Concordia Nursing & Rehab, Llc

F-F688. These deficient practices have the potential to affect all the residents residing in the facility.

It was determined the facility ' s non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) situation was related to State Operation Manual, Appendix PP, S483.70 Administration at a scope and severity of L .

The IJ began on 04/29/2025 after the survey team identified five IJs including

F-F689. Observation of bed rails on beds, care plans for residents in place; in-service provided to Administrator by Regional Director on 04/30/2025; in-service provided to nursing staff regarding policy and procedure of bed rails, assessing, consent to use and physician order required; consent forms for residents with bed rails, bed rail assessments for residents with bed rails. Six (6) residents identified as having bed rails with no assessments / consents. Assessments and consents obtained. Monitoring sheets completed on 05/08/2025 by Administrator and Director of Nursing (DON), 05/12/2025 by Housekeeping Supervisor and 05/13/2025 by Administrator and DON, for bed rail assessment and consents. File containing manufacturer guidelines for bed rails provided. The Housekeeping Supervisor confirmed they were in-serviced by the Administrator regarding bedrails, maintenance, ensuring bedrails are compatible with the bed frame, and has reviewed and will refer to guidelines if needed. Review of the in-service document date 05/02/2025 revealed the regional director in-serviced the governing body by telephone and the Administrator was in-serviced in person regarding responsibility of the governing body, survey findings, plan of removal to correct findings during survey, and plan moving forward to improve findings. A total of 6 staff interviews were conducted with staff from all shifts verifying training had been completed. The staff interviewed included Certified Nursing Assistants, Housekeeping Supervisor. The staff interviewed verified they had been trained on bed rails and enhanced barrier precautions. A review of in-service sheets provided indicated 24 staff were provided with training. Staff who were not physically present to receive the in-services were in-serviced by telephone, with the in-service information provided and

the employee acknowledging receipt and voicing understanding.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 59 045143 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045143 B. Wing 05/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Nursing & Rehab, LLC 7 Professional Drive Bella Vista, AR 72714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm 50924

Residents Affected - Many Based on facility document review, and facility policy review, it was determined that the facility failed to conduct a thorough self-assessment for facility staffing available, the competencies and training of the staff, Note: The nursing home is conduct community-based risk analysis identifying the potential natural disasters, and formulate a plan for disputing this citation. staff recruitment to meet the needs of the residents when the facility assessment was received.

The findings include:

1. A review of a facility policy titled, Facility Assessment, revised October 2024, indicated:

a. A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in the assessment. The team responsible for conducting, reviewing, and updating the facility assessment includes the Administrator, a representative of the governing body, Medical Director, Director of Nursing, Infection preventionist and a director/designee from the following departments: environmental services, physical operations, dietary services, social services, activities services, and rehabilitation services. The facility assessment includes a detailed review of

the resident population. This part of the assessment includes: Resident census data from the last 12 months, resident capacity and the occupancy rate for the late 12 months, factors that affect the overall acuity of the residents such as assistance with ADLs (Activities of Daily Living), mobility impairments, incontinence of bowel and bladder, cognitive or behavioral impairments, and conditions or diseases that require specialized care (dialysis, ventilators, wound care). A breakdown of the training, licensure, education, skill level, and measures of competency for all personnel. The current status of health information technology includes electronic health records, electronic exchange of information with organizations, and personnel access to devices, equipment, and internet.

b. The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps to determine budget, staffing, training, equipment, and supplies needed. It is separate from the Quality Assurance and Performance Improvement evaluation.

c. Our facility's ability to meet the requirements of our residents during emergency situations is a component of the facility assessment. This assessment is based on the information acquired during the assessment of operations under normal conditions, and the facility's Hazards Vulnerability Assessment conducted as part of our emergency preparedness plan.

d. Our facility's ability to address the needs of residents during emergencies of infectious disease events or outbreaks is a component of the facility assessment. This assessment is based on information acquired

during a facility-based infection control risk assessment, as well as a community-based risk assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 59 045143 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045143 B. Wing 05/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Nursing & Rehab, LLC 7 Professional Drive Bella Vista, AR 72714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 e. The facility assessment is reviewed and updated annually, and as needed. Facility or resident changes or modifications that may prompt a reassessment sooner include; A decision to provide specialized care or Level of Harm - Minimal harm or services that had not been previously available to residents; A change in the physical, environment that potential for actual harm would affect the care and services provided to our residents; A significant change in the resident census and/or overall acuity of our residents; or A change in cultural, ethnic, or religious factors that may affect the Residents Affected - Many provision of care or services.

