**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with staff and the Wound Care Physician, the facility failed to (1) follow Physician's instructions to apply betadine (an antiseptic) and leave it open to air on a resident's right heel pressure wound, (2) ensure a resident's left buttock pressure ulcer was cleaned before applying a clean dressing, and (3) clean wounds starting from the center of the wound and moving to the outer edges of the wound in a continuous circular motion. This deficient practice affected 1 of 3 residents observed for pressure ulcers (Resident #56).Findings included:Resident #56 was readmitted on [DATE]. Resident #56 had diagnoses of an unstageable pressure ulcer on the right heel and a stage 2 pressure ulcer on the left buttock.The Significant Change Minimum Data Set (MDS) dated [DATE] revealed Resident #56 was severely cognitively impaired with no behaviors. The MDS documented a stage 2 pressure ulcer and deep tissue injury. The MDS also showed Resident #56 was dependent on all activities of daily living. The care plan for Resident #56 dated 08/13/25 showed a focus for a stage 2 pressure ulcer to the left buttock and deep tissue injury (DTI) pressure ulcer to the right heel and potential for pressure ulcer development related to history of ulcers, and immobility. The goals for Resident #56 included the pressure ulcers would show signs of healing and remain free from infection. Interventions included administer treatments as ordered and monitor for effectiveness and follow facility policies/protocols for the prevention/treatment of skin breakdown.A physician order dated 08/13/25 for the right heel wound care revealed: Cleanse the right heel with wound cleanser. Pat dry. Apply betadine and leave open to air every - day shift for DTI.A physician order dated 08/13/25 for the left buttock wound revealed: Cleanse with wound cleanser. Pat dry. Apply collagen particles (a protein that regulates wound healing and forms a protective barrier against bacteria) and medihoney (used for antibacterial and anti-inflammatory effects and removes dead wound tissue). Cover with dry dressing every - day shift for wound care.Review of wound care documentation written by the Wound Nurse Practitioner (NP) dated 08/07/25 revealed a right heel deep tissue injury (DTI). The DTI measured 4 x 3 x 0 centimeters (cm). The wound was described as improving with 100% epithelial tissue (a type of body tissue that covers internal and external surfaces) without drainage.Review of wound care documentation written by the Wound NP dated 08/13/25 revealed an unstageable right heel pressure ulcer and a stage 2 left buttock pressure ulcer. The right heel pressure ulcer measured 4 x 3 x 0 cm. The wound was described as deteriorating with 100% eschar (black, crusty, dead tissue over or around a wound) without drainage. The left buttock pressure ulcer measured 2 x 2 x 0.1 cm with a small amount of serosanguinous drainage (light pink to red colored fluid) affecting the dermis (middle layer of skin).Observation and interview for Resident #56's wound care occurred on 08/14/25 at 10:05 AM with Nurse #2, Wound Care Nurse, and Nurse Aide (NA) #3. Nurse #2 removed the old dressing from Resident #56's right heel that showed a circular eschar (black, crusty, dead tissue over or around a wound) area with a yellow-pink center. Nurse #2 wiped and patted the heel wound with wound cleanser and then obtained a gauze 4x4 that Nurse #2 had previously placed betadine on. Nurse #2 used the betadine 4x4 gauze to pat Resident #56's right heel. She then used a clean 4x4 gauze and wiped over the betadine area of the right heel and replaced Resident #56's sock. Nurse #2 explained she was wiping off any excess betadine from Resident #56's heel. The Wound Care Nurse at this time spoke with Nurse #2 and told her that the heel was to have a generous amount of betadine and left to dry to air. Nurse #2 voiced understanding however Nurse #2 nor the Wound Care Nurse corrected the wound care that was provided.Continued observation of wound care at 10:20 AM revealed after performing hand hygiene, Nurse #2 moved to Resident #56's left buttock wound. NA #3 was observed holding Resident #56 on his right side. Resident #56 was wearing a brief. The brief was observed not to have any visible contamination. Nurse #2 unfastened the brief and removed the old dressing. There was no drainage observed on the old dressing. Nurse #2 obtained a 4x4 gauze that contained wound cleanser and proceeded to wipe Resident #56's wound from the bottom of the wound to the top then left outer edge to the right outer edge. When Nurse #2 turned to perform hand hygiene and obtain the clean dressing, NA #3 was observed to lay Resident #56 back onto his brief allowing the clean wound to touch his brief. Nurse #2 returned with the clean dressing and applied the dressing to Resident #56's left buttock wound without re-cleaning the area. The Wound Care Nurse was interviewed on 08/14/25 at 10:45 AM. All wound care provided for Resident #56 was reviewed. The Wound Care Nurse stated the left