Every finding on record at Tygart Center at Fairmont Campus

Based on observation, resident interview, staff interview, the facility failed to ensure they had maintained a safe and functional envrionment for residents who wanted to go outside to the patio area. This practice had the potential to affect more than an isolated number of residents. Facility census: 101.a) During an interview on 07/22/26 at approximately 9:25 AM the Maintenance director stated that the door to the patio was a sometimes issue. This meant the door sometimes worked and sometimes did not. He continued to state that he would have to contact the vendor to come and fix it. During an interview on 07/22/26 at 9:37 AM the Administrator stated that the door to the patio was not working correctly during their previous annual survey in February 2026. She stated that they had it fixed at that time after receiving a federal tag. During an interview on 07/22/26 at approximately 9:40 AM the Maintenance director stated that the door was temporarily fixed. Two surveyors observed the maintenance director try to demonstrate the door opening, The door did not function correctly at this time, he pushed the button 2 or 3 times. He verified that the door was not functioning correctly and said he would arrange for service. On 07/22/26 at 9:19 AM Resident #1 was locked out of the facility. She was in the courtyard and came over to the door of the sunroom where the survey team was located and knocked. This surveyor let her in and the alarm on the door went off. Resident #1 seemed to be upset and even more so that the alarm was going off. She stated I am sorry, I am so embarrassed. Two surveyors spoke to the Activity Director, who stated, This was an issue during our annual survey. The surveyors asked her how a resident could get back into the facility once they were in the courtyard. The Activity Director pushed the handicapped accessible button that was two (2) feet away from the door that Resident #1 tried to open and nothing happened. She then pushed it with both hands and the door did not open on its own, but she could open the door manually. On 07/22/26 at 9:37 AM the Administrator came to the survey team and stated that W will monitor the door and get the battery checked by the manufacturer.

Based on observation and staff interview the facility failed to provide a clean comfortable, homelike environment. This was a random opportunity for discovery and had the potential to effect more than a limited number of residents during the Long-Term Care Survey Process. Resident identifiers: #5, #8, #50. Facility Census: 106.Findings include: a) Resident #5 Packaged Terminal Air Conditioner (PTAC) unit An observation on 02/09/26 at 1:03 PM, of the Packaged Terminal Air Conditioner (PTAC), unit in Resident #5's room revealed both filters in the PTAC unit to be fully covered in approximately (2) two inches of dust/debris. During an interview on 02/09/26 at 2:00 PM, Housekeeper (HK) #53 stated, The person in charge of this department is out right now. I am filling in for her from the building across the road. HK #53 confirmed the PTAC units filters were dirty and needed cleaned. During an interview on 02/09/26 at 3:20 PM, The Director of Maintenance (DM) stated, I don't have a policy or a schedule written down but we clean them monthly. We will get them cleaned. b) Resident #50 On 02/09/2026 at 12:30 PM , during the initial resident interview process the following was observed in Resident #50's room: Twall behind the bed and on the right side of the had multiple scratches with paint missing. At 1:05 PM, Licensed Practical Nurse #32 confirmed the walls were missing paint and had multiple scratches.

Based on record review, staff interview and observation, the facility failed to ensure care and services were provided in accordance with current standards of practice. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #80, #30 and #11. Facility Census: 106. b) Resident #30: During a dining room observation on 02/10/26 at At 12:10 PM, Employee #17 retrieved Resident number 30's tray, assisted him in set up, handed him his sandwich, then went back to get another resident's tray. Resident # 30 was left food unsupervised for 8 minutes. A further review of Resident's tray ticket read as follows: resident (Name) 1:1 feed assist and ordered supervision for all meals. Record Reviews: A record review on 02/11/26 at 1:30 pm, found the physician dietary order for Resident #30 that read as follows: resident is receiving regular dysphagia diet with 1:1 feed assist and is to have supervision for all meals. On 02/10/2026 at 12:28PM, a record review of Resident # 30's Care Plan stated as written: Resident is receiving a regular dysphagia pureed diet and thin liquids with 1:1 supervision at meals. Date initiated: 05/07/2025. Staff Interviews: In an interview on 02/10/26 at 12:15PM, with Employee #17 acknowledged she did take Resident #30's tray to him set up his meal then left him to eat by himself without supervision for 8 minutes She stated that's not good. In an interview with the Corporate Coordinator, she stated she was made aware of the lack of supervision for Resident # 30 in the dining room acknowledged the Physician Orders of 1:1 Feed and Supervision for all meals were not followed. Findings included: a) Resident #80 - The facility failed to document donning and doffing of contracture management devices per order. The facility's policy and procedure for SPLINT: APPLICATION OF stated, 15. Document: 15.1 Date/time splint was applied; 15.2 Type of Splint; 15.3 Medications administered, if applicable; 15.4 Patient assessment findings; 15.5 Skin condition; 15.6 Neuromuscular status of affected limb; 16.7 Provide notification, if applicable 15.8 Patient education provided The resident's orders stated:: -Contractures - Staff to don Right elbow extension splint Tues Thurs Sat x2 hours with skin checks.-Device: Staff to don Left elbow extension splint MWF x2 hours with skin checks.-Device: Staff to don Right resting hand splint MWF x2 hours with skin checks.-Device: Staff to don Left palm protector Tues Thurs Sat x2 hours with skin checks. Resident # 80's Medication Administration Record and Treatment Administration Records, Kardex and Tasks were reviewed with no documentation of the resident's splints be taking on and off with skin checks per orders found. On 02/11/2026 at 12:40 PM, the Director of Nursing stated, I don't have anything that says it was donned and doffed. c) Resident #11 A record review on 02/10/26 at 1:30 pm, found a Tube feeding order for Resident #11 that read as follows: one time a day Jevity 1.5 cal. Administer via pump at 60 ml per hour X 20 hours QD or until total nutrient delivered to provide 1200cc/1800 kcal, 76 g protein and 912 cc free water. Downtime 5am-7am and 5pm-7pm An observation on 02/10/26 at 3:00 PM, revealed Resident #11 lying in bed, his tube feeding was running. The pump was set at 55 Milliliters (ml) per hour and written on the bottle of Jevity was 55 ml. An observation on 02/11/26 at 9:10 AM, revealed Resident #11 lying in bed, his tube feeding was running. The pump was set at 55 Milliliters (ml) per hour and written on the bottle of Jevity was 55 ml. During an observation and interview on 02/11/26 at 9:20 AM, The Director of Nursing (DON) confirmed that the Jevity was set at 55 ml and order read 60 ml. The DON further stated, Let me go see what the Dietician order says and I will get back to you. During an interview on 02/11/26 at 9:40 AM, The DON stated, The Dietician had changed the order for 55ml for 12 hours and then moved it back to 60 ml. This is where the confusion come in. We are going to get it updated now.

