Every finding on record at The Pavilion at Kenton

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure staff followed its policy and the resident-centered, comprehensive care plan for 1 of 32 residents, Resident (R) 79.R79 had been dependent on staff for total care and mobility since her admission in 2021. However, staff failed to follow and implement R79's care plan intervention for the use of a mechanical lift for all transfers. Review of the facility's Investigation Statement, dated 07/13/2026, revealed Certified Nursing Assistant (CNA) 9 admitted to transferring R79 to bed using a scoop method and not the care planned mechanical lift. On 07/13/2026, R79 was sent to the emergency room (ER) and was diagnosed with a fractured humerus due to staffs' failure to follow the resident's care plan intervention for use of the mechanical lift. The findings include:Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, revealed the intent was to provide a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs, which was developed and implemented for each resident. Further review revealed care plan interventions were chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the residents' problem areas and their causes, and relevant clinical decision-making.Review of the facility's policy titled, Lifting Machine, using a Mechanical, revised 07/2017, revealed, at least two nursing assistants are needed to safely move a resident with a mechanical lift. Further policy review revealed mechanical lifts might be used for transfers from surface to surface and repositioning.Review of the facility's mechanical lift and care plan in-services signed by CNA 2 on 04/15/2026, and CNA 9 on 04/25/2026. Even though CNA 9 and CNA 2 received the care plan and mechanical lift in-services they both failed to follow R79's care plan intervention for use of two staff and the mechanical lift.Review of R79's Face Sheet revealed the facility admitted R79 on 08/05/2021, with diagnoses of vascular dementia, severe protein calorie malnutrition, chronic pain, and contracture of left elbow and left hand.Review of R79's Quarterly Minimum Data Set (MDS), with an Assessment Review Date (ARD) of 07/03/2026, revealed the facility assessed the resident with severe cognitive impairment, and unable to recall any of the questions asked. Additional review revealed the facility also assessed R79 was dependent on staff for eating, hygiene, mobility, and transfers. Review of R79's Comprehensive Care Plan (CCP) revealed a Nurse Aide Care Plan focus initiated on 08/06/2021, with a Goal of ensuring resident safety and well-being. The Intervention, initiated on 08/25/2021 and revised on 02/12/2025, revealed R79 required a mechanical Hoyer lift with two staff assists for transfers.Review of the facility's, Incident Report documentation from 02/11/2026 through 08/11/2026, revealed no reported falls for R79 during that time.Review of the hospital X-ray report dated 07/13/2026, revealed R79 had a proximal humerus fracture through the proximal shaft of the right humerus which is displaced and angulated. Review of the facility's Quarterly MDS Assessment for R18 (R79's roommate) with an ARD of 04/30/2026, revealed the facility assessed R18 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no cognitive deficits.During an interview on 08/13/2026 at 1:13 PM with R18, she stated she was aware the lift was not used for R79 on the day of the incident. She stated the lift had not, if ever, been used for R79 before that date.Review of the facility's Investigation Statement dated 07/13/2026, part of the facility's investigation documentation, revealed it was noted CNA 8 stated she left R79's room to gather towels and a gown for the resident to change her and get her ready for bed. Per review of the Statement, CNA 8 said when she returned to R79's room CNA 9 had already put the resident to bed by herself. During an interview on 08/13/2026 at 1:33 PM, CNA 8 confirmed her facility witness statement documentation. She stated she had been the CNA assigned to R79 on the day of the incident. CNA 8 stated CNA 9 had agreed to help her. She stated she thought CNA 9 would wait for her to return, and they would use the lift which had been available in the hall; however, CNA 9 had not waited. She stated when she got to R79's room, CNA 9 had already put R79 to bed, unassisted and without use of the Hoyer lift. Continued review of the facility's Investigation Statement, part of the facility's investigation documentation, revealed CNA 9 initially stated she had used the mechanical lift to transfer R79 to bed, but then admitted to transferring R79 using a scoop method. Per review, CNA 9 stated while she was removing R79's shirt from her right arm, she heard a pop. Review of the Statement also revealed CNA 9 said after the pop she continued to change R79 and get her ready for bed. An interview with CNA 9 was attempted on 08/13/2026; however, was unsuccessful as the number had been disconnected.Review of a facility typed interview document dated 07/14/2026, between the IDON and CNA 2 had been assigned to R79's care on 07/12/2026, revealed the CNA stated the resident had already been in bed at the beginning of her shift at 7:00 PM. Per review of the interview document, CNA 2 said however, she had gotten R79 up on the morning of 07/13/2026. Review revealed CNA 2 initially stated she had used a Hoyer lift to transfer R79 but changed her story and said other staff were doing rounds and she had not used anyone else to help transfer R79. Continued review of the interview statement revealed CNA 2 denied seeing any bruising or swelling to any of R79's extremities. Review revealed at the end of the interview CNA 2 had been advised by the IDON of her suspension pending further investigation. Further review of the documentation of the interview of CNA 2 dated 07/14/2026, revealed interview between the Interim Administrator and CNA 2. Review of that interview information revealed CNA 2 reported the battery had been low on the Hoyer lift, and as a result, she lifted R79 with one arm under the resident's legs, her other arm against the resident's mid-back, and gently sat her in the chair, noting the resident was fragile and old. Per review of the interview information, CNA 2 denied being taught to do that transfer method by anyone in the facility but stated she had learned it along the way as a CNA. Review of the interview information revealed CNA 2 revealed she denied anything out of the ordinary or unusual at the time of her transfer of R79.An interview with CNA 2 was attempted on 08/14/2026 at 1:56 PM and 3:14 PM, with voicemail messages left; however, the CNA did not return the call. During an interview on 08/13/2026 at 2:35 PM, the IDON stated she expected staff to be familiar with a resident's care plan and to follow the facility's policies. She stated after the facility completed a thorough investigation of the incident involving R79 on 07/13/2026, both CNA 2 and CNA 9 were terminated for failure to follow R79's care plan and the facility's Hoyer lift policy. The IDON stated the nurses accessed residents' care plans in the facility's electronic medical record. During an interview on 08/13/2026 at 3:40 PM with the Interim Administrator, she stated she expected staff to follow the facility's policy for mechanical lifts and to be aware of how each resident was to be transferred safely. She stated she did not feel the incident involving R79 had been a case of intentional harm, but a failure to follow the resident's care plan and facility's mechanical lift policy. The Interim Administrator stated the staff identified as not following the facility's policy on 07/13/2026 had been terminated.

Based on interview, record review, and review of facility documentation and policy, the facility failed to ensure an environment free of accidents hazards by failing to use/provide the necessary assistance/device required during transfer of 1 of 32 sampled residents. (Resident (R) 79). On 07/13/2026, R79 was observed with a large bruise and swelling to her right upper extremity. Review of the facility's investigation documentation revealed CNA 9 failed to follow R79's care-planned intervention requiring the use of a mechanical lift with a two-person assist for transfers and instead manually transferred R79 to the bed. The investigation further revealed CNA 9 continued dressing R79 and reported hearing a pop. During interview, CNA 8 stated she was going to assist CNA 9 with R79's transfer but left the room to obtain supplies. CNA 8 stated that when she returned, CNA 9 had already transferred R79 without the mechanical lift and without the required two-person assistance. R79 was subsequently sent to the emergency room (ER) for evaluation, where an X-ray confirmed a displaced and angulated fracture of the proximal right humerus. The findings include:Review of the facility's policy titled, Lifting Machine, using a Mechanical, revised 07/2017, revealed, at least two nursing assistants are needed to safely move a resident with a mechanical lift. Further policy review revealed mechanical lifts might be used for transfers from surface to surface and repositioning.Review of the facility's Face Sheet for R79 revealed the facility admitted the resident on 08/05/2021, with diagnoses of contracture of the left elbow and hand, vascular dementia, chronic pain, and generalized anxiety.Review of the facility's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 07/03/2026, revealed the facility assessed R79 to have severe cognitive impairment. Per MDS review, the facility noted R79 had been unable to recall any of the questions asked. Additional MDS review revealed the facility assessed R79 as dependent on staff for mobility, and transfers. Review of R79's Comprehensive Care Plan (CCP) revealed a Nurse Aide Care Plan focus initiated on 08/06/2021, with a Goal of ensuring resident safety and well-being. Continued review of the CCP revealed the interventions included an intervention initiated on 08/25/2021 and revised on 02/12/2025, noting R79 required a mechanical Hoyer lift with two staff assist for transfers. Review of the facility's Incident Report documentation from 02/11/2026 through 08/11/2026, revealed no reported falls for R79 during that time period. Review of the most recent assessment completed by the Wound Care provider dated 07/08/2026, revealed a note regarding a resolved skin tear to R79's right upper extremity. Further review revealed, however, no documentation related to discoloration or edema of R79's upper extremities. Review of the hospital X-ray report dated 07/13/2026, revealed a proximal humerus fracture (fracture close to the shoulder joint, a serious injury) through the proximal shaft of the right humerus which was displaced and angulated.Review of the sign-in sheets for education provided for staff on 0415/2026, 04/25/2026, 05/27/2026, and 05/28/2026, revealed the education was regarding the importance of following residents' care plans, including, but not limited to, mechanical lifts. Continued review revealed CNA 9 and CNA 2 received the education which was provided by LPN 3/IADON and the current IDON. Review of the facility's document titled, Investigation Summary dated 07/13/2026, revealed R18 (R79's roommate) denied seeing anything unusual or R79 having a fall. Continued review of the Statement revealed R18 stated, I can tell you no one uses the lift to get her in or out of bed, and added, not just today but they never use it.Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 04/30/2026, revealed the facility assessed R18 as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no cognitive deficits. Review of the facility's investigation documentation revealed a Investigation Statement dated 07/13/2026, noting Certified Nursing Assistant (CNA) 8's interview after the incident on 07/13/2026 involving R79. Continued review revealed CNA 8 stated she left R79's room, where CNA 9 also was waiting to provide assistance, to gather supplies and get the resident ready for bed. Per review of CNA 8's statement, when she returned to R79's room, CNA 9 had already put the resident to bed by herself. Review of CNA 8's statement revealed she and CNA 9 removed R79's clothes and proceeded to place on gown on the resident. Further review of the statement revealed R79's right gown sleeve was so tight she would have cut it off if she had scissors.Observation of R79 on 08/12/2026 at 9:42 AM, revealed the resident lying in the bed, dressed in a clean gown with her right arm and right wrist contracted. Per observation R79 was non-verbal and did not respond to verbal conversation. Observation of R79 on 08/14/2026 at 10:10 AM, revealed the resident was dressed in a clean gown and was resting on the bed with eyes closed. During a telephone interview on 08/14/2026 at 1:40 PM, R79's State Guardian stated she could not recall who notified her of the incident involving R79 on 07/13/2026 but thought it had been someone from the hospital. During an interview on 08/13/2026 at 1:13 PM with R18, she reiterated the same information noted in her statement on 07/13/2026. She stated she had not seen or heard anything concerning on that date. R18 stated however, she was aware the lift was not used, and recalled it was seldom, if ever, used before that date. During an interview on 08/13/2026 at 1:33 PM, CNA 8 confirmed her witness statement located in the facility's investigation documentation. She stated she had been assigned to R79's care on 07/13/2026. The CNA stated when she returned from gathering supplies CNA 9 had already put R79 to bed and removed the left side of the resident's shirt and was removing the right sleeve from her arm. She stated she had not expected CNA 9 not to wait for her to return to provide help. CNA 8 stated she had not expected CNA 9 would not use the lift as required, since it was in the hall and available for use. She stated R79's right sleeve was tight and as the shirt was removed, she said CNA 9 reported hearing a pop. CNA 8 stated she had not heard that sound but saw there was already bruising and swelling of R79's upper right arm. She stated a nurse came into the room at that time for a scheduled skin check, saw the bruising and reported that information to the Interim Assistant Director of Nursing (IADON). The CNA stated she and CNA 9 continued getting R79 ready for bed. She stated after that a lot of questions were asked of the people working and an investigation was started. CNA 8 stated she and CNA 9 were sent home pending the results of the investigation.Review of the Investigation Statement for CNA 9, part of the facility's investigation documentation for the incident on 07/13/2026, revealed CNA 9 initially stated she had used the mechanical lift to transfer R79 to bed. Per review, however, CNA 9 later admitted to transferring R79 using a scoop method. Continued review of the CNA 9's statement revealed the CNA added that while she had been removing R79's shirt from her upper body, she heard a pop. Further review revealed she continued to finish changing R79 and get the resident ready for bed. A telephone interview was attempted on 08/13/2026 at 1:10 PM with CNA 9; however, the number had been disconnected.During an interview on 08/12/2026 at 09:47 AM, with Licensed Practical Nurse (LPN) 4, she stated she was going to see R79 for a skin assessment and observed CNA 8 and CNA 9 getting R79 ready for bed. She stated she observed a large bruise and swelling of R79's right upper arm, and she immediately reported that information to the IADON. She stated she did not recall seeing anything wrong with R79's arm before that. LPN 4 stated she was not aware of a fall or how R79 might have been injured. Review of the facility's investigation documentation revealed a Investigation Statement dated 07/13/2026, noting the IADON went to the Interim Administrator's office and reported extreme bruising and swelling to R79's right shoulder and upper arm. The Interim Administrator and IADON went and assessed R79 together and the IADON then reached out to the provider and requested an order to send the resident out to the ER for evaluation.During an interview on 08/12/2026 at 1:35 PM, LPN 3/IADON stated LPN 4 reported to her an observation of a large bruise and edema to R79's right arm, which she (LPN 4) had not observed before. She stated she went with the Interim Administrator to assess R79's arm, and it was determined it should be further examined. LPN 3/IADON stated an order was obtained to send R79 to the ER for evaluation. She stated an investigation was initiated immediately, and CNA 8 and CNA 9 were both suspended pending investigation. LPN 3/IADON stated she had been with the Wound Care provider during the last visit on 07/08/2026, and there had been no discoloration or edema observed on R79's right arm at that time.Review of the facility's typed interview document, between IDON and CNA 2, assigned to care for R79 on the night of 07/12/2026, revealed CNA 2 stated the resident had been already in bed at the beginning of her shift at 7:00 PM. Per review, CNA 2 reported getting R79 up on the morning of 07/13/2026. Review of the typed interview documentation revealed CNA 2 initially stated she had used a Hoyer lift to transfer R79; however, changed her story later. Continued review revealed CNA stated the other staff present were doing rounds and she had not requested help to transfer R79. CNA 2 admitted to transferring R79 alone and denied seeing any bruising or swelling to any of the resident's extremities. Review revealed at the end of the interview, CNA 2 was advised by the IDON of her suspension pending further investigation.Continued review of the documentation of the interview with CNA 2 dated 07/14/2026, revealed an interview between the Interim Administrator and the CNA. Per review, CNA 2 reported the battery on the Hoyer lift had been low, and so she lifted R79 with one arm under the resident's legs, and her other arm against the resident's mid-back. Review revealed CNA 2 stated she gently sat R79 in the chair, saying the resident was fragile and old. Continued review revealed CNA 2 denied having been taught to do such a transfer by anyone in the facility and said she had learned it along the way as a CNA. Further review revealed CNA 2 denied there having been anything out of the ordinary or unusual at the time of her transfer of R79. A telephone interview was attempted on 08/13/2026 at 1:10 PM with CNA 2; with no answer and a voicemail message left. However, no return call was received.During an interview on 08/13/2026 at 2:35 PM, the IDON stated she expected staff to be familiar with a resident's care plan and to follow the facility policies. The IDON stated the facility used contracted agency staff who were educated by their agency. She stated the facility's regular staff were in orientation for several days with a preceptor and could be re-educated as needed. The IDON stated after the facility performed a thorough investigation of the incident involving R79 that occurred on 07/13/2026, both CNA 2 and CNA 9 were terminated for failure to follow the facility's policy. In interview on 08/13/2026 at 3:40 PM, the Interim Administrator stated she expected staff to follow the facility's policy for mechanical lifts and to be aware of how to transfer each resident safely. She stated she did not feel the incident involving R79 had been a case of intentional harm but felt it had been a failure to follow the facility's mechanical lift policy. The Interim Administrator stated the staff identified as not following the facility's mechanical lift policy had both been terminated.

