resident is provided with extensive to total assist with dressing, mechanical lift, and maximal assist with repositioning. Staff #98 further stated resident #5 requires set up for meals, everything placed within reach on her right side, and feeds herself with her right hand. Staff #98 stated that resident refuses her medications, getting out of bed, and will sometimes miss her hair and nail appointments. She further stated resident #5 is a diabetic and is referred to a podiatrist for nailcare. An observation was conducted by staff #98, who noted that she observed dark buildup underneath the resident's fingernails and her left thumbnail, and that the odor was caused by dead skin and sweat. She stated the cleansing of the resident's hands nails should be conducted during her bed baths and that all staff are responsible for ensuring the resident's nails are clean. She further stated that she had received no reports that the resident had refused nail care, nor had it been reported during the resident's weekly skin assessments. Staff #98 stated that the best practice is to clean the resident's hands with morning and afternoon care, and the risk of not providing nail and hand care are skin breakdown and infection.An interview was conducted on May 28, 2026 at 12:58 PM with the director of nursing (DON/Staff #13). Staff #13 stated that nail care should be provided by all nursing staff during showers and daily care. She stated that if an odor or unclean nails are observed by CNAs, they should report to the nurses and the nurses would need to notify the doctor or the Infection Preventionist (IP) to find the root cause and determine how often the resident's hands are being cleaned. She further stated the risks include a fungal infection as a result of self-inflicted scratch marks or pressure ulcers on the palm of the resident's hand.Review of the facility policy titled Medical, nursing, and personal care, revision date October 17, 2017 revealed that skilled nursing provides the necessary care and services in order to obtain or maintain the highest practicable, physical, mental, and psychological well being of the residents in accordance with each resident's assessment and plan of care. Nursing care and personal care are provided to meet the needs of each resident.2. General nursing care is provided 24 hours a day, 7 days per week, and includes, but is not limited to personal care per resident preference, including skin care, nail care, oral hygiene, bathing, hair care, clean and appropriate clothing, and clean bed linens.

Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure one resident (#5) was provided with occupational therapy treatment and services per physician orders in accordance with professional standards of practice. The deficient practice could result in care or services resulting in an actual or potential decline in residents' physical, mental, and/or psychosocial well being. The universe was 18 and the sample size was 1. Findings include: Resident #5 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis, muscle weakness, abnormalities of gait and mobility, and polyneuropathy.A physician order start date for February 5, 2026 revealed a Physical Therapy (PT) and Occupational Therapy (OT) order to evaluate and treat. No frequency or end date were included in the order.A care plan dated March 30, 2026 identified a problem area for restorative passive range of motion (PROM) to maintain joint function, prevent stiffness and atrophy, was at risk for falls, and had impaired Activities of Daily Living (ADL) related to left-sided weakness. The approaches included PT and OT consult and treatment. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition, substantial or maximal assistance needed for toileting and personal hygiene, dependent for bathing, always incontinent of bowel and bladder, and as needed pain medications with several pain indicators. Further review of the MDS revealed the resident was not receiving OT services.An interview was conducted, during an initial screening on May 26, 2026 at 9:24 AM with resident #5. She was observed lying in bed with the left hand contracted and fingers tightly curled into the palm of her hand. The resident stated she was supposed to receive therapy, and had not received therapy for a period of time, but could not recall the length of time. She further stated she was unable to get out of bed, unable to move, and had pain on the left side of her body, including her left hand.An interview was conducted on May 27, 2026 at 1:02 PM with a Licensed Practical Nurse (LPN/Staff #98). She reviewed the physician's orders, progress notes, and care plan in the electronic health record (EHR) and stated that the resident had previous orders for PT and OT, and that the order for PT had been discontinued on April 15, 2026 and that the resident was discharged from PT. She further stated there was no documentation or update to the care plan regarding the ordered OT evaluation and treatment.An interview was conducted on May 27, 2026 at 1:48 PM with the Director of Rehabilitation (DOR, Staff #152). Staff #152 stated that resident #5 received PT services on February 16 through April 16, 2026. During the interview, staff #152 conducted a clinical record review, and stated no OT evaluation was completed despite active orders from February 2026, but the resident had met her PT baseline; she stated no further recommendations for OT services were documented after April 16, 2026. She further stated there was a lack of documentation confirming any communication about OT services for the resident due to changes in staffing within the therapy department, and that she was recently hired in April 2026. She stated that preventative measures for contractures include PROM, placement of a carrot, or rolled-up washcloth which does not need an order as this is best practice. She further stated that the risks of further contracture without prevention are frozen joints or pain.An interview was conducted on May 27, 2026 at 3:09 PM with Physical Therapist (staff #167). He stated that PT focuses on treating and making recommendations for the lower extremities, while OT addresses upper extremity function and contracture-related interventions. He further stated splints and carrots are typically interventions recommended for contractures by OT and stated no PT interventions had been implemented for the resident's contracted left hand. He further stated orders are required for carrots or rolled up washcloths following the OT therapy evaluation and that they are placed in the hands to keep them open. He stated the risk for not implementing interventions for a contracted hand are skin breakdown as a result of moisture trapped in the hands, and potential infection as a result of bacteria buildup.An interview was conducted on May 28, 2026 at 1:14 PM with the DON (Staff #13). The DON stated therapy orders should be implemented once written, and nursing must notify therapy of the new orders. The DON conducted a review of the resident's EHR, and stated PT and OT eval and treat orders were entered in February 2026, but were open-ended, and no OT evaluation was completed. She further stated the resident was admitted with a contracture, and the facility missed it by not implementing the interventions. She stated there were no contracture monitoring sheets or care plan interventions for contracture prevention. The DON stated the resident should have received OT for contracture management, and that not receiving OT services placed the resident at risk for infection, decline in ADLs, and delay in care.An interview was conducted on May 28, 2026 at 2:06 PM with the DOR (Staff #152). The DOR stated an OT evaluation had not been conducted for resident #5 because of the poor communication between the therapy and the nursing department, due to recent changes in staffing. The DOR stated lack of communication between the therapy and nursing department placed the resident at risk for worsening conditions. During the interview, staff #152 contacted the Regional Director of Rehabilitation (RDOR/Staff #200) for support and confirmation of the resident's orders for OT. The RDOR reviewed the resident's therapy notes, and confirmed that the OT evaluation or treatment order was not conducted. The RDOR stated that there was no coordination between the nursing and therapy department. However, the therapy department had received the order for PT and OT evaluation, but had failed to schedule the OT evaluation. Review of the facility policy, revision date December 2024 titled Medication and Treatment Management, states that the policy outlines requirements for medication and treatment management in the licensed care venues at the company.7. If for any reason a medication and treatment order cannot be followed or the resident refuses a medication or treatment that has been prescribed, the healthcare provider with prescriptive authority is notified as soon as is reasonable, depending on the situation. The reason the medication and treatment order was not carried out is documented in their Electronic Medication Administration Record (eMAR).