buttock wound touching the resident's brief, after it was cleaned, was acceptable due to the brief usually being changed prior to the wound care by the Nurse Aides. She stated a clean barrier did not need to be placed under the resident's buttocks due to the brief being clean. The Wound Care Nurse stated wounds did not have to be cleaned by starting at the center of the wound and moving to the outer edges of the wound in a continuous circular motion. She stated wounds could be cleaned by swiping from the center of a wound and outward repeatedly and was acceptable if the process began at the center of the wound. The Wound Care Nurse stated she did not realize Nurse #2 had not cleaned the wound starting from the center. The Wound Care Nurse stated that it was difficult to see betadine on a person of color due to skin tone; therefore, betadine could not be visualized during each treatment. She verified she was knowledgeable with the Wound NP's orders and preferences regarding wound care. She stated that Nurse #2 was nervous during the observation. The Wound Care Nurse confirmed Nurse #2 did not provide wound care often. She stated that she did not supervise wound care treatment for each resident because the other nurses knew how to provide the treatment but that she was available if needed.During an interview with Nurse #2 on 08/15/25 at 9:10 AM via telephone, Nurse #2 denied she had received wound care education from the Wound NP. She discussed not providing wound care to the residents very often and received education from the Wound Care Nurse. Interview with the Wound NP by phone on 08/14/25 at 11:25 AM confirmed she was familiar with Resident #56. Her wound care orders were reviewed. The Wound NP explained Resident #56's heel wound should be cleansed with gauze saturated with wound cleanser. She stated the wound should be cleaned using the technique of wiping the wound starting at the center of the wound and moving to the outer edges of the wound in a continuous circular motion. A clean gauze should be used to pat the wound dry. Lastly, the Wound Nurse NP stated the wound should be wiped from the center of the wound and moving to the outer wound edges of the wound in a continuous circular motion, with gauze saturated in betadine. The betadine should be left to air dry. She explained she expected the Wound Care Nurse to be generous with the betadine. The Wound NP stated socks/heel protectors should be placed after the betadine had completely air-dried. The Wound NP stated the right heel wound care should have been repeated using the process previously described. She stated she tried to provide education to the nurses to use copious amounts of betadine for wound care requiring betadine. Next, Resident #56's left buttock wound care was discussed. The Wound NP stated gauze saturated with wound cleanser should be used to clean the wound as previously described and patted dry. Then, the medihoney and collagen should be applied and covered with an adhesive dry dressing. The Wound NP was informed of the observation of the left buttock wound care performed today (08/14/25) that included the wound being cleaned by wiping in an upward motion and side-to-side; and the resident being laid down on the brief after the wound was cleaned and the clean dressing being applied without re-cleaning the wound. The Wound NP stated the wound should have been recleaned after the wound contacted the resident's brief. She stated wound care was done using clean technique and not by sterile technique. A clean barrier should have been placed under the resident's buttocks prior to the wound care being performed. During weekly facility visits, the Wound NP stated she provided education on correct wound care technique to the staff nurses.An interview with the Wound Care Nurse was conducted on 08/15/25 at 7:58 AM. The Wound Care Nurse stated she was aware the Wound NP expected betadine to be used liberally on Resident #56's heel. She stated she was aware when Nurse #2 did not provide this treatment and stated betadine was applied.The Director of Nursing (DON) was interviewed on 08/15/25 at 4:07 PM. The DON stated wounds did not have to be cleaned by starting at the center of a wound and moving to the outer edges of the wound in a continuous circular motion. She explained Resident #56 was a resident of color and that betadine was difficult to see on a person of color. She also stated she was not aware the Wound NP expected betadine to be used liberally on a wound. The DON also discussed Resident #56's left buttock wound and stated she did not think the wound should have been re-cleaned after being placed on his brief. The DON stated the Wound Care Nurse was responsible for providing wound care education.Interview with the Administrator on 08/15/25 at 4:27 PM revealed the Wound Care Nurse had made her aware of the wound care treatment on 08/14/25 for Resident #56. She confirmed Nurse #2 was nervous and did not routinely provide wound care. The Administrator explained Nurse #2 was knowledgeable in how to provide wound care but was nervous having