Based on observation and staff interview, the facility failed to store and administer medications according to professional standards of practice. This failed practice had the potential to affect more than a limited number of residents. Facility census: 106.Findings included:Medication administrationOn 02/12/26 at 8:25 AM , Registered Nurse (RN) #81 was observed pouring medications for a resident and then hand the poured medications to Licensed Practical Nurse (LPN) #72 who then gave the medications to the resident. When RN #81 was asked why she poured the medications and gave them to LPN #72 to administer she stated that she watched me pour them. When asked if this was the policy to pour the medications and then have another nurse administered the medications, there was no response.In an interview with the Director of Nursing (DON) on 02/12/26 at approximately 10:35 AM, she stated this was not the practice for one nurse to pour medications and another nurse to administer the medications. Medication RoomObservation of the 200 Hall medication room on 02/12/26 at 8:25 AM with RN #81 found an Emergency Kit with an orange label REFRIGERATE sitting on the cabinet for an undetermined amount of time. RN #81 could offer no explanation as to why this was not in the refrigerator. Medication Refrigerator Two (2) locked clear plastic boxes with Ativan (a controlled substance) in the lower box was found on 02/12/26 at 8:25 AM. The plastic boxes were not permanently affixed in the refrigerator. This was confirmed with RN #81.

Based on record review, staff interview and observation, the facility failed to ensure menus were followed. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #40 and #63. Facility Census: 106.Findings included: a) The facility's policy and procedure for Menus stated, 6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. b) The facility's menu given to the state surveyor included Salisbury Steak with Mushroom Gravy for Monday 02/09/26 for regular, dysphagia advanced and puree lunch meals. The tray cards for Resident #40 and #63 stated Salisbury Steak w/Mushroom Gravy. Resident #40's tray card specified Gravy-#10 scoop for the Ground Meat Salisbury Steak. Nurse Practitioner #24 confirmed there was no gravy on both resident's meat served at lunch.

Based on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. This is true for the facility kitchen and nourishment pantry. This had the potential to affect all residents in the facility. Facility census 106.Findings included:a) On 02/09/26 at 11:30 AM, during Initial Brief Tour of Kitchen, with Dietary Account Manager (DM) the DM acknowledged the following in the kitchen and the nourishment rooms : Walk in Cooler:-A shelved food cart of deserts that were covered without labels or dates.-A salad marked Name on it in which the Dietary Account Manager stated it belonged to an employee and removed it -The top utensil drawer was found to have a powdery white residue covering the inside bottom underneath the utensils-The bottom drawer was found to have utensils scattered not facing in the same direction -Coffee grounds were scattered and brownish spots from spilled liquids were observed on the kitchen floor in front of the shelves and around the tray line and in front of the stove- Sugar and Flour Bin lids were dusty on the top with flour and sugar with both spilled into the floor. When asked, the Dietary Account Manager acknowledged the unclean floor on 02/09/26 at 11:40 AM, and stated that the floors should have been cleaned the night before but did not have a cleaning schedule or sign off sheets. A large plastic purple cup was observed with a lid and a straw in the top cabinent shelf, in which the Dietary Account Manager stated that it belonged to an employee that should not have been in the nourishment room cabinet. It was observed 2(two) boxes filled with toiletries were observed in the bottom cabinet shelf. This box included bottles of lotions, body powder, and perfumes, a donut shaped seat cushion and a large case of plastic gloves On 02/09/26 at 11: 50AM, an interview with The Corporate Coordinator (CC) was completed. CC acknowledged the 2 boxes of toiletries, case of gloves, and the cushion discovered in the 200 Hall Nourishment Room and stated that was not supposed to be there and removed it. In the 200 Hall Refridgerator the following was obsered: An unopened bottle of Pepsi without a label or date belonging to an employee. The Dietary Account Manager removed it and placed it in the trash canIn the upper cabinent it was observed a packet of peanut butter had a tear in the cover exposing the peanut butter to air. On 02/09/26 at 1:45 PM a review of the facility food service policy labeled HCSG Policy 019, Food Storage: Cold Foods. Procedures, number 5 stated All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

Based on observation, and staff interviews, the facility failed to dispose of garbage and refuse properly. This had the potential to affect more than an isolated number of residents in the facility. Facility census: 106. a) On 2/10/26, at 3:45 PM during an observation of the dumpsters, it was observed that debris and trash were scattered around and behind both dumpsters. [NAME] plastic gloves, plastic cup lids, Styrofoam cups, plastic bags were in the front and sides of both right and left dumpsters. An opened box with take-out food in was observed left opened and a clear bag of trash laying on the ground on the left side of the left dumpster. In an interview with the Director-Senior Maintenance Employee (DSME) #7, he stated he had seen the trash and debris scattered around the dumpster and would get it taken care of.