Based on clinical record review, staff interviews, observations, facility documentation, and policy and procedure, the facility failed to ensure rehabilitation services were provided as ordered for one resident (#5). The deficient practice could result in residents not receiving therapy services to maintain function and prevent further decline. The universe was 18 and the sample size was 1. Findings include:Resident #5 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis, muscle weakness, abnormalities of gait and mobility, and polyneuropathy.A physician order start date of February 5, 2026 revealed a Physical Therapy (PT) and Occupational Therapy (OT) order to evaluate and treat. No frequency or end date was ordered. PT outpatient treatment notes dated February 16, 2026 to April 16, 2026 revealed the resident received passive range of motion (PROM) to the left upper and lower extremities. During treatment, the resident became upset and complained of pain, stating she never signed up for this and wanted it to stop. The rehab manager was notified. PT planned for discharge. However, further review of the outpatient treatment notes revealed that an OT evaluation or treatment was not conducted. A care plan dated March 30, 2026 identified a problem area for restorative PROM to maintain joint function and prevent stiffness and atrophy, was at risk for falls, and had impaired Activities of Daily Living (ADL) related to left-sided weakness. The approaches included PT and OT consult and treatment. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition, substantial or maximal assistance needed for toileting and personal hygiene, dependent for bathing, always incontinent of bowel and bladder, and as needed pain medications with several pain indicators. During the lookback period, the resident was not receiving PT or OT services.An interview was conducted during initial screening on May 26, 2026 at 9:24 AM. with Resident #5. The resident stated she was supposed to have therapy, but had not received any since she was admitted to the facility. The resident stated that she is unable to get out of bed and unable to move her left side. She further stated she used to be able to go to the beauty shop, get her nails done, attend activities, and now is no longer able to get out of bed. Observations of the resident revealed a left hand contracture. A second interview was conducted on May 27, 2026 at 10:36 AM with resident #5. The resident stated that she had not received any therapy services for a long period of time, but could not recall for how long. Observations of the resident revealed contracture of the left hand with a strong odor coming from the left hand. Further observation revealed no carrot or washcloth to prevent further contracture. An interview was conducted on May 27, 2026 at 1:02 PM with a Licensed Practical Nurse (LPN/Staff #98). She reviewed the orders and the progress notes in the electronic health record (EHR) and stated that the resident had previous orders for PT and OT, and that the order for PT had been discontinued on April 15, 2026 and that the resident was discharged from PT. She further stated there was no documentation regarding the ordered OT evaluation or treatment.An interview was conducted on May 27, 2026 at 1:18 PM with a restorative nursing assistant (RNA/Staff #3). She stated that therapy makes the recommendation for a carrot or washcloth for a contracture, and that nursing staff had provided a washcloth for the resident's left hand in December 2025, but the resident complained of pain and occasionally refused to have it placed. She further stated that the Director of Nursing (DON) made a verbal recommendation for the use of a washcloth and carrot for resident #5. Further review of the EHR revealed no orders for a carrot or washcloth placement for left hand contracture.An interview was conducted on May 27, 2026 at 1:48 PM with the Director of Rehabilitation (DOR, Staff #152). Staff #152 stated that resident #5 received PT services on February 16 through April 16, 2026. During the interview, staff #152 conducted a clinical record review, and stated no OT evaluation was completed despite active orders from February 2026, but the resident had met her PT baseline; she stated no further recommendations for OT services were documented after April 16, 2026. She further stated there was a lack of documentation confirming any communication about OT services for the resident due to changes in staffing within the therapy department, and that she was recently hired in April 2026. She stated that preventative measures for contractures include PROM, placement of a carrot, or rolled-up washcloth which does not need an order as this is best practice. She further stated that the risks of further contracture without prevention are frozen joints or pain.An interview was conducted on May 27, 2026 at 3:09 PM with the former DOR and current Physical Therapist (Staff #167). He stated therapy is responsible for setting frequency and communicating resident needs. During the interview, staff #167 conducted a clinical record review, and stated resident #5 had received PT services only and that no OT services were provided. He further stated he was unaware the resident had a left-hand contracture. Staff #167 stated that if nursing was aware of the contractures, it was not communicated to the PT department. He further stated no splinting or formal contracture management plan had been put into place, and that OT would usually recommend a splint after evaluation. He stated that for contractures, a carrot or rolled-up wash cloths are used to keep the hand open, but that this form of prevention requires an order. Staff #167 stated that the risks of failing to implement measures to prevent further contracture include excessive moisture accumulation in the hand, which can create an environment conducive to skin breakdown and increase the risk of infection. An interview was conducted on May 28, 2026 at 1:14 PM with the DON (Staff #13). The DON stated therapy orders should be implemented once written, and nursing must notify therapy of the new orders. The DON conducted a review of the resident's EHR, and stated PT and OT eval and treat orders were entered in February 2026, but were open-ended, and no OT evaluation was completed. She further stated the resident was admitted with a contracture, and the facility missed it by not implementing the interventions. She stated there were no contracture monitoring sheets or care plan interventions for contracture prevention, and the RNA did not report the odor or issues with the resident's hand until May 27, 2026. The DON stated the resident should have received OT for contracture management, and that not receiving OT services placed the resident at risk for infection, decline in ADLs, and delay in care.An interview was conducted on May 28, 2026 at 2:06 PM with the DOR (Staff #152). The DOR stated an OT evaluation had not been conducted for resident #5 because of the poor communication between the therapy and the nursing department, due to recent changes in staffing. The DOR stated lack of communication between the therapy and nursing department placed the resident at risk for worsening conditions. During the interview, staff #152 contacted the Regional Director of Rehabilitation (RDOR/Staff #200) for support and confirmation of the resident's orders for OT. The RDOR reviewed the resident's therapy notes, and confirmed that the OT evaluation or treatment order was not conducted. The RDOR stated that there was no coordination between the nursing and therapy department. However, the therapy department had received the order for PT and OT evaluation, but had failed to schedule the OT evaluation. Review of the facility policy, revision date December 2024 titled Medication and Treatment Management, states that the policy outlines requirements for medication and treatment management in the licensed care venues at the company. 