Inspection·February 26, 2026

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide quality of care according to professional standards for one (Resident #97) out of one resident sampled who was in respiratory distress as evidenced by record review revealed an antidepressant was given while Resident #97 was in respiratory distress. This medication had the potential to worsen Resident #97's condition. There were 86 residents residing in the facility at the time of survey. The findings include:Record review of Resident # 97's clinical records revealed the resident was admitted to the facility on [DATE] with diagnosis that included: Heart Failure and discharged on 7/3/25 due to respiratory distress. Record review of a Quarterly Minimum Data Set reference dated 7/3/25 revealed Resident # 97 had a Brief Interview of Mental Status score of 15, indicated no cognitive impairment and received oxygen therapy. Record review of a care plan initiated on 4/11/24 revealed Resident # 97 had self-care deficit with interventions included to observe for medication side effects. Record review of a physician's order sheet for Resident #97 revealed orders dated 7/3/25 for Trazodone Hydrochloride (HCl) Oral Tablet 50 milligram (mg). Give 0.5 tablet by mouth two times a day related to Major Depressive Disorder. Record review of a Nursing notes dated 7/3/2024 timestamped 1:00 PM indicated Resident # 97 was in bed awake drowsy, vital were taken, and oxygen was applied at 2 Liters per minute.Record review of an order note dated 7/3/2024 timestamped 1:05 PM revealed Resident # 97 was administered Trazodone Hydrochloride (HCl) Oral Tablet 50 MG, 0.5 tablet.Review of nursing notes dated 7/3/2025 revealed at 1:45 PM Resident # 97 continued with shortness of breath (SOB), very lethargic, and 911 was called.Record review of Resident # 97's July 2025 Medication Administration Record (MAR) revealed a signature on 7/3/2025 at 2:00 PM that indicated Trazodone Hydrochloride (HCl) Oral Tablet 50 milligrams (mg), half tablet was administered to Resident # 97.Interview on 02/26/2026 at 10:51 AM; the Director of Nursing stated: On 7/3/25 at 8:00 AM [Resident # 97] reported not feeling well and the nurse measured vitals and informed the medical doctor. Around 1:00 PM, the Oxygen saturation was 89% and [Resident # 97] was drowsy and the nurse administered Trazodone. In this situation the trazodone should not be given because [Resident # 97] was drowsy and side effects of Trazodone includes sedation.Record review of the facility's policy titled, Compliance Risks - Resident Quality of Care and Quality of Life dated January 2025 indicated. Policy Statement:Compliance with the Medicare and Medicaid Requirements of Participation for resident quality of care and resident quality of life is consistent with the goals of the overall compliance and ethics program. The facility does not submit claims for reimbursement that do not meet professional standards of quality. Residents Affected - Few Note: The nursing home is disputing this citation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105575 If continuation sheet Page 2 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palmetto Care Center and Rehab 6750 West 22nd Court Hialeah, FL 33016 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide an environment that is free from potential accidents and hazards on one (medication cart #1) out of four medication carts, one out of two Soiled utility rooms as evidenced by: Observation of lancets on top of the South Wing medication cart #1, unattended. Observation of an unlocked Soiled Utility Room door that contained Biohazard materials. A container of disinfectant wipes Resident #89's nightstand. Box of razors left unattended in the North Wing. There were 86 residents residing in the facility at the time of survey. The findings include:1) On [DATE] at 6:05 AM an observation was made of lancets left unattended on top of the South Wing medication cart #1(photo).On [DATE] at 6:07 AM, Staff H, Registered Nurse (RN) was notified and revealed lancets are to be keep locked in the carts. 2) On [DATE] at 6:21 AM an observation was made of The Soiled Utility room door left unlocked.On [DATE] at 6:30 AM Staff H, RN was notified and stated, The door is to be locked.During an interview on [DATE] at 6:58 AM, the Director of Nursing (DON) stated: The Soiled Utility room to be kept locked for infection control and the safety of residents. Also revealed the room contains Biohazard materials. 3) On [DATE] at 6:50 AM a container labeled Disinfectant wipes was observed at Resident # 89's bedside.On [DATE] at 6:52 AM, the DON was made aware and removed the container. The DON revealed the wipes are to be kept in the drawer.Record review of a demographic sheet revealed Resident # 89 was admitted to the facility on [DATE] with diagnosis that included but not limited to: Orthopedic aftercare. Record review of an admission Minimum Data Set reference dated [DATE] revealed Resident # 89 had a Brief Interview for Mental Status score of 15 indicated no cognitive impairment, required set up clean up assistance for eating and substantial/ maximal assistance for toileting and was dependent for transfers.Record review of a care plan initiated on [DATE] revealed Resident # 89 displayed deceased safety awareness related to generalized weakness after surgery with interventions that included: Self-care management training.Record review of a February 2026 physician orders sheet for Resident # 89 revealed order dated [DATE] for Mobility: Activities as tolerated. 