Based on record review and staff interview the facility failed to ensure it had a Quality Assessment and Assurance (QAA) committee to meet at least quarterly with the required minimum staff. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Facility census: 106. Findings Include: a) QAA meetings A review on 02/11/26 at 9:49 PM, of the QAA sign in sheets from 01/25 to 01/26 revealed, that The Director of Nursing (DON) did not attend the 2nd quarter or 3rd quarter meetings as required. During an interview on 02/12/26 at 8:40 AM, The Administrator stated, We had the Assistant Director of Nursing (ADON), filling in as our Director of Nursing (DON) for the facility because we were in between DON's. Further review on 02/12/26 at 8:45 AM, of the QAA sign in sheets revealed that neither the ADON or the DON attended the QAA meeting for the 2nd and 3rd quarter of 2025. On 02/12/26 at 8:58 AM, The Administrator confirmed that they did not have a DON or ADON in attendance for the 2nd and 3rd quarter of 2025. b) Policy titled Quality Assurance and Performance Improvement Plan. A review on 02/12/26 at 9:30 AM, of the policy titled {Quality Assurance and Performance Improvement Plan}, under frame work, reads as follows:Committee must be comprised of DON, IP, Medical Director or designee and 3 additional team members one of which is the administrator. A consultant pharmacist is recommended to serve on the committee. This is a minimum requirements .

Based on record review, staff interview and observation, the facility failed to ensure an effective infection prevention and control program. was maintained. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #33, #106, #90, #96, #57, #65, #51 and #78. Facility Census: 106. On 02/09/26 at 2:24 PM, it was observed Activities Assistant #49 enter Resident #78's room with droplet precautions sign on door and a red stop sign draped across the front of the door. Activities Assistant walked into room and handed her a package without wearing Personal Protective Equipment PPE. During this time, other staff was in the room wearing PPE. On 02/09/26 at 2:30 PM, during an interview with Activities Assistant #49 when asked if Resident #78 was under precautions, she reported, She doesn't have anything. She has been going to dining room with no mask. When the sign was pointed out on the door and nurse aide whispered this resident had COVID, Activities Assistant #49 stated, Then yes, I should have been suited up. 02/09/26 1:25 PM the Hall 200 Tray Delivery and Meal Set up was observed. During this time It was observed that the Admissions Coordinator did not offer proper hand hygiene to Resident #96 and #106 when she delivered and assisted in the meal set up. On 02/09/26 at 1:28 PM, It was observed that Employee #24 did not offer proper hand hygiene to Resident #90 on the 200 Hall during lunch tray delivery and meal set up On 02/09/2026 1:25 PM, in an interview with the Admissions Coordinator, she acknowledged she did not offer hand sanitizer to Resident #96, and #106. ON 02/09/26 1:28 PM, during an interview with Employee #24, she acknowledged she forgot to offer the proper hand hygiene. She stated she usually was very good at remembering that. On 02/10/26 at 1:45 PM, during dining room observation, it was observed that Employee #47 carried Resident #33's plate with his thumb resting in the inside of the plate's food's barrier. In an interview with Employee # 47 he acknowledged he had placed his thumb too far into the plate's food barrier while carrying Resident # 33's plate. In an interview with the Corporate Coordinator, on 02/10/26 at 2:25 PM, she acknowledged the staff's lack of proper hand hygiene in the 200 hall on 02/09/26 and the dining room on 02/10/26. Findings included: a) The facility's policy and procedure for Exhaust System Inspection stated that exhaust fans for soiled and clean laundry rooms should be inspected monthly and ensure that air flow is sufficient enough to hold a piece of paper to the vent when operating. On 02/11/2026 at 2:20 PM, an investigation of the laundry room was initiated with the Life Safety Surveyor and the Maintenance Director. It was observed that the air was not pulling from clean side to the soiled side of the door with the tissue test. The facility's policy and procedure for Special Contact and Droplet Precautions stated, 2. Keep the patient's door to the room closed unless doing so would endanger the patient. Multiple doors to covid positive resident rooms were observed to be open on two halls on 12/09/2026 during the initial survey process. On 02/10/2026 at 11:30 AM, the state surveyor and the Infection Preventionist Registered Nurse observed two covid positive room doors opened. In one, the nurse reported the resident wears a mask and leaves his room. In the other room, the door was closed by the nurse during the 200 hall observation. c) The facility's policy and procedure for Special Contact and Droplet Precautions stated, 4. Wear proper PPE including respiratory protection (N95 respirator), gown, and gloves prior to entering the room of those who require Special Contact and Droplet Precautions. Eye Protections is highly recommended for encounters with positive patients, and is required for use during aerosol-generating procedures (AGP). On 02/09/2026 at 12:40 PM, the Occupational Therapist was observed with no eye protection on while inside a covid positive patient's room When asked if they had a face shield or glasses, the Occupational Therapist stated, No, I don't have it.

Based on record review and staff interview, the facility failed to ensure education was offered for all staff for Covid-19 vaccines. The failed practice had the potential to affect more than a limited number of residents. Facility Census: 106.Findings included: a) The federal guidelines stated that education must be provided for all staff for the risks and benefits of the vaccine and the Covid-19 vaccine should be offered by the facility or the facility should offer information on how to obtain the vaccine. b) HealthStream education system provided to staff was reviewed for five nursing assistants by the surveyor assigned staffing No documentation was found for education on the covid vaccine. On 02/11/2026 at 12:00 PM, the Infection Preventionist Registered Nurse reported she only gives information to staff if they request it for the Covid-19 vaccine 02/12/26 at 10:42 AM, the Infection Preventionist Registered Nurse stated, there was Nothing in HealthStream.

Based on electronic medical record review, and staff interview, the facility failed to ensure two (2) of four (4) resident's Pre admission Screening and Resident Review (PASARR) was current and accurate. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #16, #67. Facility census: 106. a) Resident # 67 On 02/10/26 at approximately 2:55PM, a record review found that Resident # 67 was diagnosed with vascular dementia, moderate, with anxiety was not updated in the PASARR. In an interview with the DON on 02/10/26 at 3:25 PM, she acknowledged Resident # 67's PASARR was not updated r/t (related to) the diagnosis of vascular dementia, moderate, with anxiety. She stated she was aware that PASARRs facility wide were in need of updating and an audit was started to rectify the issue. b) Resident #16 On 02/12/26 at 12:15 AM a review of Resident #16's medical record found a PASARR dated 12/23/24. Under physician recommendations was marked as the resident eventually returned home or be discharged in less than three (3) months. The physician specified 90 days. In an interview with the Social Worker (SW) on 02/10/26 at 2:44 PM, the social worker stated the PASARR for Resident #16 was not current as the resident is still in the facility. The SW stated an updated PASARR would be completed immediately.

