Every finding on record at Norfolk Health Care Center

The facility staff failed to implement the facility abuse policies for one Resident (Resident #1) of 2 residents in the survey sample.The findings included:The facility staff failed to implement their abuse policy and report an unusual occurrence that resulted in a missing person report being filed for Resident #1, who a Certified Nursing Assistant/Aide (CNA B) was not trained on LOA (leave of absence) permitted Resident #1 to leave the facility for approximately 3 days without family or nursing staff knowledge. The Resident was returned by his daughter/power of attorney (POA) approximately 72 hours after his departure with a cousin.Resident #1 was admitted on [DATE] with diagnoses including Stroke, hypertension, chronic systolic heart failure, left sided hemiparesis, and aphasia. The Resident's face sheet listed the Resident's daughter as his POA for financial and medical decision making. The Document was not derived until 3-10-26 upon his return to the facility. Prior to that he was his own decision maker. The Resident's most recent Minimum data set (MDS) federally mandated assessment was dated 2-25-26 and was a quarterly review. The Resident had a Brief Interview for Mental Status (BIMS) score of 7 of a possible 15 points indicating moderate cognitive impairment. The Resident also required assistance with all activities of daily living.On 3-12-26, facility staff and Resident #1 were interviewed, and the facility Administrator was asked for the full facility investigation into the incident. Those records and interviews revealed the following timeline of events in chronological order.On 3-7-26 at approximately 2:00 P.M. Resident #1 left the facility and was signed out for a LOA by a family member identified as a cousin by family, which was documented by her signature on the facility sign out sheets. Licensed Practical Nurse (LPN #1) recounted that Resident #1 went out with family for a cookout and would return at approximately 7:00 P.M. that same night. LPN #1 Stated she was told that by CNA #2. LPN #1 gave that report to the oncoming LPN and left the building at the end of her shift at 7:00 P.M The Director of Medical Records was the Manager on Duty (MOD) that day and stated she had also seen Resident #1 exit with the family member and they told her he was going out to a cookout and would be back later in the evening. She stated she asked them if he had been signed out, and both the cousin and the Resident stated yes. On Sunday 3-8-26 LPN #1 became concerned as the Resident was not yet back in the building to receive his medications, and so she called the Resident's daughter to find out when he would be returning, and that is when the daughter found out he was missing and the family actually had no idea he was missing and they had not removed him.An interview conducted with the Administrator on 3-12-26 @ 1:00 P.M. revealed that CNA #2 helped him leave, (which was an error). The Administrator further stated that CNA #2 was currently suspended and would be terminated. The Administrator went on to say that staff members have either resigned or been terminated with respect to their roles in this situation. On 3-8-26 the Administrator was made aware of the incident by LPN #2 (on call nurse manager) via a phone call, as she had been contacted by LPN #1 who was onsite with concerns. On 3-9-26 The daughter was made aware of the incident and was irate understandably according to the Administrator who also stated the daughter was made aware on the evening of 3-8-26, however, she did not come to the facility until 3-9-26. The Administrator also called local police and issued a missing person's complaint. The Administrator told the daughter the name of the individual who signed Resident #1 out, and the daughter calmed down after learning the name of the person who took the Resident out. The Daughter stated to the Administrator that she had a cousin by that name. On 3-9-26 at 3:38 P.M. the state agency received this anonymous complaint, 2 days after the incident occurred. The complaint has an addendum which stated that the Resident called in a report to the state agency when he found out he had been deemed a missing person and wished to discharge from the facility and called to say he was making his own decisions regarding discharge.No report to the state agency was ever made by the facility for this unusual occurrence as per the facility's abuse policy. The facility received the Resident back on 3-10-26 after the daughter was called and alerted by a near by Hospital that Resident #1 had been left there by the cousin in the emergency room. He was evaluated there and needed no care, so the daughter returned him to the facility.On 3-10-26 The daughter gave the facility 2 POA's (financial & medical) that were completed on that day and attested as signed by the Resident in front of a notary public, possibly at the hospital.The facility investigation was reviewed and included staff interviews, QAPI (quality assurance and process improvement) plan, and ongoing education with staff sign-in sheets on the LOA process which were being conducted. The Administrator stated the education on LOA would continue being conducted upon hire, and (since re-started on 3-10-26), would be conducted for all staff currently as they come to work until everyone has received it. The investigation was not complete and did not include statements from residents, nor all individuals involved in the incident, nor did it indicate the chronology of events that would lead to a conclusion for planning of comprehensive corrections to the failed LOA policy. Further, no initial report nor 5 day follow up report was ever sent to the state agency as mandated by law.The facility policy on abuse titled, Abuse/Neglect/Misappropriation/Crime- Administrative Reference Guide, with an effective date of 1/23/2020 was reviewed. The policy read in part, . 4. Centers are to report to teh State Survey Agency any unusual incidents or occurrences. Examples of unusual occurrences include: a. Any event involving a patient that is likely to result in legal action . h. Any unusual event involving a patient or patients that may result in media coverage or law enforcement involvement . With regard to reporting the abuse policy indicated that reports are to be made to the state agency but not later than 2 hours after the allegation is made if the allegation involves abuse or not later than 24 hours if the allegation does not involve abuse. The document revealed that a through investigation should be conducted and findings submitted to the state agency within 5 working days of the incident. On 3-12-26 The Resident had been in the facility since his return on 3-10-26 with no issues. The Resident was interviewed and wanted to go home, and had a good time while I was out, however, he has cognitive decline and hemiparesis due to a stroke and is unable to care for himself. His daughter is a college student and unable to care for her father, therefore no discharge plan has been initiated.Resident #1 was permitted to leave the facility with a family member incorrectly and unsafely, with no medications and no plan. The Resident was assisted by a staff member who was not trained to provide a safe LOA, however, as he was his own responsible party at the time he insisted and left. The Administrator and Director of Nursing (DON) were made aware of the findings at the end of day debriefing on 3-12-26. They both stated they had no further information to provide.

Based on staff interview, Resident interview, clinical record review, and facility documentation review, the facility staff failed to maintain competency necessary to care for resident needs in Nursing Aide proficiency related to leaves of absence (LOA) for one Resident (Resident #1) of 2 Residents in the survey sample. The findings included:Certified Nursing Assistant/Aide (CNA B) was found to have not been trained on LOA which she provided to Resident #1 resulting in him leaving the facility for approximately 3 days without family or nursing staff knowledge. The Resident was returned by his daughter/power of attorney (POA) approximately 72 hours after his departure with a cousin.Resident #1 was admitted on [DATE] with diagnoses including Stroke, hypertension, chronic systolic heart failure, left sided hemiparesis, and aphasia. The Resident's face sheet listed the Resident's daughter as his POA for financial and medical decision making. The Document was not derived until 3-10-26 upon his return to the facility. Prior to that he was his own decision maker. The Resident's most recent Minimum data set (MDS) federally mandated assessment was dated 2-25-26 and was a quarterly review. The Resident had a Brief Interview for Mental Status (BIMS) score of 7 of a possible 15 points indicating moderate cognitive impairment. The Resident also required assistance with all activities of daily living.Staff and the Resident were interviewed, and the facility Administrator was asked for the full facility investigation into the incident. Those records and interviews revealed the following timeline of events in chronological order.On 3-7-26 at approximately 2:00 P.M. Resident #1 left the facility and was signed out for a LOA by a family member identified as a cousin by family, which was documented by her signature on the facility sign out sheets. Licensed Practical Nurse (LPN #1) recounted that Resident #1 went out with family for a cookout and would return at approximately 7:00 P.M. that same night. LPN #1 Stated she was told that by CNA #2. LPN #1 gave that report to the oncoming LPN and left the building at the end of her shift at 7:00 P.M The Director of Medical Records was the Manager on Duty (MOD) that day and stated she had also seen Resident #1 exit with the family member and they told her he was going out to a cookout and would be back later in the evening. She stated she asked them if he had been signed out, and both the cousin and the Resident stated yes. On Sunday 3-8-26 LPN #1 became concerned as the Resident was not yet back in the building to receive his medications, and so she called the Resident's daughter to find out when he would be returning, and that is when the daughter found out he was missing and the family actually had no idea he was missing and they had not removed him.An interview conducted with the Administrator on 3-12-26 @ 1:00 P.M. revealed that CNA #2 helped him leave, (which was an error). The Administrator further stated that CNA #2 was currently suspended and would be terminated. The Administrator went on to say that staff members have either resigned or been terminated with respect to their roles in this situation. On 3-8-26 the Administrator was made aware of the incident by LPN #2 (on call nurse manager) via a phone call, as she had been contacted by LPN #1 who was onsite with concerns. On 3-9-26 The daughter was made aware of the incident and was irate understandably according to the Administrator who also stated the daughter was made aware on the evening of 3-8-26, however, she did not come to the facility until 3-9-26. The Administrator also called local police and issued a missing person's complaint. The Administrator told the daughter the name of the individual who signed Resident #1 out, and the daughter calmed down after learning the name of the person who took the Resident out. The Daughter stated to the Administrator that she had a cousin by that name. On 3-9-26 at 3:38 P.M. the state agency received this anonymous complaint, 2 days after the incident occurred. The complaint has an addendum which stated that the Resident called in a report to the state agency when he found out he had been deemed a missing person and wished to discharge from the facility and called to say he was making his own decisions regarding discharge.No report to the state agency was ever made by the facility. The facility received the Resident back on 3-10-26 after the daughter was called and alerted by a near by Hospital that Resident #1 had been left there by the cousin in the emergency room. He was evaluated there and needed no care, so the daughter returned him to the facility.On 3-10-26 The daughter gave the facility 2 POA's (financial & medical) that were completed on that day and attested as signed by the Resident in front of a notary public, possibly at the hospital.Other LOAs were reviewed in consideration of the allegations, and only 1 Resident was found to have used the LOA in 6 months (Resident #2). Those records were reviewed and followed the facility policy without incident. The facility investigation was reviewed and included staff interviews, QAPI (quality assurance and process improvement) plan, and ongoing education with staff sign-in sheets on the LOA process which were being conducted. The Administrator stated the education on LOA would continue being conducted upon hire, and (since re-started on 3-10-26), would be conducted for all staff currently as they come to work until everyone has received it. The investigation was not complete and did not include statements from residents, nor all individuals involved in the incident, nor did it indicate the chronology of events that would lead to a conclusion for planning of comprehensive corrections to the failed LOA policy. Further, no initial report nor 5 day follow up report was ever sent to the state agency as mandated by law.On 3-12-26 The Resident had been in the facility since his return on 3-10-26 with no issues. The Resident was interviewed and wanted to go home, and had a good time while I was out, however, he has cognitive decline and hemiparesis due to a stroke and is unable to care for himself. His daughter is a college student and unable to care for her father, therefore no discharge plan has been initiated.Review of the facility LOA policy revealed that the patient or Responsible party must notify a licensed nurse on the unit prior to leaving, and an estimated time of return to be included. The Resident will receive medications, and an LOA will be documented in the medical record. The policy goes on to say that the Administrator, or business office manager, or admissions director must be made aware if the Resident will not return the same day. The Resident left with a family member incorrectly and unsafely with no medications and no plan. The Resident was assisted by a staff member who was not trained to provide a safe LOA, however, as he was his own responsible party at the time he insisted and left. The Administrator and Director of Nursing (DON) were made aware of the findings at the end of day debriefing on 3-12-26. They both stated they had no further information to provide.