the Wound Care Nurse, and surveyors present. She stated the Wound Care Nurse was available to assist/educate any staff providing wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to keep a urinary catheter drainage bag from touching the floor to reduce the risk of infection for 1 of 1 resident reviewed for urinary catheter (Resident #56).Findings included:Resident #56 was readmitted on [DATE]. Related diagnoses included urinary tract infection, chronic kidney disease, bacteremia (bloodstream infection), pyonephrosis (kidney infection).Physician order dated 08/06/25 for an indwelling urinary catheter to straight drainage related to acute kidney injury and secure indwelling catheter tubing using anchoring device to prevent movement and urethral traction every shift for acute kidney injury.The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #56 was severely cognitively impaired without behaviors. The MDS documented an indwelling urinary catheter. The MDS showed Resident #56 was dependent on rolling left to right and lying to sitting on the side of the bed was not attempted.Care plan for Resident #56 dated 08/13/25 showed a focus for an indwelling catheter. The goals were for the resident to be/remain free from catheter-related trauma; and the resident will show no signs and symptoms of urinary infection. Interventions included position catheter bag and tubing below the level of the bladder and away from entrance room door and check tubing for kinks.On 08/15/25 at 8:08 AM an observation of Resident #56 showed the resident lying in bed. The indwelling urinary catheter bag was observed positioned below the level of the bladder on the floor and partially under the bed, covered with a privacy bag.Another observation on 08/15/25 at 8:53 AM showed the indwelling urinary catheter bag was positioned below the level of the bladder on the floor and partially under the bed, covered with a privacy bag.Follow-up observation on 08/15/25 at 10:10 AM revealed the catheter bag remained positioned below the level of the bladder on the floor covered with the privacy bag. A subsequent observation on 08/15/25 at 11:39 AM revealed the catheter bag remained on the floor covered with the privacy bag.Interview with Nursing Aide (NA) #2 on 08/15/25 at 1:32 PM confirmed that she was assigned to Resident #56. The NA observed the resident's catheter on the floor with the surveyor. NA #2 stated the catheter should not be touching the floor. She stated she did not know how the catheter ended up on the floor because she had hung it up on the side of the bed after providing Resident #56 with morning care. NA #2 stated the resident could not reach the catheter bag to knock it on the floor.Interview with Nurse #3 on 08/15/25 at 2:51 PM confirmed she was assigned to Resident #56. Nurse #3 stated she was unaware of the catheter bag lying on the floor. She confirmed that she had been in the resident's room throughout the day (08/15/25) and had not assessed the catheter and/or catheter bag. She stated she assessed catheters once per shift.Interview with the Director of Nursing (DON) on 08/15/25 at 4:07 PM revealed NA #2 made her aware Resident #56's catheter bag was lying on the floor. She acknowledged the bag should not be lying on the floor. Stated there were areas on the bedframe that were thinner and could be used to clip the bag to those areas. The DON stated the bag clip may be broken and the bag may need to be replaced.Interview with the Administrator on 08/15/25 at 4:27 PM revealed she was made aware of the catheter on the floor by NA #2 and that it should not be on the floor. She stated that it was difficult to keep catheter bags off the floor when the bed was in the lowest position. The Administrator stated that the resident could be responsible for the catheter drainage bag being on the floor by knocking it off.

Based on observation and staff interviews, the facility failed to keep 1 of 1 walk-in refrigerator walls free of a dark black/green substance. The Findings Included: An initial tour of the kitchen was conducted on 8/12/2025 at 10:20 am. A dark black /green substance was observed on all four walls of the walk-in refrigerator. An area located under the refrigerator rack and adjacent to the walk-in freezer door was observed to have a large area of a dark black/green substance in the corner that extended to the floor. An interview and observation were conducted on 8/12/2025 at 10:25 am of the walk-in- refrigerator with the Dietary Manager. Upon observation of the walk-in refrigerator, the Dietary Manager stated she did not know what the substance was on the walk-in refrigerator walls. She further stated the dietary staff cleaned the walk-in- refrigerator every Wednesday. Although the walk-in refrigerator was cleaned, the substance continued to come back. The Dietary Manager indicated she had not notified the Maintenance Director or the Administrator that the substance continued to return. Interview and observation with the Maintenance Director on 8/12/2025 at 10:36 am revealed the dark black/green substance in the walk-in