Based on electronic medical record review and staff interview, the facility failed to accurately complete section N of the annual Minimum Data Set (MDS) for one (1) of 34 residents. Resident identifier: #16. Facility census: 106. Findings included: a) Resident #16 On 02/11/26 at 10:14 AM a review of the annual MDS with an Assessment Reference Date (ARD) of 12/29/25 found Section N was marked as Resident #16 was receiving insulin. A review of the current physician orders and the Medication Administration Record (MAR) did not find an order for insulin or that insulin had been administered.An interview with the MDS Coordinator at 11:04 AM on 02/11/26 confirmed the MDS Section N had been marked incorrectly.

Based on record review, staff interview and observation, the facility failed to ensure call lights were within the resident's reach for two (2) residents. Resident Identifiers: #40 and #50. Facility Census: 106.Findings included: a) Resident #40 The policy and procedure for Call Lights stated, 4. Staff will ensure the call light is within reach of the patient and secured as needed. On 02/09/2026 at 12:45 PM, Resident #40's call light was observed not to be within the resident's reach. Nurse Practitioner #24 confirmed the call light was not in reach, unwrapped the call light from the bedrail and placed the call light within the resident's reach. b) Resident #50 On 02/02/26 at 12:30 PM, Resident #50's call light, tv remote and bed remote were observed on the floor. The resident's lunch tray was passed. At 1:05 PM, the resident's call light, tv remote and bed remote remained on the floor beside the resident's bed. Licensed Practical Nurse # 32 confirmed the resident's call light was in the floor and not within reach and stated, I'm sorry. The policy and procedure for Call Lights stated, 4. Staff will ensure the call light is within reach of the patient and secured as needed.

Based on record review and staff interview the facility failed to include all appropriate diagnosis on the most recent Pre-admission Screening and Resident Review (PASARR). This failed practice was found true for (2) two of (5) five residents reviewed for PASARR accuracy during the Long-Term Care Survey Process. Resident identifiers: #5, and #10. Facility Census: 106. a) Resident #10 A record review on 02/10/26 revealed that Resident #10 has a current diagnosis of Schizophrenia with a start date of 10/30/25. Further record review of Resident #10's most recent PASSAR completed on 05/02/22, revealed that Schizophrenia is not indicated on section 30, or listed in any other section of the PASSAR. During an interview on 02/10/26 at 2:12 PM, The Licensed Social Worker (LSW) #59, confirmed that Resident #10 had a diagnosis of Schizophrenia and that it is not indicated on the most recent PASSAR. LSW #59 stated, We just missed it. We are starting an audit now. Findings Include: a) Resident #5 A record review on 02/10/26 at 1:25 PM, revealed that Resident #5 has a current diagnosis of Epilepsy and is currently being treated for the Epilepsy with Lacosamide oral tablet 100 Milligrams (MG) (2) two times a day. Further record review of Resident #5's most recent PASSAR completed on 04/02/25, revealed that Epilepsy is not indicated on section 30, or listed in any other section of the PASSAR. During an interview on 02/10/26 at 2:12 PM, The Licensed Social Worker (LSW) #59, confirmed that Resident #5 has a diagnosis of Epilepsy and that it is not indicated on the most recent PASSAR. LSW #59 stated, We just missed it. We are starting an audit now.

Based on observation, record review, and staff interview the facility failed to develop and/or implement care plans related to physician dietary orders and Auditory needs. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifiers: #30, and #104. Facility census: 106. Findings Included:a) Resident # 30 On 02/10/2026, at12:06 PM, During Dining Room tray pass, It was observed that Resident #30's meal ticket stated, 1:1 Feed Assist and Supervision for all meals. Employee #17 retrieved Resident #30's tray, assisted in set up, then went back to get another resident's tray leaving Resident # 30 unsupervised for 8 minutes. Record Reviews:On 02/10/2026 at 1:15PM, a completed record review of Resident #30's Physician Orders coincided with the meal ticket stating resident was a 1:1 feed assist and ordered supervision for all meals.On 02/10/2026 at 1:28PM, a record review of Resident # 30's Care Plan stated as written:Resident is receiving a regular dysphagia pureed diet and thin liquids with 1:1 supervision at meals. Date initiated: 05/07/2025.Staff Interviews:In an interview on 02/10/26 at 12:15PM, with Employee #17 acknowledged she did take Resident #30's tray to him set up his meal then left him to eat by himself without supervision for 8 minutes She stated, That's not good. In an interview with the Corporate Coordinator, she stated she had heard about Resident # 30's tray set up and the lack of supervision for 8 minutes. She acknowledged the Physician Orders:of 1:1 Feed and Supervision for all meals were not followed for Resident #30. b) Resident #104:On 02/09/26 at 2:45 PM, during facility entry interview, Resident #104 stated she was not able to hear and has had a hard time communicating with others. During the interview written notes were used, She read and verbally responded her answers. she stated she had 2 hearing aides but they do not work well. On 02/10/26 at 3:20PM A record review of the resident's Physician Orders and Care Plan found no mention of her auditory needs or of her wearing hearing aides. On 02/10/26 at 3:45PM, Employee #81 was observed talking very loudly to Resident # 104, but stated to the surveyor she was not aware of resident having trouble with her hearing and she said, She seems to hear me ok. When asked in the presence of Employee # 81, Resident # 104 said she was not able to hear what was being said. Upon checking, Employee #81 discovered a hearing aid in the resident's left ear but nothing in the right ear. During an interview with the DON on 02/10/26 at 3:55 PM, She acknowledged the Care Plan failed to include Resident #104's auditory needs.