Based on observations, resident and staff interviews, and clinical record review, the facility staff failed to ensure that 3 of 28 residents (Residents #108, #107, and #124) in the survey sample had meals served that followed the menu and meal tickets. The findings included: 1. The facility's staff failed to serve food items according to the menu and meal ticket. Resident #108 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included stroke, renal failure, and heart failure. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/13/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated that Resident #108's cognitive abilities for daily decision-making were moderately impaired. In section GG (Functional Abilities and Goals), the resident was coded as requiring setup or clean-up assistance with eating, dependent with oral hygiene, toileting hygiene, showers/bathes, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, rolling, and sit-to-lying. On 1/13/25 at approximately 12:30 PM, an observation was made of Resident #108 during the lunch meal. The meal served was roasted pork with gravy, beets, mashed potatoes, a biscuit, and an apple dessert. The menu and the resident's personal meal ticket read that the resident was to receive cornbread, not a biscuit. The resident's meal ticket dated 1/13/26 for the lunch meal read: fluids restricted to 1200 milliliters per day. A regular diet: Roasted pork 3 ounces, pork gravy 2 ounces, Harvard beets 1/2 cup, creamy mashed potatoes 4 ounces, corn bread 1 piece, margarine 1 each, apple crisp 1/2 cup, allowed one 8-ounce beverage. On 1/14/26 at approximately 4:25 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that he didn't have cornbread for the meal on 1/13/26 because the food delivery didn't occur when it was supposed to. He also said that the cornbread substitute was not updated on the menu or on residents' personal meal tickets to notify them of the change, due to the difficulties with the menu/meal ticket software. On 1/14/26 at approximately 5:50 PM, a final interview was conducted with the Administrator, Director of Nursing, the Regional [NAME] President, and the Regional Nurse Consultant. An opportunity was provided for the facility to provide feedback, but they offered none. 2. The facility's staff failed to serve food items according to the menu and meal ticket to serve chopped meat to a resident on a mechanically advanced/chopped diet on 1/13/26. Resident #107 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included tracheostomy, diabetes, PVD, and heart failure. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/25/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #107's cognitive abilities for daily decision making were intact. The residents' meal ticket dated 1/13/26 read: mechanical advanced/chopped diabetic diet. Serve a mechanical advanced/chopped roasted pork loin 3 ounces, pork gravy 2 ounces, diced beets 1/2 cup, creamy mashed potatoes 4 ounces, a dinner roll, 1, margarine 1 each, apple crisp 1/4 of a cup, 2% milk 8 ounces, and hot coffee or hot tea 6 ounces. In section GG (Functional Abilities and Goals), the resident was coded as requiring setup or clean-up assistance with eating, substantial/maximal assistance with oral hygiene, was dependent with toileting hygiene, showers/bathes, upper body dressing, lower body dressing, putting on and taking off footwear, and personal hygiene. The resident also required partial/moderate assistance with rolling and sit-to-lying. On 1/13/25 at approximately 12:41 PM, an observation was made of Resident #107 during the lunch meal. The residents' meal consisted of a whole slice of roasted pork with gravy (this should have been chopped roasted pork per the meal ticket), diced beets, mashed potatoes, a biscuit (the menu and meal ticket read a dinner roll was to be served), and an apple dessert. On 1/14/26 at approximately 4:25 PM, an interview was conducted with the Dietary Manager (DM). The DM further stated that it was an error that the residents' pork loin was not chopped, and he would in-service the staff on the foodservice line to be more aware of what is on the meal tickets. The DM further stated that he didn't have dinner rolls for the lunch meal on 1/13/26 because the food delivery didn't occur when it was supposed to. He also said that the dinner roll substitute was not updated on the menu or on residents' personal meal tickets to notify them of the change, due to the difficulties with the menu/meal ticket software. On 1/14/26 at approximately 5:50 PM, a final interview was conducted with the Administrator, Director of Nursing, the Regional [NAME] President, and the Regional Nurse Consultant. An opportunity was provided for the facility to provide feedback, but they offered none. 3. The facility staff failed to serve portion of food listed on the menu. Resident #124 was originally admitted to the facility 3/03/17 from an acute care facility and re-admitted on [DATE]. The current diagnoses included; Dysphagia, Mechanically Altered PO Intake and Cerebral Palsy. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/03/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #124 cognitive abilities for daily decision making were intact. In Section GG (Functional Abilities and Goals) the resident was coded as using suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. On 1/13/26 at approximately 11:50 am., Resident #124 was observed sitting in his wheelchair outside of his room. The resident stated I want my food to get my weight back; I don't have enough fat on me. The resident was asked if he was getting extra portions of food, he said no and I ask all of the time. He also said, I want you to look at my tray when they bring it. On 1/13/26 at approximately 12:14 pm., an observation of the resident's meal and tray was conducted at lunch time. The residents' meal consisted of Roasted Pork Loin, Pork Gravy, Diced Harvard Beets, Creamy Mashed Potatoes, a Biscuit and Apple Crisp. The resident's meal ticket listed all of the above including Cornbread that was not present on the resident's tray but 1 biscuit was observed on the resident's tray instead. The resident said that it comes like that sometimes but I got to get my weight up. On 1/13/26 at approximately 3:20 pm., an end-of-day meeting was conducted with the Administrator and with the Director of Nursing (DON) concerning the above issues. The DON said that the meal ticket should be followed due to weight loss, the resident gets double portions. On 1/14/26 at approximately 11:30 am., Resident #124 said that he was going out to eat lunch today. On 1/14/26 at approximately 4:35 pm., an interview was conducted with the Dietary Manager (DM) concerning Resident #124. The DM said that there was no cornbread mix available, so the resident was served a biscuit instead. On 1/14/26 at approximately 5:45 pm., the above findings were shared with the Administrator, Director of Nursing, the Regional Nurse Consultant and the Regional [NAME] President. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on resident interview, staff interview, and clinical record review the facility staff failed to provide needed durable medical equipment and home health services in a timely manner for 1 of 27 residents (Resident #115), in the survey sample. The findings included: Resident #115 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #115 was originally admitted to the facility 10/29/25. The diagnoses included; atherosclerotic heart disease of native coronary artery without angina pectoris, morbid obesity due to excess calories, end stage renal disease, and muscle weakness. The discharge Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/27/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #115's cognitive abilities for daily decision making were intact.On 1/13/26 at 12:08 PM an interview was conducted with Resident #115. Resident #115 stated that she was discharge from the facility to home on [DATE] and a physicians order was written for a bedside commode and a front-wheeled walker to be delivered to her home, as well as a physician's order for home health services which included nursing and physical therapy services. Resident #115 also stated that the bedside commode and the front-wheeled walker was not delivered to her home until 12/30/25 and home health services did not begin services until 1/3/26. Resident #115 further stated that she had to use a bedpan for 4 days and due to her limited mobility, it was very difficult on her body and mental state. Resident #115 lastly stated that due to not having home health services and physical therapy for a week after arriving home, her body became weaker and one of her legs became flaccid. On 1/14/26 at 11:05 AM an interview was conducted with the Director of Social Services. The Director of Social Services stated Resident #115 was discharged from the facility to home on [DATE]. The Director of Social Services also stated that the bedside commode and the front-wheeled walker did not arrive to Resident #115's home until 12/30/25 and home health services did not begin until 1/3/26. The Director of Social Services further stated, It is an issue them not delivering the DME (durable medical equipment) until 12/30/25 and the HH company not showing up until 1/3/26. It is not typical for this to occur.On 1/14/26 at 12:38 PM an interview was conducted with the Director of Rehabilitation. The Director of Rehabilitation stated that prior to Resident #115 being discharged from the facility to home, she gave Resident #115 a bedpan to go home with since the bedside commode was not going to be at the home prior to the resident's arrival home. The Director of Rehabilitation also stated that she went to Resident #115 home on [DATE] to set up the bedside commode due to the Durable Medical Equipment provider not being able to set the equipment up. The Director of Rehabilitation further stated that it was an issue that the bedside commode and the home health provider did not show up in a reasonable time frame, however this is not a normal occurrence. On 1/14/26 at 5:40 PM an interview was conducted with the Administrator. The Administrator stated that it was not acceptable that the bedside commode and the front-wheeled walker was delivered to Resident #115's home on [DATE]. The Administrator also stated that it was not an acceptable time frame regarding the home health provider starting services a week after Resident #115 arrived home from the facility. Discharge Planning Progress Notes included the following notations: 12/30/2025 12:05 PM: Ms. [NAME] called stating that her DME has not been delivered and that the PCA company called her stating that per the Medicaid portal, it shows that Ms. [NAME] is on a spend down and they are no longer able to cover PCA services. SW reached out to adapt health and spoke with Ms. [NAME] regarding ETA for DME. Per Ms. [NAME] the BSC and rollator will now be arriving today between 11:35am - 1:35pm. 12/30/2025 5:08 PM: Ms. [NAME] informed SW that the DME was delivered, however they did not set up the BSC, SW called adapt health to see if they can send someone over to at least set it up, per adapt health rep they would not be able send any one over to set it up. SW notified IDT team. Rehab director stated she would stop by the house and set it up for her. SW asked Ms. [NAME] if it was okay for our rehab director to stop by to help set it up. Ms. [NAME] was grateful and stated yes that is fine. SW also informed Ms. [NAME] that due to her HH not returning her calls, SW will send out another HH referral to a different company. No other needs or concerns reported at this time. SW will continue to follow up. 12/31/2025 1:22 PM: SW sent HH referral to Enhabit, Interim, Westminister [NAME], Medi USA, Centerwell, Adoration, and Hope-in-Home. SW will follow up. Continue POC. 12/31/2025 4:29 PM: Ms. [NAME] contacted SW regarding her HH. Ms. [NAME] informed SW that Amedysis contacted her and informed her that they will begin services on Saturday, 1/3/26. On 1/14/26 at approximately 5:50 PM, a final interview was conducted with the Administrator, Director of Nursing, Regional Director of Clinical Services, and [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on observations, resident and staff interviews, and clinical record review, the facility staff failed to ensure that 4 of 28 residents (Residents #124, #122, #108, and #107) in the survey sample received fluids as listed on the menu, per their preferences, or as ordered. The findings included: 1.The facility staff failed to serve a beverage listed on the menu. Resident #124 was originally admitted to the facility 3/03/17 from an acute care facility and re-admitted on [DATE]. The current diagnoses included; Dysphagia, Mechanically Altered PO Intake and Cerebral Palsy. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/03/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #124 cognitive abilities for daily decision making were intact. In Section GG (Functional Abilities and Goals) the resident was coded as using suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. On 1/13/26 at approximately 12:14 pm., an observation of the resident's meal ticket at lunch time read Hot Coffee or Hot Tea. Resident #124 overheard his roommate complaining to the nurse about not having anything to drink brought in with his lunch. Resident #124 said that he didn't get anything to drink either, holding up his water bottle, saying I can drink this. On 1/13/26 at approximately 3:20 pm., an end-of-day meeting was conducted with the Administrator and with the Director of Nursing (DON) concerning the above issues. The DON said that the meal ticket should be followed. On 1/14/26 at approximately 4:35 pm., an interview was conducted with the Dietary Manager (DM) concerning Resident #124. The DM said that beverages should have been available. On 1/14/26 at approximately 5:45 pm., the above findings were shared with the Administrator, Director of Nursing, the Regional Nurse Consultant and the Regional [NAME] President. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. 2.The facility staff failed to serve a beverage listed on the menu. Resident #122 was originally admitted to the facility 10/26/19 from an acute care facility and re-admitted on [DATE]. The current diagnoses includes: Moderate Protein Calorie Malnutrition. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/01/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #122 cognitive abilities for daily decision making were intact. On 1/13/26 at approximately 12:00 pm., during rounds was approached by Resident #122 concerning the poor services he's receiving from the nursing and dietary staff. On 1/13/26 at approximately 12:16 pm., an observation of the resident's meal and tray was conducted at lunch time. The resident's meal ticket listed Hot tea or Coffee no beverage was observed on the resident's tray other than what he already had on his bedside table. The resident was overheard asking for his tea or coffee to LPN #2. LPN #2 was observed shrugging her shoulders, leaving the room but not returning with a beverage. On 1/13/26 at approximately 3:20 pm., an end-of-day meeting was conducted with the Administrator and with the Director of Nursing (DON) concerning the above issues. The DON said that the meal ticket should be followed. On 1/14/26 at approximately 4:35 pm., an interview was conducted with the Dietary Manager (DM) concerning Resident #122. The DM said that the resident's should have received their beverages. On 1/14/26 at approximately 5:45 pm., the above findings were shared with the Administrator, Director of Nursing, the Regional Nurse Consultant and the Regional [NAME] President. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. 3. The facility's staff failed to serve an 8 ounce beverage according to the menu and the residents' personalized meal ticket. Resident #108 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included stroke, renal failure, and heart failure. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/13/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated that Resident #108's cognitive abilities for daily decision-making were moderately impaired. In section GG (Functional Abilities and Goals), the resident was coded as requiring setup or clean-up assistance with eating, dependent with oral hygiene, toileting hygiene, showers/bathes, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, rolling, and sit-to-lying. On 1/13/25 at approximately 12:30 PM, an observation was made of Resident #108 during the lunch meal. The meal served was roasted pork with gravy, beets, mashed potatoes, a biscuit, and an apple dessert. No fluids were served. An interview was conducted with the Certified Nursing Assistant (CNA) #1 at approximately 12:33 PM. She was observed in the hallway distributing trays and drinks. CNA #1 stated she did not provide the resident with a drink because he had a water pitcher at bedside. CNA #1 asked if I wanted the resident to have a glass of tea, and I responded that she should proceed according to the facility's protocol. The menu stated that residents were to receive an 8-ounce and a 6-ounce beverage at lunch. Resident #108's beverages were restricted to 1200 milliliters per day, with an allowance of 8 ounces at lunch, which was not provided. The resident's lunch meal ticket read: allowed one 8-ounce beverage. On 1/14/26 at approximately 12:25 PM, the resident was observed in bed with the lunch meal before him, and the Assistant Director of Nursing (ADON) was present. The meal consisted of a thick piece of breaded chicken, mixed vegetables, and rice. No fluids were served to him. The ADON stated that, based on the residents' meal ticket, he should have received an 8-ounce beverage with his lunch. The ADON further said she would ensure the resident received his beverage of choice. On 1/14/26 at approximately 4:25 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that the resident was supposed to receive his meal as planned on the menu, with modifications based solely on his personal preferences and limitations, as ordered by the physician. The DM stated that drinks had been spilling onto the trays; therefore, a decision was made to send beverages up separately to avoid spills that ruined meals. He also stated that no one had raised concerns about the beverage distribution method, so he was unaware that not all residents were receiving beverages in accordance with the menu, preferences, and physician orders. The DM stated he would address the concern with the administrative team so they could strategize on a solution. On 1/14/26 at approximately 5:50 PM, a final interview was conducted with the Administrator, Director of Nursing, the Regional [NAME] President, and the Regional Nurse Consultant. An opportunity was provided for the facility to provide feedback, but they offered none. 4. The facility's staff failed to serve an 8 ounce beverage and a 6 ounce beverage to Resident #107, according to the menu and the residents' personalized meal ticket. Resident #107 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included tracheostomy, diabetes, PVD, and heart failure. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/25/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #107's cognitive abilities for daily decision making were intact. In section GG (Functional Abilities and Goals), the resident was coded as requiring setup or clean-up assistance with eating, substantial/maximal assistance with oral hygiene, was dependent with toileting hygiene, showers/bathes, upper body dressing, lower body dressing, putting on and taking off footwear, and personal hygiene. The resident also required partial/moderate assistance with rolling and sit-to-lying. On 1/13/25 at approximately 12:41 PM, an observation was made of Resident #107 during the lunch meal. The residents' meal consisted of a whole slice of roasted pork with gravy (this should have been chopped per the meal ticket), diced beets, mashed potatoes, a biscuit, and an apple dessert. No fluids were served. The menu stated that residents were to receive an 8-ounce and a 6-ounce beverage at lunch. Resident #107's lunch meal ticket read: 2 percent milk, 8 ounces, and hot coffee or hot tea, 6 ounces. On 1/14/25 at approximately 12:37 PM, an observation was made with the ADON of Resident #107 during the lunch meal. The resident's meal consisted of chopped, breaded chicken, mixed vegetables, and rice. No fluids were served with the meal. The ADON stated that, based on the Resident #107's meal ticket, he should have received an 8-ounce and a 6 ounce beverage with his lunch. The ADON further stated she would ensure the resident received his beverages of choice. On 1/14/26 at approximately 4:25 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that the resident was supposed to receive his meal as planned on the menu, with modifications based solely on his personal preferences and limitations, as ordered by the physician. The DM stated that it was an error in the menu software to offer milk at lunch, as the facility does not provide milk during lunch. The DM stated that drinks had been spilling onto the trays; therefore, a decision was made to send beverages up separately to avoid spills that ruined meals. He also stated that no one had raised concerns about the beverage distribution method, so he was unaware that not all residents were receiving beverages in accordance with the menu, preferences, and physician orders. The DM stated he would address the concern with the administrative team so they could strategize on a solution. On 1/14/26 at approximately 5:50 PM, a final interview was conducted with the Administrator, Director of Nursing, the Regional [NAME] President, and the Regional Nurse Consultant. An opportunity was provided for the facility to provide feedback, but they offered none

Based on observation, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure an enhanced barrier precaution sign was posted for 1 resident to prevent the spread of infection for 1 of 28 residents (Resident # 117), in the survey sample.The findings include: Resident #117 was originally admitted to the facility 10/23/25 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Tracheostomy Status. The discharge Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/17/25 coded the resident as having short-term memory loss which indicated Resident #117 cognitive abilities for daily decision making were moderately impaired. Section K (Swallowing/Nutritional Status) coded the resident as having a Feeding Tube. A review of the Physician's order Summary for December 2025 read Enhanced Precaution r/t Trach every shift. Active from 11/04/25. On 1/13/26 and during the initial tour of the facility at approximately, no Enhanced Barrier (EHB) signage was observed on Resident's door or wall before entering room [ROOM NUMBER] B.On 1/14/26 no EHB signage was observed on the resident's door or wall of room [ROOM NUMBER] B. The resident was observed resting quietly in bed with her eyes closed, Tracheostomy attached, enteral feeding observed at the bedsideOn 1/14/26 interviews were conducted at 11:45 am., with staff on unit 1, 2nd floor concerning EHB precautions. Certified Nursing Assistant # 3 (CNA) was asked to explain why some of the rooms on the unit displayed EHB signage on the wall before entering a residents room. CNA #3 said that they were in- serviced on EHB Precautions, and only residents with tracheostomies, feeding tubes, staff must follow the EHB signs on what to wear such as gowns, masks, gloves, providing ADL care, and changing briefs.On 1/14/26 at approximately 11:55 am., an interview was conducted with Registered Nurse #1 concerning EHB precaution signage. RN #1 said that if a resident has a PICC Line, Trach., or attends dialysis they should be on EHB Precautions. RN #1 was asked if Resident #117 should be under EHB precautions. RN #1 said yes, there should have been EHB signage on the door or wall. RN #1 also said because the resident was moved to another room yesterday, no signage was put up.Throughout the course of the survey EHB Precaution signs were observed on all floors. The signage read: STOP! Perform hand hygiene using soap and water and or alcohol-based hand rub before entering room and before exiting room. Wear gown and gloves when entering room to provide the following high-contact resident care activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing hygiene, Changing briefs or assisting with toileting, Device care or use: central line urinary catheter, feeding tube, tracheostomy, wound care: any sin opening requiring a dressing, Bag linen and discard trash to prevent contamination of self, environment or outside bag.On 1/14/26 at approximately 5:45 pm., the above findings were shared with the Administrator, Director of Nursing, the Regional Nurse Consultant and the Regional [NAME] President. The DON said there was signage on the door of the resident's room (room [ROOM NUMBER] B). The DON was informed by the surveyor that no signage was observed on the resident's wall or door since rounds were conducted from 1/12/26 through 1/14/26. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observations, resident interviews, staff interviews, and clinical record review, the facility staff failed to maintain a sanitary and comfortable environment for all.The findings included: 1. The facility staff failed to provide a sanitary and comfortable environment in the 200-unit. On 1/12/25, it took 12 minutes from the time the call button was activated until the elevator arrived at the front lobby. Upon arriving at the 200's unit on 1/12/24 at approximately 3:30 PM, the lower numeral corridor was observed to be littered with debris on the floor, had many dark spots on the floor that appeared to be uncleaned spills, and the corridor was cluttered with various medical equipment. In room [ROOM NUMBER], the floor was simply dirty, the trash can was without a liner, and a used glove was observed on the floor. The A bed resident had mats at the bedside with holes and a dark substance on them. Under the head of the bed, the floor space was filled with broken, useless items, a wheelchair leg rest, and a lot of dust and dirt. The room was also very cluttered. The resident in the B bed stated that the resident in the A bed had a television remote control that changed the television channels on his side of the room. In room [ROOM NUMBER], the room was dark and smelly, the floor was covered with dirt and debris, and the bathroom toilet was dirty and smelly. The corridor was also extremely odorous after passing room [ROOM NUMBER], and the odor didn't dissipate over time. An interview was conducted with the environmental services staff (EVS) on 1/13/25 at 12:27 PM. The EVS stated that she works extremely hard to keep the unit clean and that she had been complimented for her success in turning the unit around. The EVS stated that she moves nothing on the floor when she mops because she doesn't know what items are there, so she mops around them. She also said that she had scrubbed the fall mats on the floors, but she was unsuccessful in getting some of them clean. She stated that she records the information in her daily notes and then gives them to her supervisor. On 1/14/26 at approximately 5:50 PM, a final interview was conducted with the Administrator, Director of Nursing, the Regional [NAME] President, and the Regional Nurse Consultant. An opportunity was provided for the facility to provide feedback; they nodded that they agreed there were environmental concerns. 2.The facility staff failed to provide a sanitary and comfortable environment on the 400 floor. On 1/12/26 at approximately 4:05 pm., an initial tour was conducted on the 400 floor. A strong urine odor was detected in the hallways, the floors had dirt and debris. A housekeeper was observed standing near her cart. On 1/13/26 at approximately 2:10 pm., a tour of the 400 floor was conducted. The floors appeared clean and no odor was present. Several housekeeping staff were observed cleaning rooms and mopping floors. On 1/14/26 at approximately 12:40 pm., a brief tour was made of the 400 floor. A strong urine odor was present. Only a few Housekeepers were noticed on the unit. On 1/14/26 at approximately 5:45 pm, a final interview was conducted with the Administrator, Director of Nursing, the Regional [NAME] President, and the Regional Nurse Consultant.

Based on staff interviews, Facility documentation reviews, and clinical record reviews, the facility staff failed to ensure competent Professional nursing staff oversight, assessment, and administration of tracheostomy care for three residents (Resident #185, #186, and #190) in a survey sample of 60 Residents, resulting in Immediate Jeopardy. After accepting the plan to remove the immediacy from the Administrator and confirming that the Immediate Jeopardy was removed, the deficiency was assigned a Scope and Severity level of 3 (G), isolated (harm).The findings included: 1. Resident #185 was initially admitted to the nursing facility on 7-7-25 with diagnoses including stroke, respiratory failure with tracheostomy for breathing, dysphagia with gastrostomy tube for feeding, anemia, diabetes, stage 4 pressure ulcer, and malnutrition. Review of hospital records revealed that the Resident was sent back out to the hospital 6 days after admission on [DATE] with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia and Clostridium Difficile diarrhea combined infections resulting in sepsis (whole body blood infection), and a fecal impaction. The Resident was also dehydrated and received 2 liters of IV (intravenous) fluid upon arrival in the emergency department. The Resident returned to the nursing facility after 11 days in the hospital on 7-24-25. The Resident was ordered to receive strong antibiotic therapy with Vancomycin. There were two orders issued upon his return, as follows: 1. Vancomycin 1.25 grams every 18 hours intravenously (IV) infused for the sepsis treatment for 8 days. 2. Oral Vancomycin drops 125 MG (milligrams) to be given in the Resident's Peg feeding tube every day at 9:00 A.M. until 8-5-25. During review of the Resident's medication Administration record (MAR), the following was revealed. 7-24-25 – No antibiotic given. 7-25-25 – IV vancomycin given one time at 6:02 P.M. No oral drops given. 7-26-25 – Oral drops given at 9:00 A.M., no IV Vancomycin given. 7-27-25 - Oral drops given at 9:00 A.M., no IV Vancomycin given. 7-28-25 – IV at 10:40 A.M., and oral drops given at 9:00 A.M. The IV vancomycin was decreased to one dose daily with no reason given at 9:00 A.M. on 7-29-25. 