7. If for any reason a medication and treatment order cannot be followed or the resident refuses a medication or treatment that has been prescribed, the healthcare provider with prescriptive authority is notified as soon as is reasonable, depending on the situation. The reason the medication and treatment order was not carried out is documented in their Electronic Medication Administration Record (eMAR).

Number of residents sampled: 1 Number of residents cited: 1 Based on record review, staff interviews, review of facility documents and policy, the facility failed to maintain accurate documented medical records for 1 resident's advance directives (#3) in accordance with accepted professional standards and practice. The deficient practice could result in residents' medical records not having accurate documents.Findings include:Resident #3 was admitted to the facility on [DATE], with diagnoses that included a displaced fracture of upper end of right arm, subsequent encounter for fracture with routine healing, history of falling, syncope and collapse, low back pain, generalized muscle weakness, unsteadiness on feet, major depressive disorder, and anxiety disorder.The nursing progress notes dated 03/02/2026, revealed a note indicating that the Resident was full code.A review of the physician's order dated 4/9/2026 revealed that the Resident had an order for a full code status. A review of the Resident's Quarterly MDS assessment 06/04/2026, revealed a Brief Interview for Mental Status (BIMS) score of 15.0, indicating that the Resident was cognitively intact. On 05/26/2026, at 10:58 AM, a review of the Resident's advanced directives in the electronic medical record under the Advanced Directives tab revealed the following:From date 08/08/2025 to date 08/08/2025, with an attached date of 09/10/2025 revealed a document title, Advance Directive Form. The form revealed a State OF Arizona Prehospital Medical Care Directive (Do Not Resuscitate).From date 08/27/2024 to date 08/27/2024, with an attached date of 10/18/2024, revealed a document title, Advance Directive Form. The form revealed a State OF Arizona Prehospital Medical Care Directive (Do Not Resuscitate).However, the two Advanced Directive Forms, State OF Arizona Prehospital Medical Care Directive (Do Not Resuscitate), included in Resident #3' electronic medical record contained a different date of birth . The date of birth on the Do Not Resuscitate forms were not Resident #3's date of birth . On 05/27/2026, at 11:17 AM, an interview was conducted with a Licensed Practical Nurse (LPN/Staff #98) at the nurses' station. Staff #98 stated that when a new resident is admitted , one of the paper works discussed with the resident is about advance directives, which includes the living will and medical power of attorney. She said that if the Resident did not have one, she would help facilitate, and their social service will be involved if the Resident wanted them to facilitate and help with their advance directives. She said that if the residents already have completed their advanced directives, she would ask them to bring a copy and once she received the copy, she would upload it in the Resident's electronic chart and also would have a physical copy in the hard chart. She also stated that if the Resident was DNR (Do Not Resuscitate), their admission packet has a paper that the resident and the provider would sign and once the form is filled out and signed, she would copy it in an orange colored paper. The orange colored form, or the DNR form would have the Resident's name, date of birth , DOB, hair color, eye color, and their facility doctor to complete the form. She stated that once the DNR form is completed and signed, and it matches the order and the Resident's care plan, she would upload it in the Resident's electronic medical record. During the interview, Staff #98 also looked at Resident #3's hard chart, and she stated that Resident #3 was full code and that Resident #3 should not have an orange form in her chart. Staff #98 also looked at Resident #3's electronic record under the Advance Directive tab, and she stated that the advance directive orange form in Resident #3's electronic record was uploaded on the wrong chart. She said that the form has the same first name but different last name written on top of the form. She said that Resident #3 is full code and there should not be an orange form in her chart. She said that the date of birth listed on the orange forms were not Resident #3's date of birth . She said that the document should not be in the resident's medical record because it is not the correct resident.Furthermore, Staff #98 stated that if there was an emergency she would use the hard chart, that indicates the resident's code status. She said that Resident #3's care plan indicated a full code status. She stated that there are so many steps to identify if a resident is full code or DNR. Further, she stated that for whatever reason, someone accidentally uploaded the orange form in the Resident's electronic chart.On 05/27/2026, at 11:34 AM an interview was conducted with the medical Record Coordinator (Staff #88) in her office. Staff #88 stated that her responsibilities included filing and uploading documents in the electronic record, taking care of residents' charts after they discharge, and also filing their hard chart in the resident's medical records by bringing the hard chart and putting it in their folders. She stated that when uploading documents in the electronic medical records, she would check the Resident's name and date of birth to go to the resident file. She would double check by going back to make sure it is the right resident, and if she uploads it to the wrong file, she would make sure it is redirected to the right resident's file.Regarding Resident #3, Staff #88 stated that Resident #3 is a full code, the order in the Resident's electronic medical record is s full code, the banner in the electronic medical record