Based on record review, and staff interviews, the facility failed to ensure a resident's care plan was revised in the areas of discontinued physician orders and for resident advance directive status. Resident identifiers: #4 and #11. Facility Census:106 a)Resident #4 A record review on 02/11/26 at 10:00 AM, of Resident #4's Care Plan stated : Focus: Name is receiving antibiotic treatment for a Urinary Tract Infection. Interventions: Administer medication(s) as ordered. date initiated 01/21/26 A Further record review of Resident #4's Physician Orders, an order for the antibiotic could not be found. During an interview on 02/11/26 at 2:55 PM, The Director of Nursing (DON) She provided the discontinued Physician Order written below: Physician Orders were as follows: Fosfomycin Tromethamine Oral Packet 3GM Give 1 packet by mouth one time only for UTI for 1 day. start date 01/21/26 and confirmed that the care plan was not revised to reflect Resident #4's antibiotic treatment for the Urinary tract infection had been discontinued. b) Resident #11 A record review on 02/11/26 at 9:00 AM, of Resident #11's ordered, revealed that Resident #11 was changed from a full code status to a Do Not Resuscitate (DNR) on 02/02/26. Further record review of Resident #11's current Advance Direct care plan read as follows: Focus: Full code- Attempt to sustain life by all medically effective means. Provide appropriate medical and surgical treatment as indicated to attempt to prolong life including intensive care. Provide feeding through new or existing surgically-placed tubes. with a revision date of 01/06/26. During an interview on 02/11/26 at 10:17 AM, The Director of Nursing (DON) confirmed that the care plan did not reflect Resident #11's current code status.

Based on record review, staff interview and observation, the facility failed to ensure the residents' environment remained as free of accident hazards as possible. Resident Identifier: #80. Facility Census: 106. Findings included:a) Resident #80 The facility failed to ensure suction equipment was in place with the suction machine at the resident's bedside. On 02/09/26 at 2:00 PM, during the initial interview process, Resident #80 had a suction machine on his bedside table. No canister was in the suction machine or around the machine. On 02/09/26 observation of Suction machine at bedside revealed no canister was attached. At 2:05 PM, Nurse Aide #3 verified there was no canister in the suction machine. On additional observations during the Long Term Care Survey Process, a package containing the sterile catheter, container and gloves was hanging on the resident's bedside table. On 02/11/2026 Nurse Educator #81 reported they were looking at getting the order discontinued for the suction machine. The Director of Nursing and Nurse Educator reported they don't set the suction machines up except the sterile equipment.

Based upon record review and staff interview, the facility failed to provide accurate daily staffing posting for actual hours worked. This was found to be true for 14 (fourteen) of 15 (fifteen) days of staffing data reviewed during the annual survey process. Facility census: 106 Findings included: Nursing staffing data and time and attendance reports were reviewed for the following dates: 04/25/25, 04/26/25, 03/21/25, 03/22/25, 03/23/25,02/20/25, 02/21/25, 02/22/25, 02/23/25 01/01/25, 01/02/25, 01/03/25, 12/31/24, 11/25/24, 11/27/24 Examples of staffing data not aligning with time and attendance reports: On 11/27/24, posted nurse staffing data showed 258 total hours worked for RNs, LPNS, and Certified Nurse Aides. A review of the time and attendance report for the same date, showed 227.78 hours worked. On 12/31/24, posted nurse staffing data showed 264 total hours worked for RNs, LPNs, and Certified Nurse Aides. A review of time and attendance reports for the same date shows 231.40 total hours worked. On 04/26/25, posted nurse staffing data showed 243 total hours worked for RNs, LPNs, and Certified Nurse Aides. A review of time and attendance reports for the same date shows 197.21 total hours worked. This data was reviewed with the Director of Nurses (DON) on 05/06/25. When asked about the differences, the DON did not have a response.

Based on observations and staff interviews, the facility failed to maintain an effective pest control program so the facility is free of pests and rodents. This was a random opportunity for discovery with the possibility of affecting multiple residents. Facility census: 106. Findings include: a) During a walk-through of the dish room side of the kitchen, on 04/30/25, at 12:00 PM, many mature gnats were observed swarming around the drain area under the dishwasher table. In an interview with the district manager on 04/30/25 at 12:15 PM, he acknowledged the gnats and stated the facility had contacted the extermination for advice a week ago, but the facility had not yet been treated for the gnats.

Based on observation and staff interview, the facility failed to ensure resident's rooms were a clean and homelike environment (residents' privacy curtains were stained). This is true for Resident #94 and Resident #133. Findings included: a) On 04/29/25 at 9:45 AM an observation of Resident #94's room revealed that her privacy curtain was dirty with stains. On 04/29/25 at 9:50 AM an interview was conducted with Licensed Practical Nurse #133 who acknowledged that the curtain in Resident #94's room needed cleaned. She stated that generally when they see them dirty they will contact house keeping to be cleaned, b)On 04/29/25 at 12:53 PM during an interview with Resident #103, stains on his privacy curtain were observed and he stated it was vomit. Based on observations and staff interviews, the facility failed to ensure a safe, clean, comfortable and homelike environment for three (3) residents. Resident identifiers: #82, #65, and #3. Room identifiers: #404, #400, #412. Facility census: 106. Findings include: a) room [ROOM NUMBER] 04/29/25 at 1:17 PM, the following issues were observed in room [ROOM NUMBER]. In the bathroom areas there were screws sticking out of the drywall on the left side wall. There was an unfinished dry wall patch on the right-side wall. Resident #82 resided in this room. b) room [ROOM NUMBER] On 04/29/25 at 11:53 AM the following issues were observed in room [ROOM NUMBER]'s room. In the bathroom screws sticking out of the bathroom dry wall in the paint on right side wall. Resident #65 resided in this room. c) room [ROOM NUMBER] On 4/29/25 at 1:355 PM the following issues were observed in room [ROOM NUMBER]. In the bathroom there were unfinished dry wall patches to the left of the sink above the towel rack. Resident #3 resided in this room. During a walk through and interview with the DON on 04/30/25 at 10:55 AM, she acknowledged the bathroom areas were not in good repair for room [ROOM NUMBER], #404, #412 and stated she would report to maintenance for repairs.