7-29-25 - IV at 5:22 A.M., and oral drops given at 9:00 A.M. 7-30-25 – IV at 9:00 A.M., and oral drops given at 9:00 A.M 7-31-25 - IV at 9:00 A.M., and oral drops given at 9:00 A.M 8-1-25 – IV at 9:00 A.M., and oral drops given at 9:00 A.M 8-2-25 – IV at 9:00 A.M., and oral drops given at 9:00 A.M 8-3-25 – IV at 9:00 A.M., and oral drops given at 9:00 A.M 8-4-25 – IV at 9:00 A.M., and oral drops given at 9:00 A.M 8-5-25 – IV at 9:00 A.M., and oral drops given at 9:00 A.M 8-6-25 – only IV given at 9:00 A.M. This review indicated that the IV antibiotic was omitted on 7-24-25, 7-26-25, 7-27-25, and the oral drops were omitted on 7-24-25 and 7-25-25. Analysis reveals that the necessary antibiotic treatment was not fully implemented in a timely manner to treat the pneumonia for the new tracheostomy patient and was not effectively administered for 4 days. This prolonged the sporadic treatment to 13 days. The resident returned to the facility from the hospital for continuing treatment, specifically due to contracting sepsis in this nursing facility. Review of Resident #185's nursing and physician progress notes revealed the following worsening course of events in chronological order. On 8-11-25 at 2:13 A.M, the resident exhibited a low-grade fever of 100.0 Fahrenheit (F) after receiving oxycodone with Tylenol previously at midnight. The Resident had a resting heart rate of 88 beats per minute, a blood pressure of 94/65, and 18 respirations per minute with large amounts of dark liquid stool on the bed. The resident was under the care of a Licensed Practical Nurse (LPN) during the entire 11:00 P.M. to 7:00 A.M. shift. On 8-11-25 at 11:52 P.M., an LPN (agency nurse) documented temp 99.4 F tympanic. On 8-12-25 at 2:03 A.M., the nurse documented No fentanyl patch available at midnight (8-11-25), ordered to be applied every 72 hours for the Resident. This reveals that his pain medication was not administered from 8-11-25 through 8-13-25 (3 days), according to the Medication administration record, because he was admitted to the hospital on [DATE], and the pain patch was not documented as administered for those days. On 8-12-25 at 2:50 P.M., the following assessment note indicated that the nurse practitioner saw the Resident and reported to the staff nurse that the Resident was febrile with a fever of 102.5. The note goes on to say STAT (immediate) orders were received for a Tylenol suppository and to remove the PICC (central line catheter for Antibiotic infusions). At 9:33 P.M., a note describes BP (blood pressure) low. There was no dedicated Registered Nurse (RN) on the 3:00 P.M. to 11:00 P.M. shift this night as mandated by state law to perform assessments and make treatment decisions for Residents on a specialized tracheostomy unit. On 8-13-25 at 4:45 A.M., a note describes temp 100.2. pulse Ox (oxygenation) 96% .trach care and suction provided. At 6:48 A.M., (2 hours later) a note describes (oxygen) Saturation at 54% on trach collar, heart rate 143 beats per minute, temp 100.7, blood sugar 188, 911 called, (oxygen) sats increased to 64% with rescue squad. An oxygen saturation level below 88% is considered critical and, if not quickly reversed, will lead to hypoxia and death according to the National Institutes of Health (NIH). A physician's order was placed, stating that the doctor had instructed the resident to be sent to the emergency department via 911 at 5:41 A.M. However, nursing documents revealed that he did not go out for over an hour after the order was received. Resident #185 left at 6:59 A.M. and expired the same day in the hospital. During the survey, LPNs and Certified Nursing Assistants (CNAs) were interviewed and stated that they did remember the 2 Residents involved during these [DATE] incidents. They said there were times when RNs were not present to help and admitted that they often felt inadequate to care for tracheostomy Residents. They further stated they were not always sure when those residents were exhibiting signs of distress or worsening conditions until the residents were seriously ill. Those staff members would only speak on grounds of anonymity for fear of job loss from the administration. None were able to answer what strength of suctioning in millimeters of mercury was safe for the Residents. The facility assessment was reviewed and revealed that the specialty care unit for tracheostomies would be staffed with RNs on every shift and every day indicating that they were aware of that state and federal requirement for the specialty unit. The Resident's care plan was reviewed and revealed focuses for Respiratory, and the Resident is at risk for complications secondary to a tracheostomy added upon admission on [DATE] with interventions including administer oxygen as ordered, vitals as needed, observe for signs and symptoms of respiratory complications including infection and or respiratory blockage or mucus plug and notify MD (doctor) as indicated, suction as needed, tracheostomy care per order, and tracheostomy tie change per order. On 8-5-25 new care plan interventions were added after returning from the hospital with pneumonia on 7-24-25 (12 days after return) that revealed a focus for Respiratory infection the resident has developed an infection secondary to pneumonia MRSA (Methicillin Resistant Staphylococcus Aureus) and is on antibiotics. The interventions included Auscultate lung sounds as needed, diagnostics and labs as ordered, head of bed elevated to prevent shortness of breath as tolerated, medications as ordered, oxygen as ordered, vitals as needed. Resident #185 exhibited symptoms of a worsening infection for a period of greater than 48 hours without adequate assessment or intervention. The Resident had recently been hospitalized for known sepsis from pneumonia. The combination of medication administration lapses and Registered Nursing insufficiency, assessment and care on the dedicated tracheostomy specialty unit potentially resulted in therapeutic interventions being overly prolonged or omitted. Within 5 days of the completion of the antibiotics the Resident was again seriously ill. He was eventually sent out 911 to the hospital and did not recover. This was not a singular event, and the insufficient staffing on the dedicated specialty tracheostomy unit had a profound impact on a neighbor of this Resident during this time period as well. On 9-11-25 at 3:00 P.M., the facility's corporate staff were asked to provide time clock records for the relevant period, which they supplied. Both the Director of Nursing and the Administrator were new employees of only a few days. The Corporate staff responded that they were aware Registered Nurses had not been dedicated to the tracheostomy unit on the specified days and times, and stated they had nothing further to provide as evidence. 2. Resident #186 was ordered to have low-dose Aspirin for pain and anticoagulation, 81 milligrams every day, increasing the likelihood of bleeding should trauma occur at the trach site, making the Resident high risk for hemorrhage. Review of physician and nursing progress notes the following chronological record of events occurred: On 8-16-25, the oncoming LPN at 11:00 P.M. assumed care of the Resident. At 12:31 A.M. (1.5 hours later) on 8-17-25, the LPN completed a respiratory evaluation. On 8-17-25 at 2:09 A.M., that nurse documented that the Resident was coughing up large amounts of bright red blood with what appeared to be lung tissue. Nurse suctioned mouth and trachea and denoted an oxygen saturation of 59% on 10 liters of oxygen via trachea. Nurse assessed lung sounds and patient has rhonchi (coarse gurgling sounds) in all fields. 911 called, .Patient to ER. (emergency room). Third eye contacted and RP (responsible party) notified. On 8-18-25 at 4:00 A.M., another nursing note reveals that the Resident was admitted to the hospital with a tracheal tear and was on comfort measures. The resident expired that day. LPNs are not permitted to complete Deep tracheal suctioning, and they may only independently provide oral and nasopharyngeal suctioning after training for such without the direct supervision of an RN, according to the National Library of Medicine. During the survey, LPNs and Certified Nursing Assistants (CNAs) were interviewed and stated that they did remember the two (2) Residents involved during these [DATE] incidents. They stated there were times when RNs were not present to help and admitted that they often felt inadequate to care for tracheostomy Residents. They further stated they were not always sure when those residents were exhibiting signs of distress or worsening conditions until the residents were seriously ill. None were able to answer what the safe strength of suctioning in millimeters of mercury was for the Residents. The facility assessment was reviewed and revealed that the specialty care unit for tracheostomies would be staffed with RNs on every shift and every day, indicating that they were aware of the state and federal requirements for the specialty unit. The Resident's care plan was reviewed and revealed current focuses for The Resident is at risk for complications secondary to a tracheostomy initiated on 5-15-25 after admission with interventions including observe for signs and symptoms of respiratory complications including infection and or respiratory blockage or mucus plug and notify MD (doctor) as indicated, suction as needed, tracheostomy care per order. The Resident had other care plan interventions for a respiratory infection/pneumonia early on in his stay; however, they were discontinued as resolved on 6-24-25. No oxygen with humidification therapy, inner cannula cleaning and replacement, nor size and location of spare cannulas, nebulizer treatments, strength of suction devices, nor trach support tie changes were ever placed on the care plan to guide care for nurses. The combination of lapses in care planning, Registered Nursing insufficiency, and the lack of assessment and care contributed to the situation on the dedicated tracheostomy specialty unit. The result was that care was given improperly, and therapeutic interventions were potentially being omitted. Resident #186 was eventually sent out by 911 to the hospital and did not recover. On 9-11-25 at 3:00 P.M., both the Director of Nursing and the Administrator were identified as new employees of only a few days. The Corporate staff responded that they were aware Registered Nurses had not been dedicated to the tracheostomy unit on the specified days and times, and stated they had nothing further to provide as evidence. They were notified at this time that immediate jeopardy was a finding in the investigation and asked for a plan to remove the immediacy requirement principle, which infers that this could happen again with other Residents on this specialized nursing unit if not fixed immediately. The facility staff supplied an immediacy removal plan which included the following. The facility staff failed to provide Registered Nurse (RN) staffing on the specialized tracheostomy unit on the 3:00 P.M. to 11:00 P.M. shift on 8-12-25, 11P.M. to 7:00 A.M. shift on 8-16-25/8-17-25, and previously on 5-6-25 for another Resident causing adverse outcomes resulting in death. Those included Resident #185, #186, and #190. The Residents that could be affected included all with tracheostomies residing on the tracheostomy unit that are not afforded care/assessment by an RN trained in tracheostomy care The actions the facility will take to prevent serious adverse outcomes from occurring or reoccurring, and when action will be complete follows below: 1. Effective 9-12-25 a Registered Nurse with documented tracheostomy competency training will be assigned to the tracheostomy unit every shift 7 days per week. 2. Effective 9-12-25 Director of Nursing (DON) or designee will verify and document on assignment sheet the presence of an RN with documented tracheostomy training. 3. Effective 9-12-25 the Regional Director of Specialty Care or designee will ensure all RN staff scheduled to work on the tracheostomy unit have completed immediate reeducation and competency validation in care of tracheostomy patients, prior to assuming an assignment. 4. Effective 9-12-25 a roster of RN's will be maintained by the DON or designee and provided to staffing scheduler to ensure immediate coverage in the event of call-off. The plan's credible evidence was evaluated by the survey team on 9-12-25 through observation, review of educational documents, direct interviews with staff, and staffing schedule reviews. The plan was accepted on 9-12-25 at 2:00 P.M. and was re-evaluated to ensure staff maintained the four points during the rest of the survey. Upon accepting the plan, the Immediate Jeopardy was lowered to a level 3 isolated (harm). 3. For Resident #190, the facility staff failed to have the required RN (Registered Nurse) assigned to work the tracheostomy unit during the 7:00 p.m. to 7:00 am shift on [DATE]. Resident #190 was admitted to the facility on [DATE] with diagnoses including but not limited to acute encephalopathy, anemia in chronic kidney disease stage 5, atherosclerosis of arteries, hypertension, chronic pain, continuous opioid dependence, dysphagia, end stage renal failure on dialysis, type 2 diabetes, anoxic brain damage, subclavian and axillary DVT (Deep Vein Thrombosis) chronic respiratory failure. Resident #190 had a tracheostomy and a g tube, was non-verbal, in a chronic vegetative state, and totally dependent on staff for all aspects of care. Resident #190 was coded as a DNR (Do Not Resuscitate) and on palliative care. A review of the staffing worksheet revealed that RN #3 was scheduled to work the 7:00 p.m. – 7:00 a.m. shift on the 2nd floor tracheostomy unit on [DATE]. A review of the timecard punches revealed RN #3 clocked in at 6:59 p.m. and that she clocked out at 8:47 p.m. On [DATE] at approximately 9:30 a.m., an interview was conducted with RN #3, who stated that she was scheduled for work on [DATE] and that she was a new RN and a new employee at the facility. She stated that she was still in training and that it would have been her first night working on the tracheostomy unit. She stated that after clocking in, she heard the staff discussing the people who had called out, including the RN supervisor. She stated that she suddenly realized she would be the only RN on the specialized tracheostomy unit responsible for the entire unit, which she had never worked before, and as a new nurse, she had not had much experience with tracheostomies. She stated that she began to get nervous about what could happen, and she called the supervisor, and they called the DON (Director of Nursing), who refused to come in. She stated that at that point, she was worried about what could happen if something went wrong. She stated that she did not feel comfortable taking the assignment, so she handed the keys over, clocked out, and went home at 8:47 pm. A review of the facility records revealed that the DON did, in fact, refuse to come to the facility on the night of [DATE]. The DON was issued a Corrective Action form that read as follows: On [DATE], you failed to ensure there was adequate nurse coverage after being informed of the callouts on the unit. You were also instructed that a member from the nursing leadership needed to come into the center, and no one did. A review of the staffing revealed that there was no RN coverage on the specialized tracheostomy unit when Resident #190 was found deceased . The RN from another floor had to be called down to pronounce Resident #190's death, as there were only LPNs working the specialized unit. On [DATE], an interview was conducted with the Administrator, who stated that she was aware that a Registered Nurse was required to be scheduled on all shifts on the specialized tracheostomy unit. On [DATE], during the end-of-day meeting, the Administrator was made aware of the concerns, and no further information was provided.