is full code, and the Resident's care plan has her as full code. Staff #88 opened the tab in the electronic medical record, Advance Directive, and she stated that the Advance directive should not be there because the date of birth was incorrect. She stated that the second advance directive was also not Resident #3's because the date of birth was not matching, and she said that normally when a resident is full code, the prehospital medical care directive is not filled out. She said that the impact could be not double checking what was uploaded. After looking at Resident #3's advance directive in the electronic medical record, Staff #88 removed the advance directive documents uploaded in the electronic medical record of Resident #3, and she stated that the reason was, it was an incorrect data, so now the advance directive is gone because she removed it. On 05/27/2026, at 11:48 AM, an interview was conducted with the Director of Nursing (DON/Staff #13) in her office. The DON stated that the advance directives are usually done on admission, if issues with resident not sure what they want regarding their advance directives, their social worker gets involve. The DON stated that if the resident knows what they want, the staff asked for a copy of their advance directive, get order for the Resident's code status and would be reflected in their care plan, and then she would file their advance directives under the document tab in the electronic medical record and also in the Resident's hard copy. The DON stated that during the weekends, the staff nurse uploads the advance directives, and during the weekday, the medical records uploads the documents in the electronic medical record under the documents tab.Regarding Resident #3, the DON looked at the electronic medical record of Resident #3, and she said that the Resident has a full code status, the order is full code, the care plan is full code, and the DON stated that she did not see an advance directive filed in Resident #3's electronic medical record, but that she would look in the Resident's hard chart.On 05/27/2026, at 11:55 AM, the DON entered the charting room behind the nurses' station, she grabbed Resident #3's hard copy chart and took it outside the room to the nurses' station. The DON stated that the resident wants to be full code because the form (Prehospital Medical Care Directive (Do Not Resuscitate) was not filled out. At 11:58 AM, the interview continued at the DON's office. The DON was informed that 2-advance directives were uploaded in Resident #3's electronic medical record which did not match the resident's code status and date of birth , and the forms were removed from the electronic medical record by Staff #88.A review of the facility's policy titled Advance Directives Protocol with a revised date of 10/2023, revealed that the facility respects the resident's right to make decisions relating to his or her own medical treatment.A review of the facility's policy titled Medical Records Requirements with a revision date of 10/2023, revealed that all medical and financial records information is confidential and only released with written permission from the resident or representatives or as otherwise provided by law

Based on observations, record reviews, staff interviews, and review of facility policy and procedures, the facility failed to ensure a blood pressure cuff and monitor were properly sanitized after each resident use. The deficient practice could result in transmission of infection in the facility. Findings include: During a medication administration observation conducted on March 12, 2025 at 7:27 AM a Registered Nurse (RN/staff #57), was observed to perform blood pressure (BP) testing on a resident. After the procedure, the RN was observed to place the blood pressure cuff and monitor on top of the medication cart without cleaning/sanitizing the blood pressure cuff and monitor. As the medication observation continued, at 7:52 AM the RN (staff #57) removed the same BP cuff and monitor from the top of the medication cart and carried it into another resident's room, placing the monitor on the resident's bed and wrapping the cuff on the resident's arm. After the procedure the RN returned the BP cuff and monitor to the top of the medication cart without cleaning/sanitizing them after performing the procedure on the resident. At 8:02 AM the RN (staff #57) was observed to take the same BP cuff/monitor from the top of the medication cart and carry them into a third resident's room and perform another BP procedure on the resident. After the procedure, the RN was observed to carry the BP cuff/monitor out of the resident's room and place them on top of the medication cart without cleaning/sanitizing the BP cuff or monitor. An interview was conducted with the RN (staff #57) on March 12, 2025 at 8:11 AM, who stated that resident care equipment should be sanitized between each resident use with a sanitizing wipe, and left to dry for 2 minutes. The RN also stated that she does not normally sanitize the blood pressure cuff after she uses it, unless the resident is on isolation precautions. She further stated that she was not sure what the facility policy included regarding equipment cleaning. The RN also stated that she did not sanitize the BP cuff between patient use during the medication observation. An interview was conducted with a Registered Nurse (RN/staff #61) at 8:45 AM on March 12, 2025, who stated that she keeps a blood pressure cuff/monitor in her medication cart. She also stated that the blood pressure cuff/monitor would need to be sanitized between each resident use, per the facility policy. She further stated that the cuff/monitor would be sanitized with a sanitizing wipe and left to dry for 2 minutes. An interview was conducted with the Director of Nursing (DON/staff #30) on March 12, 2025 at 11:33 AM, who stated that she expected all multi-use resident equipment to be sanitized between each resident use. Further interview was conducted with the DON (staff #30) on March 12, 2025 at 02:40 PM. The DON stated that she expected all BP cuffs to be cleaned between each resident use. She also stated that all resident equipment, including BP cuffs, should be sanitized using a disinfectant wipe, and then left to dry. She further stated that all of the nurses are educated on equipment use annually at a skills fair. She also relayed that it did not meet her expectations that the nurse did not sanitize the BP cuff between each resident use during the medication observation. The DON stated that risk of not sanitizing patient use equipment, including BP cuffs, could result in nosocomial infection/transmission. Review of a facility policy titled, Equipment Cleaning, revealed that medical equipment used in the care of the resident is cleaned with community approved disinfectant before it is stored or used for another resident. All equipment is cleaned according to manufacturers' guidelines and/or specifications.