refrigerator appeared to be mold. He further revealed that what appeared to be mold could have been due to condensation. If the walk-in refrigerator door was not closed properly, the door seal would not ensure the walk-in refrigerator stayed cooled. The Maintenance Director stated he had not been notified of the substance in the walk-in refrigerator or that when it was cleaned it would return. An interview with the Administrator on 8/15/2025 at 4:51 pm revealed she had observed the walk-in refrigerator on 8/12/2025. She revealed she did not know what the substance was, but it was dark in color. She thought the substance was from when the walk-in refrigerator doors were not being closed properly. An outside agency had cleaned the walk-in refrigerator months ago, but she was not informed that the black substance had come back. She was unaware the Maintenance Director had no knowledge of the dark black/green substance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with resident and staff, the facility failed to ensure the resident's right to file a grievance and receive written notification of the decision regarding the grievance investigation for 4 of 5 residents reviewed for the grievance process. (Resident #17, Resident #9, Resident #22, and Resident #21) The findings included: Review of the facility policy dated 3/8/22 titled Grievance Policy read in part: 7. The facility must ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident ' s grievance, the steps taken to investigate the grievance, a summary of the pertinent finding or conclusions regarding the residents ' concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken by the facility, and the date the written decision was issued. 1. Resident #17 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #17 was cognitively intact. Review of a grievance filed since the last standard survey on 5/11/23 revealed Resident #17 had filed a grievance on 8/16/23. The 8/16/23 grievance revealed Resident #17 expressed concerns about receiving pork despite her saying she does not eat pork. An interview was conducted with Resident #17 on 8/13/24 at 2:00 PM and she explained she had not received a written resolution regarding the outcomes of the grievance she had reported and had not been told verbally. Resident #17 reported that she still received pork on her meal tray. During an interview with the Administrator on 8/14/24 at 10:56 AM he stated he was responsible for coordinating the grievance process. He indicated grievances were reviewed each morning with the interdisciplinary team during morning meetings. He stated the grievances were dispersed to the corresponding department and resolution completed within 72 hours. The Administrator further stated the grievances came back to the interdisciplinary team and were reviewed by the grievance officer. The grievance outcome was given to the person who filed the grievance in writing but was sometimes provided verbally. He revealed he told Resident #17 verbally of the grievance outcome. 2. Resident #9 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was cognitively intact. Review of the grievances filed since the last standard survey on 5/11/23 revealed Resident #9 had filed a grievance on 8/2/23. The 8/2/23 grievance revealed Resident #9 had an issue with her bed not being made. An interview was conducted with Resident #9 on 8/13/24 at 2:22 PM and she explained she had not received a written resolution regarding the outcomes of the grievance she had reported and had not been told verbally. During an interview with the Administrator on 8/14/24 at 10:56 AM he stated he was responsible for coordinating the grievance process. He indicated grievances were reviewed each morning with the interdisciplinary team during morning meetings. He stated the grievances were dispersed to the corresponding department and resolution completed within 72 hours. The Administrator further stated the grievances came back to the interdisciplinary team and were reviewed by the grievance officer. The grievance outcome was given to the person who filed the grievance in writing but was sometimes provided verbally. He revealed he told Resident #9 verbally of the grievance outcome. 3. Resident #22 was admitted to the facility on [DATE]. A review of the most recent annual MDS dated [DATE] revealed the resident was cognitively intact. Review of the grievances filed since the last standard survey on 5/11/23 revealed Resident #22 had filed 8 grievances with the facility on 7/9/23, 9/25/23, 11/15/23, 12/7/23, 12/28/23, 1/3/24, 5/6/24, 5/8/24, 7/19/24. Review of the 7/9/23 grievance revealed Resident #22 complained of cold food. The 9/25/23 grievance expressed by Resident #22 was related to an argument with another resident in the dining room. The grievance shared on 11/15/23 was regarding the Administrator ' s action when delivering her groceries. Review of the grievance initiated on 12/7/23 revealed Resident #22 had a disagreement with another resident. The 12/28/23 grievance expressed by Resident #22 was related to a pair of missing pants and