Based on record review, and resident and staff interviews, the facility failed to ensure Resident # 90 was transferred in a safe manner to prevent physical injury. This resulted in actual harm for Resident #90 who sustained a laceration to her lower extremity requiring16 stitches. After the incident with Resident #90 the facility identified the failures and took appropriate action to correct the failures prior to the state agency entering the facility to conduct this complaint investigation. Therefore this will be cited as past non compliance. This was true for one (1) of three (3) sampled residents. Resident Identifier: #90. Facility Census: 110. Findings Include: A) Resident #90 On 04/09/24 Nurse Aide (NA) # 136 was transferring Resident #90 from the wheelchair to the bed when the resident sustained a laceration to her right lower extremity. Resident #90 was taken to the emergency room requiring 16 stitches. The facility reported the incident as required to all state agencies and began an investigation into what happened. A review of the facility's investigation found a statement written by NA #136, in this statement she confirmed she did not use the appropriate procedure when lifting Resident #90. Based on the Care Plan, Resident #90 was a lift sit to stand transfer. NA #136 used a gait belt to transfer resident # 90 from the wheelchair to her bed and discovered the resident's laceration to her right lower extremity. The facility substantiated neglect and reported NA #136 to the state registry and terminated her employment on 04/10/24. During the course of the investigation the facility discovered other NA's caring for Resident #90 may not have been transferring her appropriately. The facility then completed a whole house audit finding incorrect transfer procedures to be isolated to Resident #90. Staff inservices and education on resident transfers and lifts using the kardex started 04/10/24 and was completed 04/17/24 with scheduled future staff monitoring. During an interview with Resident #90, on 1/29/25 at 9:18 AM, she was up and sitting in her wheelchair down the hall from her room. She stated staff used a lift to transfer her to her wheel chair. She stated she did not have to wait for long periods of time for transfers when she requested to be up. She stated she hasn't missed meals or activities due to waiting to be transferred to the chair. She stated her call lights were answered timely. She did not remember being hurt during her transfer from the bed to the chair. She stated she hasn't had any falls lately. Resident room observation: at 9:24 Am 01/29/24 found Resident #90's bed is at wheelchair level and against the wall and bedside table at bed level with a longreach appliance tool. Grip strips fall prevention on the floor and call light clipped to bed within resident's reach while in the room. During an interview with the DON, Nurse Administrator, and Corporate Resource Nurse, on 01/29/24 at approx 2:30 PM, the facility provided verification of employment termination of NA #136, staff transfers/lift education and inservices/monitoring(pre and post incident), and whole house transfer/lifts audits. No further incidents related to improper transferring were identified during course of the survey.

Part I -- Based on observation, medical record review, and staff interview, the facility failed to ensure one (1) of twenty (20) sampled residents was effectively pre-medicated prior to completion of painful dressing changes to her wounds. Resident identifier: #57. Facility census: 112. Findings include: a) Resident #57 Observation of a dressing change, on the morning of 08/05/09, found Resident #57 had an ulceration on her left outer aspect of her heal. This area was noted to have a necrotic center measuring approximately 6 cm, and the surrounding tissue was reddened. Prior to the dressing being changed, staff began to remove her air boots (pressure reducing device from her toes to knees), and she immediately raised her legs up in the air and began to cry. Staff consoled her and removed the air boots. The nurse then attempted to remove the old dressing by cutting it with scissors; Resident #57 responded by guarding, raising her feet into the air, and crying. Once the dressing was removed, the nurse assessed and measured the wound using a cotton-tipped swab. As the swab got close to the wound, the resident again guarded the wound and cried. The nurse cleansed the wound and applied Santyl ointment; the resident responded to her wound being touched with facial grimacing, guarding, and crying. When staff asked if she was having pain, she identified "yes". When asked where her pain was, she identified "my heart". According to a significant change in status minimum data set assessment (MDS) completed on 06/05/09, Resident #57's cognitive skills for daily decision-making were severely impaired. Further review of her record revealed she received [MEDICATION NAME] for behavioral disturbances and [MEDICATION NAME] for [MEDICAL CONDITION]. Following the completion of the first of two (2) dressing changes, the nurse decided to complete the second dressing change in the afternoon. The nurse identified that Resident #57 had received [MEDICATION NAME] at 7:50 a.m. and a dose of Tylenol could not be given until 12:30 p.m. On 08/04/09 at 5:30 p.m., the director of nursing (DON) was interviewed concerning Resident #57 having pain during the dressing change, as evidenced by non-verbal signs of guarding and facial grimacing, as well as crying out. On 08/04/09 at 6:00 p.m., a physician order [REDACTED]. The facility failed to identify and act upon the verbal and non-verbal signs of pain exhibited by Resident #57 during a dressing change and failed to identify the [MEDICATION NAME] given prior to the dressing change was ineffective in controlling the resident's pain. --- Part II -- Based on record review, review of the facility's standing orders for constipation, and staff interview, the facility failed the monitor residents for irregularities in bowel elimination and failed to implement standing orders to alleviate constipation for three (3) of twenty (20) sampled residents, one (1) of whom was not checked for possible fecal impaction until she exhibited non-verbal signs of pain. Resident identifiers: #65, #57, and #39. Facility census: 112. Findings include: a) Resident #65 Review, on 08/03/09, of Resident #65's ADL record for July 2009 found the resident had no bowel movement for five (5) consecutive days, from 07/04/09 through 07/08/09. Review of the July 2009 MAR for this time period found no evidence that any medication was given to alleviate this constipation. On 07/09/09 at 11:40 a.m., a nurse wrote, "Digital rectal (check) revealed formed stool. Resident (arrow pointing down) bed & restless & moaning & moving about. Fleets enema x 1 Xlg (extra large) results & resident then pleasant & quietly." Resident #65 was identified as having problems with constipation, which was originally addressed in her care plan on 10/15/03. The facility failed to adequately monitor her bowel elimination and implement standing orders when indicated to alleviate constipation. Subsequently, the resident experienced pain evidenced by the non-verbal signs of "restless & moaning & moving about". b) Resident #57 Medical record review, conducted on the morning of 08/04/09, revealed that, on 05/12/09, Resident #57 was started on [MEDICATION NAME] 5/500 mg 1 tablet by mouth very eight (8) hours as needed (PRN) for pain. Information found via the Internet, at http://www.drugs.com/[MEDICATION NAME], revealed the following recommendation: "Drink 6 to 8 full glasses of water daily to help prevent constipation while you are taking [MEDICATION NAME]. Ask your doctor about ways to increase the fiber in your diet." Review of the comprehensive plan of care, developed on 06/11/09, found on page 5: "Resident exhibits or is at risk for dehydration as evidence by other UTI; and inadequate oral intake of food & fluids." On page 13 was: "Resident is at risk for alterations in comfort related to chronic pain." The facility failed to develop a comprehensive plan of care for constipation for Resident #57, who had a decreased intake of oral fluids and who was on a pain medication which caused constipation. (See citation at F279.) Review of Resident #57's activities of daily living (ADL) record for July 2009 found five (5) consecutive full days when the resident did not have a bowel movement followed by no bowel movement on the next two (2) consecutive shifts on the sixth day (from 07/01/09 through 07/06/09). Review of the July 2009 MAR for this time period found no medication was given to alleviate this constipation. According to the facility's standing orders for constipation: If no bowel movement in three days, give milk of magnesia 30 cc by mouth times one dose. If no bowel movement on day four, give [MEDICATION NAME] suppository per rectally times one. If no bowel movement on day five, give fleets enema. If no results from fleets enema, call physician for further orders. On 08/04/09 at 5:00 p.m., the DON was asked if there was any medication given to help alleviate Resident #57's constipation between 07/01/09 and 07/06/09. On the following morning (08/05/09), the DON identified she did not have any additional information regarding treatment of [REDACTED]. c) Resident #39 Review of Resident #39's medical record revealed a [AGE] year old female who had been determined to have the capacity to make her own medical decisions, with [DIAGNOSES REDACTED]. She received [MEDICATION NAME] 5/500 mg per enteral tube every twelve (12) hours for backache and also had a [MEDICATION NAME] pump for pain control. She had self-imposed immobility, refusing to get out of bed except for a rare shower or to travel via ambulance for maintenance of her [MEDICATION NAME] pump. She had standing orders as follows: "If no bowel movement (BM) in three days, give milk of magnesia (MOM) 30 cc PO (by mouth) x one dose. If no bowel movement on day four, give [MEDICATION NAME] suppository PR (per rectum) x one. If no bowel movement on day five, give Fleet enema. If no results from Fleet enema, call physician for further orders." The July 2009 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The nurses' notes, on 07/12/09, stated the resident was complaining of nausea and had refused her tube feeding. At 7:00 a.m. on 07/16/09, the nurses' notes stated, "Resident assisted with digital removal of lg (large) BM via this nurse." Review of previous MARs indicated use of MOM on a continuing basis and, although the frequency of bowel movements was difficult to determine, it was recorded in the nurses' notes on 04/16/09 that she had no BM x 4 days and, on 04/26/09, "No BM x several days." On both of these occasions, she refused an enema, and there was no mention in the record of her receiving a [MEDICATION NAME] suppository. There was no evidence in the record that staff had contacted the physician for further orders, although he was notified of her complaints of nausea and refusal of tube feedings. The care plan for Resident #39, initiated on 01/26/04 and revised on 07/09/09, addressed "... complications related to immobility and [DIAGNOSES REDACTED]." The only interventions were: "Administer medications as ordered...." and "Observe abdomen for distention, bowel sounds and tenderness". Both interventions were initiated on 01/26/04. No additional interventions had been added since 2004, although it was clear the goals had not been met. (See citation at F279.) During an interview with the minimum data set assessment / care plan nurse (Employee #9) at 1:40 p.m. on 08/05/09, she agreed the resident had chronic constipation and required intervention on a continuing basis, although she refused enemas. After reviewing the record, Employee #9 was unable to say why the suppository was not used or if the physician was notified. .