Based on closed clinical record review, staff interviews, facility documentation and policy review and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure discharge MDS assessment was completed for one sampled resident #12. The deficient practice could result in not having resident specific information for payment and quality measures purposes. Findings include: Resident #12 was admitted on [DATE] with diagnoses of aphasia, paroxysmal atrial fibrillation, muscle weakness, lack of coordination and unsteadiness on feet. The nursing note dated November 2, 2024 revealed resident had a primary diagnosis of aphasia with right sided weakness. Per the documentation the resident was able to walk with walker and stand by assist. The social services note dated November 4, 2024 included that the resident's goal was to be discharge to skilled nursing facility in another state. Per the documentation, the resident was alert and oriented X 4 with a BIMS (brief interview for mental status) score of 15/15. The admission/5-day MDS (Minimum Data Set) assessment dated [DATE] included an entry date of November 2, 2024. The assessment was signed as complete on November 15, 2024 by the Director of Nursing (DON/staff #30). Review of the resident assessments screen in the electronic record revealed that the admission/5-day MDS assessment dated [DATE] was accepted. The social service note dated November 20, 2024 revealed that resident requested to discharge to home and back to another state with outpatient therapy on November 21, 2024 and the resident had last covered date of November 20, 2024. The nursing note dated November 20, 2024 revealed that a new order to discharge resident to home on November 21, 2024 with outpatient rehab for therapy. A physician order dated November 21, 2024 included for resident to discharge home on November 21, 2024 to outpatient rehab for therapy; and, may discharge with all medications including narcotics. The nursing note dated November 21, 2024 revealed that the resident was discharged back to another state; and, the signed the consent for medications and discharge summary. An email correspondence addressed to the Ombudsman by the social service manager and dated November 25, 2024 revealed that the Ombudsman was notified of the resident's discharge to home on November 21, 2024. Despite documentation that the resident was discharged on [DATE], the clinical record revealed no evidence that a discharge MDS assessment was completed for resident #12. A review of the facility's resident assessment electronic record screen revealed that the last assessment completed and accepted was the admission/5-day MDS assessment on November 6, 2024; and that, there were no assessments due within the next 100 days. An interview with the DON (staff #30) was conducted on March 13, 2025 at 10:02 a.m. She stated that facility's MDS coordinator/nurse was on leave and not available; and that, while the MDS nurse is out she and/or the corporate clinical reimbursement manager ensure that MDS assessment were completed. In another interview with the DON conducted on March 13, 2024 at 10:39 a.m., the DON stated that she checks the portal for any discharges/transfer on a daily basis. She said that the medical records staff also downloads a report for their discharges and gives it to her; and, the concierge will report to her if there were transfers. She stated that out of the 23 residents at the facility, there were only 5 residents admitted as short-stay. She said that if the resident was short-stay, this meant that residents were in the facility for therapy only; and, weekly IDT (interdisciplinary team) meeting were conducted to discuss the resident's individual status, goals/disease process. The DON stated that the therapy department was the driver for the discharge of residents on short-stay; and, once therapy have a projected discharge for the resident, this is communicated to the nurses on the floor and the social worker who will then ensure that resident was set for discharge. The DON said that there was ample days before the projected discharge date to issue the resident the NOMNOC. She stated that discharge MDS assessment must be completed for residents discharged from the facility. A review of the clinical record was conducted by the DON during the interview. She stated that she could not find in the clinical record that a discharge assessment was completed for resident #12. At approximately 10:45 a.m., the Corporate Director of Clinical Reimbursement (staff #27) joined the interview via the telephone. The Corporate Director of Clinical Reimbursement stated that the resident was discharged on [DATE] and she could not tell the reason why the MDS discharge assessment for resident #12 was not completed. The Corporate Director of Clinical Reimbursement further stated that it should have been completed. In another interview with the Corporate Director of Clinical Reimbursement (staff #27) and the DON (staff #30) conducted on March 13, 2025 at 11:22 a.m., the Corporate Director of Clinical Reimbursement stated that the facility has processes in place to include pulling out a report monthly from iQIES regarding missing assessments; and, reports from their electronic record software. She stated that both the reports from iQIES and their electronic record software did not show that there was missing assessment. The facility policy on MDS revised on March 2021 revealed that the MDS process is completed on residents in the SN (skilled nursing) venue. SN residents have a completed MDS according to regulatory requirements. OBRA required assessments include discharge assessment. The RAI manual included that a RAI (MDS, CAA process, and Utilization Guidelines) must be completed for any resident residing in the facility, including short-term residents. A RAI must be completed for any individual residing more than 14 days on a unit of a facility that is certified as a long-term care facility for participation in the Medicare or Medicaid programs. There are three types of discharges: two are OBRA required-return anticipated and return not anticipated; the third is Medicare required-Part A PPS Discharge. A Discharge assessment is required with all three types of discharges. Section 2.6 provides detailed instructions regarding return anticipated and return not anticipated types, and Section 2.8 provides detailed instructions regarding the Part A PPS Discharge type. Any of the following situations warrant a Discharge assessment, regardless of facility policies regarding opening and closing clinical records and bed holds such as resident is discharged from the facility to a private residence (as opposed to going on an LOA). The RAI also included that discharge assessment-return not anticipated Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days, must be completed within 14 days after the discharge date and must be submitted within 14 days after the MDS completion date.