Based on observations, resident and staff interviews, and clinical record review, the facility staff failed to ensure that 3 of 28 residents (Residents #108, #107, and #124) in the survey sample received fluids as listed on the menu, per their preferences, or as ordered. The findings included: 3.The facility staff failed to serve a beverage listed on the menu. Resident #124 was originally admitted to the facility 3/03/17 from an acute care facility and re-admitted on [DATE]. The current diagnoses included; Dysphagia, Mechanically Altered PO Intake and Cerebral Palsy. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/03/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #124 cognitive abilities for daily decision making were intact. In Section GG (Functional Abilities and Goals) the resident was coded as using suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. On 1/13/26 at approximately 12:14 pm., an observation of the resident's meal ticket at lunch time read Hot Coffee or Hot Tea. Resident #124 overheard his roommate complaining to the nurse about not having anything to drink brought in with his lunch. Resident #124 said that he didn't get anything to drink either, holding up his water bottle, saying I can drink this. On 1/13/26 at approximately 3:20 pm., an end-of-day meeting was conducted with the Administrator and with the Director of Nursing (DON) concerning the above issues. The DON said that the meal ticket should be followed. On 1/14/26 at approximately 4:35 pm., an interview was conducted with the Dietary Manager (DM) concerning Resident #124. The DM said that beverages should have been available. On 1/14/26 at approximately 5:45 pm., the above findings were shared with the Administrator, Director of Nursing, the Regional Nurse Consultant and the Regional [NAME] President. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. 4.The facility staff failed to serve a beverage listed on the menu. Resident #122 was originally admitted to the facility 10/26/19 from an acute care facility and re-admitted on [DATE]. The current diagnoses includes: Moderate Protein Calorie Malnutrition. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/01/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #122 cognitive abilities for daily decision making were intact. On 1/13/26 at approximately 12:00 pm., during rounds was approached by Resident #122 concerning the poor services he's receiving from the nursing and dietary staff. On 1/13/26 at approximately 12:16 pm., an observation of the resident's meal and tray was conducted at lunch time. The resident's meal ticket listed Hot tea or Coffee no beverage was observed on the resident's tray other than what he already had on his bedside table. The resident was overheard asking for his tea or coffee to LPN #2. LPN #2 was observed shrugging her shoulders, leaving the room but not returning with a beverage. On 1/13/26 at approximately 3:20 pm., an end-of-day meeting was conducted with the Administrator and with the Director of Nursing (DON) concerning the above issues. The DON said that the meal ticket should be followed. On 1/14/26 at approximately 4:35 pm., an interview was conducted with the Dietary Manager (DM) concerning Resident #122. The DM said that the resident's should have received their beverages. On 1/14/26 at approximately 5:45 pm., the above findings were shared with the Administrator, Director of Nursing, the Regional Nurse Consultant and the Regional [NAME] President. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. 1. The facility's staff failed to serve an 8 ounce beverage according to the menu and the residents' personalized meal ticket. Resident #108 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included stroke, renal failure, and heart failure. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/13/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated that Resident #108's cognitive abilities for daily decision-making were moderately impaired. In section GG (Functional Abilities and Goals), the resident was coded as requiring setup or clean-up assistance with eating, dependent with oral hygiene, toileting hygiene, showers/bathes, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, rolling, and sit-to-lying. On 1/13/25 at approximately 12:30 PM, an observation was made of Resident #108 during the lunch meal. The meal served was roasted pork with gravy, beets, mashed potatoes, a biscuit, and an apple dessert. No fluids were served. An interview was conducted with the Certified Nursing Assistant (CNA) #1 at approximately 12:33 PM. She was observed in the hallway distributing trays and drinks. CNA #1 stated she did not provide the resident with a drink because he had a water pitcher at bedside. CNA #1 asked if I wanted the resident to have a glass of tea, and I responded that she should proceed according to the facility's protocol. The menu stated that residents were to receive an 8-ounce and a 6-ounce beverage at lunch. Resident #108's beverages were restricted to 1200 milliliters per day, with an allowance of 8 ounces at lunch, which was not provided. The resident's lunch meal ticket read: allowed one 8-ounce beverage. On 1/14/26 at approximately 12:25 PM, the resident was observed in bed with the lunch meal before him, and the Assistant Director of Nursing (ADON) was present. The meal consisted of a thick piece of breaded chicken, mixed vegetables, and rice. No fluids were served to him. The ADON stated that, based on the residents' meal ticket, he should have received an 8-ounce beverage with his lunch. The ADON further said she would ensure the resident received his beverage of choice. On 1/14/26 at approximately 4:25 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that the resident was supposed to receive his meal as planned on the menu, with modifications based solely on his personal preferences and limitations, as ordered by the physician. The DM stated that drinks had been spilling onto the trays; therefore, a decision was made to send beverages up separately to avoid spills that ruined meals. He also stated that no one had raised concerns about the beverage distribution method, so he was unaware that not all residents were receiving beverages in accordance with the menu, preferences, and physician orders. The DM stated he would address the concern with the administrative team so they could strategize on a solution. On 1/14/26 at approximately 5:50 PM, a final interview was conducted with the Administrator, Director of Nursing, the Regional [NAME] President, and the Regional Nurse Consultant. An opportunity was provided for the facility to provide feedback, but they offered none. 2. The facility's staff failed to serve an 8 ounce beverage and a 6 ounce beverage to Resident #107, according to the menu and the residents' personalized meal ticket. Resident #107 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included tracheostomy, diabetes, PVD, and heart failure. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/25/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #107's cognitive abilities for daily decision making were intact. In section GG (Functional Abilities and Goals), the resident was coded as requiring setup or clean-up assistance with eating, substantial/maximal assistance with oral hygiene, was dependent with toileting hygiene, showers/bathes, upper body dressing, lower body dressing, putting on and taking off footwear, and personal hygiene. The resident also required partial/moderate assistance with rolling and sit-to-lying. On 1/13/25 at approximately 12:41 PM, an observation was made of Resident #107 during the lunch meal. The residents' meal consisted of a whole slice of roasted pork with gravy (this should have been chopped per the meal ticket), diced beets, mashed potatoes, a biscuit, and an apple dessert. No fluids were served. The menu stated that residents were to receive an 8-ounce and a 6-ounce beverage at lunch. Resident #107's lunch meal ticket read: 2 percent milk, 8 ounces, and hot coffee or hot tea, 6 ounces. On 1/14/25 at approximately 12:37 PM, an observation was made with the ADON of Resident #107 during the lunch meal. The resident's meal consisted of chopped, breaded chicken, mixed vegetables, and rice. No fluids were served with the meal. The ADON stated that, based on the Resident #107's meal ticket, he should have received an 8-ounce and a 6 ounce beverage with his lunch. The ADON further stated she would ensure the resident received his beverages of choice. On 1/14/26 at approximately 4:25 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that the resident was supposed to receive his meal as planned on the menu, with modifications based solely on his personal preferences and limitations, as ordered by the physician. The DM stated that it was an error in the menu software to offer milk at lunch, as the facility does not provide milk during lunch. The DM stated that drinks had been spilling onto the trays; therefore, a decision was made to send beverages up separately to avoid spills that ruined meals. He also stated that no one had raised concerns about the beverage distribution method, so he was unaware that not all residents were receiving beverages in accordance with the menu, preferences, and physician orders. The DM stated he would address the concern with the administrative team so they could strategize on a solution. On 1/14/26 at approximately 5:50 PM, a final interview was conducted with the Administrator, Director of Nursing, the Regional [NAME] President, and the Regional Nurse Consultant. An opportunity was provided for the facility to provide feedback, but they offered none

Based on resident interview, staff interview, and clinical record review the facility staff failed to provide needed durable medical equipment and home health services in a timely manner for 1 of 28 residents (Resident #115), in the survey sample. The findings included: Resident #115 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #115 was originally admitted to the facility 10/29/25. The diagnoses included; atherosclerotic heart disease of native coronary artery without angina pectoris, morbid obesity due to excess calories, end stage renal disease, and muscle weakness. The discharge Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/27/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #115's cognitive abilities for daily decision making were intact.On 1/13/26 at 12:08 PM an interview was conducted with Resident #115. Resident #115 stated that she was discharge from the facility to home on [DATE] and a physicians order was written for a bedside commode and a front-wheeled walker to be delivered to her home, as well as a physician's order for home health services which included nursing and physical therapy services. Resident #115 also stated that the bedside commode and the front-wheeled walker was not delivered to her home until 12/30/25 and home health services did not begin services until 1/3/26. Resident #115 further stated that she had to use a bedpan for 4 days and due to her limited mobility, it was very difficult on her body and mental state. Resident #115 lastly stated that due to not having home health services and physical therapy for a week after arriving home, her body became weaker and one of her legs became flaccid. On 1/14/26 at 11:05 AM an interview was conducted with the Director of Social Services. The Director of Social Services stated Resident #115 was discharged from the facility to home on [DATE]. The Director of Social Services also stated that the bedside commode and the front-wheeled walker did not arrive to Resident #115's home until 12/30/25 and home health services did not begin until 1/3/26. The Director of Social Services further stated, It is an issue them not delivering the DME (durable medical equipment) until 12/30/25 and the HH company not showing up until 1/3/26. It is not typical for this to occur.On 1/14/26 at 12:38 PM an interview was conducted with the Director of Rehabilitation. The Director of Rehabilitation stated that prior to Resident #115 being discharged from the facility to home, she gave Resident #115 a bedpan to go home with since the bedside commode was not going to be at the home prior to the resident's arrival home. The Director of Rehabilitation also stated that she went to Resident #115 home on [DATE] to set up the bedside commode due to the Durable Medical Equipment provider not being able to set the equipment up. The Director of Rehabilitation further stated that it was an issue that the bedside commode and the home health provider did not show up in a reasonable time frame, however this is not a normal occurrence. On 1/14/26 at 5:40 PM an interview was conducted with the Administrator. The Administrator stated that it was not acceptable that the bedside commode and the front-wheeled walker was delivered to Resident #115's home on [DATE]. The Administrator also stated that it was not an acceptable time frame regarding the home health provider starting services a week after Resident #115 arrived home from the facility. Discharge Planning Progress Notes included the following notations: 12/30/2025 12:05 PM: Ms. [NAME] called stating that her DME has not been delivered and that the PCA company called her stating that per the Medicaid portal, it shows that Ms. [NAME] is on a spend down and they are no longer able to cover PCA services. SW reached out to adapt health and spoke with Ms. [NAME] regarding ETA for DME. Per Ms. [NAME] the BSC and rollator will now be arriving today between 11:35am - 1:35pm. 12/30/2025 5:08 PM: Ms. [NAME] informed SW that the DME was delivered, however they did not set up the BSC, SW called adapt health to see if they can send someone over to at least set it up, per adapt health rep they would not be able send any one over to set it up. SW notified IDT team. Rehab director stated she would stop by the house and set it up for her. SW asked Ms. [NAME] if it was okay for our rehab director to stop by to help set it up. Ms. [NAME] was grateful and stated yes that is fine. SW also informed Ms. [NAME] that due to her HH not returning her calls, SW will send out another HH referral to a different company. No other needs or concerns reported at this time. SW will continue to follow up. 12/31/2025 1:22 PM: SW sent HH referral to Enhabit, Interim, Westminister [NAME], Medi USA, Centerwell, Adoration, and Hope-in-Home. SW will follow up. Continue POC. 12/31/2025 4:29 PM: Ms. [NAME] contacted SW regarding her HH. Ms. [NAME] informed SW that Amedysis contacted her and informed her that they will begin services on Saturday, 1/3/26. On 1/14/26 at approximately 5:50 PM, a final interview was conducted with the Administrator, Director of Nursing, Regional Director of Clinical Services, and [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on observations, resident and staff interviews, and clinical record review, the facility staff failed to ensure that 3 of 28 residents (Residents #124, #108, and #107) in the survey sample had meals served in accordance with the menu and meal tickets. The findings included: 1.The facility staff failed to serve portion of food listed on the menu. Resident #124 was originally admitted to the facility 3/03/17 from an acute care facility and re-admitted on [DATE]. The current diagnoses included; Dysphagia, Mechanically Altered PO Intake and Cerebral Palsy. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/03/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #124 cognitive abilities for daily decision making were intact. In Section GG (Functional Abilities and Goals) the resident was coded as using suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. On 1/13/26 at approximately 11:50 am., Resident #124 was observed sitting in his wheelchair outside of his room. The resident stated I want my food to get my weight back; I don't have enough fat on me. The resident was asked if he was getting extra portions of food, he said no and I ask all of the time. He also said, I want you to look at my tray when they bring it. On 1/13/26 at approximately 12:14 pm., an observation of the resident's meal and tray was conducted at lunch time. The residents' meal consisted of Roasted Pork Loin, Pork Gravy, Diced Harvard Beets, Creamy Mashed Potatoes, a Biscuit and Apple Crisp. The resident's meal ticket listed all of the above including Cornbread that was not present on the resident's tray but 1 biscuit was observed on the resident's tray instead. The resident said that it comes like that sometimes but I got to get my weight up. On 1/13/26 at approximately 3:20 pm., an end-of-day meeting was conducted with the Administrator and with the Director of Nursing (DON) concerning the above issues. The DON said that the meal ticket should be followed due to weight loss, the resident gets double portions. On 1/14/26 at approximately 11:30 am., Resident #124 said that he was going out to eat lunch today. On 1/14/26 at approximately 4:35 pm., an interview was conducted with the Dietary Manager (DM) concerning Resident #124. The DM said that there was no cornbread mix available, so the resident was served a biscuit instead. On 1/14/26 at approximately 5:45 pm., the above findings were shared with the Administrator, Director of Nursing, the Regional Nurse Consultant and the Regional [NAME] President. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. 2. The facility's staff failed to serve food items according to the menu and meal ticket. Resident #108 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included stroke, renal failure, and heart failure. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/13/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated that Resident #108's cognitive abilities for daily decision-making were moderately impaired. In section GG (Functional Abilities and Goals), the resident was coded as requiring setup or clean-up assistance with eating, dependent with oral hygiene, toileting hygiene, showers/bathes, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, rolling, and sit-to-lying. On 1/13/25 at approximately 12:30 PM, an observation was made of Resident #108 during the lunch meal. The meal served was roasted pork with gravy, beets, mashed potatoes, a biscuit, and an apple dessert. The menu and the resident's personal meal ticket read that the resident was to receive cornbread, not a biscuit. The resident's meal ticket dated 1/13/26 for the lunch meal read: fluids restricted to 1200 milliliters per day. A regular diet: Roasted pork 3 ounces, pork gravy 2 ounces, Harvard beets 1/2 cup, creamy mashed potatoes 4 ounces, corn bread 1 piece, margarine 1 each, apple crisp 1/2 cup, allowed one 8-ounce beverage. On 1/14/26 at approximately 4:25 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that he didn't have cornbread for the meal on 1/13/26 because the food delivery didn't occur when it was supposed to. He also said that the cornbread substitute was not updated on the menu or on residents' personal meal tickets to notify them of the change, due to the difficulties with the menu/meal ticket software. On 1/14/26 at approximately 5:50 PM, a final interview was conducted with the Administrator, Director of Nursing, the Regional [NAME] President, and the Regional Nurse Consultant. An opportunity was provided for the facility to provide feedback, but they offered none. 3. The facility's staff failed to serve food items according to the menu and meal ticket to serve chopped meat to a resident on a mechanically advanced/chopped diet on 1/13/26. Resident #107 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included tracheostomy, diabetes, PVD, and heart failure. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/25/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #107's cognitive abilities for daily decision making were intact. The residents' meal ticket dated 1/13/26 read: mechanical advanced/chopped diabetic diet. Serve a mechanical advanced/chopped roasted pork loin 3 ounces, pork gravy 2 ounces, diced beets 1/2 cup, creamy mashed potatoes 4 ounces, a dinner roll, 1, margarine 1 each, apple crisp 1/4 of a cup, 2% milk 8 ounces, and hot coffee or hot tea 6 ounces. In section GG (Functional Abilities and Goals), the resident was coded as requiring setup or clean-up assistance with eating, substantial/maximal assistance with oral hygiene, was dependent with toileting hygiene, showers/bathes, upper body dressing, lower body dressing, putting on and taking off footwear, and personal hygiene. The resident also required partial/moderate assistance with rolling and sit-to-lying. On 1/13/25 at approximately 12:41 PM, an observation was made of Resident #107 during the lunch meal. The residents' meal consisted of a whole slice of roasted pork with gravy (this should have been chopped roasted pork per the meal ticket), diced beets, mashed potatoes, a biscuit (the menu and meal ticket read a dinner roll was to be served), and an apple dessert. On 1/14/26 at approximately 4:25 PM, an interview was conducted with the Dietary Manager (DM). The DM further stated that it was an error that the residents' pork loin was not chopped, and he would in-service the staff on the foodservice line to be more aware of what is on the meal tickets. The DM further stated that he didn't have dinner rolls for the lunch meal on 1/13/26 because the food delivery didn't occur when it was supposed to. He also said that the dinner roll substitute was not updated on the menu or on residents' personal meal tickets to notify them of the change, due to the difficulties with the menu/meal ticket software. On 1/14/26 at approximately 5:50 PM, a final interview was conducted with the Administrator, Director of Nursing, the Regional [NAME] President, and the Regional Nurse Consultant. An opportunity was provided for the facility to provide feedback, but they offered none.