Based on interview, record review, and review of facility documentation and policy, the facility failed to have an effective process in place to address systemic failures through its Quality Assurance Performance Improvement (QAPI) process. As a result of the failure the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained as required. The systemic failure placed residents at increased risk for lack of quality of care and preventable infectious diseases.The State Survey Agency (SSA) identified continued non-compliance cited on the previous standard survey on 03/26/2026 under 42 CFR 483.25 Quality of Care (F693) Enteral Feeding, and 42 CFR 483.80 (F880) Infection Control. Review of the facility's Plan of Correction (POC) with a compliance date of 06/02/2026, revealed the QAPI Committee would oversee and ensure the Director of Nursing (DON) educated, audited, and performed continued monitoring to ensure staff appropriately labeled and timed tube feeding containers; and used end caps on connector tips when tube feedings were not running. Additionally, under the Infection Control deficient practice, the facility specifically noted in the POC the DON would educate, audit, and perform continued monitoring to ensure staff appropriately followed the facility's infection control policies and standards of practice.(Cross-reference F693 and F880) The findings include:Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership, dated March 2020, revealed the policy required the QAPI Committee to ensure the QAPI program was implemented and maintained. Continued review of the policy revealed the QAPI Committee was to ensure the facility's QAPI program was to address identified priorities, sustained through leadership and staffing transitions, adequately resourced, and based on resident and staff input.Review of the facility's policy Quality Assurance and Performance Improvement (QAPI) Program - Analysis and Action, undated, revealed identified quality deficiencies would undergo appropriate corrective action, and corrective actions would be monitored by the QAPI Committee against established goals and benchmarks.Review of the facility's Administrator Job Description, undated, revealed the Administrator was responsible for leading, directing, and evaluating the facility's overall operations in accordance with federal and state regulations and facility's policies. Per review, the Administrator's responsibilities included working with the DON and department heads to identify key performance indicators and establishing systems to monitor those indicators through the QAPI process Continued review of the Job Description revealed the responsibilities also included evaluating outcomes, and determining when leadership action, education, or system revisions were necessary to improve quality regulatory compliance and resident care. Review of the facility's, Director of Nursing Services Job Description, undated, revealed the DON was responsible for directing nursing care services to ensure residents received appropriate care in accordance with regulatory requirements and the facility's policies. Per review of the Job Description, the responsibilities included communicating the facility's policies and procedures to nursing staff, monitoring staff practices and implementation, evaluating nursing staffs' performance, addressing identified performance concerns, and participating in the facility's QAPI and performance improvement (PI) activities.Based on review of the facility's acceptable POC, for the Standard Recertification/Abbreviated/Extended Survey concluded on 03/26/2026, and the off-site review, the Administrator failed to ensure the facility achieved and maintained substantial compliance as evidence by the repeat deficiencies cited during the Abbreviated Survey concluded on 08/14/2026.Continued review of the facility's acceptable POC, submitted for the 03/26/2026, survey revealed the DON or Designee was to implement systemic changes to include revised enteral feeding monitoring procedures, implementation of tube feeding labeling audits (F693), and revised infection control monitoring for enteral feeding equipment (F880).Review of the facility's documentation for the acceptable POC, for the 03/26/2026 Survey, revealed the DON completed education with Licensed Nurses by 05/29/2026, regarding enteral feeding policies and procedures with emphasis on ensuring tube feeding bottles were dated and timed prior to hanging, and infection control practices included ensuring end caps were in place when tube feedings were not running. According to review of the POC, the Human Resources or Designee was to provide education to all newly hired Licensed Nurses and agency Licensed Nurses during orientation and prior to letting them independently providing resident care to ensure ongoing compliance with enteral feeding policies and procedures.Review of the facility's tube feeding audits, which began on 06/01/2026, revealed the DON or Designee would complete audits by observing one enteral feeding daily, five times a week for four weeks to ensure proper date and time were in place, and end caps were in use for enteral feeding if they were not running. Further review revealed the findings from all audits were to be reviewed by the facility's Quality Assurance (QA) Committee and integrated into the QAPI process to ensure ongoing compliance.Review of the facility's Enteral Feeding Audit for week one, dated 06/01/2026 through 06/05/2026, revealed it had been conducted by the Regional Nurse Consultant (RNC). According to review of the audit, all tube feedings were properly dated and timed, and end caps were in use when the enteral feeding was not running. Further review of the Audit revealed no concerns or issues noted.Review of the facility's Enteral Feeding Audit for week two, dated 06/08/2026 through 06/12/2026, revealed all tube feedings were properly dated and timed, and end caps were in use when the enteral feeding was not running. Per review of the Audit information, no concerns or issues were noted during the audit. However, further review revealed the audit did not include a signature identifying the individual who performed it.Review of the facility's, Enteral Feeding Audit for week three, dated 06/15/2026 through 06/19/2026, revealed all tube feedings were properly dated and timed, and end caps were in use when the enteral feeding was not running. Continued review revealed no concerns or issues were noted during the audit. However, further review revealed the audit did not include a signature identifying the individual who performed it.Review of the facility's, Enteral Feeding Audit for week four, dated 06/22/2026 through 06/26/2026, revealed all tube feedings were properly dated and timed, and end caps were in use when the enteral feeding was not running. Per review, no concerns or issues were noted during the audit. However, further review revealed the audit did not include a signature identifying the individual who performed it.Review of the facility's, Enteral Feeding Audit #2, initiated a second audit after its first POC submission was rejected. Review of the Enteral Feeding Audit #2 for week one, dated 06/01/2026 through 06/05/2026, revealed it conducted by the DON. According to review of the Audit #2 documentation the DON ensured all tube feedings were properly dated and timed, and end caps were in use when the enteral feeding was not running. Further review revealed there were no concerns or issues noted.Review of the facility's, Enteral Feeding Audit #2 for week two, dated 06/08/2026 through 06/12/2026, was conducted by the DON. According to review of the audit, all tube feedings were properly dated and timed, and end caps were in use when the enteral feeding was not running.Review of the facility's, Enteral Feeding Audit #2 for week three, dated 06/15/2026 through 06/19/2026, was conducted by the DON. According to review of the audit, all tube feedings were properly dated and timed, and end caps were in use when the enteral feeding was not running.Review of the facility's, Enteral Feeding Audit #2 for week four, dated 06/22/2026 through 06/26/2026, was conducted by the DON. According to review of the audit, all tube feedings were properly dated and timed, and end caps were in use when the enteral feeding was not running.Review of the facility's education Presentation Focus: Infection Control (Tube Feeding), dated 04/16/2026 and 05/27/2026, revealed the education was provided by the Administrator and DON. Per review of the education revealed it included all tube feeding would be labeled with a date and time when the tube feeding was initiated and hung. Additionally, review revealed if a tube feeding was stopped and disconnected from a resident for any reason, the tube feed tubing would be capped to prevent contamination and infection. Further review revealed twenty-four clinical staff signed the document indicating they received the education.Review of the facility's QAPI meeting documentation for March, April, and May 2026, was requested from the Interim Administrator on 07/13/2026 at 5:00 PM. That documentation was requested to validate the facility's QAPI Committee met during those months and reviewed identified concerns. However, the Interim Administrator did not provide that documentation. Review of the facility's, Ad Hoc (Self-Identified Areas) Meeting Minutes, dated 04/03/2026, revealed the [NAME] President of Clinical (VPC), Regional Director of Operations (RDO), Regional Nurse Consultant (RNC), DON, Social Services Director (SSD), and the Medical Director were all in attendance. Further review of the facility's Ad Hoc QAPI meeting revealed no documented evidence the deficiencies identified during the 03/23/2026 standard survey was discussed, analyzed for underlying systemic causes, or monitored through the facility's QAPI process to ensure corrective actions were effective and sustained.Review of the facility's Ad Hoc (Self-Identified Areas) Meeting Minutes dated 04/30/2026, revealed the Administrator, DON, Activities Director (AD), Admissions Director, Business Office Manager (BOM), Dining Service Manager, Therapy Program Manager (TPM), Minimum Data Set (MDS) Coordinator, Assistant Director of Nursing (ADON), and Medical Director were all in attendance. Further review of the facility's QAPI meeting minutes revealed no documented evidence the deficiencies identified during the 03/23/2026 Standard Survey were discussed, analyzed for underlying systemic causes, or monitored through the QAPI process to ensure corrective actions were effective and sustained. Review of the facility's, QAPI Meeting Sign-In Sheet, dated 06/25/2026, revealed the Maintenance Director, Administrator, SSD, TPM, DON, DSM, and the Medical Director were in attendance. Continued review of the facility's documentation revealed no corresponding meeting agendas or minutes to validate the topics discussed during the QAPI meeting. Further review revealed no corresponding documentation to validate any ongoing monitoringReview of the QAPI Meeting Sign-In Sheet, dated 07/24/2026, revealed the Administrator, DON, DOM, SSD, TPM, and the Medical Director were in attendance. Documentation review revealed no corresponding meeting agendas or minutes to validate topics discussed, or ongoing monitoring and follow-up conducted by the QAPI Committee.During an interview on 08/14/2026 at 1:15 PM, with the Registered Dietitian (RD), she stated she was a member of the facility's QAPI team and attended monthly QAPI meetings, with the exception of July 2026, when she was on vacation. She stated the POC had been discussed during the QAPI meetings; however, she did not participate in its development. She stated she had not provided staff education or participated in audits related to enteral feedings, including monitoring to ensure feeding tubes were disconnected and capped when feedings were stopped and enteral feeding products were dated and timed. The RD stated beyond her specific departmental duties, she was not involved in ongoing QAPI activities. She further stated QAPI activities were important to improve the residents' quality of care.During an interview on 08/14/2026 at 1:30 PM with the Dining Services Manager (DSM), she stated she attended monthly QAPI meetings and that the QAPI team met immediately following the SSA Survey. She stated she conducted audits related to dietary deficiencies but was not involved in other ongoing QAPI activities. She stated QAPI was important to ensure quality care and services for residents.During an interview with the Interim Administrator on 08/13/2026 at 5:00 PM, she stated she assumed her position on 06/18/2026, after the POC had been accepted and the majority of the audits had been completed. She stated she was responsible for directing the day-to-day functions of the facility following federal, state, and local standards, guidelines, and regulations that governed nursing facilities, to ensure the facility provided the highest degree of quality care could be provided to residents at all times. Additionally, the Interim Administrator stated she was responsible for the facility's QAPI Program and ensuring consistent and appropriate employee training. She stated she facilitated monthly QAPI meetings beginning in June 2026.During continued interview with the Interim Administrator on 08/13/2026 at 5:00 PM, she stated she conducted QAPI meetings on 06/25/2026 and 07/24/2026. However, she stated she was unable to locate documentation validating the former Interim Administrator had conducted QAPI meetings related to the facility's plan of correction.When asked by the State Survey Agency (SSA) Surveyor about the facility's inability to sustain compliance with previously identified quality of care and infection-control concerns, the Interim Administrator stated she believed the primary systemic issue was a lack of consistency in leadership and staffing. She stated the facility had experienced multiple changes in Administrators, DONs, and ADONs, which affected the consistency of facility oversight and follow-through. She stated maintaining compliance was the responsibility of both the facility leadership team and regional leadership and corrective actions needed to be both attainable and sustainable. Furthermore, she acknowledged the importance of maintaining consistent leadership and oversight to ensure the quality of care and safety of residents.During an interview with the RNC on 08/13/2026 at 5:36 PM, she stated she took an active role in the facility's POC audit process, by performing audits, reviewing completed audits, and making multiple daily rounds to ensure residents' needs were met. She stated during rounding she personally monitored staff to ensure they were performing their duties as assigned. In addition, the RNC stated she assisted the Interim DON to provide education to staff as part of the POC. She stated all staff, including new hires and agency staff, were trained on enteral feeding and infection control. The RNC stated she was in the facility several days a week to provide support to the Interim DON. She stated she had not identified any concerns and believed the staff were doing well in maintaining compliance and following the facility policy. When asked by the SSA Surveyor to identify the root cause for continued noncompliance with previously cited concerns, the RNC stated she believed the primary issue was agency staffing and staffing inconsistency. Furthermore, the RNC stated it was her expectation the facility followed the POC as submitted, sustained compliance with the corrective actions, and for the QAPI Committee to provide oversight of the POC and ensure continued compliance.During an interview with the Interim Director of Nursing (IDON) on 08/13/2026 at 5:56 PM, she stated she assumed her position at the facility on 05/13/2026, after the survey and while the POC was being revised following a rejection. The IDON stated corporate clinical and operational personnel, including the [NAME] President of Clinical (VPC) and the RNC provided support during the implementation of the facility's POC. Additionally, the IDON stated corporate staff were physically present in the facility for an extended period and continued to remain available by telephone and email.In continued interview with the IDON on 08/13/2026 at 5:56 PM, she stated she was a member of the facility's QAPI, and the committee discussed the entire POC during the QAPI meetings following the survey. The IDON stated QAPI meetings were conducted monthly. She stated she and corporate personnel, including the RNC, completed audits associated with the POC. The IDON stated fewer concerns had been identified during the original audit period because the facility had more facility-employed nurses at the time and subsequently increased its use of agency nurses. The IDON stated she continued to round and observe practices after the formal POC audits ended. However, the IDON stated routine leadership rounds were not documented. She further stated she had not observed major concerns. The IDON stated if she had identified a concern during rounds, she immediately intervened and provided education as appropriate, but the routine rounding and observations were not otherwise recorded.During a telephone interview with the Regional Director of Operations (RDO) on 08/13/2026 at 6:00 PM, he stated he was familiar with and had participated as part of the team that developed the facility's Plan of Correction (POC) accepted in June 2026'; however, he was unable to discuss specific details of the facility's POC. He stated the POC was primarily driven by facility and clinical leadership and the Interim Administrator and IDON were responsible for oversight of the POC and ensuring the facility implemented the corrective actions and sustained compliance. The RDO stated he did not normally attend or participate in the facility's QAPI Committee meetings and did not typically have an active role in monitoring, auditing, or educating frontline staff regarding implementation of the POC.In continued telephone interview with the RDO on 08/13/2026 at 6:00 PM, she stated he and the RNC were present at the facility approximately twice a week. The RDO stated if he identified a concern while rounding, he would intervene, provide education as appropriate, and report the concern to the IDON for additional education and follow-up. When the SSA Surveyor informed continued noncompliance had been identified with concerns previously addressed through the POC, including infection control and enteral feeding practices, the RDO initially stated he would need to review the information before addressing the cause of the continued noncompliance.During an additional interview with the RDO on 08/14/2026 at 9:30 AM, he stated the identified agency staffing and staffing inconsistency as what he believed to be the primary root cause of the continued noncompliance. He stated the majority of the facility's nursing staff were temporary staff and acknowledged temporary staff did not know the residents or facility-specific practices. The RDO stated the facility had experienced turnover in Administrator and nursing leadership positions and had strived to obtain permanent leadership. He further acknowledged the IDON was responsible for multiple functions and stated that arrangement was not optimal When asked by the SSA Surveyor about the continue noncompliance despite corporate support and improvement efforts provided to the facility, the RDO stated he was aware multiple individuals had been working to ensure residents' needs were addressed. He stated however, he struggled to reconcile the continued concerns with the support that had been provided. The RDO stated his expectation was for the facility to follow its POC as submitted, sustain compliance with the corrective actions, and for the Interim Administrator and IDON to provide necessary oversight of the POC, and ensure the continued compliance.

Based on observation, interview, record review, review of Centers for Disease Control and Prevention (CDC) signage, and review of the facility's policies, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 4 of 4 residents sampled for infection control, Resident (R) 18, R32, R36, and R38. Specifically, staff failed to follow Enhanced Barrier Precautions (EBP), use appropriate personal protective equipment (PPE), perform hand hygiene at required opportunities, prevent cross-contamination when moving from contaminated to clean care activities, and maintain enteral-feeding equipment in a manner to reduce the risk of contamination.The findings include:Review of the facility's CDC signage for EBP, undated, revealed a gown and gloves were required for high-contact resident care activities for residents with a central line, a urinary catheter, a feeding tube, or wound care for any skin care requiring a dressing. Further review of the signage revealed everyone must clean their hands, including before entering and when leaving the resident's room.Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], dated December 2023, revealed an IPCP was established and maintained to provide a safe, sanitary, and comfortable environment to help prevent the development of transmission and communicable diseases and infections. According to the policy, members of the IPCP committee are to perform surveillance of staff adherence to IPCP practices.Review of the facility's policy titled, Hand Washing/Hand Hygiene, revised October 2023, revealed the facility considers hand hygiene the primary means of preventing the spread of health care associated infections. The policy directs all personnel to adhere to hand hygiene policies and practices to help prevent the spread of infection to personnel, residents, and visitors. The policy identifies hand hygiene as indicated immediately before touching a resident, before performing an aseptic task, including handling an invasive medical device, after contact with contaminated surfaces, and after touching a resident or the resident's environment before moving from work on a soiled body site to a clean body site or environmental surface, and immediately after glove removal. Furthermore, the policy directs staff to use single-use disposable gloves before an aseptic procedure, when anticipating contact with blood or bodily body fluids, and when in contact with a resident, the resident's equipment, or an environment when the resident is in precautions. The policy specifies the use of gloves did not replace hand hygiene.Review of the facility's policy titled, Administering Medications, revised April 2019, revealed medications are to be administered in a safe manner. The policy further stated staff are to follow established infection control procedures including hand hygiene, antiseptic technique, and appropriate infection control measures during medication administration.1. Review of R18's admission Face Sheet, found in the resident's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 12/13/2024 and most recently on 06/12/2026 with diagnoses to include lumbar spina bifida with hydrocephalus, neuromuscular dysfunction of the bladder, and chronic kidney disease, stage 3A.Review of R18's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/14/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, indicating the resident was cognitively intact.Review of R18's Order Summary Report, dated August 2026, revealed an order for an 18 French (Fr) Foley catheter related to a diagnosis of neuromuscular dysfunction of the bladder. Further review revealed an order dated 07/21/2026 for EBP related to extended spectrum beta lactamase (ESBL) identified in the resident's urine.During an observation on 08/11/2026 at 9:50 AM, CNA10 provided direct care to R18, who was on EBP, while wearing gloves but not a gown. When questioned by the State Survey Agency (SSA) Surveyor, CNA10 stated R18 was not under EBP; however, CDC signage posted outside the room identified R18 as requiring EBP. After the SSA Surveyor directed CNA10 to the signage, she exited the room while wearing the same gloves used during resident care and without removing the gloves or performing hand hygiene, opened the PPE cart drawer and obtained a clean gown. During an immediate interview with CNA10, she stated she was unaware R18 was on EBP. When asked by the SSA Surveyor whether residents with Foley catheters required EBP, CNA10 stated they did. She further stated it was important to follow instructions on CDC signage posted outside the residents' rooms to help prevent the spread of infection.An attempted interview on 08/11/2026 at 10:10 AM with R18 was refused by the resident.2. Review R36's admission Face Sheet, found in the resident's EMR under the Profile tab, revealed the facility admitted the resident on 05/27/2022 with diagnoses to include gastrostomy status, gastroesophageal reflux disease without esophagitis, and other specified chromosome abnormalities.Review of R36's quarterly MDS, with an ARD of 07/16/2026, revealed a BIMS was not conducted because the resident was unable to complete the assessment. R36 was rarely/never understood. The Staff Assessment for Mental Status was completed and indicated the resident was severely impaired for daily decision making and never/rarely made decisions. Further review revealed R36 was coded as receiving 51 percent or more of total calories and fluid intake via parenteral or tube feeding.Review of R36's Care Plan Report, undated, found in R36's EMR under the Care Plan tab, revealed the resident required tube feedings related to dysphagia, chewing problems, and difficulty swallowing. An intervention, revised on 07/13/2026, indicated staff were to monitor signs and symptoms of infection related to tube feedings. The goal indicated R36 would remain free of complications related to tube feeding.Review of the Order Summary Report, dated August 2026, revealed staff should monitor R36's gastrostomy tube site for signs or symptoms of infection every shift to support infection prevention. Further review revealed an order to cleanse feeding tube site every shift with normal saline, pat dry and apply hydrogel, cover with a split gauze dressing, daily and as needed, until healed related to gastrostomy status. Additional review of the physician's orders revealed an order dated 04/30/2026 for EBP related to a gastric feeding tube.During an observation on 08/12/2026 at 8:40 AM, LPN1 performed G-tube care to R36. LPN1 did not perform hand hygiene before donning gloves and did not don a gown as required by the posted CDC signage for a resident on EBP. Observation of R36's G-tube and stoma site revealed a split gauze dressing with fresh and dried tube-feeding leakage and bloody drainage. The skin surrounding the stoma appeared red, raw, and blistered with bloody drainage from the stoma noted. LPN1 removed the soil dressing and used the soiled gauze to wipe the area around the stoma and surrounding skin.Further observation revealed LPN1, while wearing the same contaminated gloves, opened R36's bedside table drawer and retrieved a container of nystatin powder and clean gauze. She did not remove the contaminated gloves or perform hand hygiene before touching the bedside table and obtaining clean supplies. LPN1 applied nystatin (anti-fungal) powder and placed a clean split gauze dressing over the site without first cleaning the area with clean supplies. After completing the G-tube care, LPN1 removed her gloves but did not perform hand hygiene.During an immediate interview with LPN1 regarding EBP and hand hygiene, she stated she observed CDC signage outside R36's room. When asked by the SSA Surveyor why she did not don the appropriate PPE, including a gown prior to providing direct care to R36, LPN1 stated she forgot to put on the gown. When asked why she used soil gauze to clean R36's stoma site rather than obtaining clean supplies, LPN1 stated she did not realize she had done so. LPN1 further stated she did not realize she failed to change her gloves and perform hand hygiene after completing the dirty portion of the dressing change, and before proceeding with the clean portion. When asked why she opened the bedside table drawer with the same contaminated gloves to obtain additional supplies, LPN1 again stated she did not realize she had done so. She further stated nursing care standards required a nurse to remove soiled gloves, perform hand hygiene, and don clean gloves before moving from a dirty task to an antiseptic task. LPN1 stated she did not follow the expected infection prevention and control practices during the observed G-tube care and dressing change. She further stated following these practices was important to keep germs from spreading and to protect the residents from getting an infection.3. Review of R38's admission Face Sheet, found in the resident's EMR under the Profile tab, revealed the facility admitted the resident on 09/08/2006 with diagnoses to include gastrostomy status, gastro-esophageal reflux disease without esophagitis, and moderate protein deficiency malnutrition.Review of R38's quarterly MDS, with an ARD of 05/14/2026, revealed a BIMS was not conducted because the resident was unable to complete the assessment. R38 was rarely/never understood. The Staff Assessment for Mental Status was completed and indicated the resident was severely impaired for daily decision making and never/rarely made decisions. Further review revealed R38 was coded as receiving 51 percent or more of total calories and fluid intake via parenteral or tube feeding.Review of R38's Care Plan Report, undated, found in R38's EMR under the Care Plan tab, revealed the resident required tube feedings related to dysphagia, chewing problems, and difficulty swallowing. An intervention, initiated on 02/28/2023, was to monitor signs and symptoms of infection related to tube feedings. The goal indicated R38 would remain free of complications related to tube feeding.Review of the Order Summary Report, dated 08/12/2026, revealed staff should monitor the gastrostomy tube site for signs or symptoms of infection every shift to support infection prevention. Further review of the physician's orders revealed an order dated 08/10/2024 for EBP related to a gastric feeding tube.During an observation on 08/13/2026 at 9:25 AM, LPN8 assessed R38's G-tube stoma site while R38 lay in bed with the head of the bed elevated. LPN8 did not perform hand hygiene before donning disposable gloves and did not put on a gown. During the assessment, LPN8 touched the resident's bed, bed linens, and G-tube, and subsequently touched the enteral feeding tubing and feeding pump. Additionally, the resident was not receiving enteral feeding at the time of the observation. An enteral feeding container was observed hanging from a feeding pump pole, spiked, and primed with formula. The distal connector of the enteral feeding tubing was uncapped and in direct contact with the pole. The resident's water flush bag was observed without a date or time indicating when it had been hung.4. Review of R32's admission Face Sheet, found in the resident's EMR under the Profile tab, revealed the facility admitted the resident on 08/26/2025 with diagnoses to include gastrostomy status, dysphagia, and vitamin deficiency, unspecified.Review of R32's quarterly MDS, with an ARD of 04/16/2026, revealed a BIMS was not conducted because the resident was unable to complete the assessment. R32 was rarely/never understood. The Staff Assessment for Mental Status was completed and indicated the resident was severely impaired for daily decision making and never/rarely made decisions. Further review revealed the R32 was coded as receiving 51 percent or more of total calories and fluid intake via parenteral or tube feeding.Review of R32's Care Plan Report, undated, and found in R32's EMR under the Care Plan tab, revealed the resident required tube feedings related to dysphagia, chewing problems, and difficulty swallowing. An intervention initiated on 02/28/2023 was to monitor signs and symptoms of infection related to tube feedings. The goal indicated R32 would remain free of complications related to tube feeding.Review of the Order Summary Report, dated 08/11/2026, revealed staff should monitor the gastrostomy tube site for signs or symptoms of infection every shift to support infection prevention. Further review of the physician's orders revealed an order dated 02/28/2023 for EBP related to a gastric feeding tube.Observation on 08/13/2026 at 9:42 AM revealed R32 was lying in bed with the head of the bed elevated and the resident was not receiving enteral feeding at the time of the observation. An enteral feeding container was observed hanging from a feeding pump pole, spiked, and primed with formula. The distal connector of the enteral feeding tubing was uncapped and in direct contact with the feeding pump pole. Additionally, the resident's water flush bag was observed without a date or time indicating when it had been hung. LPN8 assessed the resident's G-tube stoma site; however, she did not don a gown prior to providing direct care. During the assessment, LPN8 touched the resident's bed, bed linens, and G-tube, and subsequently touched the enteral feeding tubing, feeding pump, and the resident's environment with the contaminated gloves, before removing them and performing hand hygiene.During an interview on 08/13/2026 at 9:42 AM, LPN8 stated she did not wear a gown because she was just showing the SSA Surveyor R32 and R38's G-tube sites and did not initially believe she provided direct care to the residents. During continued interview, she stated CDC EBP signage posted outside both residents' rooms indicated a gown and gloves should be worn during all direct care activities. She stated she understood she had provided direct care and should have followed the posted EBP signage by wearing a gown and gloves. Furthermore, LPN8 stated she did not perform hand hygiene before donning gloves and after removing them to reduce cross-contamination and infection transmission from contaminated gloves on to environmental surfaces. She stated proper hand hygiene promoted resident and staff safety and helped prevent infection during care.In continued interview with LPN8, regarding enteral feeding supplies, on 08/13/2026 at 9:42 AM, the LPN stated she had not yet made rounds on her assigned residents to check their tube feedings. She stated the night shift was responsible for stopping the tube feedings as ordered, and for dating and timing the feeding and water flush supplies they hung before the day shift began. LPN8 stated she attributed the undated feeding and water flush supplies observed during the shift to the night shift staff. LPN8 stated she was an agency nurse and had worked at the facility approximately five times. She stated the facility had not provided facility-specific education on infection control practices, including EBP, hand hygiene, or capping and dating enteral feeding supplies. LPN8 stated she learned those practices through education received at another place of employment but failed to follow policy during the observation. Furthermore, LPN8 stated staff should follow the CDC EBP signage and facility infection control policies when providing high-contact care, including care involving a feeding tube. She stated those precautions helped prevent infection and protected residents and staff. LPN8 stated failing to follow the precautions could increase the risk of spreading infection among residents, staff, and the care environment.During a telephone interview with the Registered Dietician (RD) on 08/13/2026 at 10:21 AM, she stated enteral feeding tube connectors should be covered to prevent contamination and reduce the risk of infection.During an interview with the Interim Director of Nursing (IDON) on 08/13/2026 at 5:56 PM, she stated staff had received education related to enteral feedings, ensuring tubing was appropriately capped when disconnected from the resident, and infection control. She further stated staff received information during shift report regarding changes in residents' condition, including when a resident was placed on precautions or isolation related to an infection. The IDON stated staff were expected to follow posted precautions, wear the appropriate PPE, and perform hand hygiene according to the CDC signage posted outside of residents' rooms. Additionally, the IDON stated staff received education on performing hand hygiene after removing soiled gloves and to remove soiled gloves before moving from a dirty task to performing an aseptic task.The IDON further stated, on 08/13/2026 at 5:56 PM, as the acting Infection Preventionist (IP), she performed daily audits during her rounds to ensure staff followed infection prevention and control practices. However, she stated she did not maintain documented evidence of the audits she performed. She further stated she had not observed staff breaching infection prevention and control practices or failing to follow the posted CDC signage during her rounds.Furthermore, the IDON stated, on 08/13/2026 at 5:56 PM, it was her expectation that tube feedings remain capped when not in use and a new system should be set up if it is found undated, untimed, or uncapped. She stated water flushes and feedings should always be dated and timed. The IDON stated that was important to provide residents with fresh tube feeding formula and a clean water flush to reduce the risk of contamination and potential infection.During an interview with the Regional Nurse Consultant (RNC) on 08/13/2026 at 5:36 PM, she stated all staff should follow posted CDC signage to ensure the appropriate PPE is worn while providing resident care. She stated staff should follow all CDC recommendations for hand hygiene and PPE. She further stated gloves and a gown should be worn when providing direct care for a resident under EBP. The RNC stated following CDC guidelines and the facility's IPCP was important for resident safety and the prevention of healthcare associated infections.During an interview with the Interim Administrator on 08/13/2026 at 5:00 PM, she stated feeding tube connections should be capped when disconnected, and enteral feeding and water bags should be properly dated and timed so staff could determine how long the products had been in use. The Interim Administrator further stated enteral feeding equipment should be maintained in a clean and sanitary manner. She stated failure to cap feeding tube connections presented an infection control concern because the uncapped tubing could become contaminated and subsequently introduce contaminants directly into the resident.