Based on medical record review, observation, staff interview, resident interview, and review of medication side effects, the facility failed to ensure one (1) resident of a sample of twenty (20), who was exhibiting psychosocial adjustment difficulties, received appropriate treatment and services. Resident #59 was a [AGE] year old female recently admitted to the facility from a hospital stay. The resident, upon admission, began to exhibit behaviors of yelling and cursing and was placed on psychoactive medications with sedative effects and which should be used with caution in persons with renal impairment (such as Resident #59), without first assessing the resident for psychosocial needs and offering non-pharmacologic interventions. An initial care plan focused on orientation to the facility but did not address the resident's need for psychosocial interventions related to her youthful age, severe physical problems, family needs, and behaviors that exhibited anger and the resident's withdrawing from interactions with staff. Facility census: 112. Findings include: a) Resident #59 Observations of the resident, on 08/04/09 at 9:00 a.m., revealed the resident was in a private room at the end of the hallway. When observed, the resident was sleeping. At 11:00 a.m., the resident was observed sleeping. At 1:30 p.m., the resident was very lethargic but began talking about her children and plans to go home. The resident was observed nodding off to sleep several times during the interview. review of the resident's medical record revealed [REDACTED]. The resident also had a [MEDICAL CONDITION] and [MEDICAL CONDITION] tube. A social history revealed the resident had three (3) children, lived with her spouse and was employed prior to the hospitalization . The resident was very weak and was admitted to the facility for physical and occupational therapy. The resident had capacity and scored 30 out of 30 on the facility's "Mini Mental Examination." An interview with the physical therapist (Employee #146), on 08/05/09 at 9:30 a.m., revealed the resident was very angry at first and currently was very withdrawn. The resident was aware that she needed to participate with the therapy, because the resident's goal was to go home either with her mother or her husband. (The resident had steps at her home, and her mother's home did not have steps.) She further stated that anyone of the age of Resident #59, and with the severe health problems she had, would be angry and withdrawn. An interview with the occupational therapist (Employee #148), on 08/05/09 at 10: 00 a.m., revealed the resident had anger issues. She further stated the resident usually came to therapy in the afternoon, because she slept most of the morning. The resident wanted to come to therapy in the afternoon, because it was quiet and other residents weren't around at that time. She stated the resident was angry and now was withdrawn. An interview with the social worker (Employee #144), on 08/04/09 at 11:15 a.m., revealed a care conference was not held, because the resident was admitted on [DATE] and a future care conference would determine the resident's psychosocial needs at that time. She had not communicated with the nursing staff to identify any psychosocial needs requiring immediate attention. The other social worker (Employee #145) stated they like to monitor the residents for a week or more to determine if a resident has any psychosocial needs. Employee #144, who was assigned to the resident, further stated she was aware of the resident's severe medical problems and that the resident had three (3) little children. She also stated that, when the husband came in with the resident on admission to the facility, he had cried. An interview with the nurse (Employee #31), on 08/05/09 at 11:40 a.m., revealed the resident was very weak and was taking therapy to gain strength and go home. She further stated the resident was angry most of the time and was very withdrawn. (This nurse routinely took care of the resident on day shift.) A facility's "Psychoactive Medication Dosage Monitor" indicated that, on 07/29/09, the resident received Klonopin 2 mg every twelve (12) hours, [MEDICATION NAME] 5 mg every day, and [MEDICATION NAME] 30 mg every day. On 07/31/09, the physician ordered the following: "Add to Klonopin, [MEDICATION NAME] behavior as evidenced by resistive to care, yelling and cursing, multiple medical complaints." According to Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th edition): - Klonopin, a benzodiazepine, should be used with caution in debilitated persons and persons with renal impairment. Klonopin also causes central nervious system depression resulting in sedation, drowsiness, confusion and/or ataxia. - [MEDICATION NAME], an antipsychotic, is highly sedating and should be used with caution in patients with severe [MEDICAL CONDITION]. - [MEDICATION NAME] is an antidepressant. Its sedative effects may be additive with other central nervious system depressants and/or [MEDICATION NAME]. The degree of sedation is moderate-high relative to other antidepressants. It should be used with caution in patients with renal dysfunction. (See citation at F329.) .