Based on observation, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure an enhanced barrier precaution sign was posted for 1 resident to prevent the spread of infection for 1 of 28 residents (Resident # 117), in the survey sample.The findings included: Resident #117 was originally admitted to the facility 10/23/25 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Tracheostomy Status. The discharge Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/17/25 coded the resident as having short-term memory loss which indicated Resident #117 cognitive abilities for daily decision making were moderately impaired. Section K (Swallowing/Nutritional Status) coded the resident as having a Feeding Tube. A review of the Physician's order Summary for December 2025 read Enhanced Precaution r/t Trach every shift. Active from 11/04/25. On 1/13/26 and during the initial tour of the facility at approximately, no Enhanced Barrier (EHB) signage was observed on Resident's door or wall before entering room [ROOM NUMBER] B.On 1/14/26 no EHB signage was observed on the resident's door or wall of room [ROOM NUMBER] B. The resident was observed resting quietly in bed with her eyes closed, Tracheostomy attached, enteral feeding observed at the bedside On 1/14/26 interviews were conducted at 11:45 am., with staff on unit 1, 2nd floor concerning EHB precautions. Certified Nursing Assistant # 3 (CNA) was asked to explain why some of the rooms on the unit displayed EHB signage on the wall before entering a residents room. CNA #3 said that they were in- serviced on EHB Precautions, and only residents with tracheostomies, feeding tubes, staff must follow the EHB signs on what to wear such as gowns, masks, gloves, providing ADL care, and changing briefs. On 1/14/26 at approximately 11:55 am., an interview was conducted with Registered Nurse #1 concerning EHB precaution signage. RN #1 said that if a resident has a PICC Line, Trach., or attends dialysis they should be on EHB Precautions. RN #1 was asked if Resident #117 should be under EHB precautions. RN #1 said yes, there should have been EHB signage on the door or wall. RN #1 also said because the resident was moved to another room yesterday, no signage was put up.Throughout the course of the survey EHB Precaution signs were observed on all floors. The signage read: STOP! Perform hand hygiene using soap and water and or alcohol-based hand rub before entering room and before exiting room. Wear gown and gloves when entering room to provide the following high-contact resident care activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing hygiene, Changing briefs or assisting with toileting, Device care or use: central line urinary catheter, feeding tube, tracheostomy, wound care: any sin opening requiring a dressing, Bag linen and discard trash to prevent contamination of self, environment or outside bag.On 1/14/26 at approximately 5:45 pm., the above findings were shared with the Administrator, Director of Nursing, the Regional Nurse Consultant and the Regional [NAME] President. The DON said there was signage on the door of the resident's room (room [ROOM NUMBER] B). The DON was informed by the surveyor that no signage was observed on the resident's wall or door since rounds were conducted from 1/12/26 through 1/14/26. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observations, resident interviews, staff interviews, and clinical record review, the facility staff failed to maintain a sanitary and comfortable environment for all.The findings included: 1. The facility staff failed to provide a sanitary and comfortable environment in the 200-unit. On 1/12/25, it took 12 minutes from the time the call button was activated until the elevator arrived at the front lobby. Upon arriving at the 200's unit on 1/12/24 at approximately 3:30 PM, the lower numeral corridor was observed to be littered with debris on the floor, had many dark spots on the floor that appeared to be uncleaned spills, and the corridor was cluttered with various medical equipment. In room [ROOM NUMBER], the floor was simply dirty, the trash can was without a liner, and a used glove was observed on the floor. The A bed resident had mats at the bedside with holes and a dark substance on them. Under the head of the bed, the floor space was filled with broken, useless items, a wheelchair leg rest, and a lot of dust and dirt. The room was also very cluttered. The resident in the B bed stated that the resident in the A bed had a television remote control that changed the television channels on his side of the room. In room [ROOM NUMBER], the room was dark and smelly, the floor was covered with dirt and debris, and the bathroom toilet was dirty and smelly. The corridor was also extremely odorous after passing room [ROOM NUMBER], and the odor didn't dissipate over time. An interview was conducted with the environmental services staff (EVS) on 1/13/25 at 12:27 PM. The EVS stated that she works extremely hard to keep the unit clean and that she had been complimented for her success in turning the unit around. The EVS stated that she moves nothing on the floor when she mops because she doesn't know what items are there, so she mops around them. She also said that she had scrubbed the fall mats on the floors, but she was unsuccessful in getting some of them clean. She stated that she records the information in her daily notes and then gives them to her supervisor. On 1/14/26 at approximately 5:50 PM, a final interview was conducted with the Administrator, Director of Nursing, the Regional [NAME] President, and the Regional Nurse Consultant. An opportunity was provided for the facility to provide feedback; they nodded that they agreed there were environmental concerns. 2.The facility staff failed to provide a sanitary and comfortable environment on the 400 floor. On 1/12/26 at approximately 4:05 pm., an initial tour was conducted on the 400 floor. A strong urine odor was detected in the hallways, the floors had dirt and debris. A housekeeper was observed standing near her cart. On 1/13/26 at approximately 2:10 pm., a tour of the 400 floor was conducted. The floors appeared clean and no odor was present. Several housekeeping staff were observed cleaning rooms and mopping floors. On 1/14/26 at approximately 12:40 pm., a brief tour was made of the 400 floor. A strong urine odor was present. Only a few Housekeepers were noticed on the unit. On 1/14/26 at approximately 5:45 pm, a final interview was conducted with the Administrator, Director of Nursing, the Regional [NAME] President, and the Regional Nurse Consultant.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to provide timely incontinence care after each episode for 1 of 5 residents (Resident #1), in the survey sample. The findings included: Resident #1 was originally admitted to the facility on [DATE]. The current diagnoses included hypertension (HTN), congestive heart failure (CHF), Diabetes Mellitus (DM), Arthritis, and Anxiety. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/10/24 coded Resident #1 as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15, indicating Resident #1 cognitive abilities for daily decision making were intact. In section H(Bladder and Bowels) Resident #1 was coded as always incontinent of bladder and frequently incontinent of bowels. In section M(Skin Conditions) the resident was noted to be at risk for pressure ulcers and received ointment application to skin. Resident #1's care plan created on 2/5/16 and revised last on 9/15/22, had focuses of bladder and bowel incontinence and potential for skin impairment. Interventions last revised on 3/7/24 included: keep skin clean and dry, apply moisture barrier to protect skin as needed, and clean peri area with each incontinent episode. Review of Resident #1's order summary dated 9/1/24 included orders for Lasix (furosemide) 20 mg daily and Calmoseptine (menthol and zinc oxide) ointment daily, both ordered on 3/6/24. Certified Nurse Assistant (CNA) charting flow sheets from 8/23/24 to 9/5/24 indicated Resident #1 was dependent for incontinence care. An interview was conducted with Resident #1 on 9/4/24 at approximately 2:10 PM. The resident was in the bed and said he had been waiting for hours to be cleaned up and that he wanted to get up for the day and go to popcorn and a movie with activities. The resident also said that he often had to wait for hours to be changed. An interview was conducted with (CNA) #1 on 9/4/24 at approximately 2:20 PM. CNA #1 said that she knew Resident #1 had been waiting a while to be changed and that she would get to it after she got another resident out of bed. An observation was made on 9/4/24 at approximately 2:45 PM of CNA #1 and Licensed Practical Nurse (LPN) #2, providing incontinence care for Resident #1. The resident's brief was visibly heavily saturated with urine. An interview was conducted with Licensed Practical Nurse (LPN) #2, who stated because Resident #1's urine was contained within the brief the resident was okay. On 9/5/24 at approximately 5:55 PM, the above findings were shared with the Administrator, Director of Nursing and Corporate Nurse Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on resident interviews, family interviews, staff interviews, and clinical record review, the facility staff failed to manage pain by adhering to the prescribed medication regimen for two (2) of eight (8) residents (Resident #6 and #7), in the survey sample which resulted in unnecessary severe pain and constituted harm for both residents. The findings include: 1. The facility's staff failed to procure and administer Resident #6's scheduled pain medication Methadone HCL, for chronic pain which resulted in the resident missing multiple consecutive doses and experiencing such severe pain (8.5 to 9.0 out of a pain scale from ,d+[DATE]), which affected her day-to-day activities and ability to sleep. Resident #6 was admitted to the facility on [DATE] after a hospital stay and had not been discharged from the facility. The current diagnoses included a chronic compression fracture of the first lumbar vertebrae and chronic pain. The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed therefore the following information was obtained from the Admission/Readmission Nursing Collection Tool dated [DATE]. The tool revealed the resident was oriented to person, place, and situation, required maximal assistance with eating, oral care, toileting, moving from sitting on side of the bed to lying flat on the bed, coming to a standing position from sitting in a chair, and with transfers. The pain assessment completed by the nurse on [DATE] on the Admission/Readmission Nursing Collection Tool revealed the resident had experienced frequent pain over the last 5 days which made it hard to sleep at night and limited day-to-day activities, and Resident #6 rated the pain as 8 severe. A note dated [DATE] at 6:00 p.m. was documented also on the Admission/Readmission Nursing Collection Tool that indicated the Physician was notified that a narcotic prescription (a printed hard prescription) was needed because it was not sent over from the discharging facility. Concerns were identified during the survey with pain management and procurement of medications for new admissions, therefore an interview was conducted with Resident #6 on [DATE] at approximately 4:43 p.m. Resident #6 stated she was admitted to the facility on Saturday [DATE] and she was without her ordered pain medication until [DATE]. The resident stated her pain level ranged from 8.5 to 9.0 out of a range of 0 (representing no pain) to 10 (representing severe pain) throughout the weekend. The resident stated she experienced pain which affected her ability to function during daily activities and made sleeping difficult. The resident further stated she told her Family Member (#1) that if she could tolerate the pain over the weekend ([DATE] and [DATE]) she believed on Monday the facility would be able to acquire the medication and administer it to her. The resident stated not even Tylenol or Motrin, was ordered to alleviate some of the pain. There were no other physician orders for any type of analgesic for pain management. Tylenol is an analgesic to treat minor aches and pains and Motrin is an analgesic used to relieve mild to moderate pain. https://connect.mayoclinic.org/blog/adult-pain-medicine/newsfeed-post/what-to-expect-at-my-pain-medicine-appointment/ A review of the resident's medication orders revealed an order dated [DATE] at 3:58 p.m., for Methadone HCl Oral Tablet 10 MG - Give 10 mg by mouth three times a day for pain. A review of the medication administration record revealed doses were missed on [DATE] at 9:00 p.m., [DATE] at 9:00 a.m., 2:00 p.m., and 9:00 p.m. An invoice from the pharmacy revealed thirty Methadone 10 mg tablets arrived at the facility on [DATE] at 3:50 a.m. On [DATE] at approximately 5:10 p.m., the above findings were shared with the Administrator, Director of Nursing, and two Regional Nurse Consultants. An opportunity was offered to the facility's staff to present additional information and Regional Nurse Consultant #1 stated the hospital should have sent the hard prescription for the pain medication with the resident and that would have expedited receipt of the medication sooner because it wasn't a medication stocked in the facility's Omnicell. Methadone Hydrochloride is the hydrochloride salt of methadone, a synthetic opioid with analgesic activity. Like morphine and other morphine-like agents, methadone mimics the actions of endogenous peptides at CNS opioid receptors, primarily the [NAME]-receptor, resulting in characteristic morphine-like effects including analgesia, euphoria, sedation, respiratory depression, miosis, bradycardia, and physical dependence. (https://pubchem.ncbi.nlm.nih.gov/compound/Methadone-hydrochloride) 2. The facility staff failed to procure and administer Morphine Sulfate to Resident #7, who was admitted to the nursing facility for comfort care because death was imminent. Morphine sulfate treats moderate to severe pain that may be acute or chronic but is mostly used in pain management. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] after an acute hospital stay to hospice care. The current diagnoses included aspiration pneumonia, heart failure, chronic metabolic encephalopathy, chronic kidney disease, and functional quadriplegia. The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed therefore the following information was obtained from the Admission/Readmission Nursing Collection Tool dated [DATE] that evidenced the resident was oriented to self and communicated verbally and non-verbally. The resident required two-person assistance with activities of daily living had an indwelling urinary catheter in place and utilized oxygen at 3 liters per minute. Resident #7's pain assessment on completed [DATE], revealed the resident experienced pain over the last 5 days and the pain level was 8 out of a range of 0 (representing no pain) to 10 (representing severe pain). An interview was conducted with the resident's Family Member (#2) on [DATE] at approximately 10:00 a.m. The resident's Family member #2 stated Resident #7 was admitted to the nursing facility on [DATE] at approximately 5:00 a.m., from the hospital. Family Member #2 also stated she had elected for the resident to receive hospice care while he was a patient at the hospital because death was imminent, and she desired that the resident die in comfort with as less pain as possible. Family Member #2 stated she arrived at the nursing facility on [DATE] at approximately 11:10 a.m. and was met by the hospice nurse who informed her that Resident #7 wasn't looking good, and asked the resident's assigned nurse, Licensed Practical Nurse (LPN) #4 to administer his pain medication to achieve comfort while easing his shortness of breath as well as pain. Family Member #2 further stated while she was speaking with the hospice nurse another Family member (#3) came to her and stated Resident #7 was uncomfortable, having trouble breathing, and was asking for food, water, and pain medication. During the above interview, Family Member #2 stated that Family Member #3 further said that LPN #4 told him that the resident's pain medication would not arrive until 2:30 p.m. on [DATE], the day of the resident's admission. Family Member #2 stated she telephoned LPN #4 and was told the pain medication ordered was Morphine Sulfate (Concentrate) Solution as needed for pain, but it wasn't available in the facility therefore it had to be ordered and the resident would receive the medication at approximately 4:00 p.m. on [DATE]. Family Member #2 stated she was extremely upset by LPN #4's response because the resident had been in pain for such a long period of time. Family Member #2 estimated it had been nearly eight hours since Resident #7 had not been administered the Morphine Sulfate solution for pain and comfort. Family Member #2 informed LPN #4 she was going to call 911 and have the resident return to the hospital because he wasn't receiving the care, he was admitted to the facility to receive, which was comfort while dying. Family Member #2 called 911. A review of the Physician's Order Summary revealed an order dated [DATE] at 5:14 a.m., for Morphine Sulfate (Concentrate) Solution 20 MG/ML - Give 0.5 ml by mouth every one (1) hour as needed for pain. A progress note written by LPN #4 nurse caring for the resident on [DATE] at 1:03 p.m., read that the Resident was lying in bed this shift and his vitals were blood pressure ,d+[DATE] heart rate 66, respirations 15, temperature 97.3, and his oxygen saturation was 95% on 3 liters of oxygen via nasal cannula. The progress note indicated, The hospice nurse was in the facility today and the as-needed liquid Morphine and Ativan were written and ordered from the pharmacy this morning.The resident's skin is cool to touch and clammy. The resident responds to yes or no questions with small head shakes. The resident presented with [NAME] stokes respirations (abnormal breaths with apnea), increased secretions, with rattles on inhale and the resident is unable to move himself while in bed and many family members came to visit him this shift . Another nurse's note written by LPN #4 on [DATE] at 2:21 p.m., read, Resident code status is Do Not Resuscitate, and he is receiving hospice care. The Resident was seen by the hospice nurse this morning who ordered Morphine (a pain medication) and Ativan (a medication to relieve anxiety) liquids for the resident and the orders were faxed to the pharmacy. The pharmacy was contacted, and the representative stated the resident's medications will not arrive until 4:00 p.m. (on [DATE]). This information was provided to (name of Family member #2), and she stated the resident could not wait until 4:00 p.m., for the pharmacy to deliver the medications. LPN #4 documented the Morphine wasn't available to be pulled from the Omnicell (automated dispensing system) and the resident's Family Member #2 called 911 for the resident to go back to the emergency room to get his pain medication. LPN #4 was unavailable to interview in that she was no longer employed by the nursing facility and there was no current contact phone number. The local hospital's discharge summary dated [DATE] revealed the resident continued to decline at the hospital after the readmission on [DATE]. He was placed on a BiPAP (a device that helps with breathing), as well as warming blankets, and pain medication that was necessary for comfort. The resident expired at the hospital on [DATE] at 8:12 a.m. On [DATE] at 5:55 p.m., an interview was conducted with a pharmacist representing the pharmaceutical company the facility contracted with to procure resident medications. The Pharmacist stated the medication Morphine Sulfate 100 MG/5ML in a 15-milliliter bottle was available in the facility's Omnicell and the Pharmacist provided the facility's nurse with a code to obtain the medication on [DATE] at 10:08 a.m., for administration to Resident #7. The formulation of Morphine Sulfate Concentrate in the facility's Omnicell required calculation of the dose for accurate administration to Resident #7. On [DATE] at approximately 5:10 p.m., the above findings were shared with the Administrator, Director of Nursing, and two Regional Nurse Consultants (RNC). An opportunity was offered to the facility's staff to present additional information. The Administrator stated the resident was supposed to arrive at 6:00 p.m., on [DATE] which would have afforded them a better opportunity to coordinate procurement of all necessary items including medications to keep the resident comfortable but because of transportation problems, he arrived at approximately 4:45 a.m., on [DATE]. Although the pharmacist stated the Morphine Sulfate was in the facility's Omnicell and a code was supplied for LPN #4 to obtain it, the Regional Nurse Consultant (RNC) #1 supported LPN #4 who documented in a nurse's progress note that the medication was not available. RNC #1 also stated although the Omnicell inventory on hand stock listed Morphine Sulfate 100 MG/5ML in a 15-milliliter bottle as available and the Pharmacist validated it was available to administer, she still believed what was documented by LPN #4. Morphine sulfate oral solution is available in three concentrations: 10 mg per 5 mL, 20 mg per 5 mL, and 100 mg per 5 mL (20 mg/mL) are formulations of morphine, an opioid analgesic, indicated for the relief of moderate to severe acute and chronic pain where the use of an opioid analgesic is appropriate. (https://www.accessdata.fda.gov/drugsatfda_docs/label/,d+[DATE]s006lbl.)

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to ensure one (1) of 37 residents in the survey sample (Resident #3) comprehensive care plan was revised to include falls on 07/03, 08/24, 08/29, 10/09 and 11/19/22. The findings included: Resident #3 was admitted to the nursing facility on 03/10/22. Diagnosis for Resident #3 included but are not limited to Alzheimer's disease, repeated falls, difficulty walking, Bipolar and Schizoaffective disorder. Resident #3's Minimum Data Set (MDS - an assessment protocol) an annual assessment with an Assessment Reference Date of 01/07/23 coded Resident #3's Brief Interview for Mental Status (BIMS) a 04 out of a possible score of 15 indicating severe cognitive impairment for decision making. In section G (Physical functioning) the MDS coded Resident #3 independent with transfer, toilet use and bathing, supervision with eating, supervision with one assist with dressing, bed mobility and personal hygiene for Activities of Daily Living (ADL) care. Resident #3's care plan initiated on 03/24/22 identified the resident at risk for falls related to cognitive impairment, poor memory, unsteady gait and refusing to use her walker. The goal set for the resident by the staff the resident will not have an injury related to a fall through the next review period 01/18/2023. Some of the interventions/approaches the staff would use to accomplish this goal is to always wear non-skid socks, remind the resident to use their walker to perform ADLs, place visual cue on walker, place bed in lowest position while resident is in bed and ensure the resident wears shoes when ambulating. An interview was conducted with the Director of Rehab on 02/16/23 at 1:30 p.m., who stated Resident #3 was picked up by Physical Therapy (PT) on 03/25/22 and received through 05/02/22 after a fall on 03/23/22. She was picked up again on 05/24/22 and received therapy through 06/20/22 after a fall on 05/13/22 and 05/17/22. She stated at the time of Resident #3's discharged from therapy on 05/17/22, the resident was independent with all ADLs to include ambulation on the unit using a rolling walker. A review of Resident #3's clinical record revealed the following falls: -On 03/23/22, a fall nurse's note indicated Resident #3 was found on the floor in front of the doorway, next to the bathroom. The floor was free of spill, clutter and the resident were wearing proper footwear. The resident was assessed without injury or complaints of pain. The note indicated the Responsible Representative (RR) was notified on 03/24/22. -On 03/26/22 at 10:17 p.m., a fall note indicated an unwitnessed fall. The note stated the resident fell between her bed and the roommate's bed hitting her head on the footboard; neuro checks started. Further review of the fall note indicated a cut over the right eye with bruising and swelling noted. The resident's (RR) was informed of fall with injury. -On 05/17/2022 at 6:45 a.m., a note indicated an unwitnessed fall. The resident was assessed and transferred back to bed. Interventions were put in place to have bed in low position and always maintain call bell within reach. The note indicated the (RR) was notified on 05/17/22. -On 07/03/22 at 2:39 a.m., the resident laying on the floor in hallway in front of a chair. The resident stated she was trying to sit down, and the chair moved away from her. The note indicated the (RR) was notified on 07/03/22. -On 08/24/22 at 12:41 p.m., the resident was found lying on floor next to bed. She complained of right knee and right hip pain. The note indicated the (RR) was notified on 08/24/22. -On 08/29/22 at 1:35 p.m., the staff heard the resident when she fell hit the floor. The resident was observed lying on her left side with her head at the corner of the closed. A large knot was forming at her forehead long the hairline; neuro checks started. The note indicated the (RR) was notified on 08/29/22. -On 10/9/22 at 1:49 p.m., the fall note indicated the resident was assessed after a fall with no complaints of pain or discomfort. The note indicated no bruising or redness noted. The resident was transferred to bed the assist of two (2) staff members. The note indicated the (RR) was notified on 10/09/22. -On 11/19/22 at 6:46 p.m., the resident was observed on the floor, lying on her stomach. The right side of her head observed with a moderate amount of blood noted. The resident was transferred to the local emergency room (ER) and was transferred back to the facility on the same day. A review of Resident #3's care plan was not revised to include falls that occurred on 07/03, 08/24, 08/29, 10/09 and 11/19/22. An interview was conducted with MDS Coordinator #1 on 02/16/23 at approximately 2:41 p.m. He stated Resident #3's fall care plan was not revised to include falls that occurred on the days mentioned. The care plan should have been revised after each fall with interventions to prevent further falls and to help maintain the residents safety. On 02/16/23 at 4:15 p.m., the Administrator, Director of Nursing and two (2) Regional Director of Clinical Services were informed of the above findings. No further information was provided prior to exit.