Based on interview, record review, and review of the facility's policies, the facility failed to ensure residents' comprehensive care plans were reviewed for effectiveness of interventions and revised to meet the needs for 2 of 32 sampled residents (Resident (R) 32, R38)1). The facility failed to revise R32's care plan with interventions to prevent the resident from irritating the gastrostomy tube stoma (G-tube) and surrounding tissue.2). The facility failed to revise R38's care plan with interventions to prevent the resident from self-extubating the G-tube. Additionally, the facility failed to revise R38's care plan with interventions to prevent the resident from irritating the G-tube stoma and surrounding tissue.The findings include:Review of the facility's policy titled, Care Plans, Compressive Person-Centered, revised 03/2022, revealed the facility's policy required an individualized, comprehensive, person-centered care plan for each resident that addresses identified physical, psychosocial, and functional needs. Per policy review, the interdisciplinary team (IDT), in collaboration with the resident and/or representative, developed interventions based on the comprehensive assessment. Continued review revealed the care plan must include measurable objectives and timeframes and identify services necessary to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being in accordance with recognized standards of practice. Further review revealed the IDT must review and revise the resident's care plan following a significant change in condition, when desired outcomes were not achieved, upon readmission, and at least quarterly in conjunction with the required Minimum Data Set (MDS) Assessment.1). Review of the admission Face Sheet, for R32 found in the facility's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 08/26/2025, with diagnoses which included cerebral palsy, epilepsy, and gastrostomy status revealed the facility admitted the resident on 08/26/2025, with diagnoses which included cerebral palsy, epilepsy, and gastrostomy status.Review of R32's Quarterly MDS Assessment, with an Assessment Reference Date (ARD) of 04/16/2026, revealed the facility was unable to conduct a Brief Interview for Mental Status (BIMS) assessment. Per MDS review, the facility assessed R32 as rarely/never understood. Further review revealed the Staff Assessment for Mental Status was completed and indicated R32 was severely impaired for daily decision making and never/rarely made decisions.Review of R32's Care Plan Report, dated 06/25/2026, found in the EMR under the Care Plan tab, revealed the resident required tube feedings related to dysphagia, chewing problems, and difficulty swallowing. Per review, the care plan goal was to prevent side effects or complications related to her tube feeding. Continued review revealed the interventions initiated on 02/28/2023, included directing staff to monitor, document, and report episodes of self-extubation. Further review revealed however, there were no intervention documented to prevent R32 from self-extubating the feeding tube. In addition, review revealed the care plan had not been updated to include interventions to prevent the resident from scratching or irritating the G-tube stoma site and surrounding tissue.Review of R32's Care Plan Report, dated 06/25/2026, found in the EMR under the Care Plan tab, revealed the resident required tube feedings related to dysphagia, chewing problems, and difficulty swallowing. Per review, the care plan goal was to prevent side effects or complications related to her tube feeding. Continued review revealed the interventions initiated 02/28/2023, included directing staff to monitor, document, and report episodes of self-extubation. Further review revealed however, there were no intervention documented to prevent R32 from self-extubating the feeding tube. In addition, review revealed the care plan had not been updated to include interventions to prevent the resident from scratching or irritating the G-tube stoma site and surrounding tissue.Review of the hospital, Emergency Department (ED) Provider Note, dated 05/07/2026, and found in R32's EMR under the Miscellaneous tab, revealed R32's G-tube had been evaluated to have a surrounding red, moist rash with tunneling noted at the site, consistent with a pressure ulcer. Further review of the ED Provider Note revealed clear drainage surrounding the G-tube site had been noted.During an interview with R32's State Guardian (SG) on 08/12/2026 at 3:50 PM, she stated there had been chronic concerns regarding R32's G-tube. She stated R32 had been sent to the ED from the resident's Day Program over G-tube dislodgement and stoma site infection. The SG stated she had multiple meetings with the facility's Administrator, and Director of Nursing (DON), and Social Services Director (SSD). She stated however, the facility was not addressing her concerns or the care needs of her residents. The SG stated R32 scratched at the G-tube stoma site, pulled on the G-tube, and had self-extubated her feeding tube before. Additionally, the SG stated she felt there should have been an intervention in place to address R32's scratching at the affected G-tube area.2). Review of the facility's admission Face Sheet, found in R38's EMR under the Profile tab, revealed the facility admitted the resident on 09/08/2006, with diagnoses which included cerebral palsy, epilepsy, and gastrostomy status.Review of R38's Quarterly MDS Assessment, with an ARD of 04/16/2026, revealed the facility did not conduct a BIMS assessment of the resident. Per review, the facility assessed R38 as rarely/never understood. Further MDS review revealed the facility completed the Staff Assessment for Mental Status which indicated R38 was severely impaired for daily decision making and never/rarely made decisions.Review of R38's Care Plan Report, dated 06/25/2026, found in the EMR under the Care Plan tab, revealed the facility care planned the resident to require tube feedings related to dysphagia, chewing problems, and difficulty swallowing. Per review, the goal was to prevent side effects or complications related to her tube feeding. Continued review revealed the Interventions, initiated 02/28/2023, include staff to monitor, document, and report episodes of self-extubation. Further review revealed however, there were no documented intervention to prevent R38 from self-extubating the feeding tube. Additional review revealed the care plan had not been revised to include interventions to prevent R38 from scratching or irritating the G-tube stoma site and surrounding tissue.Review of the hospital, Emergency Department Provider Note, dated 07/31/2026, found in the EMR under the Miscellaneous tab, revealed R38 presented to the ED with G-tube dislodgment for an unknown amount of time. Continued review revealed R38 had self-extubated the G-tube. Additionally, review revealed the Physician noted R38 had frequent visits to the ED for G-tube dislodgment, per his review of her EMR.During a telephone interview with R38's Guardian on 08/12/2026 at 9:40 AM, she stated the facility notified her on 08/12/2026 at 9:40 AM, R38 was being transferred to the local hospital ED after the resident's G-tube became dislodged while she was being given a shower. The Guardian stated she later learned R38 had self-extubated the G-tube.During an interview with the Interim Director of Nursing (IDON) on 08/12/2026 at 1:00 PM, the State Survey Agency (SSA) Surveyor asked her about R32 and R38's G-tube complications and skin issues surrounding their stoma sites, which resulted in both residents being evaluated in the emergency department. The IDON stated both residents scratched and irritated their stoma sites and had attempted to pull out their G-tubes. When the SSA Surveyor asked where those behaviors were documented and whether the residents' care plans had been revised to address the scratching and pulling, and risk for G-tube dislodgement, the IDON was unable to identify any documentation or care plan interventions addressing those behaviors. The IDON stated an individualized care plan was to identify each resident's needs, activities of daily living, risks, and changes in condition. The IDON stated staff were expected to document changes in a resident's condition to ensure the care plan was revised following any change, and ensure it accurately reflected the resident's current status. She stated care plans directed staff in providing resident-specific care interventions and monitoring. Furthermore, the IDON stated updating the care plan and timely communication of changes ensured prompt assessment, treatment, physician notification, and monitoring before complications occurred. She stated delays could result in worsening condition and delayed treatment.During an interview with the Interim Administrator on 08/13/2026 at 5:00 PM, she stated care plans directed residents' care and reflected individualized needs, interventions, and changes in condition. The Interim Administrator stated staff were expected to follow the facility's policies, implement the residents' care plans, and revise residents' care plans following significant changes in a resident's condition. She stated timely care plan revisions ensured all staff had access to current resident information and interventions. Furthermore, she stated updates and revisions of the residents' care plans ensured prompt assessment, treatment, physician notification, and monitoring before complications occurred.During an interview with the Regional MDS Nurse on 08/14/2026 at 10:16 AM, she stated the IDON was responsible for updating residents' care plans based on new orders and nursing documentation from the previous day. She stated the facility did not have a full-time MDS Nurse, so anyone could update the residents' care plans and follow-up with leadership. When asked by the SSA Surveyor if a behavior such as picking at a G-tube or stoma site, pulling, or self-extubation of the G-tube should be care planned, she stated, Yes. She further stated those behaviors should have been included in the care plan as behavioral concerns when a resident exhibited picking, pulling, or other behavioral involving the G-tube or stoma sight.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure nursing staff had appropriate competencies and skills sets to provide nursing and related services to assure safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and to care for resident's needs. The findings include: Review of the facility's policy Administering Medications, dated April 2019 revealed medications were to be administered safely, and as prescribed. The policy further directed staff to check the medication expiration or beyond use date prior to administration. Review of the facility's Licensed Practical Nurse (LPN) Position Description, undated, revealed the LPN was expected to possess the knowledge and skills necessary to safely provide nursing services to residents. Further review revealed the nurse was required to demonstrate competency in safe administration of medications and proper use of nursing supplies and equipment. Review of LPN1's Nursing Assistant Core Competency Review Checklist, dated 06/25/2026, LPN1's orientation date, revealed the checklist instructions directed the employee, upon hire, to document previous skill experience/knowledge for each clinical area using a self-evaluation scale of zero through three. The scale identified zero as no experience, one as minimal experience, two as experienced, and three as does not apply (N/A/not applicable). The instructions further directed the evaluator to enter the review date when the employee completed the return demonstration and provide a signature validating that the return demonstration was completed. The checklist was to be completed annually thereafter. Further review revealed on 06/25/2026, LPN1 marked a 3, indicating does not apply (N/A/not applicable), for multiple areas of skill and competency applicable to the provision of resident care. These included resident safety, skin and wound prevention, and infection-control practices. Continued review of the competency checklist revealed no documented return demonstrations for the identified skills, no documented dates establishing completion of the competencies, and no evaluator or nursing leadership signatures validating that the employee successfully demonstrated the required skills and competencies. Therefore, the competency documentation did not contain evidence that the employee's ability to perform the identified resident-care and infection-control competencies had been evaluated and validated in accordance with the instructions contained on the facility's competency checklist. 1. Review of the admission Face Sheet, found in R36's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 05/27/2022 with diagnoses which included gastrostomy status, gastroesophageal reflux disease without esophagitis, and other specified chromosome abnormalities. Review of R36's quarterly Minimum Data Set [MDS] assessment, with an annual review date (ARD) of 07/16/2026, revealed a Brief Interview for Mental Status [BIMS] was not conducted because the resident was unable to complete the assessment. The resident was rarely/never understood. The Staff Assessment for Mental Status was completed and indicated the resident was severely impaired for daily decision making and never/rarely made decisions. Further review revealed the resident was coded as receiving 51 percent or more of total calories and fluid intake via parenteral or tube feeding. Review of the Care Plan Report, undated, found in R36's EMR under the Care Plan tab, revealed the resident required tube feedings related to dysphagia, chewing problems, and difficulty swallowing. An intervention, revised on 07/13/2026, indicated staff were to monitor signs and symptoms of infection related to tube feedings. The goal indicated R36 would remain free of complications related to tube feeding. Additionally, a focus, revised on 07/13/2026, for actual impairment to skin integrity of the abdomen surrounding G-tube site. The goal indicated the resident will have no complications related to skin impairment. An intervention, initiated on 06/18/2026, indicated staff were to follow facility protocols for treatment. Review of the Order Summary Report, dated August 2026, revealed staff should monitor R36's gastrostomy tube site for signs or symptoms of infection every shift to support infection prevention. An order to cleanse feeding tube site every shift with normal saline, pat dry and apply hydrogel (wound gel), cover with a split gauze dressing, daily and as needed, until healed related to gastrostomy status. Further review revealed no current order for miconazole powder. Review of the Order Summary Report, dated January 2023, revealed an order for Antifungal External Powder 2 % (miconazole powder) apply to groin topically every shift for excoriation. The medication was ordered 01/20/2023. During an observation on 08/12/2026 at 8:40 AM, LPN1 obtained miconazole nitrate powder from R36's bedside table and applied it around her G-tube stoma and surrounding skin. During an immediate interview, LPN1 stated she had been at the facility for two months and had routinely used the miconazole powder stored in the R36's beside drawer to treat the rash surrounding R36's stoma site. When asked by the State Survey Agency (SSA) Surveyor why she used miconazole powder, LPN1, she stated she believed the miconazole powder was R36's current prescribed treatment for her stoma site. However, she stated she had not verified the current treatment order prior to using the miconazole powder. An observation on 08/12/2026 at 1:52 PM, revealed the miconazole powder located in R36's drawer was first prescribed on 01/20/2023 to treat a fungal infection in her groin. Further review revealed the medicated powder had an expiration date of August 2024. 2. Observation of the Providence Hall Treatment Cart on 08/12/2026 at 1:52 PM revealed six bottles of hydrogel present, all with expiration dates of 08/2025. During an interview with LPN1 on 08/12/2026 at 1:55 PM, she stated she used hydrogel from the treatment cart and applied it to R36's stoma site without checking the expiration date. LPN1 stated the nurse was responsible for checking the medication against the physician's order before administration. LPN1 stated nursing standards of practice required nurses to follow the Seven Rights of Medication Administration, including the right resident, medication, dose, route, time, indication, and documentation. Additionally, LPN1 stated she did not follow the medication administration protocol when she applied miconazole powder to R36. She stated she applied miconazole antifungal powder to R36's stoma site even though the medication had been discontinued and was expired. LPN1 stated she did not review R36's Treatment Administration Record (TAR) or Medication Administration Record (MAR) before applying the miconazole powder. She stated she applied the powder because another staff member had previously shown her to perform the treatment that way. When asked where she documented the application of miconazole powder, LPN1 stated she did not document its use. Furthermore, when asked about concerns related to administering a medication when there was no indication, LPN1 stated the medication should not have been administered and stated using a medication not intended for the condition could potentially worsen the area. During an interview with the Interim Administrator on 08/12/2026 at 4:00 PM, she stated every employee received training and education upon hire. She stated facility nurses, regardless of experience are precepted and checked off to ensure competent nursing skills. During an interview with the Interim Director of Nursing (IDON) on 08/13/2026 at 11:00 AM, she stated facility-employed nurses received orientation and approximately three days of floor training, which could be extended if additional training was needed. She stated a competency checklist was used during orientation and that nursing staff should be observed to ensure they were able to perform required nursing duties. She further stated it was important for nurses to be educated and competent in their assigned responsibilities to ensure they knew what to do, how to provide the required care, and when to seek assistance. During a continued interview with Interim Administrator on 08/13/2026 at 5:00 PM, she stated nurses were expected to review current physician orders prior to providing care and verify medications and treatment products were not expired. She stated staff should not administer a treatment simply because it had previously been used, as physician orders could change. She stated following current orders and checking products for expiration were important for resident safety and quality of care. Further, the Interim Administrator, stated on 08/13/2026 at 5:00 PM, she believed leadership often failed to adequately follow up with new employees after the initial orientation period. She stated leadership needed to do a better job of following newly hired staff to determine whether they were comfortable and competent to independently perform their assigned duties. She stated that not every clinical situation could occur during a three-day orientation and that it was unrealistic to assume a nurse would be prepared for every situation solely based on completing the initial orientation period. She stated LPN1 began orientation on 06/25/2026, completed one day of general orientation and four days of floor training prior to independently working. She stated nursing leadership should ensure staff demonstrated competencies necessary to safely perform their assigned responsibilities prior to working independently. She stated it was important to ensure quality care and resident safety. During an interview with the Regional Nurse Consultant (RNC) on 08/13/2026 at 5:36 PM, she stated LPN1 failed to follow the physician's orders and did not verify the medication was current and matched the prescribed order before administration. The RNC stated nurses were expected to follow facility and standards of nursing care practice to promote resident safety, provide quality care and prevent harm. During an interview with the facility's contracted Pharmacist on 08/13/2026 at 5:59 PM, she stated she expected medications available for residents' use to be within their expiration dates and expired medications not to be used. She stated that after the expiration date, the medication could become less effective, which could potentially result in harm if the resident's condition was not adequately treated with the correct medication. When asked about administering a medication without a physician's order, the Pharmacist stated the currently prescribed order should always be followed. She further stated unordered, expired, or discontinued medication could potentially cause harm due to an allergy, sensitivity, or ineffectiveness, especially if the medication was ordered to treat a different condition. The pharmacist reiterated that medication should be administered in accordance with prescribed orders.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure proper control, accountability, reconciliation, and safeguarding of controlled substances in accordance with professional standards of practice, to include 6 of the facility's 6 medication carts.Observation during narcotic counts of the facility's six medication carts on 08/11/2026 and 08/12/2026 revealed the Controlled Medication Shift Change Log had been pre-signed by day shift prior to evening shift arrival.Observation during a narcotic count on 08/11/2026 revealed a controlled substance had not been signed out by Licensed Practical Nurse (LPN) 6 on the Controlled Drug Record.Observation during a narcotic count on 08/12/2026 revealed a controlled substance had been wasted by LPN1 without a witness.The findings include:Review of facility policy titled Controlled Substances with a revision date of 11/ 2022, revealed the facility would comply with all laws, regulations, and other requirements to include storage, disposal, and documentation of controlled medications. The policy stated controlled substance inventory was monitored and reconciled to identify potential diversion which included destruction, waste and return to pharmacy records. Continued review of policy revealed the process included that nursing staff would count controlled medication inventory at the end of each shift using records to reconcile the inventory count. The policy stated the nurse coming on duty and the nurse going off duty would conduct the count together and document and report any discrepancies to the Director of Nursing Services. Additional review revealed waste and or disposal of controlled medications were done in the presence of the nurse and a witness who also signed the disposition sheet.1. Observation during a narcotic count at medication cart Purpose 1, on 08/11/2026 at 2:41 PM with LPN8 revealed the controlled medication shift change log had been pre-signed by LPN6 before the arrival of oncoming shift nurse.Observation on 08/12/2026 at 1:19 PM during a narcotic count with LPN7 at the medication cart Purpose 2, revealed the controlled shift change log had been pre-signed by LPN6 before the arrival of the oncoming shift nurse.Observation during a narcotic count for the medication cart Providence 2, on 08/12/2026 at 1:19 PM with LPN 7, revealed the controlled medication shift change log had been pre-signed by LPN1 before the arrival of the oncoming shift nurse.Observation during a narcotic count on the medication cart Providence 1 on 08/12/2026 at 1:34 PM with LPN7, revealed the controlled medication shift change log had been pre-signed by LPN1 before the arrival of the oncoming shift nurse.Observation during a narcotic count on the medication cart Honor 2 with LPN5, on 08/12/2026 at 1:58 PM, revealed the controlled medication shift change log was pre-signed by LPN5 before the arrival of the oncoming shift nurse.Observation during a narcotic count on the medication cart Honor 1 with LPN5, on 08/12/2026 at 2:10 PM, revealed the controlled medication shift change log was pre-signed by LPN5 before the arrival of the oncoming shift nurse. During interview with LPN6 on 08/11/2026 at 2:54 PM she stated she had pre-signed the narcotic shift change log so she would not forget to do it at end of shift. She stated she should not have signed it until the next shift got there. She stated it is important to sign with the oncoming shift after the cart was counted to make sure everything was correct and all medications were accounted for. When asked what her signature on the document meant, she stated it showed both shifts had counted together and everything was correct.During an interview with LPN5 on 08/11/2026 at 3:35PM, she stated it was important to count narcotics with the oncoming shift before any forms were signed. She stated it was important to ensure all the narcotics were accounted for.During additional interview with LPN5 on 08/12/2026 at 2:06 PM she stated she had pre-signed the controlled medication shift change log so she would not forget. She stated that she should have waited until the oncoming shift got there and the count was done to ensure all medications were correct and accounted for.During an interview with LPN1 on 08/12/2026 at 10:42 AM she stated she was aware of the facility's policy, and the practice should be signed after the countDuring additional interview with LPN1, on 08/12/2026 at 2:24 PM she stated she had pre-signed the controlled medication shift change log, but she should not have before counting with the oncoming shift. She stated both shifts were supposed to count the narcotics together before signing anything to show all medications were accounted for.2. Observation during a narcotic count with LPN8, on 08/11/2026 at 2:49 PM, revealed the count was incorrect for one medication on cart Purpose 1, Oxycod/APAP (Oxycodone with Tylenol) Tab- 5-325 milligrams (mg).During an immediate interview with LPN 6, she stated that she had given the medication on 08/10/2026 at 9:00 PM and had also given the same medication on 08/11/2026 at 9:00 AM but had not signed it out. She stated she should have signed it out as soon as she removed it from the blister pack. She stated it was important to keep track of narcotics given and had planned on signing it out later. She further stated this was not good practice, and it was not following the facility's policy.3. Observation during a narcotic count on 08/12/2026 at 1:34 with LPN7 revealed LPN1's signature indicated a controlled substance, Lacosamide had been wasted without second signature.During the initiation of the Providence Hall cart count, with LPN7, LPN1 stated she did not want her assigned cart counted by anyone other than her. When LPN7 stated she would count the cart, LPN1 stated she had wasted a medication earlier in the day that needed a second signature and wanted to get that signature prior to the count. LPN1 then requested LPN7 to sign as the second signature for the wasted medication, but LPN7 refused telling LPN1 he had not seen the wastage, and he would not sign for something he had not witnessed.During an interview with LPN1 on 08/12/2026 at 2:24 PM she stated she had dropped the medication on the floor and ran over it with the medication cart. She stated she then wasted it by crushing it and putting in hand sanitizer and then dropping it in the sharp's container.During an interview with LPN7 on 08/14/2026 at 8:50 AM he stated it is important to have a witness when wasting medication to make sure it was wasted. He stated he would need to see the medication being wasted before he signed.During an interview with the Interim Director of Nursing (IDON) on 08/13/2026 at 1:56 PM she stated that she was surprised the staff were pre-signing the controlled shift change log. She stated they had just had recent training on signing out narcotics, but she did not think the two-person signature at shift change was covered since there had been no issues reported. She stated her expectations of the staff were to wait for the oncoming shift, do the count, and then sign all the forms together. She stated it was important for them to count together in case discrepancies were found.During an interview with the Interim Administrator on 08/12/2026 at 12:51 PM, she stated a narcotic count should be performed together between the shifts and the shift change audit documentation should not be pre-signed by either shift until the other shift got there. She stated her expectation was for the staff to follow the facility's policy for narcotic count and for shift change documentation and staff have had training on this.During additional interview with the Interim Administrator on 08/14/2026 at 8:46 AM, she stated her expectations were for staff to follow policy when giving or wasting medications. She stated there should always be 2 nurses present when wasting medication to ensure the medication was actually being wasted/destroyed. She stated when a narcotic was given it should be signed out immediately before giving. She stated nurses get busy and could forget and they could possibly give medication again. She stated the carts are counted and then all documents are signed between oncoming shift and off going shift, after the count.During an interview with the Regional Nurse Consultant (RNC) on 08/12/2026 at 7:09 PM, she stated her expectations of staff were to follow all narcotic policies and procedures to ensure all the medications and narcotics were accounted for.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates for 1 of 1 sampled resident, Resident (R) 36.The findings include:Review of the facility's policy Medication Labeling and Storage, undated, revealed the policy required all medications and biologicals to be stored in a locked compartment. According to the policy, it was the responsibility of nursing staff to maintain medication storage in a safe and sanitary manner. Additionally, discontinued, outdated or deteriorated medications should be removed and sent back to the pharmacy.Review of the facility's policy Administering Medications, dated April 2019, revealed staff were responsible for the safe administration of medications according to physician's orders. The policy further directed staff to check the medication expiration or beyond use date prior to administration.1. Review of the admission Face Sheet, found in R36's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 05/27/2022 with diagnoses which included gastrostomy status, gastroesophageal reflux disease without esophagitis, and other specified chromosome abnormalities.Review of R36's quarterly Minimum Data Set [MDS] assessment, with an annual review date (ARD) of 07/16/2026, revealed a Brief Interview for Mental Status [BIMS] was not conducted because the resident was unable to complete the assessment. The resident was rarely/never understood.Review of the Order Summary Report, dated August 2026, revealed staff should monitor R36's gastrostomy tube site for signs or symptoms of infection every shift to support infection prevention. An order to cleanse feeding tube site every shift with normal saline, pat dry and apply hydrogel (wound gel), cover with a split gauze dressing, daily and as needed, until healed related to gastrostomy status. Review of the Treatment Administration Record (TAR) dated 08/12/2026, revealed Licensed Practical Nurse (LPN)1 documented that she cleansed the residents feeding tube site with normal saline, applied hydrogel to the site and covered the site with split gauze.During an observation on 08/12/2026 at 8:40 AM, LPN1 obtained miconazole nitrate powder from R36's bedside table and applied it around her G-tube stoma and surrounding skin. During an immediate interview, LPN1 stated she had been at the facility for two months and had routinely used the miconazole powder stored in the R36's beside drawer to treat the rash surrounding R36's stoma site. When asked by the State Survey Agency (SSA) Surveyor why she used miconazole powder, LPN1, she stated she believed the miconazole powder was R36's current prescribed treatment for her stoma site. However, she stated she had not verified the current treatment order prior to using the miconazole powder.An observation on 08/12/2026 at 1:52 PM, revealed a bottle of miconazole powder located in R36's drawer with a pharmacy label affixed to the container. The bottle and pharmacy label were worn, and portions of the label were faded and unreadable. The date of the prescription was 01/20/2023. Label instructions were faded; however, R36's name was readable. The medication had an expiration date of August 2024.2. Observation of the Providence Hall Treatment Cart on 08/12/2026 at 1:52 PM revealed six bottles of hydrogel present, all with expiration dates of 08/2025. The bottles were unlabeled, not bagged together, and without a pharmacy label indicating R36's name, and appropriate instructions.During an interview with LPN1 on 08/12/2026 at 1:55 PM, she stated she used hydrogel from the treatment cart and applied it to R36's stoma site without checking the expiration date. LPN1 stated the night shift was responsible for removing expired medications; however, when asked by the SSA Surveyor whether the nurse administering a medication was responsible for checking its expiration date before administration, she stated, Yes. LPN1 stated nurses should follow the Seven Rights of Medication Administration, including the right resident, medication, dose, route, time, indication, and documentation.Additionally, during the interview on 08/12/2026 at 1:55 PM, LPN1 stated she did not follow the medication administration protocol when she applied miconazole powder to R36. She stated she applied miconazole antifungal powder to R36's stoma site even though the medication had been discontinued and expired. LPN1 stated she did not review R36's Treatment Administration Record (TAR) or Medication Administration Record (MAR) before applying the miconazole powder. She stated she applied the powder because another staff member had previously shown her to perform the treatment that way. When asked where she documented the application of miconazole powder, LPN1 stated she did not document its use. Furthermore, when asked about concerns related to applying an antifungal medication the stroma site when there was no indication, LPN1 stated the medication should not have been administered and stated using a medication not intended for the condition could potentially worsen the area.During an interview with the Interim Administrator on 08/12/2026 at 4:00 PM, she stated every employee received training and education upon hire. She stated facility nurses, regardless of experience were precepted and checked off to ensure competent nursing skills.During a continued interview with Interim Administrator on 08/13/2026 at 5:00 PM, she stated nurses were expected to review current physician orders prior to providing care and verify medications and treatment products were not expired. She stated staff should not administer a treatment simply because it had previously been used, as physician orders could change. She stated following current orders and checking products for expiration were important for resident safety and quality of care.During an interview with the Regional Nurse Consultant (RNC) on 08/13/2026 at 5:36 PM, she stated LPN1 failed to follow the physician's orders and did not verify the medication was current and matched the prescribed order before administration. The RNC stated nurses were expected to follow facility and standards of nursing care practice to promote resident safety, provide quality care and prevent harm.During an interview with the Interim Director of Nursing (IDON) on 08/13/2026 at 5:56 PM, she stated treatment and medication carts were routinely audited and staff were expected to remove expired products. The IDON stated she was unsure why expired hydrogel remained on the treatment cart or why R36's discontinued and expired miconazole powder was left at the bedside and used for resident care. The IDON further stated medication should not be stored at the resident's bedside unless the resident was assessed and approved for self-administration. The IDON stated nurses were responsible for verifying medications and treatment products before use and ensuring care was provided according to the current physician order. She stated these checks were necessary to reduce the risk of medication areas and adverse outcomes.During an interview with the facility's contracted Pharmacist on 08/13/2026 at 5:59 PM, she stated she expected medications available for resident use to be within their expiration dates and expired medications not to be used. When asked by the SSA Surveyor about the potential for harm from using expired miconazole powder or hydrogel, the Pharmacist stated the expiration date represented the period during which the manufacturer guaranteed the medication's effectiveness. She stated that after the expiration date, the medication could become less effective, which could potentially result in harm if the resident's condition was not adequately treated with the correct medication. When asked about administering medication without a physician's order, the Pharmacist stated the currently prescribed order should always be followed. She further stated unordered, expired, or discontinued medication could potentially cause harm due to an allergy, sensitivity, or ineffectiveness, especially if the medication was ordered to treat a different condition. The pharmacist reiterated that medication should be administered in accordance with prescribed orders.