socks. The grievance shared on 1/3/24 was regarding dietary staff when Resident #22 asked for an alternate meal. Review of the grievance dated 5/6/24 revealed Resident #22 she was still missing pants and food. The 5/8/24 grievance expressed by Resident #22 was related to her not being able to open the door to her room while in the wheelchair, requesting another bedside table, and remove boxes from the floor. The grievance shared on 7/19/24 was regarding staff not putting creams and lotions on resident legs and not hanging up clothing. An interview was conducted with Resident #22 on 8/12/24 at 11:40 AM and she explained she had not received a written resolution regarding the outcomes of the grievances she had reported and had not been told verbally. During an interview with the Administrator on 8/14/24 at 10:56 AM he stated he was responsible for coordinating the grievance process. He indicated grievances were reviewed each morning with the interdisciplinary team during morning meetings. He stated the grievances were dispersed to the corresponding department and resolution completed within 72 hours. The Administrator further stated the grievances came back to the interdisciplinary team and were reviewed by the grievance officer. The grievance outcome was given to the person who filed the grievance in writing but was sometimes provided verbally. He revealed he told Resident #22 verbally of the grievance outcomes. 4. Resident #21 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Review of a grievance filed since the last standard survey revealed Resident #21 had filed a grievance on 7/12/23. Review of the 7/12/23 grievance revealed Resident #21 had missing money. An interview was conducted with Resident #21 on 8/13/24 at 9:32 AM and she explained she had not received a written resolution regarding the outcomes of the grievances she had reported and had not been told verbally. During an interview with the Administrator on 8/14/24 at 10:56 AM he stated he was responsible for coordinating the grievance process. He indicated grievances were reviewed each morning with the interdisciplinary team during morning meetings. He stated the grievances were dispersed to the corresponding department and resolution completed within 72 hours. The Administrator further stated the grievances came back to the interdisciplinary team and were reviewed by the grievance officer. The grievance outcome was given to the person who filed the grievance in writing but was sometimes provided verbally. He revealed he told Resident #21 verbally of the grievance outcome.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interview the facility failed to maintain an effective pest control program as evidenced by the presence of flies on 2 of 5 Hallways that affected resident rooms 117, 118, 121, 122, and 123. The findings included: Review of the pest control receipt for 6/28/24 read: inspected and treated select areas with a focus on kitchen. Performed exterior rodent services, checked accessible bait stations and replaced bait as needed. No rodent or insect activity was noted during inspection and/or service. There was no mention of a fly program service. Review of the pest control receipt for 7/31/24 read: inspected and treated select areas. Performed exterior rodent services, checked accessible bait stations and replaced bait as needed. No rodent or insect activity was noted during inspection and/or service. There was no mention of a fly program service. a. An observation of a resident in room [ROOM NUMBER] was conducted on 08/12/24 at 09:32 AM. There were flies noted in the room that landed on the bed, the bedside table and the resident ' s hand. b. An observation of a resident in room [ROOM NUMBER] was conducted on 08/12/24 10:12 AM. There were flies noted in the room that landed on the bed, on the resident ' s leg and the bedside table. An observation of a resident in room [ROOM NUMBER] was conducted on 8/14/24 at 10:36 AM. There were flies noted on the bedside table, on the cup of orange juice on the bedside table, and on the cup of coffee on the bedside table. An observation of a resident in room [ROOM NUMBER] was conducted on 8/14/24 at 12:53 AM. There were flies in the room that landed on the bed, urinary drainage bag tubing and resident ' s foot. c. An observation of a resident in room [ROOM NUMBER] was conducted on 08/12/24 at 10:50 AM. There were flies noted in the room that landed on the bed, on the resident ' s lap and the bedside table. The resident stated he had issues with flies and had purchased a fly swatter which he was holding. d. An observation of a resident in room [ROOM NUMBER] was conducted on 08/12/24 11:08 AM. There were flies noted in the room that landed on the bed and the bedside table. e. An observation was conducted on 08/12/24 at 02:15 PM. There were flies in the room, on the resident ' s chest and on the arm rest of the wheelchair the resident was sitting in. An observation was conducted on 08/13/24 at 10:55 AM. There were flies noted in the room on the resident 's chest and the resident's bed. An interview