Note: The nursing home is 2. A review of the undated Facility Assessment Profile, revealed: disputing this citation. a. A nursing service provided was Intravenous (IV) therapy. The Director of Nurses (DON) reviews the history and physical of all new referrals along with their medication list to identify equipment needed. No plan for education or training was provided to the Licensed Practical Nurses (LPN) nor outside certification tracked for IV medication administration or care of a Peripherally Inserted Center Catheter (PICC) or other IV access. The facility failed to assess/reassess their nurse's qualifications to meet their identified nursing services. These services were ordered for Resident #33 from 02/10/2025-03/20/2025.

b. No self-assessment was conducted by the facility to identify the potential for natural disasters, analysis of

the impact on the residents including staff availability, basic utilities, and goods, nor a plan for continued care. Referral was made to a separate binder labeled Emergency Preparedness Plan. This information compiled for Life Safety Code (LSC) regulations was not incorporated into the planning or development of their facility assessment.

c. No plan was outlined to identify openings or additional needs for bedside staff, ancillary staff, or department head needs. There is no recruitment plan to fill those needs and no retention for maintaining current employees. During the survey entrance conference on 04/21/2025 at 10:42 AM the Administrator reported there was no DON on staff, who was also the Minimum Data Sheet (MDS) nurse, a cooperate LPN was completing MDSs remotely. It was revealed during an Interview on 04/28/2025 at 9:42 AM the ADON stated she was also the Infection Preventionist (IP) on staff and was not able to pick up the DON duties because she was working bedside every day and barely had time to complete her own work. During an

interview on 04/22/2025 at 12:50 PM the Med Records Nurse stated it had been a while since she was able to work in medical records because she had worked the floor for six months.

d. Staffing needs by shift were outdated on the facility assessments, reflecting staffing ratios which were revoked during the 93rd General Assembly, Regular Session in 2021 and approved on 04/14/2021. The facility added an addendum to their facility assessment addressing the staffing requirements and adjustments on 08/01/2024. The addendum indicated the facility would ensure; the composition of direct care staff would include Registered Nurses (RNs), LPN,/LVNs, and Nursing Aides (NAs); each unit would be evaluated to determine specific staffing needs; adjustments to staffing would be made based on changes in resident population, such as admissions, discharges, and changes on resident needs; and the evaluation will be conducted quarterly or more frequently if significant changes in the resident population occur. There were to be shift specific staffing adjustments identified (Day, Evening, and Night Shifts) and continuous monitoring of staffing and resident care needs to ensure compliance with the new regulations. The addendum stated

this would be documented and to include the rationale for adjustments. The committee never outlined what

the staffing needs were for the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 59 045143 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045143 B. Wing 05/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Nursing & Rehab, LLC 7 Professional Drive Bella Vista, AR 72714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 52347

Residents Affected - Many Based on interviews, record review, and facility document review, it was determined that the facility failed to have an organized record management system, accurately documented and readily available to staff, nor completed medical records of the residents to ensure proper treatment, continuity of care and clarity for the facility's staff to safely care for the residents. Specifically, physician orders, comprehensive care plans, Minimum Data Sets (MDS), Medication Administration Record (MAR), and Treatment Administration Record (TAR).

The findings include:

During an interview on 04/22/2025 at 12:50 PM with Medical Record/Licensed Practical Nurse (LPN), she stated, I am medical records and have been working the floor for about 6 months and haven't been able to do medical records, but I do it whenever I can. It has been a while since I've been able to do medical records, but resident care comes first, and paperwork comes second.

On 04/22/2025 at 4:25 PM during an interview LPN #7 stated no care plans had been generated since they didn't have a Director of Nursing (DON). The residents had a closet care plan which was filled out with their admission evaluations at the time of admission. These were filled out usually by Medical Records, who was also the charge nurse.

During an interview on 04/27/2025 9:18 AM with Registered Nurse (RN) #2, she stated We had a DON here for 2 weeks. That's why we have a written MAR. Resident #184s oxygen orders were not on the chart. The written orders are no longer on the paper chart and nurses don't know where they are or where to find them.