4) Observation on [DATE] at 10:10 AM, on the North Wing revealed a box containing razors and an open box containing A&D ointments on an unattended wheeled platform utility cart. On [DATE] at 10:15 AM, the central supply staff notified of the identified concern revealed the razors should not be left unattended for the safety of residents.Record review of facility's policy titled Hazardous Areas, Devices and Equipment undated revealed Policy Statement: All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety Event ID: Facility ID: 105575 If continuation sheet Page 3 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palmetto Care Center and Rehab 6750 West 22nd Court Hialeah, FL 33016 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review the facility failed to ensure staffing information on the North Wing and South Wing were readily available in a readable format to residents and visitors at any given time. The findings included: Record review of the Posting Direct Care Daily Staffing Numbers Policy and Procedure (no written date available) documented: Policy Statement: Our facility will post on a daily basis for each shit nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents; Policy Interpretation and Implementation: 1) Within two hours of the beginning of each shift, the number of licensed nurses (Registered Nurses-RN, Licensed Practical Nurses-LPN) and the number of unlicensed nursing personnel (Certified Nursing Assistants-CNA, Nursing Assistants-NA) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format and 2) Directly responsible for resident care means that individuals are responsible for residents' total care or some aspect of the residents' care. Shift staffing information is recorded on a form for each shift. The information recorded on the form shall include the following: b) The current date (the date for which the information is posted); c) The resident census at the beginning of the shift for which the information is posted; e) The shift for which the information is posted; f) Type (RN, LPN or CNA) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility (including contract staff); g) The actual time worked during that shift for each category and type of nursing staff and h) Total number of licensed and non-licensed nursing staff working for the posted shift. Residents Affected - Few 1) Observation of the South Wing Nursing Assignments board on 2/23/26 at 6:05 AM revealed information documented was for the oncoming 7:00 AM to 3:30 PM shift. Photographic evidence. 2) Observation of the North Wing Nursing assignments board on 2/23/26 at 6:07 AM revealed the board had staffing information documented assignments for the 7:00 AM to 3:00 PM shift for 2/23/26. It did not have staffing assignments documented for the 11:00 PM to 7:00 AM shift for 2/22/26. Photographic evidence submitted. Interview with Staff E, Registered Nurse (RN) on 2/23/26 at 6:49 AM. She revealed the staffing board is to be changed one hour before the next shift starts. She confirmed that the staffing board documented the 7:00 AM to 3:00 PM shift for 2/23/26 and not the 11:00 PM to 7:00 AM shift for 2/22/26. Interview with the Director of Nursing (DON) on 2/23/26 at 6:55 AM. She stated, The present shift changes the nursing board for the next shift. The DON confirmed that the staffing board should reflect the current nursing staff working. Interview with the Staffing coordinator on 02/24/2026 at 3:25 PM revealed the assignment boards are to be posted within two hours of the beginning of the current shift. I think the overnight staff were attempting to be proactive by posting the assignment early so the oncoming staff can know where to go. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105575 If continuation sheet Page 4 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palmetto Care Center and Rehab 6750 West 22nd Court Hialeah, FL 33016 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide safe and secure storage of medications and biologicals on for two out of two medication carts failed to ensure no medications, biologicals, treatments ointments etc. are left at residents' bedsides. As evidence by 1) unattended medications observed on South Wing Cart #1. 2) wound cleanser at Residents #32's bedside. 3) bottle of topical medicated powder at Resident #95's bedside. 4) medication cup marked Zinc Oxide observed at Resident #34's bedside and bottle with discontinued morphine solution noted in North Wing Cart #2. The findings included. Observation on [DATE] at 6:05 AM revealed unattended crushed medication, lancets, alcohol pads and an uncovered water bottle on medication cart #1on the South wing nursing unit (photo). On [DATE] at 6:07 AM, Staff H, Registered Nurse (RN) was notified of the identified concerns and stated, Medications, lancets, alcohol pads and ointments are to be kept locked in the carts. On [DATE] at 6:33 AM, an observation was made of Resident#32 in bed with no apparent distress and a bottle marked [brand] Wound Cleanser was on the nightstand next to bed (photo). On [DATE] at 6:35 AM Resident #95 was observed in bed and a bottle marked [brand] topical powder was on the nightstand (photo). On [DATE] at 6:36 AM Staff H, RN was notified of the identified items at the residents' bedsides On [DATE] at 6:58 AM, the Director of Nursing stated: No medications, ointments or lancets are to be left unattended. All are to be stored in a locked cart. Record review of the facility's policy titled Medication Labeling and Storage dated February 2023 revealed Policy heading the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. On [DATE] at 07:17 