Based on medical record review, observation, staff interview, resident interview, and review of medication side effects, the facility failed to ensure the medication regimen of one (1) resident of a sample of twenty (20), who was exhibiting psychosocial adjustment difficulties, was free of unnecessary drugs without adequate indications for use and in the presence of adverse consequences. Resident #59 was a [AGE] year old female recently admitted to the facility from a hospital stay. The resident, upon admission, began to exhibit behaviors of yelling and cursing and was placed on psychoactive medications without first assessing the resident for psychosocial needs and offering non-pharmacologic interventions. She received antipsychotic drug therapy without having been diagnosed with [REDACTED]. In addition to the antipsychotic, she also received an antidepressant and a benzodiazepine, all of which had sedative effects and should be used with caution in persons with renal impairment (such as Resident #59). Multiple observations of the resident, on 08/04/09, found her to be sleeping throughout the morning. At 1:30 p.m., the resident was very lethargic but began talking about her children and plans to go home; she was observed nodding off to sleep several times during the interview. According to an interview with therapy staff, the resident received therapy services in the afternoon, because she slept most of the morning. Facility census: 112. Findings include: a) Resident #59 Observations of the resident, on 08/04/09 at 9:00 a.m., revealed the resident was in a private room at the end of the hallway. When observed, the resident was sleeping. At 11:00 a.m., the resident was observed sleeping. At 1:30 p.m., the resident was very lethargic but began talking about her children and plans to go home. The resident was observed nodding off to sleep several times during the interview. review of the resident's medical record revealed [REDACTED]. The resident also had a [MEDICAL CONDITION] and [MEDICAL CONDITION] tube. A social history revealed the resident had three (3) children, lived with her spouse and was employed prior to the hospitalization . The resident was very weak and was admitted to the facility for physical and occupational therapy. The resident had capacity and scored 30 out of 30 on the facility's "Mini Mental Examination." An interview with the physical therapist (Employee #146), on 08/05/09 at 9:30 a.m., revealed the resident was very angry at first and currently was very withdrawn. The resident was aware that she needed to participate with the therapy, because the resident's goal was to go home either with her mother or her husband. (The resident had steps at her home, and her mother's home did not have steps.) She further stated that anyone of the age of Resident #59, and with the severe health problems she had, would be angry and withdrawn. An interview with the occupational therapist (Employee #148), on 08/05/09 at 10: 00 a.m., revealed the resident had anger issues. She further stated the resident usually came to therapy in the afternoon, because she slept most of the morning. The resident wanted to come to therapy in the afternoon, because it was quiet and other residents weren't around at that time. She stated the resident was angry and now was withdrawn. An interview with the social worker (Employee #144), on 08/04/09 at 11:15 a.m., revealed a care conference was not held, because the resident was admitted on [DATE] and a future care conference would determine the resident's psychosocial needs at that time. She had not communicated with the nursing staff to identify any psychosocial needs requiring immediate attention. The other social worker (Employee #145) stated they like to monitor the residents for a week or more to determine if a resident has any psychosocial needs. Employee #144, who was assigned to the resident, further stated she was aware of the resident's severe medical problems and that the resident had three (3) little children. She also stated that, when the husband came in with the resident on admission to the facility, he had cried. (See citation at F319.) An interview with the nurse (Employee #31), on 08/05/09 at 11:40 a.m., revealed the resident was very weak and was taking therapy to gain strength and go home. She further stated the resident was angry most of the time and was very withdrawn. (This nurse routinely took care of the resident on day shift.) A facility's "Psychoactive Medication Dosage Monitor" indicated that, on 07/29/09, the resident received Klonopin 2 mg every twelve (12) hours, [MEDICATION NAME] 5 mg every day, and [MEDICATION NAME] 30 mg every day. On 07/31/09, the physician ordered the following: "Add to Klonopin, [MEDICATION NAME] behavior as evidenced by resistive to care, yelling and cursing, multiple medical complaints." According to Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th edition): - Klonopin, a benzodiazepine, should be used with caution in debilitated persons and persons with renal impairment. Klonopin also causes central nervious system depression resulting in sedation, drowsiness, confusion and/or ataxia. - [MEDICATION NAME], an antipsychotic, is highly sedating and should be used with caution in patients with severe [MEDICAL CONDITION]. - [MEDICATION NAME] is an antidepressant. Its sedative effects may be additive with other central nervious system depressants and/or [MEDICATION NAME]. The degree of sedation is moderate-high relative to other antidepressants. It should be used with caution in patients with renal dysfunction. .