Based on observations, interviews, and record review, the facility failed to provide a comprehensive plan of care for 2 of 2 residents sampled for care plans. (Resident #21 and #24) The findings include: Resident #21 A record review of Resident #21's electronic medical record (EMR) revealed that the resident is dependent on staff for activities for daily living. A review of the care plan developed by the facility for Resident #21 did not include an intervention to address the need for assistance in activities for daily living. On 4/23/2025 at approximately 1:00 PM, an interview was conducted with the Minimum Data Set Coordinator (MDS) and Care Plan Coordinator. The Care Plan Coordinator confirmed that there was not a care plan for Resident #21 in regards to activities of daily living. The Care Plan Coordinator further indicated that the information did trigger from the MDS and should have been included in the care plan. Resident #24 A record review was conducted on Resident #24's EMR concerning End Stage Renal Disease (ESRD) and dependence on hemodialysis services. The care plan developed by the facility for Resident #24 did not include goals and interventions to manage ESRD and hemodialysis services. The Care Plan Coordinator confirmed that there was not a care plan for Resident #24 for ESRD/Dialysis. She further indicated that it had triggered for a care plan from the MDS and should have been included in the care plan. The Care Plan Coordinator acknowledged that she missed developing a care plan for both of these residents. On 4/23/2025 at approximately 1:50 PM, an interview was conducted with the Director of Nursing (DON). The DON indicated that it is her expectation that, if the MDS triggers care areas, then the care plan should be updated to include those areas. The facility policy titled Comprehensive Care Plans stated: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed. 3. The Comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would be otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations.

Based on observation, record review, staff interviews, and policy review, the facility failed to ensure staff provide appropriate care and services to promote healing and prevent cross contamination of pressure ulcers for 1 of 1 sampled residents with pressure ulcers. (Resident #43) The findings include: A review of Resident #43's medical record was conducted which revealed she had a stage 3 pressure ulcer on her sacrum. An observation of wound care for Resident #43 was conducted on 9/20/2022 at 12:51 PM with Employee A (Licensed Practical Nurse). Employee A gathered supplies for the wound care from the treatment cart to include a bottle of wound cleanser dated 9/3/2022, took the supplies to the resident's room, and placed them on the over bed table with no barrier on the table. Employee A washed her hands and applied clean gloves, removed the old dressing from the resident's sacrum, removed the bottle of wound cleanser from the over bed table and set it on the resident's bed, then picked up the bottle of wound cleanser and used it to clean the wound. Employee A then applied gauze with Iodosorb to the wound bed, then removed her gloves and applied clean gloves and applied the adhesive dressing to the wound. Employee A did not wash her hands and change gloves after removing the soiled dressing and did not wash hands after cleansing the wound. After completing the wound care, Employee A returned the wound cleanser to the treatment cart by placing it back in the cart. She did not sanitize the bottle of wound cleanser before placing it back in the cart. An interview was conducted with Employee A on 9/20/2022 at 12:59 PM. She stated the bottle of wound cleanser she used was used on multiple residents and they use bleach wipes to clean the bottle. She then removed the bottle of wound cleanser from the treatment cart and cleansed the bottle of wound cleanser with a bleach wipe before placing it back in the same area of the treatment cart. Review of the facility policy for Clean Dressing Change (revised 1/5/2022) revealed it is the policy of this facility to provide wound care in a manner to decrease the potential for infection and/or cross contamination. Multi-use wound care supplies will be maintained as clean after initial use. Set up a clean field on the over bed table with needed supplies for wound cleansing and dressing application. Place a disposable cloth or linen saver on the over bed table. Place only the supplies to be used per wound on the clean field at one time. Wash hands and put on clean gloves, loosen the tape and remove existing dressing, remove gloves pulling inside out over the dressing and discard, wash hands and put on clean gloves, cleanse the wound as ordered, wash hands and put on clean gloves, apply topical ointments or creams and dress the wound as ordered, secure the dressing. An interview was conducted with the Director of Nursing (DON) on 9/20/2022 at 1:33 PM. She stated the wound cleanser should be maintained and placed on a barrier, then cleansed with sanitizing wipes before you place it back in the cart. She stated staff would be expected to wash hands, apply gloves, remove the old dressing, remove gloves, wash hands and apply clean gloves, cleanse the wound as ordered, remove gloves, wash hands and apply clean gloves, then apply the dressing as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to implement safety precautions related to smoking to ensure the resident environment remained as free of accident hazards as possible for 1 of 1 sampled residents who smoked tobacco products. (Resident #8) The findings include: An observation was conducted for Resident #8 on 9/19/2022 at 1:10 PM. The resident was outside on the smoking patio, which is located outside the dining room, smoking a cigarette. No staff were present on the patio at this time. He was observed to have his cigarettes and lighter in a plastic bag and lit his own cigarette. He was again observed to be smoking on the patio on 9/21/2022 at 8:50 AM with no staff present. An interview was conducted with Resident #8 on 9/21/2022 at 11:41 AM. He stated he keeps his cigarettes and lighter in his room in the dresser drawer. I observed the resident remove his cigarettes and lighter from an unlocked dresser drawer in his room. No locking mechanism was observed on the dresser drawer. He stated he had been in the facility so long they trusted him. Review of Resident #8's medical record revealed a smoking assessment dated [DATE] indicating the resident had no cognitive loss and the resident needs the facility to store his lighter and cigarettes. The current care plan for risk for injury due to smoking initiated on 6/29/2018 and revised 6/15/2022 indicated Resident #8's cigarettes and lighter will be kept on the nurse's cart with staff/family supervision while smoking. An interview was conducted with Employee B (Certified Nurse Aide) on 9/20/2022 at 4:34 PM. She stated all resident smoking materials are kept locked up in the soiled utility room. An interview was conducted with the Director of Nursing (DON) on 9/20/2022 at approximately 4:45 PM. She stated Resident #8 did not require supervision to smoke. He has been assessed and his smoking materials are kept in the lock box and when he wants to go smoke the staff give them to him. She stated supervision was on the care plan in error. Further interview was conducted with the DON on 9/21/2022 at 11:45 AM. She stated she remembered this morning that the resident is allowed to keep his cigarettes and lighter in a lock box in his room, however it was not care planned or documented. Review of the facility policy for smoking (Attachment Q1 dated 4/22/2015) revealed the facility shall establish and maintain safe resident smoking practices. All residents that desire to smoke will be assessed upon admission, quarterly and as needed for level of safety awareness to determine if the resident is safe or unsafe and what restrictions, if any, will be placed on the resident's smoking privileges. Any resident who has been assessed as unsafe will not be permitted to smoke without the direct supervision of a responsible staff member, visitor, or volunteer. Smoking articles for residents who are assessed to be safe with independent smoking privileges: a. Residents who have independent smoking privileges shall be permitted to keep, cigarettes, pipes, tobacco, and other tobacco products in their possession. b. Residents may not have or keep lighter fluids, including butane gas, or any other forms of gas or fluids, or matches at any time. c. Residents who are safe may request a lighter from the nursing staff but it must be returned promptly after smoking has been completed.