During a medical record review on 04/23/205 at 12:45 PM, Resident #85's medical record (admitted [DATE REDACTED]) did not include a MDS which showed how the resident was assessed, a baseline care plan which directs and informs bedside staff of how to initially take care of resident until comprehensive care plan is developed, comprehensive care plan which directs and informs bedside staff how to care for the resident and what to monitor, physician progress notes which had to be emailed from the Medical Director's (MD) office, or activity notes that indicated activity participation or the offering of activities to the resident.

During a record review on 04/22/2025 at 2:00 PM, Resident #184's medical record (admitted [DATE REDACTED]) did not include a comprehensive care plan, MDS, Preadmission Screening and Resident Review (PASARR) I, provider notes, or provider orders for oxygen or continuous positive airway pressure (CPAP). No diagnoses were not found in the paper chart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 59 045143 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045143 B. Wing 05/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Nursing & Rehab, LLC 7 Professional Drive Bella Vista, AR 72714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 During an interview with the MD on 04/27/2025 at 11:18 AM, he stated when a resident is admitted from the hospital he gets a call. The nurses will ignore what the order was before the resident returned from the Level of Harm - Minimal harm or hospital. The order will be in the communication binder at the nurses' station, and I sign them off from the potential for actual harm binder. While discussing Resident #184 oxygen status and looking at the paper chart, the MD got up and left

the room two times to go look for the orders in medical records. The MD came back and stated, There is a Residents Affected - Many delay of trying to get caught up and it is my fault why notes are not in the chart. The order sheet was not in

the chart, and I could not find it. He did find one piece of paper in medical records that he stated, was in a pile. He responded, I don't know how nurses check orders or where nurses' get the orders and information from to provide care to the residents and I don't know where my order for (Resident #184s) Oxygen and CPAP is. The MD stated there was a system failure. I don't know how staff take care of residents if it's not in

the paper chart. The MD stated, I don't have anything to do with resident care plans and I don't look at them.

A lot of them come out of a book. They just do it to say they do it. He stated, I would rather have a good floor nurse than a DON. The DON does Administrator stuff, and I haven't been totally impressed by the DONs in

the past. They come in, care for the patients, and don't know them. If they just come in for a short time, their primary concern is not the patient. It's more paperwork and stuff like that and there is a lack of paperwork.

The MD didn't know if there is a Registered Nurse (RN) in the building and stated, it doesn't affect him. He was informed an RN had to be the one to do resident assessments and nine (9) assessments had not been done as required, he stated I don't know. He stated, He understands the importance of having RNs due to assessments and orders but I don't have anything to do with it.

On 04/26/25 at 1:39 PM, the Surveyor received an email from the Administrator providing some after visit summaries, history and physicals, and doctor notes and visits from the medical director for requested residents. Orders are on paper and appear to be signed as he comes in for telephone orders.

During a phone interview on 04/29/2025 at 9:42 AM the Assistant Director of Nursing (ADON), stated the DON was responsible for doing the care plans, fall assessments, and MDSs. Since there is not currently a DON, nobody had assumed those responsibilities. Some residents have one care plan in the closet, and it is not comprehensive, it is mainly about transfers, incontinence, or how they eat. She stated, I have all I can do with working the floor and keeping up with infection control.

A review of policy Resident Assessment Instrument, revision dated September 2024, indicated a comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. The Assessment Coordinator was responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviewed according to the following schedule: Within fourteen (14) days of the resident's admission to the facility; when there had been a significant change in the resident's condition; at least quarterly; and once every twelve (12) months. It revealed the comprehensive assessment helped the staff to plan care that allowed the residents to reach their highest practicable level of functioning and within seven (7) days of completion of the residents' assessment, a comprehensive care plan would be developed. All staff that completed any portion of the MDS Resident Assessment Form must sign

the assessment document attesting to the accuracy of such information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 59 045143 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045143 B. Wing 05/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Nursing & Rehab, LLC 7 Professional Drive Bella Vista, AR 72714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 A review of a facility policy, Care Plans, Comprehensive Person-Centered, revision dated July 2024, revealed a comprehensive, person-centered care plan which included measurable objectives and timetables Level of Harm - Minimal harm or to meet the resident's physical, psychosocial and functional needs is developed and implemented for each potential for actual harm resident. Care plan interventions are derived from a thorough analysis of the information gathered as part of

the comprehensive assessment. Areas of concern that are identified during the resident assessment will be Residents Affected - Many evaluated before interventions are added to the care plan. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). The Interdisciplinary Team must review and update the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment.