Based on observation, staff interview and policy review the facility failed to ensure that medications were discarded according to the standard of practice. The deficient practice could result in medication misappropriation, medications being used by other residents or staff. Findings include: During a medication observation conducted on March 12, 2025 at 8:32 AM with a Registered Nurse (RN/staff #61), the RN was observed to prepare the medications for a resident, which included amlodipine 5mg, acetaminophen 500mg, and Eliquis 2.5 mg tablets. The RN crushed the medications and mixed them with pudding in a medication cup and when the RN attempted to administer the medications, the resident refused. The RN was observed to carry the mediation cup with medications out of the resident's room and dispose of them in a trash can on the medication cart. An interview was conducted with the Director of Nursing (DON/staff #30) on March 12, 2025 at 11:33 AM, who stated that all medications, except for narcotics, should be disposed of in a sharps container. On March 12, 2025 at 01:59 PM an interview was conducted an RN (staff #53), who stated that it is the facility policy to discard any unused/refused medications in a sharps container. She further stated that the risk of discarding medications in a trash can could result in another person/resident taking the medication or giving the medication to another person. Further interview was conducted on March 12, 2025 at 02:40 PM with the DON (staff #30), who stated that her expectation and the facility policy is to discard any unused/refused medications in a sharps container. She also stated that risk could result in another resident taking the medication, would be a biohazard risk. She further stated that it did not meet her expectation that the nurse placed the unused medication in the trash can during the medication observation. A facility policy titled, Medication Treatment/Management Protocol, revealed that Medications are stored/kept in a locked cabinet, medicine cart or storage area at all times, and are accessible only to the staff responsive for administration of medications. Non-controlled substances are destroyed according to state law. Non-Controlled medications that are refused are disposed of in the medication disposal container or bio-hazardous waste sharps container for destruction with other medications being destroyed.

Based on clinical record review, staff and resident interviews, and observation of current practice the facility failed to ensure resident #1 was free from abuse from an employee. The deficient practice could result in residents experiencing emotional and mental trauma from the abuse. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, acute pulmonary edema, and acute respiratory failure with hypoxia. The quarterly MDS (Minimum Data Set) assessment dated [DATE] included a BIMS (Brief Interview for Mental Status) score of 11, indicating the resident was cognitively moderate impaired. The MDS also indicated the resident had no indicators of psychosis, behaviors, rejection of care, or wandering. On November 3, 2023 at 2:44 PM the DON (Director of Nursing/Staff #30) reported an alleged abuse incident to the Arizona Department of Health Services. A review of resident #1's progress notes revealed there was no documentation regarding the alleged incident of a staff member's abuse towards the resident on November 3, 2023. Further review of resident #1's electronic health record also revealed no documentation regarding the alleged incident. An interview was conducted with resident #1 on November 28, 2023 at 8:36 AM. When asked about the alleged incident, the resident stated that a staff person used inappropriate language with him but the staff person has been fired. When asked about the name of the staff person, the resident stated it was staff #52 who was a Registered Nurse at the facility. Resident #1 indicated they currently felt safe and happy at the facility. Interviews were conducted with the following residents on November 28, 2023: Resident #17, Resident #11, and Resident #12. They all stated they currently felt safe in the facility and that staff treated them with respect. An interview was conducted on November 28, 2023 at 10:44 AM with a Registered Nurse (staff #54) who stated they remembered staff #52. Staff #54 indicated that she was not aware of any situations that occurred between staff #52 and any other residents but she was aware of the incident between staff #52 and resident #1. Staff #54 stated that staff #52 had a difficult personality and the situation was a matter of time. She also stated that staff #52 was the type of person to come into work and not give you the time of the day. When asked if resident #1 had exhibited any mood changes as a result of the alleged abuse, staff #54 denied any changes. Staff #54 also confirmed that she participates in Abuse training as a part of her annual training. An interview was conducted on November 28, 2023 at 11:44 AM with a Housekeeper (staff #55) who witnessed the alleged incident. Staff #55 stated they were a few feet outside of resident #1's room and she saw the call light go on. The resident's door was open at the time. Staff indicated they could see staff #52 at the Nurses station down the hallway ignoring the resident's call light. Staff #55 then heard staff #54 on the phone stating why are you hitting the button, why do you keep hitting the button? She then called him (resident #1) an asshole and hung up. Staff #55 observed a Certified Nurse Assistant (CNA/Staff #56) enter resident #1's room shortly after. Staff #55 then observed staff #56 come out of resident #1's room and inform an RNA what had happened. Staff #55 stated she then went to Human Resources to report the incident. When asked if staff #55 receives training on abuse, they stated they recently received the training when they were hired. A review of staff #52's personnel file was conducted on November 28, 2023. It was revealed that staff #52 had taken a course module titled Preventing, Recognizing, and Reporting Abuse on the following dates: June 29, 2020; November 11, 2021; June 4, 2022; and March 28, 2023. Additional Abuse training titled Abuse and Neglect and Abuse, Neglect, and Exploitation were