Based on observation, interview, and record review, the facility failed to provide necessary care and services consistent with professional standards of practice and the residents' assessed needs for 2 of 32 residents reviewed for quality of care (Residents (R)32 and R36). Specifically, the facility failed to provide appropriate care and monitoring of gastrostomy tube (G-tube) sites and failed to timely identify and/or address changes in skin condition and other care needs. For R32, the deficient practice resulted in concerns related to the resident's G-tube, including dislodgement and infection of the stoma site that required evaluation in the emergency department. For R36, the facility failed to consistently provide and/or document necessary care related to the resident's G-tube site and skin integrity.Additionally, despite the State Guardian communicating ongoing concerns regarding the residents' G-tube care, skin breakdown, and overall quality of care to facility leadership on multiple occasions, the facility failed to demonstrate that the concerns were consistently assessed, addressed, and followed through to ensure the residents received necessary care and services.This deficient practice had the potential to result in worsening skin conditions, G-tube complications, infection, pain, and other avoidable declines in the residents' physical condition.The findings include:Review of the facility's policy titled, Enteral Nutrition, revised November 2018, revealed nursing staff were responsible for monitoring residents for enteral feeding complications. The policy further stated nursing staff were responsible for recognizing and reporting concerns associated with enteral feeding.Review of the facility's policy titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol, revised March 2014, revealed nursing staff were expected to assess, treat, and monitor residents at risk for skin breakdown. The policy directed nursing staff to monitor, assess and document wound/skin breakdown and report findings to the physician for appropriate treatment.Review of the facility's policy titled, Wound Care - [NAME] III, undated, revealed the purpose of the policy was to provide guidance for the care of wounds. Before treatment, staff were to verify the physician's order, assemble supplies, and follow established infection control and professional practice safeguards for the safety and comfort of the resident.1. Review of the admission Face Sheet, found in R36's EMR under the Profile tab, revealed the facility admitted the resident on 05/27/2022 with diagnoses which included gastrostomy status, gastroesophageal reflux disease without esophagitis, and other specified chromosome abnormalities.Review of R36's quarterly MDS assessment, with an annual review date (ARD) of 07/16/2026, revealed a BIMS was not conducted because the resident was unable to complete the assessment. The resident was rarely/never understood. The Staff Assessment for Mental Status was completed and indicated the resident was severely impaired for daily decision making and never/rarely made decisions. Further review revealed the resident was coded as receiving 51 percent or more of total calories and fluid intake via parenteral or tube feeding.Review of the Order Summary Report, dated August 2026, revealed the physician ordered 07/10/2026 for Glucerna 1.5 237 milliliters/hour (mL/hr) per tube, bolus three times a day; and bolus Glucerna 1.5 120 mL/hr per tube at hour of sleep. Staff should monitor R36's gastrostomy tube site for signs or symptoms of infection every shift to support infection prevention. An order to cleanse feeding tube site every shift with normal saline, pat dry and apply hydrogel, cover with a split gauze dressing, daily and as needed, until healed related to gastrostomy status. Further review of the physician's orders revealed an order dated 04/30/2026 for EBPs related to gastric feeding tube.Review of the Care Plan Report, undated, found in R36's EMR under the Care Plan tab, revealed the resident required tube feedings related to dysphagia, chewing problems, and difficulty swallowing. An intervention, revised on 07/13/2026, indicated staff were to monitor signs and symptoms of infection related to tube feedings. The goal indicated R36 would remain free of complications related to tube feeding. Additionally, a focus, revised on 07/13/2026, for actual impairment to skin integrity of the abdomen surrounding G-tube site. The goal indicated the resident will have no complications related to skin impairment. An intervention, initiated on 06/18/2026, indicated staff were to follow facility protocols for treatment.Review of the VOHRA Wound Physician Assessment, dated 06/17/2026, revealed the wound care provider performed cauterization and issued new orders for saline at the time of dressing changes, calcium alginate, and a split dressing placed under the G-tube. The wound measured 0.7 cm x 0.2 cm x 0.1 cm, and a new order was issued for close monitoring. New orders to cleanse the wound with normal saline at time of dressing change, and apply an alginate calcium dressing, once daily and as needed, if saturated, soiled, or dislodged for 26 days. According to the order, a split gauze dressing was to be placed under the peg flange.Review of the Treatment Administration Record [TAR], dated June 2026, revealed nursing staff documented R36 received G-tube treatment for the day shift (7:00 AM to 7:00 PM) and the night shifts day shift (7:00 PM to 7:00 AM) on 06/17/2026 and 06/18/2026. However, there were no corresponding progress notes or skin integrity assessments documenting the condition of the gastrostomy site, including findings such as redness, drainage, skin breakdown, or other concerns, prior to sending R36 to her Adult Day Care Center on 06/18/2026.Review of an Incident Report, dated 06/18/2026 from the Adult Day Care Center, revealed R36 presented with complications related to the G-tube. According to the note, at approximately 8:50 AM, a nurse from the Adult Day Care Center noted R36 had Significant redness and inflammation surrounding the insertion area, along with visible skin breakdown and maceration. Further review of the note revealed a moderate amount of serosanguineous drainage was present, and active bleeding was observed at the stoma site. Additionally, a yellow-brown exudate and slough were also noted along the wound margins. According to the report, the surrounding tissue appeared moist, irritated, and fragile.Review of photographs of R36's G-tube and surrounding skin, date stamped 06/18/2026 and attached to the Adult Day Care Center's report, revealed redness and irritation extending several centimeters beyond the immediate G-tube stoma site and involving the surrounding abdominal skin. The skin immediately surrounding the stoma appeared red, raw, and irritated, with bloody drainage noted at and around the insertion site. A moderate amount of fluid and drainage was visible on the skin surrounding the G-tube and on the removed dressing. Additionally, dried and fresh dark brown to reddish-brown drainage was visible on the dressing. A white, powdery substance was also visible over portions of the reddened and irritated skin surrounding the stoma.Review of the VOHRA Wound Physician Assessment Notes, dated 06/24/2026 through 07/15/2026, revealed progressive deterioration of the wound surrounding R36's G-tube site. On 06/24/2026, treatment orders were changed to include a saline wash and triple-antibiotic ointment. The calcium alginate was discontinued, the triple-antibiotic ointment was subsequently discontinued, and hydrogel with a split gauze dressing was added. On 07/08/2026, the wound measured 1.5 cm x 0.9 cm x 0.1 cm with moderate serous exudate. By 07/15/2026, the wound had increased to 1.7 cm x 1.5 cm x 0.1 cm with moderate serous exudate, and a new open ulceration measuring 1.28 cm was documented. Further review of the medical record revealed no documented evidence that nursing staff identified and documented the progressive deterioration of R36's G-tube site through routine skin assessments or notified the provider of the worsening condition for further evaluation and treatment.Review of the Incident Report, dated 07/21/2026 from the Adult Day Care Center, revealed R36 presented with complications related to the gastrostomy (G-tube).Review of photographs of R36's G-tube and surrounding skin, date stamped on 07/21/2026, attached to the report revealed significant redness and discoloration of the surrounding skin, an area of visible skin breakdown/raw tissue immediately adjacent to the insertion site, and a moderate amount of yellow drainage and residue present around the G-tube and dressing. The split gauze dressing was saturated with moisture extending beyond the dressing and visibly wetting the R36's shirt. The surrounding abdominal skin was reddened and irritated over an area extending beyond the immediate G-tube insertion site.Review of the Order Summary Report, dated August 2026, revealed staff should monitor R36's gastrostomy tube site for signs or symptoms of infection every shift to support infection prevention. An order to cleanse feeding tube site every shift with normal saline, pat dry and apply hydrogel (wound gel), cover with a split gauze dressing, daily and as needed, until healed related to gastrostomy status. Further review revealed no current order for miconazole powder.Observation of R36's G-tube site on 08/12/2026 at 8:40 AM, revealed the split gauze dressing was wet with tube feed leakage and small amount of bloody drainage. The stoma had tube feeding leaking out and a small amount of bloody drainage at the insertion site. The surrounding area was red, raw, and blistered and was the size of the split gauze dressing, approximately four inches square. No scabs were present.During a telephone interview with the Adult Day Care Center's Administrative Supervisor on 08/12/2026 at 10:15 AM, she stated R36 came to the Adult Day Care Center on 06/18/2026 and 07/21/2026 with issues related to her G-tube site and skin breakdown around the stoma site. She stated she called the IDON at the facility and made an Adult Protective Service (APS) referral because the G-tube site was leaking and R36's stoma site was red, irritated, with notable bleeding. Further interview revealed the resident's skin had deteriorated since the last visit to the center, which raised concern for a possible infection or other complication related to the tube insertion site. Due to the concerns on 06/18/2026, the resident was transferred to the local emergency department.In an interview with R36's State Guardian (SG), on 08/13/2026 at 3:50 PM, she stated R36's G-tube stoma site was consistently red and irritated. She stated the IDON had informed her that the appearance of the site was related to cauterization. According to the SG, following the cauterization, the site appeared red with scabbing; however, the area continued to be irritated, reddened, and blistered without improvement. The SG further stated R36 continued to scratch at the G-tube site.During an interview with the Social Services Director (SSD) on 08/12/2026 at 1:43 PM, he stated he not received any concerns or grievances from R36's State Guardian regarding enteral feedings. He stated the SG attends Care Plan conferences; however, the SSD stated the SG voiced no concerns regarding R36's care.2. Review of the admission Face Sheet, found in R32's EMR under the Profile tab, revealed the facility admitted the resident on 08/26/2025, with diagnoses which included gastrostomy status, dysphagia, and vitamin deficiency, unspecified.Review of R32's quarterly MDS assessment, with an ARD of 04/16/2026, revealed a BIMS was not conducted because the resident was unable to complete the assessment. The resident was rarely/never understood. The Staff Assessment for Mental Status was completed and indicated the resident was severely impaired for daily decision making and never/rarely made decisions. Further review revealed the resident was coded as receiving 51 percent or more of total calories and fluid intake via parenteral or tube feeding.Review of R32's Care Plan Report, undated, and found in R32's EMR under the Care Plan tab, revealed the resident required tube feedings related to dysphagia, chewing problems, and difficulty swallowing. An intervention initiated on 02/28/2023 was to monitor signs and symptoms of infection related to tube feedings. Additionally, staff were to monitor for extubation of the G-tube. The goal indicated R32 would remain free of complications related to tube feeding.Review of the PHC- Skin Check- V3, dated 05/05/2026 revealed R32 was assessed as having her G-tube in place, and the skin assessment identified the area surrounding the G-tube as red, with treatment in place.Review of the Treatment Administration Record (TAR), dated May 2026, revealed nursing staff documented from 05/05/2026 through 05/13/2026, on both the day and night shifts, that no drainage was observed from R32's G-tube site and no signs or symptoms of infection were identified.Interviews with the nursing staff who completed the documentation during the period under review could not be conducted because those staff members were no longer employed by the facility. The nursing staff currently employed by the facility were not employed during the relevant time period. Additionally, the Interim Administrator and Interim Director of Nursing began their employment after the period under review and did not have firsthand knowledge of R32's condition or the care provided during that time.Review of the Emergency Department (ED) Provider Notes, dated 05/07/2026, revealed R32was transferred to the local ED by emergency medical services (EMS) with complaints of G-tube dysfunction, active drainage from her G-tube site with surrounding redness. The resident's G-tube was replaced, and she was referred to a gastroenterologist for follow-up care. Additionally, R32 was diagnosed with a yeast infection around the stoma site and an unstageable pressure injury. According to the note there was red, moist rash with clear drainage surrounding the G-tube. There was tunnelling at the five o'clock position consistent with a pressure ulcer. A new order for miconazole nitrate (Micatin) 2% topical cream to treat the yeast infection and instructions to use a protective four by four gauze to prevent further erosion of the stoma site. R32 was discharged home to the facility.Review of the Gastroenterology Consult Note, dated 05/11/2026, revealed R32 was evaluated for G-tube leakage and associated skin irritation following a recent upsizing of the G-tube to an 18 French tube in the emergency department. The GI Specialist further upsized R32's G-tube to a 20 French tube and recommended discontinuing drain sponges, applying barrier cream, and keeping the G-tube site clean, dry, and open to air.Further review of R32's Treatment Administration Record (TAR) revealed the GI Specialist's recommendations were implemented and documented as completed by facility staff.Review of the ED Provider Notes, dated 05/13/2026, revealed R32 was transferred by emergency medical services (EMS) from the Adult Day Care Center to the local emergency department (ED) for concerns related to G-tube redness and infection. The provider documented that R32 had previously been evaluated in the ED on 05/07/2026 for similar concerns. R32 was diagnosed with feeding tube dysfunction and a fungal infection surrounding the G-tube site. Discharge instructions included precautions related to the use of barrier cream and keeping the G-tube site clean and dry. The ED Provider Note further documented that continued feeding tube and skin care instructions were reiterated to the facility's nursing staff. A new order was issued for Nystatin (Mycostatin) topical cream to treat the fungal infection, with instructions to use protective four-by-four gauze to prevent further skin erosion. R32 was subsequently discharged to the facility.Review of the photograph associated with the ED visit revealed pronounced redness extending beyond the immediate G-tube stoma onto the surrounding abdominal tissue. The affected skin appeared moist, shiny, and reddened, with areas of broken skin adjacent to the device. Brownish drainage and residue were also visible beneath and adjacent to the G-tube site.Further review of R32's physician orders for May 2026 identified no concerns related to the facility's implementation of the new treatment orders following the 05/07/2026 and 05/13/2026 ED visits.Review of the Order Summary Report, dated 08/11/2026, revealed the physician ordered Fibersource HN at 60 mL/hr for 14 hours per day (on at 4:00 PM and turn off at 6:00 AM). Additionally, staff should monitor the gastrostomy tube site for signs or symptoms of infection every shift to support infection prevention.During an interview with the Interim Director of Nursing (IDON) on 08/13/2026 at 11:00 AM, she stated skin assessments are completed for pressure and non-pressure wounds. She stated G-tube sites and the skin surrounding the site were checked every shift. She stated if there was a change nursing staff are expected to document the change. According to the IDON, all questions on the skin assessment should be answered completely and a note documenting the observations should be completed on the skin assessment form. IDON stated if worsening, s/s of infection, or increased drainage, she expected the nurse to document and follow-up with provider. The IDON stated the facility did not have a policy specific to completion of an overall nursing assessment; however, nurses were expected to complete required assigned assessments each shift.During an interview with the Regional Nurse Consultant (RNC) on 08/13/2026 at 11:00 AM, she stated the in-house physician was aware of G-tube leakage and associated skin concerns involving R32 and R36. The RNC stated R32 was subsequently eval The RNC stated she had communicated with the Adult Daycare Center regarding G-tube and skin concerns involving R32 and R36. She further stated she had communication with the State Guardian. In continued interview, the RNC stated that on 04/26/2026, she contacted the Adult Daycare Center's Executive [NAME] President of Operations (EVP) regarding concerns with its nursing staff contacting Adult Protective Services and sending residents to the emergency room for G-tube related concerns the facility believed could be managed in-house. When asked for documentation of email or telephone communication with the EVP of the Adult Day Care Center, the RNC stated she did not have documentation of the discussion.During a telephone interview with the State Guardian (SG) for R32 and R36 on 08/13/2026 at 3:50 PM, she stated she contacted Adult Protective Services (APS) regarding ongoing concerns with R32 and R36's G-tube sites, associated skin breakdown, and the care provided by the facility. The SG stated she had participated in multiple meetings with the facility's Administrator, Director of Nursing (DON), and Social Services Director (SSD); however, she did not believe her concerns regarding the residents' care had been adequately addressed.Further, the SG stated, on 08/13/2026 at 3:50 PM, R32 had been transferred to the emergency department from the Adult Day Care Center due to G-tube dislodgement and concerns related to infection of the stoma site. She stated R32 scratched at the stoma site, pulled on the G-tube, and had previously self-extubated the feeding tube. She stated she contacted APS regarding concerns identified by the Adult Day Care Center involving R32 and R36. According to the SG, during the most recent care plan meeting, the IDON and Interim Administrator requested that she contact facility leadership with concerns before contacting APS. The SG stated, however, that she did not believe her concerns were being adequately addressed.During a continued interview with the Interim Director of Nursing (IDON) on 08/13/2026 at 1:50 PM, she stated weekly skin assessments were expected to identify new skin concerns and residents' G-tube sites were assessed every shift and as needed (PRN). The IDON stated the facility's contracted wound care physician was following R36 and nursing staff were expected to follow each resident's treatment plan and communicate identified concerns and changes in condition to the appropriate individuals. The IDON stated R36 scratched at her G-tube site, which caused redness and irritation. She stated the in-house provider was aware of the residents' leaking G-tubes and associated skin concerns. The IDON further stated R36's State Guardian had contacted Adult Protective Services (APS) regarding the appearance of R36's G-tube site following cauterization. According to the IDON, the State Guardian had not expressed concerns related to R32 or R36 during their in-person care conferences.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 2 of 2 residents sampled for enteral feeding, with a total of ten facility residents receiving enteral feeding, Resident (R) 32 and R38.The findings include:Review of the facility's policy titled, Enteral Nutrition, revised November 2018, revealed nursing staff were responsible for monitoring residents for enteral feeding complications. The policy further stated nursing staff were responsible for recognizing and reporting concerns associated with enteral feeding.Review of the manufacturer's Ready-to-Hang Suggested Setup Procedure, undated, revealed staff were to label the tube feeding container and water flush with the resident's name, room number, date, start time and rate and mark the feeding set with the start date and time. The manufacturer identified proper labeling and dating as essential for resident safety. Additionally, when the feeding set was discontinued from the feeding tube, staff were directed to cover the end of the tube with the provided cap cover to reduce the risk of touch contamination.Review of Abbott's manufacturer's guidance Guide to Adult Tube Feeding, dated 09/2022, revealed ready-to-use enteral formula in a closed system could remain hanging for up to 48 hours when the system remained closed and intact. Additionally, the manufacturer's guidance instructed that once the formula and water flush was opened, the container should be labeled with the date and time. Furthermore, handling of the feeding system should be performed in a manner to prevent contamination, including avoiding contact with components that would come into contact with the formula.1. Review of the admission Face Sheet, found in R38's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 09/08/2006 with diagnoses which included gastrostomy status, gastro-esophageal reflux disease without esophagitis, and moderate protein deficiency malnutrition.Review of R38's quarterly Minimum Data Set (MDS) assessment, with an annual review date (ARD) of 05/14/2026, revealed a Brief Interview for Mental Status (BIMS) was not conducted because the resident was unable to complete the assessment. The resident was rarely/never understood. The Staff Assessment for Mental Status was completed and indicated the resident was severely impaired for daily decision making and never/rarely made decisions. Further review revealed the resident was coded as receiving 51 percent or more of total calories and fluid intake via parenteral or tube feeding.Review of R38's Care Plan Report, undated, found in R38's EMR under the Care Plan tab, revealed the resident required tube feedings related to dysphagia, chewing problems, and difficulty swallowing. An intervention initiated on 02/28/2023 was to monitor signs and symptoms of infection related to tube feedings. The goal indicated R38 would remain free of complications related to tube feeding.Review of the Order Summary Report, dated 08/12/2026, revealed staff should monitor the gastrostomy tube site for signs or symptoms of infection every shift to support infection prevention. Additionally, the physician ordered Isosource 1.5 at 55 milliliters per hour (mL/hr) for 15 hours (on at 4:00 PM and off at 7:00 AM).Observation of R38 on 08/13/2026 at 9:25 AM revealed the resident was lying in bed with the head of the bed elevated. The resident was not receiving enteral feeding at the time of the observation. An enteral feeding container was observed hanging from a feeding pump pole, spiked, and primed with formula. The distal connector of the enteral feeding tubing was uncapped and in direct contact with the pole. The resident's water flush bag was observed without a date or time indicating when it had been hung.During an immediate interview with Licensed Practical Nurse (LPN) 8 on 08/13/2026 at 9:25 AM, she stated she had not yet made rounds on R38. When shown the uncapped feeding tubing, LPN 8 stated the end should be capped when not in use and placed in the feeding pump holder to prevent contact with other surfaces. She stated capping the connector tubing was important to prevent contamination of the connector. She further stated the water flush should be dated when hung to ensure fresh water is provided to prevent infection. Additionally, LPN8 stated she was an agency nurse and it was approximately her fifth time working at the facility. She stated further she had not received facility specific education on capping and dating tube feeding supplies.2. Review of the admission Face Sheet, found in R32's EMR under the Profile tab, revealed the facility admitted the resident on 08/26/2025, with diagnoses which included gastrostomy status, dysphagia, and vitamin deficiency, unspecified.Review of R32's quarterly MDS assessment, with an ARD of 04/16/2026, revealed a BIMS was not conducted because the resident was unable to complete the assessment. The resident was rarely/never understood. The Staff Assessment for Mental Status was completed and indicated the resident was severely impaired for daily decision making and never/rarely made decisions. Further review revealed the resident was coded as receiving 51 percent or more of total calories and fluid intake via parenteral or tube feeding.Review of R32's Care Plan Report, undated, and found in R32's EMR under the Care Plan tab, revealed the resident required tube feedings related to dysphagia, chewing problems, and difficulty swallowing. An intervention initiated on 02/28/2023 was to monitor signs and symptoms of infection related to tube feedings. The goal indicated R38 would remain free of complications related to tube feeding.Review of the Order Summary Report, dated 08/11/2026, revealed staff should monitor the gastrostomy tube site for signs or symptoms of infection every shift to support infection prevention. Additionally, the physician ordered Fibersource HN at 60 mL/hr for 14 hours per day (on at 4:00 PM and turn off at 6:00 AM).Observation of R32 on 08/13/2026 at 9:42 AM revealed the resident was lying in bed with the head of the bed elevated. The resident was not receiving enteral feeding at the time of the observation. An enteral feeding container was observed hanging from a feeding pump pole, spiked, and primed with formula. The distal connector of the enteral feeding tubing was uncapped and in direct contact with the feeding pump pole. Additionally, the resident's water flush bag was observed without a date or time indicating when it had been hung.During an immediate interview with LPN8 on 08/13/2026 at 9:42 AM, she stated she should have rounded on her assigned residents and observed their enteral feeding equipment. She stated that had she rounded, she would have identified that the feeding tube was left uncapped. LPN8 stated she did not know why the tubing was uncapped because each enteral feeding kit is supplied with an end cap. She further stated the tubing should remain capped when not in use to prevent contact with environmental surfaces and infection.During a telephone interview with the Registered Dietician (RD) on 08/13/2026 at 10:21 AM, she stated enteral feedings should be administered according to the prescribed schedule to ensure the resident received the ordered nutritional intake. She stated feedings should remain consistent with the prescribed regimen. The RD further stated feeding tube connectors should be covered to prevent contamination and reduce the risk of infection.During an interview with the Interim Administrator on 08/13/2026 at 5:00 PM, she stated feeding tube connections should be capped when disconnected, and enteral feeding and water bags should be properly dated and timed so staff could determine how long the products had been in use. The Interim Administrator further stated enteral feeding equipment should be maintained in a clean and sanitary manner. She stated failure to cap feeding tube connections presented an infection control concern because the uncapped tubing could become contaminated and subsequently introduce contaminants directly into the resident.During an interview with the Interim Director of Nursing (IDON) on 08/13/2026 at 5:56 PM, she stated staff had received education related to enteral feedings, cleaning of feeding pump pole, and ensuring tubing was appropriately capped when disconnected from the resident. The IDON stated LPN8 was an agency nurse and had received the same education as the facility's staff nurses prior to taking the assignment. When informed tubing had been observed hanging without caps, the IDON stated she would provide additional education to the involved nurse and follow up with the staffing agency. The IDON stated it was her expectation that tube feedings remain capped when not in use and a new system should be set up if it is found undated, untimed, or uncapped. She stated water flushes and feedings should always be dated and timed. Additionally, the IDON stated it was important to provide residents with fresh tube feeding formula and a clean water flush to reduce the risk of contamination and potential infection.