AM, Resident #34 was observed in bed with eyes closed. A medication container labeled Zinc Oxide Ointment was noted on the night table. On [DATE] at 7:18 AM Staff E Registered Nurse (RN) revealed the medication jar was empty and ready to be discarded but had not yet been removed. Interview with Director of Nursing on [DATE] 12:15 PM, revealed the facility's protocol prohibits keeping any medications, including over?the?counter products, in residents' rooms. Residents are educated that if family members bring any over?the?counter medications, these must be given directly to the nursing staff to ensure proper handling and compliance with safety procedures. Observation on [DATE] at 12:13 PM with Staff C, Registered Nurse (RN) during a narcotic count on North Wing Cart 2, it was revealed that a resident who expired on [DATE] at 18:29 Morphine Sulfate Oral Solution narcotic still remained in the cart as of [DATE] at 2:02 PM. Additionally, the Morphine Sulfate Oral Solution 100 mg/5 mL bottle shows 16 mL remaining, while the last documented administration was 12.5 mL on [DATE] at 01:03. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105575 If continuation sheet Page 5 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palmetto Care Center and Rehab 6750 West 22nd Court Hialeah, FL 33016 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Interview on [DATE] at 1:41 PM the Director of Nursing (DON) stated: Medications and narcotics are expected to be removed from the medication cart following a resident's discharge. however, in this instance the resident expired over the weekend, and removal had not yet occurred. Narcotics are discarded according to facility protocol either with the pharmacy, the Assistant Director of Nursing (ADON), or another authorized nurse administering the waste process. Residents Affected - Few Interview on [DATE] at 2:18 PM with Pharmacist Consultant stated: Once a resident is discharged or expires, narcotics should be removed from the medication cart and secured for destruction, although the exact timeframe may depend on the facility's policy.' Record review of the facility's policy titled Controlled substances [DATE] stated 22. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed.23. Accountability records for discontinued controlled substances are kept with the unused supply until it is destroyed or disposed of as required by applicable law or regulation.24. The consultant pharmacist or designee routinely monitors controlled substance storage records. Record review of the facility's policy titled Medication Labeling and Storage February 2023 stated 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105575 If continuation sheet Page 6 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palmetto Care Center and Rehab 6750 West 22nd Court Hialeah, FL 33016 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation. FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and record review the facility failed to store food under sanitary condition as evidenced by resident's food items were not dated and labeled in the South Wing Pantry refrigerator. This has the potential to affect seven-nine out of eighty-six residents who eat orally residing in the facility at the time of the survey.The findings included: Record review of the Foods Brought by Family/Visitors Policy and Procedure (no written date); Policy Statement-Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents; Policy Interpretation and Implementation: 7) Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food; b) Containers will be labeled with the resident's name, the item and the use by date and 8) The nursing staff will discard perishable foods on or before the use by date.Observation of the South Wing Pantry refrigerator used to store resident's foods on 02/23/26 at 07:03 AM revealed the refrigerator contained a bag with one container of yogurt and one container of cottage cheese. The bag was not labeled or dated. Photographic evidence submitted.Observation and interview with the DON on 02/23/26 at 07:33 AM. She stated, Since there is no name or date on this bag, I am throwing it away in the garbage. She confirmed that food items in the refrigerator should be labeled and dated. Event ID: Facility ID: 105575 If continuation sheet Page 7 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palmetto Care Center and Rehab 6750 West 22nd Court Hialeah, FL 33016 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F583 Personal Privacy/Confidentiality of Records related to the facility's staff failed to close a computer screen on the South medication cart # 2 during medication administration which left resident's information visible and it was observed a staff member administering medications to Resident # 89 in the hallways and F880 Infection Prevention and Control failed to ensure infection control standards were followed on the South Wing Soiled Utility Room and for one (Resident # 96) out of one sample resident receiving oxygen as evidenced by 1)Observation of facility's staff placing a dirty nasal cannula into Resident # 96's nostrils. 