was conducted with NA #1 on 8/12/24 at 2:40 PM. NA #1 stated she was a full-time employee at the facility and worked on the hallway where rooms 116, 117, 121 were located. NA #1 stated that there were insect lights on the wall in the hallway and a door blower over the exit door to help with flies. During a resident council meeting held on 8/13/24 at 2:00 PM, the council reported that they had been having issues with flies and had mentioned it to the Administrator. An interview was conducted with the Maintenance Director on 8/14/24 at 9:13 AM. The Maintenance Director stated that the Pest Control Technician comes to the facility once a month. The Maintenance Director stated he provided the fly program service and the number of flies in the facility depended on the weather. He explained that the facility had insect lights on the hallway walls and door blowers over the C Hall (Rooms 114 to 121) and D Hall (Rooms 122 -126) exit doors. The D Hall exit door lead out to the smoking gazebo which resident entered and exited multiple times each day. The Maintenance Director stated the glue boards in the insect lights were checked every month and changed every three months or sooner if needed. The Maintenance Director stated he sprays fly spray around the outside of the kitchen back door and the outside exit doors daily but is unable to use the fly spray inside the facility due to some residents being sensitive to the chemicals. The Administrator was interviewed on 8/14/24 at 10:56 AM. The Administrator stated the Pest Control Technician comes to the facility once a month to inspect and treat selected areas of the facility. The Administrator stated he felt that the facility had insect lights and door blowers to help with the flies. The Administrator stated the Maintenance Director was responsible for the maintenance of the hallway insect lights and he was unaware of any issues with the equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interviews, the facility failed to allow two residents that were non-compliant with the facility smoking policy to remain in the facility for 2 of 2 residents reviewed for facility-initiated discharge (Resident #32 and Resident #23). The findings included: 1. Resident #32 was admitted to the facility on [DATE] with diagnoses which included anxiety disorder, opioid abuse, and chronic pain. A care plan was initiated on 8/10/22 and last revised on 5/02/23 for non-compliance with following the smoking policy. Resident #32 was re-educated on the smoking policy. The interventions included smoking materials will remain in designated areas and not in resident room, resident would be supervised in designated smoking area., and will continue to be monitored for non-compliance. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #32 was cognitively intact and used tobacco. Resident #32 was coded for behaviors directed towards others and other behavioral behavior symptoms. A behavior note dated 2/18/23 at 2:20 pm revealed Resident #32 was verbally aggressive and used inappropriate language towards staff because he was upset about smoking location. Staff were unable to calm or redirect Resident #32 and he continued to speak loudly and call staff names. The Nursing Home Notice of Transfer/discharge date d 3/15/23 revealed Resident #32 was issued a 30-day discharge notice which stated the reasons for transfer/discharge was his needs could not be met in the facility and the safety of individuals in the facility was endangered due to the clinical or behavioral status of the resident. The notice was signed by Resident #32 with a date of transfer listed as 4/14/23 to another skilled nursing facility that provided the same services. A discharge progress note dated 3/31/23 at 3:40 pm by the Social Worker revealed Resident #32 was discharged from the facility at approximately 10:00 am and was transported by facility staff in the facility van. During an interview on 5/08/23 at 12:40 pm Resident #32 revealed he was non-compliant with the smoking policy at the facility but did not see it to be a problem. He stated he does go out when it is not time to smoke because he wants to smoke, and he stated he had been provided the smoking policy on several occasions. An interview was conducted on 5/09/23 at 11:30 am with the Social Worker who revealed she was present when the 30-day Discharge Notice was delivered to Resident #32, and he did not have any questions at the time the notice was presented. During an interview on 5/10/23 at 2:22 pm the previous Director of Nursing (DON) revealed she worked at the facility when Resident #32 was presented the 30-day discharge notice. The previous DON stated Resident #32 was non-compliant with the smoking policy during the time she worked at the facility by going out during non-smoking times and not properly storing smoking materials. An interview was conducted with the Administrator on 5/10/23 at 2:50 pm who revealed Resident #32 had multiple violations of the facility smoking policy and he had spoken with Resident #32 on multiple occasions to re-educate on the policy and discuss his non-compliance. He stated Resident #32 had put all the residents of the facility at risk due to his non-compliance and he felt the 30-day Discharge Notice was appropriate due to those concerns. He stated Resident #32 had the opportunity to ask questions and request an appeal, but he chose to discharge. 