Based on observation, interview, and review of the facility's documents and policy, the facility failed to provide food and drink served at a safe and appetizing temperature to residents. The lunch test tray on 03/24/2026 revealed food items that were in the temperature danger zone range for both hot and cold foods. Resident attendees in the Resident Council meeting on 03/23/2026 stated they received cold food at mealtimes. Also, on 03/23/2026, Resident (R) 45 stated she received cold food all the time. This deficient practice had the potential to affect all 78 current residents that received food prepared in the kitchen. The findings include: Review of the facility's policy titled, Food Preparation and Service, dated 2001, revealed the temperature danger zone for food temperatures was above 41 degrees Fahrenheit (F) and below 135 degrees Fahrenheit (F). Per the policy, that temperature range promoted the rapid growth of pathogenic microorganisms that caused foodborne illness. The policy stated potentially hazardous foods must be maintained at or below 41 degrees F or at or above 135 degrees F. Observation of R45 in her room on 03/22/2026 at 5:44 PM revealed there were several snacks at the bedside.Review of R45's admission Record revealed the facility admitted the resident on 11/25/2025 with diagnoses of diabetes mellitus type 2, major depressive disorder, and anxiety. Review of R45's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/22/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, which indicated the resident was cognitively intact. In an interview with R45 on 03/22/2026 at 5:44 PM, she stated she received cold food all the time. In an interview with the Resident Council meeting attendees on 03/23/2026 at 2:00 PM, the residents stated they received cold food at mealtimes. Review of the facility's document Providence Pavilion Test Tray Assessment, for the lunch dated 01/05/2026 with no time given, in the main (Honor) dining room's mechanical soft diet revealed the temperatures for baked ravioli at125 degrees F; cauliflower at 120 degrees F; apple bar at 55 degrees F; and milk at 42 degrees F. Review of the facility's document Providence Pavilion Test Tray Assessment, for the lunch dated 01/22/2026 with no time given, in the Rehabilitation Unit's regular diet revealed the temperature for baked chicken at 130 degrees F; rice pilaf at 127 degrees F; and carrots at 121 degrees F. Review of the facility's document Providence Pavilion Test Tray Assessment, for the dinner dated 02/02/2026 with no time given, in the main (Honor) dining room with the diet not stated revealed the temperatures for cold ham and cheese sandwich at 47 degrees F; carrots at 118 degrees F; pudding at 48 degrees F; and juice at 52 degrees F. Review of the facility's document Providence Pavilion Test Tray Assessment, for the lunch dated 02/25/2026 with a start time of 12:36 PM and an end time of 12:40 PM, in the Providence Unit's regular diet revealed the temperatures for rosemary chicken at 131 degrees F; mushroom rice at 122 degrees F; and au gratin cauliflower at 118 degrees F.Review of the facility's document Providence Pavilion Test Tray Assessment, for the lunch dated 03/12/2026 with no time given, in the main (Honor) dining room's diet puree revealed the temperatures for broccoli at 124 degrees F; mashed potatoes at 132 degrees F; and milk at 43 degrees F. Observation on 03/24/2026 at 12:55 of the last tray cart delivered to the Honor Unit revealed it contained the test tray. Observation of the test tray on 03/24/2026 at 1:04 PM, tested by the Dietary Manager, revealed the temperatures for the beef stroganoff at 121 degrees F; lemonade at 61 degrees F; and broccoli at 117 degrees F. All of these foods were in the temperature danger zone of 41 degrees F to 140 degrees F for hot foods and over 41 degrees F for cold foods. Taste tests by two State Survey Agency (SSA) Surveyors revealed they described the temperatures of the beef stroganoff as room temperature, the broccoli as cold, and the lemonade as warm to the taste. In an interview with the Dietary Manager on 03/24/2026 at 1:10 PM, she stated she liked the temperature of hot food served to residents at 130 degrees F. She stated the steam tables for the dining rooms were turned on one-half hour prior to meal service. In an interview with the Registered Dietitian (RD) on 03/24/2026 at 9:55 AM, she stated she completed sanitation walk throughs and test trays. She stated the hot food was always hot, and the temperatures recorded were showed the hot food was hot.In a continued interview with the RD on 03/24/2026 at 1:04 PM, she stated department heads always passed out trays. She stated more people passed trays because staff was taking temperatures to ensure the temperatures were good for the test tray audit. She stated the temperatures were accurate with regular everyday meal pass because administration wanted department heads to pass trays. In an interview with the Director of Nursing on 03/25/2026 at 12:39 PM, she stated her expectation was for residents to receive food at the proper temperature. In an interview with the Administrator on 03/26/2026 at 1:40 PM, she stated her expectation was for food temperatures to be adequate when served to residents. She stated the hot food should be hot, and the cold food should be cold.

Based on interview, record review, review of the Facility Assessment, and review of the facility's documents and policy, the facility failed to maintain sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population. Review of the facility's staffing for the past 30 days revealed the facility consistently failed to provide sufficient staff as determined in the Facility Assessment to ensure resident needs were met. The deficient practice had the potential to affect all 80 current residents.The findings Include:Review of the Facility Assessment, approved 12/10/2025, revealed staffing needs per shift for an average daily census of 74 were four to five nurses for day shift and four to five nurses for night shift. Continued review for an average daily census of 74 revealed eight to 10 nurse aides were required for day shift, and seven to eight nurse aides were required for night shift. These numbers reflected minimum staffing standards of 3.48 total direct care hours per resident day (HPRD) and 2.45 nurse aide HPRD.Review of the Facility Assessment, approved 03/06/2026, revealed no change from the 12/10/2025 approved assessment with staffing needs based on an average daily census of 74 with the requirement of four to five nurses per shift and eight to 10 nurse aides for day shift and seven to eight nurse aides on night shift. Review of the facility's document Pavilion at [NAME], a staffing guide provided by the Director of Nursing (DON) and used to determine staffing needs revealed for a census of 80 (the most frequently occurring number during a 30-day look-back period), three nurses were required for day shift and three nurses for night shift. Continued review for a census of 80 revealed seven aides were required for dayshift, and five or six aides were required for nightshift. Of note, five aides were required when utilizing agency staff versus six without utilizing agency staff, bringing total hours per day for aides to between 210 and 222 hours. For a census of 74, three nurses for day shift and three nurses for night shift remained the same, with staffing for day shift aides at seven or six with agency staff and night shift aides at five.Comparison of Facility Assessment(s) with the staffing guide provided by the DON revealed for a census of 74 residents one to two fewer nurses per shift were noted as required on the staffing guide, and two to four fewer nurse aides were required for day shift, with two to three fewer aides required on night shift. Of note, the facility census provided during the past 30 days, from 02/23/2026 to 03/23/2026, never fell below 78 with 80 being the most common and with 81 at its highest. Review of the facility's policy titled, Call System, Resident, dated September 2022, revealed all residents were provided with a means to call staff for assistance, and calls for assistance were to be answered as soon as possible.Review of a list provided by the facility of residents requiring the assist of two or more staff with transfers, including those utilizing mechanical lifts, revealed 27 residents required a two person assist for transfers. Review of the facility's staffing for the period of 02/23/2026 through 03/23/2026, revealed the facility consistently fell below the staffing requirements identified in their Facility Assessments. In comparing staffing with the facility's staffing guide, the facility only met its staffing goals for seven day shift aides on three dates, 03/03/2026, 03/05/2026, and 03/03/2026. The average nurse aide staffing HPRD was 1.46, significantly below the 2.45 HPRD indicated on the Facility Assessment. Further review revealed Monday, 03/16/2026, was the lowest in terms of nurse aide staffing at 1.07 HPRD.Review of the Resident Council minutes for the past six months revealed on 09/26/2025 one resident expressed concern about not getting their medications on time. Multiple residents expressed concerns about waiting a long time for staff to respond to call lights and also were concerned about receiving the wrong foods on their meal trays or receiving warm milk. On 10/24/2025, resident concerns about long waits for call light response continued. Residents also expressed concern about having trouble getting aides to get them out of bed or put them back to bed. On 12/17/2025 residents expressed the desire for staff to screen nurses and aides better in hopes that new hires might stay longer and care about resident needs. On 01/14/2026 residents expressed concern that medication was not given out completely or at all during night shifts. On 02/18/2026 residents complained about showers not being given and medication being given late at night. Residents also expressed concern aides were telling them to stop visiting each other in the evening and to stay in their rooms. In addition to the minutes, one grievance occurred on 03/09/2026 when a family member of Resident (R) 25 complained they were unable to reach anyone at facility by phone and were concerned about the resident's well-being. Review of resident showers for the past three weeks for nine residents (R1, R2, R9, R13, R18, R21, R32, R46, and R64), all of whom required extensive assist of two, revealed while residents were consistently getting cleaned twice a week, the majority of residents were receiving bed baths. However, even though some residents were documented as receiving showers, this information was brought into question (see 483.10 Resident Rights, F558, involving R9). In an interview with State Trained Nurse Aide (STNA) 1 on 03/22/2026 at 5:08 PM, she stated a fifth aide just arrived; but prior to that they were working with four aides and a nurse helping out as an aide. She stated sometimes there were only three aides, meaning one to a hallway, and there were multiple residents requiring a two staff assist for care or transfers. She stated a lot of aides get burnt out, and a lot of agency aides know how hard they worked at the facility and would not come. She stated the group she usually worked with helped each other to ensure resident needs were met to the best of their ability. She stated some nurses did help out, while others did not. She stated STNAs were also told not to go off of our hallway, but when there were not enough aides, staff had to help each other in order to get the work done. She stated residents did complain when call lights were not answered quickly or when trays were not served quickly. In an interview with STNA7 on 03/23/2026 at 3:35 PM, she stated call-ins or no shows were frequent. She stated there were four aides currently working, which included an agency aide, as well as a nurse working as an aide, bringing the total to five. She stated it work was rough, especially when aides were required to work on two different units. She stated she tried to get resident showers that were scheduled on her shift done. She stated night shift scheduled showers were rarely completed by night shift and were put off onto day shift, despite night shift usually being more fully staffed. In an interview with STNA8 on 03/24/2026 at 9:00 AM, she stated last year there were four to five aides on her rotation, and now they were down to three. She stated they had been working short for the past two months or so. She stated there were two sets of rotation for staff, with groups of aides and nurses usually assigned to the same shifts. She stated they usually had some dependable agency staff to assist, and they were able to make it work. She stated there were some things they might not have time to complete, like when residents were supposed to receive a shower, they might have to give bed baths instead as it was less time consuming than getting residents up for showers. She stated when working short, they picked up extra rooms and were not always able to check on residents every two hours. She stated the majority of nurses did help, although there were some that did not help. She stated they try to get as much done as possible, although it was difficult as there were a lot of residents that required a two staff assist and a lot of residents that required mechanical lifts for transfer. In an interview with R2 on 03/23/2026 at 9:00 AM, he stated he had to wait 45 minutes before staff responded to his call light, and long waits happened more often during night shift. He stated he had been told by staff on Mondays that they are short on aides and had missed getting showers on Mondays as a result. In an interview with the Director of Nursing (DON) on 03/26/2026 at 8:44 AM, she stated she had been the acting scheduler, although she was currently in the process of training a new person to handle the schedule. She stated she was not familiar with the Facility Assessment, but when compared to staffing schedules for the past month, she acknowledged it did not match with the staffing grid she was provided. She stated she tried to schedule extra staff with agency, but they often call off at the last minute. She stated she was uncertain why the staffing guide Pavilion at [NAME] required less staff than the staffing numbers in the Facility Assessment. She stated she was uncertain what the rationale was for the staffing guide that when agency STNAs were working, fewer STNAs would be required but did note from a cost perspective agency aides were more expensive. When asked about the purpose of the Facility Assessment, the DON stated it was used to determine staffing needs based on resident acuity. She stated staff was working on hiring more staff and would continue to use agency staffing until they had enough regular staff. She stated her expectation was that nurses were never too busy to help out, and there were always more than four people in the building. She stated she viewed nurses and aides as a team, along with management when present. She stated non-clinical staff could answer call lights, with the whole team expected to help out to ensure resident needs were met. She stated she worked hard on the schedule and had never had an aide or nurse come to her and say they needed help. In an interview with the Administrator on 03/26/2026 at 1:42 PM, she stated management heard frequent concerns about staffing, which was an issue in every facility she had been in. She stated they could not control call-offs but did their best with management coming to fill in. She stated her expectation was that the facility was staffed according to resident needs. She stated she had not had the opportunity to delve into the Facility Assessment and had only done a quick review. She stated the purpose of the Facility Assessment was to determine the overall facility and resident needs, which included staffing. She stated her expectation was that resident needs be met, and if there was a change in the acuity of residents or the population served, that would be reflected in the Facility Assessment.

Based on observation, interview, and review of the facility's policies, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety. Observations revealed the nourishment refrigerators on the Purpose, Providence, and Honor Unit were not clean. In addition, opened but not dated food containers were observed on the Honor Unit and the kitchen, and the kitchen contained an item that was unrefrigerated which should have been refrigerated. The deficient practice had the potential to affect all 80 current residents. The findings include: Review of the facility's policy titled, Refrigerators and Freezers, dated 2001, revealed refrigerators and freezers were kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often as necessary. Review of the facility's policy titled, Food Receiving and Storage, dated 2001, revealed all foods stored in the refrigerator or freezer were covered, labeled, and dated with use by date. Observation of the main dining room Honor Unit refrigerator on 03/22/2026 at 1:18 PM revealed the refrigerator and freezer were soiled with dry food products throughout each side and on the shelves. Further observation revealed an opened grape jelly container sitting on top of the refrigerator, not dated and not stored in the refrigerator. The label stated to store in the refrigerator after opening. Observation of the Pavilion Unit refrigerator and freezer on 03/22/2026 at 1:20 PM revealed soiled shelves with dried food in both sides of the shelves. Observation of the Purpose Unit dining room refrigerator and freezer on 03/22/2026 at 5:28 PM revealed the refrigerator was soiled with dried food. In an interview with State Trained Nurse Aide (STNA) 7 on 03/22/2026 at 4:54 PM, she stated Dietary was responsible to clean the unit nourishment refrigerators. Observation of the kitchen on 03/24/2026 at 11:58 AM revealed two opened and undated grape jelly containers found out of the refrigerator. In an interview with the Dietary Manager on 03/25/2026 at 10:05 AM, she stated the nourishment refrigerators were cleaned twice weekly and any spills should be cleaned up by staff. She stated they kept the jelly out to make peanut and butter jelly sandwiches. She stated the grape jelly should be dated when opened and kept in the refrigerator. In an interview with the Director of Nursing on 03/25/2026 at 12:39 PM, she stated her expectation for the nourishment refrigerators was for them to be clean. In an interview with the Administrator on 03/26/2026 at 1:40 PM, she stated her expectation was for staff to wipe up any spills in the nourishment refrigerators and maintain the cleanliness of the nourishment and resident refrigerators.