2) Observation of facility's staff exiting the Soiled Utility room without performing hand hygiene. This deficient practice had the potential to affect 86 residents residing in the facility at the time of survey. The findings included.The findings included:Record review of the facility's survey history revealed, during a recertification survey with exit dated February 27, 2025. F583 Personal Privacy/Confidentially of Records facility failed to safeguard and ensure privacy of resident's confidential Electronic Health Records (EHR); as evidenced by one out of four of the facility's medication carts' computer screen was left unlocked and unattended revealing resident's information. F880 Infection Prevention and Control, facility failed to follow infection prevention and control procedures for Resident # 183, as evidenced by Resident # 183's Spirometer was observed at Resident # 183's bedside with no protective covering. Interview with the Administrator on 02/26/2026 at 2:20 PM. She stated that the QAPI (Quality Assurance and Performance Improvement) meeting is held on the last Thursday of every month. She stated QAPI Committee included the Administrator, Director of Nursing, Medical Director, Social Services Director, Dietary Director, Infection Preventions, Medical Records Director, Nurse supervisors, the Maintenance Director, Environmental Director, MDS Coordinator and a Certified Nursing Assistant is invited. She stated they have a meeting every morning; staff revealed the issues from the prior day. She stated is the issue is high risk for residents; it is addressed immediately. She stated last month's meetings were discussed and working to prevent falls and it worked; the residents' fall incidents decreased in comparison to last year. She stated the facility reported that it is working to improve and maintain its systems by continuing to conduct audits of customer services, program advocacy processes, and quarterly resident sample interviews based on the critical pathway. The quality manager also interviews residents, family members, and staff involved with the same resident to support ongoing quality monitoring and service enhancement.Review of the Policy and Procedures for Quality Assurance and Performance Improvement (QAPI) Program not dated revealed Policy Statement: This facility shall develop, implement, and maintain an ongoing, facility-wide date-driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents. Policy Interpretation and Implementation: The objectives of the QAPI Program are to 1-Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2- Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3-Reinforce and build upon effective systems and processes related to the delivery of quality of care and services. 4-Establish systems through which to monitor and evaluate corrective actions. Event ID: Facility ID: 105575 If continuation sheet Page 8 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105575 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palmetto Care Center and Rehab 6750 West 22nd Court Hialeah, FL 33016 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure infection control standards were followed for one (Resident #96) out of one sampled resident receiving oxygen and the South Wing Soiled Utility Room as evidenced by: 1) Observation of facility's staff placing a dirty nasal cannula into Resident # 96's nostrils. 2) observation of facility's staff exiting the Soiled Utility room without performing hand hygiene. There were 86 residents residing in the facility at the time of survey. The findings include:Observation on 02/23/2026 at 6:39 AM in Resident # 96's room revealed the resident seated in a wheelchair; a nasal cannula was on the floor at the opposite side of the bed connected to the oxygen concentrator (photo).On 02/23/2026 at 6:40 AM Staff H, Registered Nurse (RN) was notified about the identified concern and stated, [Resident #96] requires continuous oxygen. Staff H, RN and surveyor entered the room and Staff H, RN picked up the nasal cannula from floor and placed into Resident # 96's nostrils. The Surveyor asked if this was within infection control protocol for oxygen supplies and Staff H, RN stated, The cannula was on the floor, and I should have used a new cannula. During an interview on 02/23/2026 at 6:58 AM, the Director of Nursing (DON) revealed oxygen tubing is to be stored in a dated bag with the room number and placed in the drawer. If a resident's nasal cannula comes out and is on the floor the nurse is to use the pulse oximeter and measure oxygen level then change the tubing and date it.Record review of a demographic sheet revealed Resident # 96 was admitted on [DATE] with Diagnosis that included but not limited to: Chronic Obstructive Pulmonary Disease (COPD) and Acute Pulmonary edema.Record review of a baseline care plan initiated on 2/2/2026 revealed Resident # 96 had the potential for complications of respiratory distress and the interventions included: Administer supplemental oxygen as ordered and perform lung sounds/respiratory assessment as needed.Record review of a physician order sheet revealed Resident#96 had an order dated:2/19/26 for Oxygen at 2 Liters per minute via Nasal Cannula as needed for Shortness of breath. 2) On 02/24/2026 at 12:01 PM, Staff J, Certified Nursing Assistant (CNA) was observed entering The Soiled Utility Room with a plastic bag of trash and exiting without performing hand hygiene.On 02/24/2026 at 12:07 PM the Assistant Director of Nursing/Infection Preventionist revealed staff are to perform hand hygiene before leaving the Soiled Utility Room. Interview on 02/24/2026 at 12:12 PM with Staff J, CNA (translated by other surveyor) Staff J, CNA revealed I did not wash my hands before exiting the Soiled Utility Room because I did not touch anything while in the room. Record review of facility's policy titled Infection Prevention and Control Program dated December 2025 revealed Policy Statement: An infection prevention and control (IPC) program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105575 If continuation sheet Page 9 of 9