A review of a facility document, Director of Nursing Facility Job Posting, dated 04/23/2025, indicated the DONs responsibilities were not limited to maintaining and monitoring procedures for administration and control of medication and policies for the care, use and stocking of all nursing supplies and equipment; meet daily with critical core team members regarding admission, placement or discharge of patients, in addition, participates in coordination of patient services through departmental staff meetings and assists in the development of patient's care plans. Oversee the complete and timely completion of care plans; review all infection control reports, and pharmacy consultant reports; maintain all required records and meet monthly with the nursing staff regarding chart audits and physician orders.

A review of a facility document, Director of Nursing Job Description, undated, indicated the same information as the job posting but included plan, direct, and organize patient care, recommend the number of nursing personnel to be employed within sound fiscal guidelines and quality patient care, and meet with staff on each shift monthly providing in-services as necessary to maintain a quality nursing program.

A facility document review, Medical Director Retainer Agreement, dated January 2, 2014, indicated the MD would assume the administrative authority, responsibility, and accountability of implementing the facility's medical services, policies, and procedures; the MD would implement methods to keep the quality of care under constant surveillance; participating in the development of a system providing a medical care plan for each resident which covers medications, nursing care and other services as appropriate; and being knowledgeable concerning policies and programs of public health agencies which may affect resident care programs of the facility.

During an interview on 05/05/2025 at 11:56 AM, the Human Resources Director (HR), now former HR director, stated, I have a hard moral line, and I could not stay there anymore. She stated after the surveyors ' arrival and when items were requested, I have witnessed the Administrator [NAME] signatures on assessments for registered nurses, signing staff names to in-services, wanted me to change time punches to show an RN was in the building for eight (8) hours. Referring to a TAR for Resident #33 the HR Director stated, I knew you would know it was fake since it took so long to get it. The interim DON said there was all kinds of problems and didn't think some of the diagnoses on the MDs were right. The Interim DON left on Sunday 05/04/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 59 045143 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045143 B. Wing 05/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Nursing & Rehab, LLC 7 Professional Drive Bella Vista, AR 72714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0844 Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. Level of Harm - Minimal harm or potential for actual harm 50924

Residents Affected - Many Based on interviews, the facility failed to provide disclosure of ownership paperwork upon request.

On 04/26/2025 at 10:44 AM, a request was made to the Administrator for disclosure of ownership paperwork.

On 04/28/2025 at 12:46 PM, a request was made to the Administrator for disclosure of ownership paperwork.

On 04/29/2025 at 8:40 AM, a request was made to the Administrator for disclosure of ownership paperwork.

On 04/29/2025 at 8:40 AM, the Administrator reported that the Director of Operations was coming that day and information would be provided as requested.

On 05/06/2025 at 11:47 AM, at time of survey exit, disclosure of ownership was never provided as requested.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 59 045143 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045143 B. Wing 05/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Nursing & Rehab, LLC 7 Professional Drive Bella Vista, AR 72714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Level of Harm - Minimal harm or 50924 potential for actual harm Based on observation, interviews, record review, and facility document review, it was determined that the Residents Affected - Some facility failed to ensure the arbitration agreement, signed by residents or their representatives stated it was not a condition of admission. Note: The nursing home is disputing this citation. The findings include:

A review of the facility's undated Arbitration Agreement, and the Arbitration Checklist revealed that nowhere was the statement made, that signing the arbitration agreement was not a condition of admission. The Arbitration Agreement stated, I am signing this agreement voluntarily and with full knowledge of its terms, including that I may rescind it within ten days by written notice to the facility.

During a concurrent observation and interview on 04/28/2025 at 2:12 PM, the Business Office Manager (BOM) stated she went over the admission packet with residents and/or their representatives, which contained the Arbitration Agreement. The BOM stated she did tell them it was not a condition of admission.

The BOM was given a paper copy of the Arbitration Agreement to read over. The BOM stated the agreement stated above the signature portion it stated signing was voluntary, but did not state it was not a condition of admission.