Based on complaint investigation, staff interviews and clinical record review, the facility staff failed to notify the resident's representative of a new order to leave out the Percutaneous endoscopic gastrostomy (PEG) feeding tube for 1 out of 3 resident's (Resident #9) in the survey sample. The findings included: The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 02/22/22 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 99 indicating short and long term memory problems and with severe cognitive impairment - never/rarely made decisions. Resident #9 was coded total dependence of two with toilet use, personal hygiene and bathing, total dependence of one with transfer, extensive assistance of two with bed mobility and dressing and extensive assistance of one with eating for Activities of Daily Living (ADL). The care plan with a revision date of 11/11/21 identified Resident #9 requiring tube feeding related to dysphagia (difficulty swallowing). The goal set for the resident by the staff was that the resident will remain free of side effects or complications related to tube feeding and the resident's insertion site will be free of signs and symptoms of infection through of 05/23/22. Some of the interventions/approaches the staff would use to accomplish this goal is to provide water flushes per MD orders, Registered Dietitian (RD) and Speech Therapy (ST) consult and needed. A nurse's note entered by Registered Nurse (RN) #1 on 01/18/22 (3p-11p) shift at approximately 9:30 p.m., revealed the following Informed by the Certified Nursing Assistant (CNA) that Resident #9's PEG tube was completely pulled out with the balloon still intact. The on call physician informed with a new order to leave the PEG tube out since Resident #9 takes his medications crushed in pudding an is on a pureed diet. Review of Resident #9's clinical record did not reveal that the resident's representative was informed that the resident's PEG tube had come out with new orders to leave the PEG tube out. An interview was conducted with RN #1 on 04/06/22 at 3:45 p.m., who stated, I did not notify Resident #9's representative that the resident PEG tube had come out with a new order to leave the PEG tube out. When asked if the resident's representative should have been notified of the new order to leave out Resident #9's PEG tube out, she replied, Of course, she should have been notified. On 04/06/22 at approximately 4:10 p.m., an interview was conducted with the Director of Nursing (DON) who were informed of the above findings. The DON said RN #1 should have informed the RP and if she was not able, then it should have been passed on to the next shift but absolutely, the RP should have been notified that Resident #9, PEG tube came out with a new order to leave the tube out. On 04/07/22 at approximately 3:30 p.m., an interview was conducted with the Director of Nursing and Regional Director of Clinical Services who were informed of the above findings with no additional information provided. A debriefing was held with the Administrator, Director of Nursing and Regional Director of Clinical Services on 04/07/22 at approximately 3:41 p.m., who were informed of the above findings; no further information was provided prior to exit. The facility's policy titled Significant Change in Condition - revised on 11/01/19. All staff members shall communicate any information about patient status change to appropriate licensed personnel immediately upon observation. Procedure: 4. Responsible party will also be notified of a change in condition. Complaint deficiency

Based on observation, resident and staff interview the facility staff failed to ensure resident's environment were clean and homelike. Resident #3's bed room floors were observed to be dirty a with a dried dark sticky substance. The findings included: During the initial tour on 4/5/22 at 12: 45 P.M. Resident #3 who resided in room 401 bed A on Unit 4, floors were observed to be dirty with a dried dark sticky substance. Resident #3 was readmitted to the facility on [DATE] with diagnoses which included [CONDITION(S)], [CONDITION(S)], attention deficit-[CONDITION(S)], [CONDITION(S)], hypertension, and heart failure. A 1/30/22 Quarterly Minimum Data Set (MDS) assessed this resident in the area of cognitive ability as scoring a 15 on the Basic Interview for Mental Status (BIMS). Resident #3 was assessed as uses a walking cane and wheelchair for mobility. Resident is able to transfer independently. A revised care plan dated 02/26/22 indicated: The resident is at risk for falls r/t Deconditioning, gait/balance problems; Goals: The resident will be free of injury through next review. Interventions- Keep environment free of trip hazards. On 04/05/22 at 12:45 P.M. the floor was observed to have scuff marks, dirt, and a dark sticky substance. On 4/6/22 at 9:33 a.m. the floor tech was observed scrubbing the floor with a buffer. The suds were observed to be dark gray. The floor tech was observed to only scrub and clean half the room. During an interview with the floor tech on 4/6/22 at 9:53 a.m. he stated the substance on the floor was spilled coffee and chocolate. The floor tech stated, there was a work order put in over the weekend to clean the floor. During an interview on 4/7/22 at 10:05 a.m. with Resident #3, she stated, the floor has looked disgusting for over a month. She has been complaining about the condition of the filth and gross look of the floor for weeks. During an interview on 04/06/22 at 11:03 a.m. with the Maintenance Director he stated, the floor cleaning belongs to house keeping. The House Keeping director was out on leave during the survey. During an interview on 04/07/22 at 3:35 p.m. with the administrator, he stated, there is no work order system in place. The administrator was notified that the floor tech only cleaned half of room 401 floor. The administrator stated, the floor tech should have cleaned the entire floor. A housekeeping and environmental services policy was requested during the survey. There was no policy provided prior to exit. Complaint Deficiency

Based on complaint investigation, staff interviews, clinical record review and facility documentation review, the facility staff failed to revise 1 of 9 residents (Resident #9) comprehensive person- centered care plan in the survey sample. The findings included: The facility staff failed to revise Resident #9's comprehensive person-centered care plan for to the discontinuation of a Percutaneous endoscopic gastrostomy (PEG) feeding tube. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 02/22/22 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 99 indicating short and long term memory problems and with severe cognitive impairment - never/rarely made decisions. Resident #9 was coded total dependence of two with toilet use, personal hygiene and bathing, total dependence of one with transfer, extensive assistance of two with bed mobility and dressing and extensive assistance of one with eating for Activities of Daily Living (ADL). The care plan with a revision date of 11/11/21 identified Resident #9 requiring tube feeding related to dysphagia (difficulty swallowing). The goal set for the resident by the staff was that the resident will remain free of side effects or complications related to tube feeding and the resident's insertion site will be free of signs and symptoms of infection through of 05/23/22. Some of the interventions/approaches the staff would use to accomplish this goal is to provide water flushes per MD orders, Registered Dietitian (RD) and Speech Therapy (ST) consult and needed. A nurse's note entered by Registered Nurse (RN) #1 on 01/18/22 (3p-11p) shift at approximately 9:30 p.m., revealed the following Informed by the Certified Nursing Assistant (CNA) that Resident #9's PEG tube was completely pulled out with the balloon still intact, the on call physician informed with a new order to leave the PEG tube out since Resident #9 takes his medications crushed in pudding an is on a pureed diet. An interview was conducted with the MDS Coordinator on 04/07/22 at approximately 1:40 p.m., who stated, The Unit Manager's and all the nurses have access to update and revise the resident's care plan when changes are made. She said when the nurse received the order to leave out Resident's #9's PEG tube, she should have revise his care plan to reflect those changes, the use of his PEG tube should have been removed from his active care plan. On 04/07/22 at approximately 3:30 p.m., an interview was conducted with the Director of Nursing and Regional Director of Clinical Services who were informed of the above findings. The Director of Nursing stated, All nursing staff play in role in updating/revising the resident's care plans. She stated, When the nurse received the new order to leave out Resident #9s' PEG tube, the nurse should have revise the care plan, the use of the PEG should have been removed from his care plan. A debriefing was held with the Administrator, Director of Nursing and Regional Director of Clinical Services on 04/07/22 at approximately 3:41 p.m., who were informed of the above findings; no further information was provided prior to exit. The facility's policy titled Resident Assessment and Care Planning with a revision date of 11/01/19. Policy: A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient. Procedure: 6. Computerized care plans will be updated by each discipline on an ongoing basis as changes in the patient occur, and reviewed quarterly with the quarterly assessment. Definitions: -Percutaneous endoscopic gastrostomy (PEG) - feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. Feeding tubes are needed when you are unable to eat or drink. This may be due to stroke or other [CONDITION(S)], problems with the esophagus, surgery of the head and neck, or other conditions (https://medlineplus.gov). Complaint deficiency

Based on complaint investigation, staff interviews and clinical record review, the facility staff failed to ensure the necessary preventative treatment, care and services were provided to prevent the development of a stage II pressure ulcer for 1 out 3 resident's (Resident #9) in the survey sample. The findings included: Resident #9 was originally admitted the nursing facility on 09/30/20. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 02/22/22 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 99 indicating short and long term memory problems and with severe cognitive impairment - never/rarely made decisions. Resident #9 was coded total dependence of two with toilet use, personal hygiene and bathing, total dependence of one with transfer, extensive assistance of two with bed mobility and dressing and extensive assistance of one with eating for Activities of Daily Living (ADL). The care plan with a revision date of 12/15/21 identified Resident #9 with impaired skin impairment (pressure ulcer) behind left and right ear related to oxygen tubing. The goal set for the resident by the staff will have no evidence of further skin impairment. Some of the interventions/approaches the staff would use to accomplish this goal is for Healing Partners to provide skin/wound care as needed, keep skin clean and dry, lotion to dry skin and Weekly Skin Assessment. A Braden Risk Assessment Report was completed on 10/13/21; resident scored a sixteen indicating at risk for the development of pressure ulcers. During the initial tour and throughout the survey, residents identified using oxygen via nasal cannual were observed without having the use of a preventive device/cushion covering the oxygen tubing to protect the resident from device to skin contact. Review of the Weekly Skin Integrity Evaluation completed on 12/15/21 by License Practical Nurse (LPN) #3 revealed the following: a new stage II pressure ulcer located behind the left and right ear, cause of pressure ulcer (device related). The tissue bed noted with 100% [MEDICATION(S)] tissue (pink in color). Will refer to Healing Partners Wound team for further evaluation. Review of the initial Tissue Analytics evaluation completed on 12/16/21 by the Healing Partners Wound team (Wound Practitioner) indicated the following: 1. A new stage II pressure ulcer located behind the right ear measured 0.5 cm x 0.65 cm with 0.10 depth with scant amount of serosanguinous drainage and no odor. The issue is 100% epithelialization with attached edges. Under other: apply [MEDICATION(S)] ointment twice a day and leave open to air. Pad oxygen tubing with foam. 2. A new stage II pressure ulcer located behind the left ear measured 0.49 cm x 0.62 cm with 0.10 depth with scant amount of serosanguinous drainage and no odor. The issue is 100% epithelialization with attached edges. Under other: apply [MEDICATION(S)] ointment twice a day and leave open to air. Pad oxygen tubing with foam. Review of Resident #9's Treatment Administration Record (TAR) for December 2021 revealed the following treatment order: pressure ulcer behind the left and right ear - clean with normal saline or dermal wound cleanser, apply [MEDICATION(S)] ointment and protection gauze or dressing (start date 12/14/21). An interview was conducted with LPN #3 on 04/07/22 at approximately 10:20 a.m. The LPN stated, The pressure ulcers located behind Resident #9's left and right ear were first identified by the resident's daughter. She said the daughter informed her that Resident #9 was complaining of pain behind his ears, so she looked behind both ears and saw that there were open areas behind each ear. When asked if there were EarMates cannula cushions covering the oxygen tubing to protect the resident from device to skin contact prior to the development of his pressure ulcers, she replied, I don't remember seeing any protective covering over the oxygen tubing prior to the development of his pressure ulcers. An interview was conducted with the Director of Nursing (DON) and Regional Director of Clinical Service 04/07/22 at approximately 1:50 p.m. The DON said oxygen tubing can cause pressure between the tubing and the ear/skin so the following preventative measure should have been in place: protective foam dressing - something to break the pressure between the tubing and ear, and the staff could have used an oxygen mask instead of a nasal cannual. The facility's policy titled Respiratory/Oxygen Equipment - revised on 11/01/19. -Oxygen Therapy via Nasal Cannual, Simple Mask, Venturi Mask, and Oximizer. 4. When placing oxygen delivery device take care to avoid placing pressure on the patient's skin in contact with the system, including attention to the nares and/or ears when using a nasal cannula. A pressure ulcer prevention policy was requested from the DON and Regional Director of Clinical Service 04/07/22 at approximately 1:50 p.m. The Regional Director said the facility does not have a policy on pressure ulcer prevention but did provide a policy on General Wound care/Dressing Changes. The policy was reviewed but did not contain any information on preventing pressure ulcers. Definitions -A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages). -Pressure Injury - Stage 2 (Partial-thickness skin loss with exposed dermis_ Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages). -[MEDICATION(S)] is used to help prevent minor skin injuries such as cuts, scrapes, and [CONDITION(S)] from becoming infected. [MEDICATION(S)] is in a class of medications called antibiotics. [MEDICATION(S)] works by stopping the growth of bacteria (https://medlineplus.gov/druginfo/meds). Complaint deficiency.