completed on July 21, 2020 and March 28, 2023. An interview was conducted on November 28, 2023 at 12:42 PM with Human Resources (Staff #53). Staff #53 stated there was one disciplinary record in staff #52's file which reveals a written warning along with coaching was provided to staff #53 for unprofessional conduct with their co-workers. Staff #53 indicated they were the person who received the initial report from staff #55 regarding the alleged abuse towards resident #1. Upon hearing the initial report, they directed staff #55 to speak with the Human Resources Director (staff #53). An interview was conducted on November 29, 2023 at 9:01 AM with staff #53 in his office. When asked about his knowledge of the incident, staff #53 indicated the witness to the incident was a housekeeper who was assigned to the care center that day. The witness (staff #55) reported the alleged abuse to him and he immediately went to inform the Assistant Director of Nursing (ADON/Staff #7) which triggered the investigation process. Staff #53 stated all employees receive training on abuse upon hire and then annually thereafter. He indicated he was familiar with staff #52 and they had one disciplinary action on file. He stated that staff #52 did have a history with other employees and did not have a lot of patience with them which was addressed in a counseling plan. An interview was conducted on November 29, 2023 at 9:49 AM with the Director of Nursing (DON/Staff #30). Staff #30 indicated that after completing an internal investigation, staff #52 was terminated on November 6, 2023 due to unprofessional behavior towards a resident. Staff #30 indicated that staff #52 had a corrective action in their personnel file due to conflicts with peers but they had no complaints from other residents in the facility. A review of the facility's policy titled, Abuse/Neglect Prevention Protocol, which was last reviewed/revised December 2022, defined verbal abuse as oral language used in a disparaging or derogatory manner towards residents or families.

Based on observations, staff interviews, and policies and procedures, the facility failed to ensure that infection control standards were followed by failing to ensure the toilet seat riser available for resident use was cleaned for two residents (#1 and #2); and, failed to ensure the oxygen tubing were properly stored when not in use for two residents (#2 and #3). The deficient practice could result in the spread of infection. Findings include: Regarding resident #1 -Resident #1 was admitted on [DATE] with diagnoses that included cancer, diabetes, and multiple-resistant organisms. Review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 14 indicating the resident had no cognitive impairment. Per the MDS, the resident was frequently incontinent of bowel and bladder and required extensive assistance with toileting and hygiene needs. During an observation conducted on August 2, 2023 at 10:00 a.m., resident #1 had a gray toilet seat riser that was placed over the regular toilet located in her bathroom. The toilet seat riser had multiple dried feces underneath the right arm rest, and underneath the toilet seat. An interview with resident #1 was conducted immediately following the observation. Resident #1 stated that the toilet seat was not cleaned regularly; and, her private caregiver assisted her as needed to use the toilet but cleaning it was not a part of her job. Regarding resident #2 -Resident was admitted on [DATE] with diagnoses of pneumonia, malnutrition, and respiratory failure. The significant change MDS assessment dated [DATE] revealed a BIMS score of 14 indicating resident had no cognitive impairment. Per the MDS, the resident had an indwelling Foley catheter, required extensive assistance with toilet use and personal hygiene and was always incontinent of bowel function. The MDS also included that the resident was receiving oxygen therapy while a resident at the facility. An observation was conducted on August 2, 2023 at 10:13 a.m. Resident #2 was in bed with an oxygen concentrator at the bedside, the oxygen tubing attached on the concentrator, and the nasal cannula was coiled and tucked in on the handle of the oxygen concentrator. There was an emergency oxygen tank attached to a wheelchair located in the resident's bathroom. An oxygen tubing was attached to the emergency oxygen tank and the nasal cannula was hanging on the right arm of the wheelchair. In the resident's bathroom, a gray toilet seat riser was placed on top of a regular toilet. The toilet seat riser had multiple dried feces on the toilet seat, the handle, and the front silver metal bar where the toilet seat was attached. In an interview with resident #2 conducted immediately following the observation, resident #2 stated that he uses the oxygen daily and as needed when in bed or in a wheelchair; and goes to the bathroom with the assistance of the staff. Resident #2 stated he thinks the staff cleans the toilet seat riser after each use but he was not sure. Regarding resident #3 -Resident #3 was admitted on [DATE] with diagnoses of malnutrition and hypertension. The 14-day MDS assessment dated [DATE] revealed a BIMS score of 13 indicating the resident had intact cognition. The assessment included that the resident required extensive assistance with ADLs (activity of daily living); and that, the resident was on oxygen therapy while a resident in the facility. During an observation conducted on August 2, 2023 at 10:06 a.m. the resident was found sitting in a chair near the window. The resident had an oxygen concentrator at the bedside with an oxygen tubing attached. However, the oxygen cannula was lying directly on the bed, away from the resident. Resident #3 stated that she uses oxygen daily and the staff helps her in placing the oxygen in her nose. An interview was conducted on August 2, 2023 at about 2:00 p.m. with a certified nursing assistant (CNA/ staff #21) who stated the CNAs and the housekeeping were responsible for cleaning the toilet seat riser if they see it dirty. She stated the toilet riser should not have dried feces if it was cleaned every day. In an interview with a housekeeper (staff #11) conducted on August 2, 2023 at 2:20 p.m. the housekeeper said that if the resident's toilet riser was not