On 05/01/2025, the Administrator stated the facility did not have a policy on arbitration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 59 045143 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045143 B. Wing 05/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Nursing & Rehab, LLC 7 Professional Drive Bella Vista, AR 72714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Level of Harm - Minimal harm or 50924 potential for actual harm Based on interviews, record review, and facility document review, it was determined that the facility failed to Residents Affected - Some ensure the arbitration agreement signed by residents or their representatives stated in case of an arbitration dispute meeting a venue which is convenient for both parties would be utilized. Note: The nursing home is disputing this citation. The findings include:

A review of the facility's undated Arbitration Agreement, and the Arbitration Checklist revealed no mention of

a convenient location for both parties in the case of an arbitration dispute.

During an interview on 04/28/2025 at 2:12 PM, the Business Office Manager (BOM) stated she went over the admission packet with residents, and/or their representatives, which contained the Arbitration Agreement.

The BOM stated she did tell them it was not a condition of admission. The BOM was given a paper copy of

the Arbitration Agreement to read over. The BOM stated the agreement did not discuss any venue details for meetings.

On 05/01/2025, the Administrator stated the facility did not have a policy on arbitration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 59 045143 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045143 B. Wing 05/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Nursing & Rehab, LLC 7 Professional Drive Bella Vista, AR 72714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 49866 potential for actual harm Based on observations, interviews, facility policy review, and document review, it was determined that the Residents Affected - Some facility failed to identify a resident, Resident #33, who required Transmission Based Precautions (TBP) for an infected wound; completed wound care without utilizing appropriate Personal Protective Equipment (PPE); and failed to identify a resident, Resident #135, who required Enhanced Barrier Precautions (EBP); failed to have Personal Protective Equipment (PPE) available; and failed to ensure staff maintained clean technique while performing urinary catheter care, to prevent the spread of infection and cross contamination. This failed practice had the potential to spread infection to two (Resident #33, #135) of two sampled residents observed for wound care and urinary catheter care.

The findings include:

A review of facility policy titled, Infection Control Guidelines for All Nursing Procedures, revision date August 2024, revealed staff must have appropriate in-service training on managing infections in residents.

A review of facility policy titled, Catheter Care, Urinary, revision date December 2007, revealed, the purpose of this procedure is to prevent infection of the resident's urinary tract.

A review of facility policy titled, Enhanced Barrier Precautions, dated 2001, revealed EBP are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. Examples of high contact resident care activities include: wound care or urinary catheter care, indicating gloves and gown are applied prior to performing the high contact resident care activity. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status. The policy revealed, staff are trained prior to caring for residents on EBPs. Signs are to be posted in the door or wall outside the residents' room indicating the type of precautions and PPE required. PPE should be available outside of the residents' rooms. EBPs are indicated for residents infected or colonized with Multidrug-resistant Pseudomonas aeruginosa.

A review of facility policy titled, Isolation, Initiating Transmission-Based Precautions, revision date October 2024, revealed Transmission Based Precautions (TBP) are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. This may include Contact Precautions, Droplet Precautions, or Airborne Precautions. It indicated the Infection Preventionist would ensure that protective equipment is maintained outside the resident's room so that anyone entering

the room can apply the appropriate equipment.

Review of Physician ' s Orders for Resident #33 revealed a wound with orders to treat involving both of the resident ' s feet.

During a hall observation for Resident #33 on 04/22/2025 at 2:19 PM, no TBP signage was posted outside

the resident ' s room. There was also no PPE available at the nurses' stations, in the halls, or next to resident rooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 59 045143 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045143 B. Wing 05/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Nursing & Rehab, LLC 7 Professional Drive Bella Vista, AR 72714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a record review on 04/23/2025 at 11:37 AM, for Resident #33, there were no current orders for TBP.

Level of Harm - Minimal harm or During a record review on 04/23/2025, for Resident #33, lab results sent to the doctor and noted by Licensed potential for actual harm Practical Nurse (LPN) #9 on 02/28/2025 at 10:30 AM, revealed Pseudomonas aeruginosa detected in the wounds. Residents Affected - Some

During a document review on 04/23/2025 at 11:00 AM, Centers for Disease Control and Prevention (CDC) was referenced on the following:

CDC: Core Infection Prevention and Control Practices and CDC Guideline for Isolation Precautions: Preventing Transmission, dated 11/27/2023, revealed gown and gloves should be worn while providing care for Multi-Drug-Resistant Organisms (MDROs).

CDC: Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, dated September 2024 revealed Contact Precautions are used (i.e., to prevent transmission of an infectious agent that is not interrupted by Standard Precautions alone and that is associated with environmental contamination), donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces. Develop and implement systems for early detection and management (e.g., use of appropriate infection control measures, including isolation precautions, PPE) of potentially infectious persons at initial points of patient encounter.