2. Resident #23 was admitted to the facility on [DATE] with diagnoses which included diabetes, anxiety, and depression. Resident #23 was discharged to another facility on 4/27/23. A progress note dated 8/31/22 revealed Resident #23 was a smoker and was not compliant with the facility smoking policy at times. The care conference note dated 12/8/22 revealed Resident #23 was noted to require encouragement to allow personal hygiene. No other concerns were documented during care plan meeting regarding behaviors. A social service progress note dated 3/3/23 revealed Resident #23 was pleasant in his conversations with both staff and other residents and had behaviors such as refusing personal care, urinating on floor, and the smoking policy. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was cognitively intact, used tobacco, and was not coded for any behaviors during the 7-day look back period. The Nursing Home Notice of Transfer/discharge date d 3/22/23 revealed Resident #23 was issued a 30-day discharge notice which stated the reasons for transfer/discharge was his needs could not be met at the facility and the safety of individuals in the facility was endangered due to the clinical or behavioral status of the resident. The notice was signed by Resident #23 with a date of transfer listed as 4/21/23 to another skilled nursing facility which provided the same services. The Discharge Progress note dated 3/31/23 at 3:35 pm by the Social Worker revealed Resident #23 was discharged from the facility. The Social Worker reported Resident #23 was appreciative of the care and was excited to be closer to family and friends. Multiple attempts to interview Resident #23 at his new facility were unsuccessful. During an interview with the Social Worker on 5/09/23 at 11:30 am she revealed was present when the Administrator delivered the 30-day Discharge Notice to Resident #23. The Social Worker stated Resident #23 had requested to be transferred to be closer to his family and friends since his admission and she had sent multiple referrals to facilities in the area he wished to be transferred to but had not been able secure a location for his transfer due to his payor source, need for bariatric equipment, and his documented behaviors which included non-compliance with smoking and personal hygiene concerns. She stated when a bed became available at the receiving facility Resident #23 was asked if he wanted to transfer there and he stated he would like to transfer to the receiving facility. An interview was conducted on 5/10/23 at 2:22 pm with the previous Director of Nursing (DON) who revealed she worked at the facility at the time of Resident #23's discharge but was not involved with the 30-day Discharge Notice being issued and was not present when Resident #23 was notified a bed was available at the receiving facility. The previous DON stated Resident #23 was non-compliant with the smoking policy and had behaviors which included refusal of care and refusal of personal hygiene. During an interview on 5/10/23 at 2:44 pm the Administrator revealed Resident #23 had continued to violate the facility's smoking policy and endangered the rest of the residents in the facility by his non-compliance. The Administrator stated he felt the 30-Day Discharge Notice was presented in accordance with the regulation when it was presented to Resident #23. The Administrator stated Resident #23 wished to be discharged from the facility to a location closer to his home and agreed with the discharge, so he felt the 30-day discharge notice was no longer valid for Resident #23 because he wanted to discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interviews, Physician interview, Wound Physician interview, Ombudsman, and receiving facility's Administrator (Administrator #2) and admission Director (admission Director #2) interviews, the facility failed to provide a safe and orderly discharge when the facility staff left Resident #32 and Resident #23 at the receiving facility after being informed the residents were not accepted for admission for 2 of 2 residents reviewed for facility-initiated discharge (Resident #32 and Resident #23). The findings included: 1. Resident #32 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #32 was cognitively intact and had a colostomy and indwelling catheter. Resident #32 was coded for tobacco use and had an unstageable sacral pressure ulcer. Resident #32's care plan last revised on 3/15/23 revealed he had a care plan for attention seeking behaviors, falsely accusing other residents and staff of threatening him, and being verbally and physically aggressive towards staff. An additional care plan was in place for resistance to care which included refusal to wear colostomy bags and refusal of pressure