clean and was with feces, the nurses were responsible for cleaning it and were supposed to call the housekeeping to disinfect the toilet riser. During an interview with the director of nursing (DON/ staff #22) conducted on August 2, 2023 at 2:40 p.m., the DON stated it was her expectation that nursing staff should be cleaning the DMEs (durable medical equipment) such as the toilet seat riser when there were visible feces on it. She stated the risk if the DMEs were not cleaned or disinfected included cross contamination and potential infection outbreak. Regarding the oxygen, the DON stated that it was her expectation that the oxygen tubing/nasal cannula is placed in a bag if not in use and changed every week. She stated the risk if oxygen tubing were not placed in the bag, included respiratory infections and MRSA (multiple resistant staphylococcus aureus). Review of the facility policy on Respiratory Therapy-Infection Control, with a revision date of December 2017 included a process to keep oxygen cannula and tubing used as needed in a plastic bag when not in use. The facility policy on Communicable Disease Outbreak Management Protocol, revealed the dedicated or disposable noncritical resident-care equipment is used or if not available, then equipment is cleaned and disinfected according to manufacturer's instructions using an EPA-registered disinfectant for healthcare setting prior to use on another resident.

Based on observations and staff interviews, the facility failed to ensure the results of the most recent survey conducted by the State agency was posted in a place readily accessible to residents and the public. Findings include: During observations conducted on all days of the survey (February 12 - 14, (YEAR)), the results of the last survey conducted by the State agency was not found. On (MONTH) 14, (YEAR), a posting Department of Health Services Survey Results Available Upon Request was observed on the wall near the nurses' station. An empty wall mount pocket file was observed below the posted sign. During an interview conducted on (MONTH) 14, (YEAR) at 2:47 p.m., the Minimum Data Set Coordinator (staff #80) stated she was not sure where the survey results were located, but that the administrator knew the location of the survey results. She returned a short time later with the survey results in a binder labeled 'Department of Health Survey Results.' During an interview conducted on (MONTH) 14, (YEAR) at 2:50 p.m., the Administrator stated the survey results were located on a shelf at the receptionist's desk. An observation of the receptionist desk revealed a counter approximately 4 feet high on the outer boundary. The interior of the desk revealed a lower desk work surface in an L shape. On the lower desk surface nine white one to one and a half inch binders with various titles on the spines was observed. One of the nine binders contained the results. The binders were not visible from the outer counter. To access the binder containing the survey results a resident would have to ask the receptionist to move or ask the receptionist for assistance to access the binder.

Based on observations, staff interview, and the facility's policy, the facility failed to ensure that there were no expired items in the medication storage room and the medication cart. Findings include: An observation of the medication storage room was conducted with a Licensed Practical Nurse (staff #79) on (MONTH) 14, (YEAR) at 7:45 a.m. The following items were observed: -One 60 cc syringe with an expiration date of (MONTH) (YEAR), -One container of Asepti wipes with an expiration date of (MONTH) (YEAR), -One container of Asepti wipes with an expiration date of (MONTH) (YEAR), -One box of powder free gloves with an expiration date of September, (YEAR), -One container of hard surface wipes with an expiration date of (MONTH) (YEAR), -One container of hard surface wipes with an expiration date of (MONTH) (YEAR). During an observation of medication cart A conducted on (MONTH) 14, (YEAR) at 8:00 a.m. with staff #79, one box of powder free gloves was observed with an expiration date of (MONTH) (YEAR). An interview was conducted on (MONTH) 14, (YEAR) at 8:30 a.m. with a Registered Nurse (staff #59). She stated that the nurses continually check for expired medications and items in the medication cart on a daily basis. Staff #59 stated that she did not know how often the items in the medication storage room are checked. She also stated there is an assigned staff to check the medication storage room for expiration dates and that it is usually the night shift nurse responsibility. The facility's policy Medication/Treatment Management included that all discontinued medications, medications with damaged labels or those having an expiration date that has passed, treatment supplies, and medications of a resident that has expired or been discharged are disposed of in accordance with federal and state regulations.

Based on clinical record review, staff interview, and the facility's policy, the facility failed to ensure that a completed copy of an advance directive was in the clinical record for one resident (#10). Findings include: Resident #10 was admitted on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a Medical Care Directive form without the resident's signature and the date. Continued review of the form revealed only a handwritten statement full code. Additional review of the form revealed it must be completed, signed in front of a witness, signed by the witness, and signed by the health care provider. An interview was conducted on (MONTH) 14, (YEAR) at 10:06 a.m. with a Licensed Practical Nurse (staff #54). She stated that upon admission, a resident is to sign an Advance Directive. Staff #54 also stated that the nurses use an admission checklist to make sure all of the admission paper work is completed including the Advance Directive. The facility's policy Advance Directives included the existence of an advance directive is documented in the medical record for residents living in the skilled nursing facility and that if the resident is unable to provide this information, it is so documented. The policy also included that if available; a copy of the advance directive is included in the front of the medical record.