CDC: Infection Control: CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery

in all Settings, dated April 12, 2024, indicated facilities should require training before staff is allowed to perform duties and at least annually as a refresher. Use appropriate protective equipment: gloves, gowns and face masks.

During an observation and interview with Registered Nurse (RN) #4 on 04/22/2025 at 2:19 PM, RN #4 stated that morning (04/22/2025) was their first day working at the facility and they had been a wound nurse for thirty-eight (38) years. RN #4 performed hand hygiene before, during, and after providing care to Resident #33 and changed gloves multiple times during wound care. No gown was utilized for TBP precautions.

Review of Physician ' s Orders for Resident #135 revealed an order for an indwelling urinary catheter.

During a record review on 04/22/2025 at 9:00 AM, for Resident #135, there were no current orders for EBP.

During an observation on 04/22/2025 at 9:00 AM, outside of Resident #135's room, no EBP sign was posted. There was also no PPE available at the nurses' station, in the halls, or next to the residents ' room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 59 045143 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045143 B. Wing 05/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Nursing & Rehab, LLC 7 Professional Drive Bella Vista, AR 72714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an observation on 04/28/2025 at 1:00 PM, of urinary catheter care being provided to Resident #135 by Certified Nursing Assistant (CNA) #1, CNA #1 performed hand hygiene with soap and water then placed a Level of Harm - Minimal harm or mask, gown, and gloves on. She then, with her gloved hands, moved the bedside table, and removed the potential for actual harm remote controls and blanket from the resident's lap. CNA #1 then raised the bed level, using the bed controls

on the bedrail, and removed the resident's dirty brief. Without changing gloves or performing hand hygiene, Residents Affected - Some CNA #1 began peri-care with contaminated gloves. During peri-care, CNA #1 touched her mask, without changing gloves or performing hand hygiene, then continued catheter care. CNA #1 touched their face mask with contaminated gloves for a second time, then continued catheter care, without changing gloves or performing hand hygiene. After Resident #135 ' s peri-care, CNA #1 removed her mask, gown and gloves, placed them in the trash and washed her hands with soap and water.

During a hall observation on 04/25/2025 at 3:15 PM, two CNAs, #5 and #6, stated they were going to clean

an EBP resident up. They stated they had just been in-serviced on EBP but still had questions about what PPE they were to put on prior to care. This surveyor referred them to their policy or to ask the Administrator. CNA #5 said, we don't know; this is all new to us.

During an interview on 04/25/2025 at 3:32 PM, LPN #13 stated, the last in-service was yesterday about barrier precautions, catheters, wounds, covid, identifiable infections disease, and how not to transfer germs/infections. They have not had an in-service on putting on PPE.

On 04/25/2025 at 3:42 PM, the Medical Records/Licensed Practical Nurse stated, some were in-serviced on EBP yesterday, signs were up and posted at the nurses' station.

During an interview with LPN #7 on 04/25/2025 at 3:51 PM, LPN #7 stated EBP was started yesterday and had not been done prior to then.

During an interview with RN #2 on 04/27/2025 at 9:18 AM, RN #2 stated they had not had any training on EBP at this facility.

During an interview with the Medical Director (MD) on 04/27/2025 at 11:18 AM, the MD stated, There was a system failure at this facility. He did not know how the nurses found things such as: orders for the residents or how the staff took care of residents, if the orders were not in the chart, but it doesn't affect the way I take care of the residents.

During an interview on 04/28/2025 at 2:46 PM, the former Director of Nursing (DON) stated, I'm not sure what you mean by EBP. They did not wear protective gowns, but washed hands and used gloves during care but I do not know the difference between EBP or TBP.

During an interview with the Assistant Director of Nursing (ADON) on 04/29/2025 at 9:42 AM, she stated if

they had any infections, they used the book with a picture of the floor plan and highlighter to identify infections and track for any patterns. The ADON stated she has not assumed the DON responsibilities, and nobody has assumed them.

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 59 045143 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045143 B. Wing 05/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Nursing & Rehab, LLC 7 Professional Drive Bella Vista, AR 72714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0944 Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Level of Harm - Minimal harm or potential for actual harm 50924

Residents Affected - Many Based on interviews and facility document reviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training for all staff members in the facility upon hire, and provide in-services to direct staff when reviewed for required QAPI training.