Based on interview, record review, and review of the facility's policy, the facility failed to have a system in place for residents to send and receive mail, and to receive letters, packages, and other materials delivered to the facility on Saturdays for 15 of 15 residents participating in the Resident Council meeting, Resident (R) 3, R8, R9, R13, R15, R18, R37, R39, R43, R56, R66, R68, R71, R75, and R106.The findings include:Review of the facility's policy, Notice of Resident Rights, revised March 2018, revealed the facility shall inform the resident in writing of his or her rights as a resident, and the rules and regulations governing the resident's conduct and responsibilities during his or her stay in the facility.During the Resident Council meeting on 03/23/2026 at 2:00 PM, R3, R8, R9, R13, R15, R18, R37, R39, R43, R56, R66, R68, R71, R75, and R106 expressed their concern and frustration about the facility's failure to ensure they could send mail, letters, packages, and other materials, or receive items delivered to the facility on Saturdays. Specifically, R9, R37, and R43 all stated they had Amazon packages and grocery deliveries they do not receive on Saturdays due to the packages not being given to them upon delivery.During an interview with the Receptionist on 03/23/2026 at 9:32 AM, she stated the business office was not open on Saturdays and Sundays. She stated when mail was delivered on Saturdays and Sundays, she comes in on Monday morning it would be lying on her desk, or someone places the mail in the mailboxes for each department.During an interview with the Business Office Manager on 03/23/2026 at 9:32 AM, she stated she did not work on Saturdays and Sundays and confirmed the business office was closed on those days. She stated when mail was delivered over the weekend, facility staff placed the mail on her desk. She further stated it was then distributed to residents on the following Monday. The Business Office Manager stated the packages were delivered to the lobby of the facility, and unless residents informed staff, they had a package delivery scheduled on Saturday or Sunday, the packages sit in the lobby and are delivered on Mondays to the correct resident.During an interview with the Activities Director on 03/22/2026 at 4:15 PM, she stated she did not work on the weekends, and the business office was not open to receive mail on Saturdays. She stated that when mail was delivered on Saturdays, residents would receive their mail and other packages on Mondays.During an interview with the Social Services Director on 03/24/2026 at 3:12 PM, he stated he did not work on Saturdays and Sundays. He stated he had no idea if mail or packages were delivered on Saturdays and Sundays.During an interview with the Director of Nursing (DON) on 03/25/2026 at 4:02 PM, she stated she was unaware mail was not being delivered to residents on Saturdays and Sundays.During an interview with the Administrator on 03/25/2026 at 10:22 AM, she stated she was not aware mail was not delivered to residents on Saturdays and Sundays. She stated the activities department was responsible for delivery of mail and packages to the residents.

Based on interview, record review, and review of the facility's policies, the facility failed to have information on how to file a grievance or complaint available to residents. In addition, the facility failed to establish a grievance system to ensure the prompt resolution of all grievances. The findings include:Review of the facility's policy titled, Notice of Resident Rights, revised March 2018, revealed the facility shall inform the resident in writing of his or her rights as a resident, and the rules and regulations governing the resident's conduct and responsibilities during his or her stay in the facility.Review of facility's policy titled, Grievances/Complaints, Filing, revised April 2017, revealed the residents and their representative have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the residents and/or representatives.During the Resident Council meeting on 03/23/2026 at 2:00 PM, residents stated during their monthly resident council meetings they have expressed their concerns to department heads. However, the residents stated they had never seen a grievance form, and they did not know where they were located at. During an interview with the Activities Director on 03/22/2026 at 4:15 PM, she stated the residents come to her to verbalize their grievances. She stated she did not use a grievance form and was not sure where they were located. She further stated once residents voiced their grievance or concern, she tried to resolve the issue. The Activities Director stated she did not report to the grievance officer, who was the Social Services Director. She stated during resident council meetings she had each department head attend the meetings to speak with the residents; however, documentation or grievance forms were not completed for a tracking system.During an interview with the Social Services Director on 03/24/2026 at 3:12 PM, he stated when a resident approached him to verbalize grievances, he completed a grievance form and began an investigation. He stated that after he investigated the grievance/concerns verbalized from the residents, he reports a resolution to the resident. He further stated the grievance forms were in his office and at the nurses' station. The Social Service Director stated he was not sure if all staff were educated on how to complete the grievance form or to make sure he got all grievances/concerns to investigate.During an interview with the Director of Nursing (DON) on 03/25/2026 at 4:02 PM, she stated the Social Services Director was responsible for collecting the grievances and investigating them. She stated if staff did not complete a grievance form, then the Social Services Director had no way of knowing that a grievance or concern had been reported. She stated the importance of having a documented grievance form was to have the paper trail and a resolution could be given to the resident.During an interview with the Administrator on 03/25/2026 at 10:22 AM, she stated grievance forms were available, and the Social Services Director was the grievance compliance officer for the facility. She further stated all department heads do attend the monthly resident council meetings. The Administrator stated residents verbalize their concerns; however, the department heads just write the concerns on a piece of paper but did not use a grievance form. She stated all staff should be educated that all grievances or concerns need to be documented on a grievance form and turned in the Social Services Director.

Based on interview, record review, and review of the facility's policy, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 9 of 15 residents participating in the Resident Council meeting, Resident (R) 3, R8, R9, R18, R43, R56, R68, R71, and R75.The findings include:Review of the facility's policy titled, Notice of Resident Rights, revised March 2018, revealed the facility shall inform the resident in writing of his or her rights as a resident, and the rules and regulations governing the resident's conduct and responsibilities during his or her stay in the facility.During observation of dinner on 03/22/2026 at 6:13 PM, all residents were being served their meal on Styrofoam plates, and they were eating with plastic silverware.During observation of lunch on 03/23/2026 at 12:37PM, all residents dining in the main dining room and the rehabilitation dining room were served their meals on Styrofoam plates and were eating with plastic silverware.During the Resident Council meeting on 03/23/2026 at 2:00 PM, 9 of 15 residents (R3, R8, R9, R18, R43, R56, R68, R71, and R75) expressed their concern and frustration about being served their meals on Styrofoam plates and bowls and having to use plastic silverware. Residents stated they had eaten off Styrofoam plates and used plastic silverware for more than three months. Residents further stated they were told by facility staff residents were throwing away the silverware and the budget would not allow the facility to order more silverware. During an interview with the [NAME] on 03/22/2026 at 5:45 PM, she stated that there was a list of paper patients that instructed the kitchen to send Styrofoam to specific residents due to current diagnoses, such as behavioral or infections. She further stated a few resident names and denied a shortage of dishes, clean or otherwise. In an interview with the Dietary Manager on 03/25/2026 at 10:05 AM, she stated the only time Styrofoam was used for residents was with an order, for residents who had safety issues with utensils, when the water was turned off, when the dishwasher was not working, and for residents with COVID.During an interview with the Director of Nursing (DON) on 03/25/2026 at 4:02 PM, she stated she was not aware the residents were eating off Styrofoam plates and bowls or that they were using plastic silverware. She stated the budget at the facility was scarce and she would try to get what the facility needed from corporate.During an interview with the Administrator on 03/25/2026 at 10:22AM, she stated she was unaware residents were using Styrofoam bowls and plates or that they were using plastic silverware. She stated it could be a dignity issue considering the facility was the resident's home. She further stated she had not been notified by the dietary department that there were not any normal plates or silverware available for the residents.

Based on interview, record review, review of the facility's job description, and review of the facility's policy, the facility failed to perform a trauma-informed care assessment for 5 of 5 residents sampled for trauma-informed care, Resident (R) 4, R10, R21, R67, and R75.The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person Centered, revision date 03/2022, revealed services would be provided or arranged by the facility and outlined in the Comprehensive Care Plan [CCP] that were trauma informed. Review of the facility's job description for Social Services Director, dated with a copyright of 2020, revealed the Social Services Director (SSD) was responsible for identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident. It also stated the SSD would ensure that residents who displayed mental illness or psychosocial difficulties would have access to appropriate treatment and resources. Additional responsibilities included interviewing residents to obtain their social history. This position reported to the Administrator. 1. Review of R67's admission Record revealed the facility initially admitted the resident on 01/30/2023 and most recently on 12/30/2024 with diagnoses which included adjustment disorder with anxiety and depressed mood, schizoaffective disorder, and post-traumatic stress disorder (PTSD). Review of R67's Care Plan Report revealed a focus, dated 01/30/2023, of a potential for psychosocial well-being problem related to anxiety, schizoaffective disorder, and an inability to problem solve. The goal was adjustment related to placement in the nursing home with interventions dated 01/30/2023 to increase communication, document resident's feelings, and when conflicts arose, remove the resident to a calm, safe environment to allow to vent/share feelings. The focus was revised on 01/15/2025 because of demonstrated verbally abusive behaviors and putting hands in people's faces related to mental/emotional illness and poor impulse control. Goals revised on 02/23/2025 were control of verbal abusive behavior and effective coping skills. Interventions dated 11/27/2023 listed engaging in calm conversation, with updates dated 02/01/2023 of analyzing circumstances, anticipation of needs, assessing resident's comprehension of circumstances, and allowing the resident to express self and feelings. Review of R67's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/06/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 of 15, indicating little, if any, cognitive impairment. The MDS also revealed a mood severity score of 18, indicating the resident was affected by difficulty sleeping, little interest in participating in activities, and feeling depressed or hopeless nearly every day. It also included the diagnosis of PTSD. Review of the Psychiatry Progress Note, dated 03/03/2023, revealed R67 was seen for a consult/medication management for a history of multiple mental health diagnoses, including PTSD and schizoaffective disorder, both due to the onset of trauma in her teen years. Additionally, R67 continued to have nightmares related to abuse. 2. Review of R21's admission Record revealed the facility initially admitted the resident on 07/29/2016, again on 06/20/2018, and most recently on 01/01/2025. The diagnoses included hemiplegia and hemiparesis following stroke affecting the dominant side, dementia with behavioral disturbance, brief psychotic disorder, and delusions. It also revealed R21 had a responsible party/spouse. Review of the electronic medical record (EMR) for R21 revealed that no PTSD assessment had been performed; however, on 03/25/2026, during the survey, the SSD completed a PTSD checklist that indicated no history of trauma. During an interview on 03/26/2026 at 9:50 AM with the spouse of R21, she stated the resident had no history of PTSD or known traumatic experiences that she was aware of. During the interview, she stated she had no idea who the Social Worker was and did not know how to contact the Social Worker if she had any concerns. She stated she had never been asked about the potential of PTSD or a history of trauma by anyone else. 3. Review of R4's admission Record revealed the facility initially admitted the resident on 10/04/2018 with the most recent admission on [DATE] with diagnoses of paranoid schizophrenia, major depressive disorder, developmental disorder, and anxiety. The record also revealed R4 had a Power of Attorney (POA)/Friend. Review of R4's EMR revealed no PTSD assessment had been performed. Review of the five-day MDS, with an ARD of 02/20/2026, revealed the facility assessed the resident to have a BIMS score of 3 out of 15, indicating severe cognitive impairment. Review of R4's CCP, last revised 06/29/2023, revealed a potential for psychosocial well-being and problems related to anxiety, dependent behavior, and distractibility/inability to concentrate. Interventions included increased communications and discussing concerns, participation of family/caregivers, and referrals as needed. During an interview on 03/25/2026 at 10:10 AM with the POA of R4, she stated she was unaware of any diagnosis of PTSD or traumatic experiences. She was unaware if it had ever been discussed. 4. Review of R75's admission Record revealed the facility admitted the resident on 01/01/2025 with diagnoses of dementia, cerebral infarction (stroke), and anxiety. Review of R75's EMR revealed that no PTSD assessment had been performed. Review of R75's annual MDS, with an ARD of 03/07/2026, revealed the facility assessed R75 to have a BIMS score of 14 out of 15, indicating minimal, if any, cognitive deficit. Review of R75's CCP, dated 02/08/2023, regarding mood, anxiety, and altered mental status revealed no adverse behaviors and monitoring for signs and symptoms. During an interview on 03/26/2026 at 9:35 AM with R75, he stated he had not had any traumatic experiences in his life that he could recall and no history of military service. 5. Review of R10's admission Record revealed the facility admitted the resident on 03/16/2016 with diagnoses including PTSD, borderline personality disorder, anxiety disorder, and major depressive disorder. Review of R10's quarterly MDS, with an ARD of 01/01/2026, revealed the facility assessed the resident to have a BIMS score of nine out of 15, indicating moderately impaired cognition. Further review revealed R10 was assessed for an active diagnosis of PTSD. Review of R10's CCP, undated, revealed that PTSD and/or trauma-informed care were not addressed. Review of R10's EMR revealed R10 had a diagnosis of Post-Traumatic Stress Disorder (PTSD); however, the facility failed to complete an assessment addressing the residents' PTSD, including identification of triggers, symptoms, or interventions needed to support the resident's mental health needs. In an interview with the Social Services Director (SSD) on 03/26/2026 at 10:22 AM, he stated he had failed to complete a Trauma Informed Care Assessment [[NAME]] addressing the R10's PTSD, including identification of triggers, symptoms, or interventions needed to support the residents' mental health needs. The SSD further stated it was important that staff was aware of R10's PTSD diagnosis and any known triggers so she received resident-centered care and was not re-traumatized. In an interview with the Director of Nursing (DON) on 03/26/2026 at 10:42 PM, she stated it was her expectation that residents with PTSD would receive trauma-informed care, so staff anticipated a resident's needs, when possible, looked for changes in behavior, and provided support and encouragement. During additional interview with the SSD on 03/24/2026 at 2:44 PM, he stated he had not done the [NAME] because he did not know he was supposed to. He thought it was done by the MDS Nurse or the nurse admitting the resident. During an interview on 03/25/2026 at 11:17 AM with the MDS Nurse/Licensed Practical Nurse (LPN) 7, she stated she did not realize the SSD had not performed [NAME], and she provided documentation of immediate education to the SSD. She stated she had been off extensively for her knee but presumed the answers were negative for this diagnosis. She stated she was unaware that it had been missed and that the plan of care did include some behavioral concerns, just not specific to the PTSD diagnosis. She stated it was important to include this assessment because the resident could be retraumatized if it was not identified, with or without potential triggers. She also stated she utilized this information to help create the care plan. During an interview on 03/25/2026 at 2:15 PM with the Director of Nursing (DON), she stated the diagnosis for PTSD should have been caught on the [NAME] that was performed by the SSD. She stated she had discussed this with the MDS Nurse, and education had been provided by the MDS Nurse with the SSD as of the same date. She stated that not having the [NAME] performed could cause the resident unnecessary harm by unknowingly re-traumatizing them. She also stated that this should have been previously caught. During an interview on 03/26/2026 at 1:33 PM with the Administrator, she stated she expected an accurate and timely assessment to be performed by the entire team, including the [NAME], care plans, and nursing assessments. She stated failure to do this could result in a resident not receiving the appropriate care and could result in unnecessary adverse outcomes.

Based on observation, interview, record review, review of the manufacturer's guidance, and review of the facility's policies, the facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 6 of 6 residents sampled for enteral feeding, Resident (R) 32, R36, R38, R46, R50, and R78. Observations on 03/22/2026 and 03/23/2026 included tube feedings hanging that were not timed or dated with the connector tips without end caps; medications administered via the feeding tube without checking for placement prior to administration; and a tube feeding that was started two hours late and continued past the ordered stop time. In addition, R36 was sent to the Emergency Department on 07/02/2025 and 03/05/2026, after the adult day care center became concerned with the resident's gastrostomy tube status, and R36 was diagnosed with abdominal wall cellulitis without the facility's staff documenting the abnormal findings or contacting the provider. The findings include:Review of the facility's policy titled, Enteral Nutrition, revised November 2018, revealed nursing staff and the provider were responsible for monitoring residents for signs and symptoms of inadequate nutrition, altered hydration, and complications related to enteral nutrition. The policy indicated staff was trained to recognize and report complications associated with feeding tubes, including aspiration, tube misplacement or migration, skin breakdown at the insertion site, and gastrointestinal symptoms such as nausea, vomiting, diarrhea, and abdominal cramping. The policy further indicated that failure to confirm feeding tube placement prior to initiating feedings might increase the risk of aspiration.Review of the facility's policy titled, Gastrostomy/Jejunostomy Site Care, revised October 2011, revealed staff was to maintain the cleanliness of the gastrostomy or jejunostomy site to prevent irritation, breakdown, and infection. The policy indicated staff was to assess the site for redness, pain, swelling, or drainage and report signs of infection to the supervisor and physician. The policy further indicated that ongoing signs of irritation or infection were to be addressed and reported in accordance with facility policy and standards of practice.Review of the manufacturer's guidance from [NAME]'s Guide to Adult Tube Feeding, dated 09/2022, revealed ready-to-use enteral formula in a closed system (ready-to-hang) could remain hanging for up to 48 hours when the system remained closed and intact. The guidance further revealed that ready-to-use formula decanted into a bag (open system) could hang up to eight hours. Additionally, the manufacturer's guidance instructed that once the formula was opened, the container should be labeled with the date and time, and any unused formula should be covered and stored in a refrigerator. The guidance further indicated that handling of the feeding system should be performed in a manner to prevent contamination, including avoiding contact with components that would come into contact with the formula. Further review of the manufacturer's guidance revealed that leakage around the gastrostomy tube site was not expected and was considered a sign of an underlying problem that might increase the risk of skin breakdown and infection. The guidance also indicated that signs of infection at the stoma site might include redness, drainage, and irritation and could require evaluation and intervention. 1. Review of R36's admission Record revealed the facility admitted the resident on 12/16/2019 with diagnoses to include gastrostomy status, dysphagia, and gastro-esophageal reflux disease without esophagitis.Review of R36's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 02/16/2026, revealed the Brief Interview for Mental Status (BIMS) was not conducted because the resident was unable to complete it. The Staff Assessment for Mental Status was completed and indicated the resident was severely impaired for daily decision making and never/rarely made decisions. Further review revealed the resident was coded as receiving 51 percent or more of total calories and fluid intake via parenteral or tube feeding.Review of R36's Comprehensive Care Plan [CCP], undated, indicated the resident was care-planned for tube feeding related to dysphagia, chewing problems, and swallowing problems. An intervention initiated on 02/28/2023 was to monitor signs and symptoms of infection and to check tube placement and gastric contents/residual volume. The goals included R36 would remain free of complications related to tube feeding.Review of the Order Summary Report, dated 06/07/2025, revealed staff should monitor the gastrostomy tube site for signs or symptoms of infection every shift to support infection prevention. Additionally, on 01/26/2026, the physician ordered enteral feeding to start at 4:00 PM and stop at 5:00 AM: Glucerna 1.5, 60 milliliters (ml) for 13 hours a day.Review of the Incident Report, dated 07/02/2025 from the adult day care center, revealed R36 presented with complications related to the gastrostomy (G-tube), including abnormal findings requiring transfer to the Emergency Department (ED) for further evaluation. Documentation indicated concerns with the G-tube site, prompting emergency medical services transport.Review of R36's Emergency Department Record, dated 07/02/2025, revealed R36 was diagnosed with abdominal wall cellulitis. However, the facility's clinical record contained no evidence that staff had identified or documented signs or symptoms of infection prior to the resident leaving the facility to attend the adult day care center.Review of the Incident Report, dated 03/05/2026 from the adult day care center, revealed R36 presented with complications related to the gastrostomy (G-tube), including leakage and inability to flush the tube. Documentation indicated the resident exhibited signs of distress, and assessment of the tube site revealed abnormal findings requiring intervention. The report further indicated the resident required transfer to the ED via emergency medical services for evaluation.Review of R36's Emergency Department Record, dated 03/05/2026, revealed the resident was diagnosed with abdominal wall cellulitis. However, the facility's clinical record contained no evidence that staff identified or documented signs or symptoms of infection prior to the resident leaving the facility to attend the adult day care center.Observation on 03/22/2026 at 2:40 PM revealed R36 lying in bed with the head of the bed elevated. The resident was not receiving enteral feeding at that time. However, a feeding container was observed hanging from an IV pole, spiked, and primed with formula, without a protective cap covering the connector. The feeding pump and IV pole were observed with dried formula residue. Further observation of Licensed Practical Nurse (LPN) 1 performing G-tube care at that time revealed the site was reddened with approximately a quarter-sized amount of yellowish-green drainage present around the stoma.During an interview with LPN1 on 03/22/2026 at the time of observation, she stated the feeding container had been spiked the previous day, used from 4:00 PM to 5:00 AM, and would be reused for the next feeding. LPN1 stated the connector should be covered. However, the facility did not provide caps, so it remained uncovered between feedings. LPN1 further stated the resident's G-tube site frequently leaked.Observation on 03/22/2026 at 6:30 PM revealed R36 remained in bed with no enteral feeding in progress. An interview with LPN1 at that time revealed she had fallen behind and planned to start the enteral feeding shortly.Observation on 03/22/2026 through 03/26/2026 revealed R36's intravenous (IV) pole and enteral feeding pump had a large amount of dried feeding residue present on the exterior surfaces of the pump, along the IV pole, and at the base of the pole.During an interview with the Physician Assistant (PA) on 03/25/2026 at 2:50 PM, she stated she had not been notified by staff of excessive leakage at R36's G-tube site and indicated that such leakage could contribute to recurrent cellulitis at the site. She further stated, if notified of excessive drainage, she would have changed the g-tube size or ordered a gastrointestinal (GI) consultation.2. Observation on 03/22/2026 at 1:21 PM revealed R46 had a tube feeding hanging and infusing which was not dated or timed.Review of R46's admission Record revealed the facility initially admitted R48 on 01/21/2016 with diagnoses of cerebral palsy, malnutrition, and epilepsy.Review of R46's quarterly MDS, with an ARD of 01/18/2026, revealed the BIMS score was undetermined due to the resident being rarely/never understood.Review of R46 Orders revealed an order for enteral feeding, Nutren 2.0 continuous at 25 ml/hour, dated 01/26/2026.3. Observation on 03/22/2026 at 1:34 PM revealed R32 had a tube feeding hanging, which was not dated or timed, not infusing, and the administration set was hung on the IV pole with no end caps.Additional observation on 03/22/2026 at 5:41 PM revealed Licensed Practical Nurse (LPN) 1 administered medications to R32 via the percutaneous endoscopic gastrostomy (PEG) tube without checking for placement prior to pushing the medication.Review of R32's admission Record revealed the facility admitted the resident on 01/01/1973 with diagnoses of cerebral palsy, epilepsy, and gastrostomy status.Review of R32's quarterly MDS, with an ARD of 01/18/2026, revealed a BIMS score was undetermined due to the resident being rarely/never understood.Review of R32's Care Plan, revealed R32 was care planned for staff to check placement and gastric contents/residual volume per facility protocol, dated 04/21/2023.Review of R32's Orders revealed an order for tube feeding, Fibersource HN at 60 ml/hour for 14 hours, turn on at 4:00 PM and turn off at 6:00 AM, dated 08/10/2024.4. Observation on 03/22/2026 at 1:35 PM revealed enteral nutrition, without the opening time and date identified for both R38 and R50, hanging from a pole with the tubing primed, and without a protective covering on the end of the opened tubes.During an interview on 03/22/2026 at 1:48 PM with Licensed Practical Nurse (LPN) 1, she stated that these were her residents, but she was not the nurse responsible for hanging the tube feeding. She stated the night shift hung them and was responsible for dating the bags, and she would put the date and time on the bag if she had hung it. She stated the tube feeding itself was good for 48 hours after it was hung but could not identify with certainty when these bags were hung. She stated, if it was hung for too long, it could spoil, and the resident could get sick. The nurse also stated ends of the tubing were not covered because no caps were available. Not having caps, she stated, could allow germs to be administered to the resident when the tubing was connected and could also make the resident sick. She stated she checked for PEG tube placements prior to administering medications (however, this was not observed).During an interview on 03/23/2026 at 4:00 PM with the Physician Assistant (PA), she stated there was a possibility for introducing bacteria to feeding tube sites if the feeding tube system was not capped when not in use.5. Review of R78's admission Record revealed the facility admitted the resident on 11/12/2021 with diagnoses to include gastrostomy status, dysphagia, and gastro-esophageal reflux disease without esophagitis.Review of R78's quarterly MDS, with an ARD of 01/18/2026, revealed BIMS was not conducted because the resident was unable to complete it. The Staff Assessment for Mental Status was completed and indicated the resident was severely impaired for daily decision making, and never/rarely made decisions. Further review revealed the resident received 51 percent or more of total calories and fluid intake via parenteral or tube feeding.Review of the Comprehensive Care Plan [CCP], undated, indicated the resident was care-planned for tube feeding related to dysphagia, chewing problems, and swallowing problems. An intervention was to monitor signs and symptoms of infection and to check for tube placement and gastric contents/residual volume. The goals included that R78 would remain free of complications related to tube feeding. Further review revealed R78 had a focus on alteration in nutrition due to dehydration, tube feeding, swallowing problems, and being overweight. An intervention was to provide feeding and water flushes per order and monitor for signs and symptoms of residuals. The goal was to tolerate tube feeding and water flushes per order with no signs or symptoms of residuals.Review of the Order Summary Report, dated 11/12/2021, revealed staff should monitor the G-tube site for signs or symptoms of infection every shift for infection prevention and enteral feed to start at 4:00 PM and stop at 5:00 AM, Fiber source 1.5 at 50 ml for 13 hours a day.Observation on 03/22/2026 at 2:00 PM revealed a G-tube feeding setup present in the resident's room. The enteral feeding container was observed hanging on an IV pole with tubing already spiked and primed. The feeding bag was labeled with the date 03/22/2026 and the time at 6:00 PM. At the time of observation, the feeding was not infusing, and the labeled time indicated the feeding had not yet been initiated for that scheduled administration (approximately 3.5 hours prior to the labeled time). The end of the feeding tube connector was observed uncovered, with no protective cap in place. The Kangaroo feeding pump and IV pole were observed to have dried tan feeding residue present on the exterior surfaces.Observation on 03/22/2026 at 6:01 PM revealed LPN1 administered medication via R78's G-tube without verifying tube placement or checking for gastric residual prior to administration. Following medication administration, LPN1 proceeded to connect the enteral feeding. The review of the physician's order indicated the feeding was to begin at 4:00 PM. At the time of observation, the feeding was initiated approximately two (2) hours later than ordered. The feeding tube connector remained uncovered and was not cleansed prior to connection to the resident's G-tube.During an interview with LPN1 on 03/22/2026 at 6:01 PM, conducted at the time of the observation, she stated she typically initiated tube feedings during medication administration. LPN1 further stated the facility did not provide protective caps for feeding tube connectors and acknowledged that leaving the connector uncovered placed the resident at risk for infection. She stated she had previously notified the facility of the lack of protective caps; however, no action had been taken.Observation on 03/23/2026 at 9:00 AM, 11:11 AM, 2:12 PM, and 3:15 PM revealed R78's enteral feeding was infusing at 50 ml per hour. The review of the physician's order indicated that the feeding was to be discontinued at 5:00 AM.Observation on 03/23/2026 at 3:30 PM revealed R78 lying in bed with a large amount of emesis present on the chest of her gown and on the bed linens. In an interview at that time, Licensed Practical Nurse (LPN) 7 stated she had been running behind and had not turned off the feeding.Observation on 03/22/2026 through 03/26/2026 revealed R78's IV pole and enteral feeding pump had a large amount of dried feeding residue present on the exterior surfaces of the pump, along the IV pole, and on the base of the pole.During an interview with the [NAME] Product Line representative on 03/24/2026 at 4:46 PM, he stated he had referenced the Guide to Adult Tube Feeding and confirmed that the guidance applied to both home and facility settings. He stated a closed feeding system must remain closed and protected to maintain its integrity, and once the system was disconnected and the tubing tip was left exposed without a protective cap, it was no longer considered closed and was at risk of contamination.During an interview with the Registered Dietitian (RD) on 03/24/2026 at 9:48 AM, she stated enteral feedings should be administered according to the prescribed schedule to ensure the resident received the ordered nutritional intake. She stated there could be minor variations in timing to accommodate care needs; however, feedings should remain consistent with the prescribed regimen. The RD further stated feeding tube connectors should be covered to prevent contamination and reduce the risk of infection, and enteral feedings should not be left hanging longer than recommended timeframes. She stated concerns of excessive leakage at the G-tube site should be reported for further evaluation.During an interview with the Physician Assistant (PA) on 03/25/2026 at 2:50 PM, she stated enteral feedings should be administered in accordance with the physician's order to ensure the resident received the prescribed caloric intake and to reduce the risk of adverse effects from overfeeding. She further stated leaving the feeding tube port uncovered increased the resident's risk for infection. During an interview with the Director of Nursing (DON) on 03/26/2026 at 2:00 PM, she stated feeding tube connectors should be covered to prevent contamination and reduce the risk of infection. She further stated enteral feeding was to be administered according to physician orders and should not be hung longer than the recommended timeframes. The DON stated that if a resident has more than minimal leakage at the G-tube site, nursing staff are expected to notify the physician for further evaluation and management.During additional interview on 03/25/2026 at 3:31 PM with the Director of Nursing (DON), she stated it was her expectation that tube feedings should never be uncapped when not in use, and a new system should be set up if it is found undated, untimed, or uncapped. She stated they should always be dated and timed, and they were normally good for 24 hours, depending on the tube feeding and manufacturer. She stated it was important to make sure the residents were getting fresh tube feedings to help prevent infection.During an interview with the Administrator on 03/26/2026 at 11:00 AM, she stated she had not been made aware of concerns related to uncovered feeding tube connectors, prolonged hanging of enteral feeding, or excessive leakage at a resident's G-tube site. She stated staff was expected to report care concerns so they could be addressed. The Administrator further stated that enteral feedings should be administered according to physician orders, and equipment should be maintained in a clean and sanitary manner.