The findings include:

On 04/24/2025 at 9:17 AM, a record review of the QAPI Binder, revision date of April 2023, reviewed signatures of committee dated 04/09/2025, indicated, staff are trained in QAPI systems and culture as well as QAPIs underlying principles, including the concept that systems of care and business practices must support quality care or be changed; gathering and using QAPI data in an organized and meaningful way, such as monitor and evaluate Minimum Data Set (MDS) assessment data and care plans. No trainings were located in the QAPI binder.

On 04/26/2025 at 2:18 PM, a record review of the Facility Assessment, unknown date, indicated, in-services are held monthly for the entire staff, they include: disaster drills, abuse/neglect, staff burnout, resident rights, oral hygiene, lock out tag out, elopement, dementia training/difficult residents and corona virus. No QAPI in-services listed.

On 04/26/2025 at 3:30 PM, a record review of Employee File for Certified Nurse Assistant (CNA) #1 revealed no QAPI training upon hire. Signed hiring acknowledgement training was found including abuse, neglect, misappropriation of property, and burnout.

On 04/26/2025 at 3:30 PM, a record review of Employee File for Licensed Practical Nurse (LPN) #13, revealed no QAPI training upon hire, signed hiring acknowledgement training was found including abuse, neglect, misappropriation of property, burnout, enteral feeding, tracheostomy care and suctioning.

During an interview on 04/24/2025 at 9:17 AM, the Administrator stated when she provided the book that this was all the in-services they did at the facility, and if it was not in there, they did not cover it. She stated, QAPI in-services were in the QAPI book.

During an interview on 04/28/2025 at 11:55 AM, with the Director of Operations, she stated they had QAPI meetings quarterly, the Medical Director (MD) assisted with how to fix things, put together orders, and any input needed from the Medical Director. There was not an executive team over QAPI, it did include the Administrator, Medical Director, Director of Nursing, Minimum Data Set Nurse, Business Office Manager, and herself. The Administrator ensured QAPI was implemented and monitored to ensure the plan was completed.

52347

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 59 045143 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045143 B. Wing 05/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Concordia Nursing & Rehab, LLC 7 Professional Drive Bella Vista, AR 72714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0946 Provide training in compliance and ethics.

Level of Harm - Minimal harm or 50924 potential for actual harm Based on interviews and facility document reviews, it was determined that the facility failed to provide Residents Affected - Many Compliance and Ethics training for all staff members in the facility upon hire, and provide in-services to direct staff, when reviewed for required compliance and ethics training.

The findings include:

On 04/24/2025 at 9:17 AM, a record review of Required In-Service Book, indicated in-services provided to staff included the following: dementia/behavioral training, resident rights, infection control, emergency response, abuse and neglect and misappropriation of property. These in-services were all checked off by Certified Nurse Assistant (CNA), Licensed Practical Nurse (LPN), and Registered Nurse (RN) staff.

On 04/26/2025 at 2:18 PM, a record review of the Facility Assessment, unknown date, indicated in-services are held monthly for the entire staff which included: disaster drills, abuse/neglect, staff burnout, resident rights, oral hygiene, lock out tag out, elopement, dementia training/difficult residents and corona virus . No compliance and ethics in-services were listed.

During an interview on 04/24/2025 at 9:17 AM, the Administrator stated when she provided the book that this was all the in-services they did at the facility, and if it was not in there, they did not cover it. When asked specifically about ethics training, she did not respond.

During an interview on 04/25/2025 at 1:55 PM, Certified Nursing Assistant (CNA) #1, stated all in-services that were provided were done by the Administrator. The in-services that were done included: abuse, fire, evacuation, gait and transfer, infection control, falls and that was all. CNA #1 said, we had enhanced barrier precautions today, but no training on this before, we did not even know what it was.

On 04/26/2025 at 3:30 PM, a record review of Employee File for Certified Nurse Assistant (CNA) #1, revealed no Compliance and Ethics training upon hire. A signed hiring acknowledgement training was found including: abuse, neglect, misappropriation of property and burnout.

On 04/26/2025 at 3:30 PM, a record review of Employee File for Licensed Practical Nurse (LPN) #13 revealed no Compliance and Ethics training upon hire. A signed hiring acknowledgement training was found including: abuse, neglect, misappropriation of property, burnout, enteral feeding, tracheostomy care and suctioning.

52347

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 59 045143