Based on observation, interview, record review, review of the facility's job description, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 6 of 25 sampled residents, Resident (R) 10, R11, R23, R32, R47, and R67. The care plans for R10, R11, R47, and R67 were not fully developed at admission to reflect their diagnoses. For R23 and R32, their care plans were fully developed, but staff did not implement the interventions in their care plans. The findings include: Review of the facility's policy titled, Care Plan, Comprehensive Person-Center, revised date 03/2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy also stated services would be provided or arranged by the facility and outlined in the Comprehensive Care Plan [CCP] that were trauma informed. Review of the facility's MDS Coordinator Job Description, dated with a 2024 Copyright, stated the MDS Nurse was responsible for the implementation and ongoing evaluation of each resident's comprehensive plan of care. 1. Observation on 03/22/2026 at 1:30 PM revealed no signage on the door indicating Resident (R) 11 required Enhanced Barrier Precautions (EBP). Review of R11's admission Record revealed the facility admitted the resident on 08/18/2025 with diagnoses of behavioral and emotional disorders, anoxic brain injury, and PEG tube status. Review of R11's Care Plan revealed R11 was care planned on 03/10/2026 for requiring tube feedings and also at risk of infections, requiring EBP, dated 03/10/2026. During an interview on 03/25/2026 at 9:35 AM with the Physician Assistant (PA), she stated R11 was admitted with a percutaneous endoscopic gastrostomy (PEG) tube in place on 08/18/2025. During an interview on 03/25/2026 at 9:35 AM with the Minimum Data Set (MDS) Nurse, she stated R11 was under EBP related to the PEG tube, and this should have been added to his care plan, upon admission, prior to 03/10/2026. 2. Observation on 03/22/2026 at 1:30 PM revealed no signage on R47's door indicating the resident required EBP. Review of R47's admission Record revealed the facility admitted the resident on 07/25/2025 with diagnoses of end stage renal disease with dependence on renal dialysis and congestive heart failure. Review of R47's Care Plan, undated revealed there was no focus for the dialysis catheter or for the resident being under EBP. Review of R47's Orders revealed R47 had an order for EBP, dated 03/23/2026. During an interview on 03/25/2026 at 9:35 AM with PA, she stated R47 currently had a dialysis catheter and a fistula. She stated the resident was admitted with the catheter while she was waiting to get the fistula and for it to mature. During an interview on 03/25/2026 at 9:35 AM with the MDS Nurse, she stated R47 should have been care planned for the dialysis catheter and EBP upon her admission on [DATE]. 3. Observation on 03/22/2026 at 1:30 PM revealed R23's room had no signage on the door indicating she required EBP. Review of R23's admission Record revealed the facility admitted the resident on 01/21/2022 with diagnoses of diverticulitis of intestine with perforation and colostomy status. Review of R23's Orders revealed an order for EBP, dated 03/23/2026, and an order for colostomy care every shift, dated 07/04/2024 (original order for colostomy care dated 01/21/2022). Review of R23's Care Plan revealed R23 was care planned for EBP on 06/12/2023. During an interview on 03/25/2026 at 9:35 AM with the MDS Nurse, she stated she was told that residents with colostomies did not require EBP. She stated she did not remember who told her this, but she left EBP on the care plan and was going to question if the resident still required EBP. She stated staff should be following the care plan interventions. 4. Observation on 03/22/2026 at 5:41 PM revealed License Practical Nurse (LPN) 1 administered medications to R32 via a PEG tube without checking for placement prior to pushing the medication. Review of R32's admission Record revealed the facility admitted the resident on 01/01/1973 with diagnoses of cerebral palsy, epilepsy, and gastrostomy status. Review of R32's Care Plan revealed R32 was care planned for staff to check placement and gastric contents/residual volume prior to medication administration and per facility protocol, dated 04/21/2023. 5. Review of the admission Record for R67 revealed the facility admitted the resident with an initial admission date of 01/30/2023 and most recently on 12/30/2024, both with a diagnosis of Post Traumatic Stress Disorder (PTSD).Review of the Care Plan Report for R67, most recently updated 02/23/2025 revealed no focus for the PTSD diagnosis. Review of R67's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/06/2026, revealed a mood severity score of 18, indicating the resident was affected by difficulty sleeping, little interest in participating in activities, and feeling depressed or hopeless nearly every day. It also included the diagnosis of PTSD.Review of R67's Psychiatry Progress Note, dated 03/03/2023, revealed R67 was seen for a consult/medication management for a history of multiple mental health diagnoses, including PTSD and Schizoaffective Disorder, both due to the onset of trauma in her teen years. Additionally, R67 continued to have nightmares related to abuse.6. Review of R10's admission Record revealed the facility admitted the resident on 03/16/2016 with diagnoses including post-traumatic stress disorder (PTSD) and borderline personality disorder.Review of R10's quarterly MDS, with an ARD of 01/01/2026 revealed an active diagnosis of PTSD.Review of R10's Comprehensive Care Plan, undated, revealed no evidence that the facility had addressed the resident's PTSD diagnosis, including identification of triggers, symptoms, or interventions to support trauma-informed care and prevent re-traumatization.In an interview on 03/26/2026 at 10:22 AM, the Social Services Director (SSD) stated a care plan addressing R10's PTSD, including triggers, symptoms, and interventions, had not been completed. The SSD further stated it was important that staff was aware of a resident's PTSD diagnosis and triggers to provide resident-centered care and avoid re-traumatization.During an interview on 03/25/2026 at 11:17 AM with the MDS Nurse, who was also Licensed Practical Nurse (LPN) 7, she stated she was unaware the PTSD focus had been missed. She stated the plan of care did include some behavioral concerns, just not specific to the PTSD diagnosis. She stated it was important to include this because the resident could be retraumatized if it was not identified, with or without potential triggers.During an interview on 03/25/2026 at 2:15 PM with the Director of Nursing (DON), she stated since the MDS Nurse was an LPN, it was her job as the RN/DON to sign off on her work. She stated the diagnosis for PTSD had been overlooked on the care plan and not having it there could cause the residents unnecessary harm by unknowingly re-traumatizing them. During additional interview on 03/25/2026 at 3:31 PM with the DON, she stated it was her expectation that care plans were fully developed and communicated so staff knew how to properly take care of residents.During an interview on 03/26/2026 at 1:33 PM with the Administrator, she stated she expected an accurate assessment and plan of care for the residents. She stated failure to do this could result in a resident not receiving the appropriate care and could result in unnecessary adverse outcomes. She stated the MDS Nurse was responsible for fully developing care plans, and it was important for them to be accurate and followed to meet the needs of the residents.

Based on observation, interview, and review of facility policy, it was determined the facility failed to provide a safe, clean, comfortable and homelike environment.The findings include: Review of the facility's policy titled, Homelike Environment, last revised February 2021, revealed residents would be provided with a safe, clean, comfortable, and homelike environment, emphasizing independence and personal needs and preferences. Review of the facility's grievance logs for the previous six months revealed grievances from 12/17/2025 and 12/29/2025, expressing concerns about residents not having needed supplies, and about the small dining room remaining inaccessible. Although no resolution was documented regarding a supply issue, it was noted the facility was getting quotes for the small dining room repair. Additionally, a grievance dated 02/18/2026 noted a ceiling tile in the Honor dining room needed to be replaced and had a resolution of the tile being replaced. Review of the Resident Council minutes for the previous six months revealed a 10/24/2025 Resident Council meeting with residents expressing they would like the small dining room to be usable by Thanksgiving. Review of minutes from the 12/17/2025 Resident Council meeting revealed residents were concerned about not getting needed supplies and aides putting the wrong size briefs on residents. Also, residents continued expressing concerns regarding the need for the small dining room to be repaired. In an interview on 03/22/2026 at 5:08 PM with State Tested Nursing Assistant (STNA) 1, she stated the facility frequently did not have enough supplies to care for residents. She stated a lot of staff buy things for themselves, such as hand sanitizers and soaps, as facility runs out of them. She further stated the facility did not always have clean linens or supplies, which has been an issue for a few months. STNA1 stated the facility ran out of briefs at times, which is reported to nursing, who calls central supply to see if they are available downstairs. When not available, the Administrator is called, and supplies are purchased locally. In an interview with STNA7 on 03/23/2026 at 3:35 PM, she stated there had been housekeeping budget cuts, causing the facility to run low on supplies. STNA7 stated the facility has ran out of washcloths and disposable bed pads at times and staff has had to cut up towels to use as washcloths for peri-care. STNA stated the previous central supply staff told the STNAs the facility budgeting for briefs to be changed once every six hours. She stated, especially with residents on diuretics, every six hours was not sufficient, and it was not uncommon for residents to require being changed six or seven times during a 12-hour shift. She further stated when the facility ran out of briefs, residents have had to use a larger or smaller size and have complained. In an interview with STNA8 on 03/24/2026 at 9:00 AM, she stated the facility did run out of supplies on the unit and had to look in central supply downstairs when they do not have supplies. She stated sometimes the facility was low on linens; staff plan on two rounds of linens a day, but sometimes they need more, which could mean there are no linens available for night shift if they need them. STNA8 stated the facility sometimes ran low on peri-care supplies, like soaps or washcloths, and may run out of specific sizes of briefs and have had to use a different size. STNA8 further stated, depending on the medication residents are on, staff may need to clean some residents up more often than others. In an interview with the Activities Director on 03/24/2026 at 9:06 AM, she stated some residents had complained to her about not getting briefs. She stated the new central supply person drops briefs off on Tuesdays and Fridays, and has extra supplies if residents run out. In interview with Central Supply on 03/25/2026 at 8:27 AM, she stated she had just been in that role since the beginning of March 2026. She stated housekeeping handled washcloths, and she was unaware of any shortage. She further stated she was responsible for resident briefs and makes an inventory list of everything she has in central supply that she goes by. She stated since she has been in her current role, she has not had any issues. Central Supply stated she implemented stocking resident rooms on Tuesdays and Fridays to make sure everyone had enough briefs, and to also keep track of resident use and needs, as she noticed briefs were disappearing too quickly from central supply. She stated she was not aware of any residents complaining of not having enough briefs or not having the right size of briefs. She stated staff should not be getting briefs from other resident rooms, as briefs are resident-specific, and there were always staff present that could get briefs from central supply. 1. Observation on entry to the facility on [DATE] at 1:30 PM revealed a small dining room/activity room in the main hall, off the elevator, with tables and chairs blocking the entryways. Continued observation revealed the floor was wavy with buckled wood grain tiles throughout. Continued observation on 03/22/2026 at 3:40 PM revealed the bathroom in room [ROOM NUMBER] had an uneven floor on entry. [NAME] staining was observed on the back of the seat of a raised toilet. A line of rust-colored stains stretched from a soap dispenser down past a (non-functional) wall outlet with staining on the baseboard beneath. A light over the shower was observed with a cracked plastic cover with a dead moth inside. In an interview with the Maintenance Assistant (MA) on 03/25/2026 at 10:08, he stated he did room rounds once a month, looking at lights, extension cords, plugs, and handrails. He stated he was not aware of any issues in the bathroom of room [ROOM NUMBER] but thought it would be a be a housekeeping issue to keep the walls clean. He stated he was not sure who would have installed a soap dispenser over an outlet, but it should be moved. He stated he had not noticed the tiles in the Honor dining room and wasn't sure how long the small dining room had been closed off. The MA stated staff can request work orders, which are in a box at the nurses' station, and by the receptionist window downstairs, which would then go to the director and to him. In an interview with the Maintenance Director on 03/24/2026 at 3:28 PM, he stated the small dining room was damaged due to a water leak from the ice machine, which someone had moved, causing the drain to shift. He stated this was not caught right away, which caused it to damage the floor. He stated he believed it happened in late October 2025 or early November 2025. He stated the facility has been getting quotes to get the floor redone, but due to the age of the building, contractors do not want to work without having extensive testing done to ensure the flooring does not have asbestos. He stated it would cost $4,500 just to have the floor tested and would result in 4 holes in four different areas of the floor. The Maintenance Director stated he was not aware of any issues in the Honor dining room, or in the bathroom of room [ROOM NUMBER]. He stated his assistant does rounds in resident rooms, while he deals with the entirety of the building. In further interview with the Maintenance Director after a brief tour on 03/24/2026 at 3:38 PM, he acknowledged the bathroom outlet in room [ROOM NUMBER], although not live, would need to be removed and covered. He further stated he would expect housekeeping to make maintenance aware of issues, such as a broken light cover in the shower in room [ROOM NUMBER]. The Maintenance Director stated there were usually tables in the Honor dining room where the tile damage was and believed the rubber tiles had shrunk. 2. Observation on 03/24/2026 at 11:06 AM revealed approximately a 10' x 10' section of flooring in the Honor dining room of broken and mismatched wood grain tiles, some with gaps or 1 or more between them, stretching from the exterior wall and window. A ceiling tile was missing near the wall/window. In an interview with the Housekeeping Manager (HM) on 03/25/2026 at 10:21 AM, she stated she was aware of staining in the room [ROOM NUMBER] bathroom which had been there at least two or three months, and she and housekeeping staff had tried unsuccessfully to get that stain out. She stated since the State Survey Agency (SSA) first reported the issue, a new soap dispenser had been put into place, with plans to remove the old one. She stated she would not consider that bathroom to be a homelike environment, and also acknowledged the floor needed to be replaced in there as well. The HM stated the floors in the facility needed to be replaced in several areas, including the small dining room due to water damage. She stated she was aware of the damaged and ill-fitting tiles in the Honor dining room, as her staff cannot run an auto scrubber in there due to concern of further damaging the floor. She stated management was aware of the floor. She stated there had been a leak in the Honor dining room as well, which had caused the floor to get worse in the last month or so. The HM stated if staff see issues, it is her expectation for staff to let her know so the issue can be addressed. 3. Observation on 03/22/2026 at 2:30 PM in room [ROOM NUMBER] revealed the wall with the window had an exposed crack with the underlying sheetrock visible. Further observation revealed that the ceiling tiles above the door entrance had one tile missing and six tiles stained and sagging. No moisture was observed on the floor beneath the affected area during the observation. In an interview with Licensed Practical Nurse (LPN) 1 on 03/22/2026 at 2:30 PM, she stated there had been a leak in the room and reported that maintenance was aware of it; however, no repairs had been made. In an interview with the Maintenance Director on 03/23/2026 at 9:20 AM, he stated the leak was caused by the heating, ventilation, and air conditioning (HVAC) system and that repairs had not yet been completed, as he was waiting for warmer weather to address the issue. 4. Observation on 03/23/2026 at 9:20 AM in the Providence hallway revealed blue border floor tiles lifting and separating from the floor surface along the length of the hallway. The hallway floor also had large scuff marks, and the tile in the center of the hallway appeared dull and soiled. In an interview with the Housekeeping Manager on 03/25/2026 at 8:30 AM, she stated staff were unable to strip and wax the floor due to the condition of the tile. In an interview with the Regional Maintenance Director on 03/23/2026 at 9:21 AM, he stated the facility was in the process of obtaining quotes to replace the floor tile at a future date. He further stated the building was older and required multiple repairs. 5. Observation on 03/22/2026 at 5:44 PM of the floor in room [ROOM NUMBER] appeared to be buckled and wavy. In an interview with the Maintenance Director on 03/24/2026 3:30 PM, he stated a water leak in the wall coil assist located in the ceiling caused the floor to buckle. The facility had plans to repair the flooring in rooms [ROOM NUMBERS]. In an Interview with the Director of Nursing (DON) on 03/26/2026 at 9:58 AM, she stated her expectation was the facility, as it was the resident's home, should be kept clean, and should be made as nice as possible for residents. She stated she was unaware of the current status of the small dining room but acknowledged it needed to be repaired. She stated she wanted all spaces utilized for the benefit of residents. She stated her expectation was for all facility floors to be even, clean, dry, and free from clutter for resident safety and use In an interview with the Administrator on 03/26/2026 at 1:42 PM, she stated the facility was in the final process of getting a quote approved for repairing the floor in the small dining room. She stated the floor in the Honor shower room needed to be redone, and the facility had already started replacing holes in the floor. She stated it was her expectation that it was the resident's home, and it should be a homelike environment, with simple concerns addressed in the moment, and major repairs addressed as the facility was able to find appropriate contractors.

Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure the resident's environment remained as free from accidents and hazards as possible and failed to ensure the resident received adequate supervision to prevent accidents for one (1) of fifteen (15) sampled residents, (Resident #9). Resident #9 sustained nine (9) falls from 04/04/15 through 7/28/15. Interview and record review revealed seven (7) of the falls were sustained while the resident was attempting to self toilet (04/18/15, 04/28/15, 05/05/15, 07/03/15, 07/12/15, 07/27/15, 07/28/15). The resident sustained [REDACTED]. However, there was no documented evidence the facility conducted a thorough investigation to determine the root cause of the falls and/or revised the falls interventions to prevent further falls. Interview and record review revealed even though the facility identified self-ambulation to toilet as the root cause of some of the falls, there was no documented evidence the facility implement increased supervision, a toileting program, or a restorative program to prevent further falls. In addition, observation revealed resident room doors and bathroom doors had rough edges and there were toilet bolt caps missing. The findings include: Interview with the Director of Nursing (DON) on 08/21/15 at 4:40 PM revealed bladder assessments were conducted on admission, but the facility did not have a formal bladder assessment policy for incontinent residents. Continued interview revealed the facility did not have a toileting program or a restorative program in place to help reduce the risk for fall, and the facility did not have a Fall Risk policy. Interview on 08/21/15 at 6:15 PM with the Executive Director revealed, the facility did not have a Fall Risk policy, a bladder reassessment process after the original admission assessment, a toileting program, or a restorative program in place to help reduce the risk for fall. Review of the facility's Accident/Injury Reporting and Unusual Occurrence Investigation Policy, not dated, revealed the objective was to provide a safe healthful environment and therefore, all accidents/incidents or unusual occurrences occurring on the premises must be reported to the Nurse Manager or Director of Nursing/Designee and would undergo a follow up investigation. Paragraph # six (6) stated, reports will be analyzed for patterns and trends, statistical compilation to identify staff development needs or policy /procedure changes, etc., and reported to the Quality Assurance (QA) Committee. A weekly (and as needed) interdisciplinary team meeting will be held to review all individual resident falls, unusual skin occurrences, and Plan of Care, cause/motivators, further preventative approaches and interventions, equipment/supply needs and referrals. Further review revealed the facility did not have a Falls Risk Policy, a bladder reassessment process, a toileting program, or a restorative program for incontinent residents. Interview with Unit Manager on 08/21/15 at 4:00 PM revealed the process for investigating a fall was the nurse on duty completed the incident report summarizing the fall and documented it in the progress notes. The DON completed the follow-up investigation, obtained orders for any new interventions, and then added the interventions to the care plan. The Unit Manager further stated the root cause analysis for falls was determined during the Quality Assurance (QA) meeting. Further interview revealed the staff was trained on falls during orientation and when the need arose. 1. Observation on 08/18/15 at 12:10 PM revealed, Resident #9 sitting in wheelchair in the dining room; the resident was neat, clean and appropriately dressed. The resident was wearing gripper socks and a Wander guard alarm was in place. Continued observation revealed a self releasing seat-belt was in place. Further observation revealed the resident had what appeared to be a green bruise to the right side of face, temple and forehead area. Review of Resident #9's medical record revealed the facility admitted the resident on 12/24/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident as frequently incontinent, requiring extensive assistance with two (2) person physical assist for transfers, limited assistance with one (1) person physical assist with a walker for ambulation, and extensive assistance with one (1) person physical assist for toileting. The MDS also revealed the resident had a Brief Interview for Mental Status (BIMS) score of five ( 5) dated 06/12/15 which revealed the resident was severely impaired in cognition. Review of the Comprehensive Care Plan initiated on 01/08/15 revealed the facility identified the resident to be at risk for Falls and Activity of Daily Living (ADL) Self Care Performance and Mobility Deficit related to debility with interventions to include Bed and Chair alarm in place to alert staff of unassisted transfers - check alarms for functioning daily. Per the care plan, the resident needs a safe environment with: even floors free from spills and or clutter; adequate, glare free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls, personal items within reach, and encourage resident to use call light. Review of the fall incident/investigation follow-up documentation revealed Resident #9 fell on [DATE] at 2:44 PM while attempting to independently transfer from one wheelchair to another. Further documentation revealed the resident frequently self transferred and multiple interventions had been attempted and were noted to be ineffective. The family was notified and a consent for self releasing seat belt was obtained. Further review of the nurses progress note on 04/04/15 revealed alarm sounding, on entering the room the resident stood up from bed and began ambulating. Review of the resident's care plan revealed the care plan was revised on 04/07/15 to add a self releasing seat belt. Further review of the resident's care plan revealed the care plan was not revised to include interventions related to toileting. Review of the fall incident/investigation follow-up documentation revealed Resident #9 fell on [DATE] at 8:14 AM the resident attempted to independently ambulate to the bathroom, was found on the floor bleeding from the back of the head, behind the left ear, the resident was sent to the hospital emergency room . Review of the hospital emergency room report revealed the resident received six (6) staples to close the wound. However, there was no documented evidence the facility revised the care plan to meet the resident's toileting needs and to prevent future falls. Further review of the nurses progress note revealed no entry regarding the fall, treatment, or follow-up interventions related to the fall. Review of the fall incident/investigation follow-up documentation revealed Resident #9 fell on [DATE] at 6:20 PM while attempting to ambulate to the bathroom independently and was found lying on the floor with moderate amount of blood coming from above the right eyelid. Further documentation revealed the area to the right eyelid was cleansed, pressure dressing was applied and the resident was sent to the hospital emergency room for evaluation and treatment. Review of the hospital emergency room report revealed the resident received sutures to close the wound. The Psychologist was notified and an order was received to increase Risperdal to 0.25 milligrams three times a day related to increased behaviors. However, there was no documented evidence the facility revised the care plan to meet the resident's toileting needs and to prevent future falls. Further review of the nurses progress note revealed no entry regarding the fall, treatment or follow-up interventions related to the fall. Review of the fall incident/investigation follow-up documentation revealed Resident #9 fell on [DATE] at 4:22 AM while attempting to ambulate independently to the bathroom and was found on the floor beside the bed. Further documentation revealed the resident was assessed for injury, assisted to the bathroom then back to bed with the bed alarm in place, the bed in low position and staff was educated to offer resident assistance to toilet every one to two hours. The staff was in-serviced on 05/06/15 to ensure to offer resident assistance to toilet every one to two hours to avoid attempts to self transfer. However, there was no documented evidence the facility revised the care plan to meet the resident's toileting needs and to prevent future falls. Further review of the nurses progress note revealed no entry regarding the fall, treatment or follow-up interventions related to the fall. Review of the fall incident/investigation follow-up documentation revealed Resident #9 fell on [DATE] at 4:25 PM while attempting to self transfer and was found sitting on the floor. Further documentation revealed the Director of Nursing (DON) called the Power of Attorney (POA) and discussed the potential of a trial to use a lap buddy if the physician agrees. The POA stated she was willing to try the lap buddy but did not want the resident to become anxious. The DON further documented all interventions were in place for this resident. On 06/01/15 the DON discussed with the Psychologist to try routine Ativan before trying the lap buddy. The Psychologist assessed the resident on 06/01/15 and wrote an order to increase Buspar for anxiety. However, there was no documented evidence the facility revised the care plan to meet the resident's toileting needs and to prevent future falls. Further review of the nurses progress note revealed no entry regarding the fall or follow-up interventions related to the fall. Review of the fall incident/investigation follow-up documentation revealed Resident #9 fell on [DATE] at 4:33 AM. The resident climbed out of bed unassisted and was found sitting on the floor while attempting to ambulate independently to the bathroom. Further documentation revealed the resident's coccyx was red. The DON documented in the fall incident/investigation report the resident attempts to get out of bed when he/she feels the need to toilet. The resident needs to be offered frequent toileting. However, there was no documented evidence the facility revised the care plan to meet the resident's toileting needs and to prevent future falls. Further review of the nurses progress note revealed no entry regarding the fall or follow-up interventions related to the fall. Review of the fall incident/investigation follow-up documentation revealed Resident #9 fell on [DATE] at 6:30 PM while attempting to ambulate independently to the bathroom and was found sitting on the floor. Further review revealed the resident needed to be toileted in advance of need. Frequently offer to take the resident to the restroom to help decrease the amount of unassisted transfers. Staff education provided on 07/15/15 to offer resident frequent toileting even through the night to help decrease her rising from the bed unassisted. However, there was no documented evidence the facility revised the care plan to meet the resident's toileting needs and to prevent future falls. Further review of the nurses progress note revealed no entry regarding the fall or follow-up interventions related to this fall. Review of the fall incident/investigation follow-up documentation revealed, Resident #9 fell on [DATE] at 12:50 AM attempting to ambulate independently the resident was found sitting on the floor in the bathroom with blood coming from the side of the head. The resident was sent to the hospital emergency room for further evaluation and treatment. Review of the hospital emergency room report revealed the resident received staples to close the wound. The DON further documented the implementation of a body pillow for positioning, a cradle mattress to remind resident to call for assistance instead of climbing out of bed, one padded half side rail on the opposite side of the bed, and discussion with POA about the implementation of a fall mat could increase fall hazards related to the resident's poor safety awareness, and DON documented she would discuss medication alterations with the Psychologist. However, review of the care plan revealed the new interventions were not added to the care plan until 07/28/15. Further review of the nurses progress note revealed no entry regarding the fall or follow-up interventions. Review of the fall incident/investigation follow-up documentation revealed Resident #9 fell on [DATE] at 6:39 AM while the resident attempted to ambulate independently and wasfound on the floor in the bathroom with blood coming from the forehead and a skin tear to the left lateral arm, the resident was sent to the hospital emergency room for evaluation and treatment. Review of the hospital emergency room report revealed the resident received six (6) sutures to close the wound. It was further documented that multiple interventions had been added on 07/27/15, but review of the care plan revealed the intervention were not added until 07/28/15. However, there was no documented evidence the facility revised the care plan to meet the resident's toileting needs and to prevent future falls. Further review of the nurses progress note revealed no entry regarding the fall, treatment, or follow-up interventions at the time of the fall. Further review of the resident's care plan revealed on 07/29/15 an intervention was added to offer/assist resident to toilet in advance of need, frequently offer to take resident to the restroom. This intervention was added seventeen (17) days after the need for toileting was identified after the fall on 07/12/15. Interview with State Registered Nurse Aide (SRNA) #4 on 08/21/15 at 2:40 PM revealed, she offered toileting to Resident #9 every two (2) hours, ensured the bed and chair alarms were in place and functioning daily, ensured the resident's safety belt was on, ensured the cradle mattress was in place, and the half side rail was padded, and the body pillow was in place for positioning when the resident was in bed to help decrease falls. Further interview revealed toileting was offered every two (2) hours to Resident #9 but the SRNA#4 stated she did not document when toileting was offered, she only documented when the resident had been incontinent. Interview with SRNA #6 on 08/21/15 at 2:45 PM revealed, she offered toileting to Resident #9 every two (2) hours, ensured the bed and chair alarms were in place and functioning daily, ensured the resident's safety belt was on, ensured the cradle mattress was in place, and the half side rail was padded, and the body pillow was in place for positioning when the resident was in bed to help decrease falls. Further interview revealed toileting was offered every two (2) hours to Resident #9 but the SRNA#4 stated she did not document when toileting was offered, she only documented when the resident had been incontinent. Review of Resident #9's bowel and bladder tracking record revealed the resident had been offered toileting two (2) to three (3) times a day and was continent of urine thirty one (31) out of fifty four (54) toiletings. Interview with the Minimum Data Set (MDS) Coordinator on 08/21/15 at 4:15 PM revealed the process for investigating a fall was the nurse on duty completed the incident report summarizing the fall and documented it in the progress notes. The DON completed the follow-up investigation, orders were obtained for any new interventions and then added to the care plan. She further stated the root cause analysis for falls was determined during the Quality Assurance (QA) meeting; however, she did not attend the QA meeting on falls. Further interview revealed the staff was trained on falls during orientation and as the need arose. Interview with the DON, on 08/21/15 at 4:40 PM, revealed the process for investigating a fall was, the nurse on duty completed the incident report summarizing the fall and documents it in the progress notes, the DON completed the follow-up investigation, orders were obtained for any new interventions and then added to the care plan. She further stated the root cause analysis for falls was determined during the Quality Assurance (QA) meeting and that interventions were determined at that time. She further stated she felt the investigations conducted at the time of the falls were adequate; however, looking back the fall investigation and documentation process was lacking and could use improvement. The DON further revealed she was aware the facility did not have a bladder reassessment process after the initial admission assessment, a toileting program, or a restorative program in place and agreed that if Resident # 9 had a reassessment of bladder function and had been placed on a training program it might have helped to reduce the risk for future falls. Interview on 08/21/15 at 6:15 PM with the Administrator revealed, he felt the facility's investigation and documentation of falls was adequate, and he was not aware the facility did not have a bladder reassessment process, a toileting program, or a restorative program in place. He agreed that if Resident #9 had a reassessment of bladder function and had been placed on a training program it might have helped to reduce the risk for fall. He further stated the falls were discussed in the QA meeting. However, the facility failed to identify and address toileting needs, as a cause for the resident's falls, through a bladder reassessment and a toileting program. 2. Observation during the environmental tour of the facility on 08/20/15 at 10:00 AM revealed sharp edges on resident room doors and bathroom doors in the following rooms: 425,427,429, 431, 435, 444, 436, 439, 442, 446, 434, 435, 430, 419, and 417. Bolts at the base of the toilets was also observed to be uncovered in the following resident rooms: 425,427, 431, 435, 444, 434, 435, 430, 419, and 417. The sharp edges and exposed bolts presented a safety hazard to the residents in the facility. Interview with the Maintenance Director on 8/20/15 at 11:00 AM revealed it was a safety hazard for the residents of the facility to have sharp edges on the doors as this could cause skin tears. He stated toilet bolts not covered were also a hazard because residents that were unsteady could fall in the bathroom. He continued that he did not have a system in place to monitor rooms for needed repairs. Interview with the Administrator on 8/21/15 at 6:15 PM, revealed he was unaware of the sharp edges on resident room doors and toilet bolts uncovered. The Administrator stated he expected the Department Managers to have systems in place to assure the facility was kept clean and repairs made as needed.

Based on interview, record review, review of the facility's policy and procedures, it was determined the facility failed to review and revise each resident's care plan for one (1) of fifteen (15) sampled residents (Resident #9). Resident #9 sustained falls with injury while attempting to self toilet; however, there was no documented evidence the facility revised the falls interventions to prevent further falls. Resident #9 sustained nine (9) falls from 04/04/15 through 07/28/15. Interview and record review revealed seven (7) of the falls were sustained while the resident was attempting to self toilet. (04/18/15, 04/28/15, 05/05/15, 07/03/15, 07/12/15, 07/27/15, 07/28/15). The resident sustained [REDACTED]. However, there was no documented evidence the facility reviewed or revised the resident's Comprehensive Care Plan to implement new interventions to meet the toileting needs of the resident to prevent future falls. Interview and record review revealed even though the facility identified self-ambulation to the toilet as a root cause of some of the falls, there was no documented evidence the facility implemented increased supervision, a toileting program, or a restorative program to prevent further falls. The findings include: Review of the facility's Care Plan policy, not dated, revealed the objective was to develop an individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental and psychological needs. Additionally, paragraph #5 stated, care plans were revised as changes in the resident's condition dictated. Care plans were reviewed as new permanent orders were received, as significant change was assessed, when desired outcomes were not met, and at least quarterly. Review of the facility's Accident/Injury Reporting and Unusual Occurrence Investigation Policy, not dated, paragraph #6 revealed, reports would be analyzed for patterns and trends, statistical compilation to identify staff development needs or policy /procedure changes. The interdisciplinary team would review all individual resident falls, unusual skin occurrences, and POC's, causes/motivators, further preventative approaches and interventions, equipment/supply needs, and referrals. Review of Resident #9's medical record revealed the facility admitted the resident on 12/24/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident as frequently incontinent requiring extensive assistance with two (2) person physical assist for transfers, limited assistance with one (1) person physical assist with a walker for ambulation, and extensive assistance with one (1) person physical assist for toileting . The MDS also revealed the resident had a Brief Interview for Mental Status (BIMS) score of five ( 5) dated 06/12/15 which revealed the resident was severely impaired in cognition. Review of the Comprehensive Care Plan initiated on 01/08/15 revealed the facility identified the resident to be at risk for Falls and Activity of Daily Living (ADL) Self Care Performance and Mobility Deficit related to debility with interventions to include: Bed and Chair alarm in place to alert staff of unassisted transfers - check alarms for functioning daily; Resident needs a safe environment with: even floors free from spills and or clutter; adequate, glare free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls, personal items within reach. Review of the fall incident/investigation follow-up documentation revealed Resident #9 fell on [DATE] at 8:14 AM attempting to independently ambulate to the bathroom and was found on the floor bleeding from the back of the head, behind the left ear. Further documentation revealed all interventions in place and the resident was sent to the hospital emergency room for evaluation and treatment and the resident received staples to close the wound. Review of the resident's care plan revealed no documented evidence the facility reviewed and revised the care plan to meet the resident's toileting needs or to prevent future falls. Review of the fall incident/investigation follow-up documentation revealed Resident #9 fell on [DATE] at 6:20 PM while attempting to ambulate to the bathroom independently and was found lying on the floor with moderate amount of blood coming from above the right eyelid. The resident was sent to the hospital emergency room for evaluation and treatment and received sutures to close the wound. Review of the resident's care plan revealed no documented evidence the facility reviewed and revised the care plan to meet the resident's toileting needs or to prevent future falls. Review of the fall incident/investigation follow-up documentation revealed Resident #9 fell on [DATE] at 4:22 AM while attempting to ambulate independently to the bathroom and was found on the floor beside the bed. The staff was in-serviced on 05/06/15 to ensure to offer resident assistance to toilet every one to two hours to avoid attempts to self transfer. However, review of the resident's care plan revealed no documented evidence the facility reviewed and revised the care plan to offer resident assistance to toilet every one to two hours to avoid attempts to self transfer per the facility's investigation. Review of the fall incident/investigation follow-up documentation revealed Resident #9 fell on [DATE] at 4:33 AM. The resident climbed out of bed unassisted and was found sitting on the floor while attempting to ambulate independently to the bathroom. The DON documented in the fall incident/investigation report the resident attempts to get out of bed when he/she feels the need to toilet and the resident needs to be offered frequent toileting. However, review of the resident's care plan revealed no documented evidence the facility reviewed and revised the care plan to include frequent toileting. Review of the fall incident/investigation follow-up documentation revealed Resident #9 fell on [DATE] at 6:30 PM while attempting to ambulate independently to the bathroom and was found sitting on the floor. Further review revealed the resident needed to be toileted in advance of need and to frequently offer to take the resident to the restroom to help decrease the amount of unassisted transfers. However, further review revealed this intervention was not initiated on the care plan until 07/29/15 and was added. This intervention was added seventeen (17) days after the need for toileting was identified after the fall on 07/12/15. Review of the fall incident/investigation follow-up documentation revealed Resident #9 fell on [DATE] at 12:50 AM while the resident attempted to ambulate independently the resident was found sitting on the floor in the bathroom with blood coming from the side of the head. The resident was sent to the hospital for further evaluation and treatment and received staples to close the wound. The DON further documented the implementation of a body pillow for positioning, a cradle mattress to remind resident to call for assistance instead of climbing out of bed, one padded half side rail on the opposite side of the bed, and discussion with the POA about the implementation of a fall mat could increase fall hazards related to the residents poor safety awareness, and DON documented she would discuss medication alterations with the Psychologist. However, review of the plan of care revealed the new interventions were not added to the care plan until 07/28/15. Review of the fall incident/investigation follow-up documentation revealed Resident #9 fell on [DATE] at 6:39 AM while the resident attempted to ambulate independently and wasfound on the floor in the bathroom with blood coming from the forehead and a skin tear to the left lateral arm, the resident was sent to the hospital emergency room for evaluation and treatment and received sutures to close the wound. It was further documented that multiple interventions had been added on 07/27/15, but review of the care plan revealed the intervention was not added until 07/28/15. However, there was no documented evidence the facility reviewed and revised the care plan to meet the resident's toileting needs to prevent future falls. Further review revealed no entry regarding the fall, treatment, or follow up interventions at the time of the fall. Interview with the Minimum Data Set (MDS) Coordinator on 08/21/15 at 4:15 PM revealed her role was to review and revise the Comprehensive Care Plan once she received the copy of the physicians order. She also stated the Director of Nursing (DON) and Unit Manager could make changes to the Care Plan as the need arose. She stated the process for updating the care plan following a fall was the nurse on duty completed the incident report summarizing the fall and documented it in the progress notes, and the DON completed the follow-up investigation, obtained orders for any new interventions, and then added the new interventions to the care plan. Interview with Unit Manager on 08/21/15 at 4:00 PM revealed the process for revising the care plan following a fall was the nurse on duty completed the incident report summarizing the fall and documented it in the progress notes, and the DON completed the follow-up investigation, orders were obtained for any new interventions and then added to the care plan. Interview with the DON on 08/21/15 at 4:40 PM revealed the facility did not review and revise the care plan with new interventions after falls sustained on (04/18/15, 04/28/15, 05/05/15, 05/28/15, 07/03/15, 07/12/15, 07/28/15). The DON stated the process for revising the care plan following a fall was, the nurse on duty completed the incident report summarizing the fall and documents it in the progress notes, the DON completed the follow-up investigation, orders were obtained for any new interventions and then added to the care plan. She further stated she expected the staff to review and revise the comprehensive care plan as the resident's condition dictated and that licensed staff should follow the facility's care plan policy. Interview on 08/21/15 at 6:15 PM with the Executive Director (ED) revealed he expected the staff to review and revise the comprehensive care plan as the resident's condition dictates and that licensed staff should adhere to the facility's care plan policy.