ulcer treatments. The Nursing Home Notice of Transfer/discharge date d 3/15/23 revealed Resident #32 was issued a 30-day discharge notice with date of transfer listed as 4/14/23. The notice was signed by Resident #32. A physician order dated 3/16/23 for oxycodone oral table 30 milligrams (mg). Give 1 tablet by mouth four times a day for pain. Review of the email from the receiving facility dated 3/22/23 revealed Resident #32 was accepted for admission. An interview was conducted on 5/09/23 at 11:30 am with the Social Worker who revealed she sent Resident #32's referral packet to the receiving facility and she had received an email on 3/22/23 that Resident #32 was accepted for admission. The Social Worker stated she sent all required information in the referral which included Resident #32's smoking status. She stated admission Director #2, the receiving facility's admission Director, stated he would be able to go off campus to smoke. The Social Worker stated Resident #32 was notified on 3/30/23 that he was accepted at the receiving facility, and he agreed to be transferred to the receiving facility on 3/31/23. A discharge progress note dated 3/31/23 at 3:40 pm by the Social Worker revealed Resident #32 was discharged from the facility at approximately 10:00 am and was transported by facility staff in the facility van with his belongings and medications. During a telephone interview on 5/10/23 at 5:47 pm with Nurse #1 who discharged Resident #32 from the facility on 3/31/23 and he had no concerns before leaving. Nurse #1 stated she called the receiving facility and gave the nurse a report and they did not state Resident #32 was not being accepted for admission. During an interview on 5/09/23 at 3:45 pm the Wound Nurse revealed she accompanied Resident #32 during the transfer to the receiving facility on 3/31/23. She stated Resident #32's personal items were taken by Administrator #1 and admission Director #1, in a private car that followed the facility van. She stated when they arrived at the receiving facility Resident #32 was taken into the facility and she completed nurse to nurse report and gave Resident #32's medications to the nurse at the facility. The Wound Nurse stated Administrator #1 and admission Director #1 left the receiving facility after Resident #32's personal items were taken to his room. The Wound Nurse stated as she prepared to leave after giving report when the receiving facility's Administrator, Administrator #2, stated they needed to take Resident #32 back because she was no longer accepting him. The Wound Nurse stated she called Administrator #1 and was instructed that she was able to leave the receiving facility without Resident #32 because the facility had accepted him as a resident, so they left the facility without Resident #32. The Wound Nurse stated they were about halfway back to their facility when they received the call from Administrator #1 that they needed to return to bring Resident #32 back from the receiving facility. She stated the drive to the receiving facility was about 5 hours and she stated when she received the call they turned around and went back to pick up Resident #32. The Wound Nurse reported Resident #32 laid on the back seat and slept most of the way back from the receiving facility and woke one time to ask how much longer but never reported pain or discomfort during either transfer. An interview was conducted on 5/09/23 at 3:38 pm with the Transportation Aide who revealed she drove Resident #32 to the receiving facility on 3/31/23. She stated when they arrived at the receiving facility, a wheelchair was brought out for Resident #32, and he went into the facility. She stated his belongings were placed in the room that was assigned to him. The Transportation Aide reported that as she was leaving, the receiving facility's Administrator, Administrator #2, told her and the Wound Nurse that the facility had changed their mind and would no longer be able to admit Resident #32 and that they needed to take him back. She stated they did stop one time on the drive to the receiving facility for a bathroom break and to purchase a drink for Resident #32. The Transportation Aide stated when they returned to pick up Resident #32, he had a pizza and a drink that was given to him by the receiving facility. She stated during the ride to and from the receiving facility Resident #32 did not report pain, a need for additional stop, and she stated he slept most of the time back to the facility. admission Director #1 reported during an interview on 5/09/23 at 4:35 pm that she drove with Administrator #1 to the receiving facility with Resident #32's personal items because they were unable to fit in the facility van. admission Director #1 stated when she left the receiving facility Resident #32 was inside the facility and his belongings were in his assigned room. She stated Administrator #2, the receiving facility Administrator, did not notify her before she left that Resident #32 was not accepted at the facility, but she did contact her Administrator, Administrator #1, on the phone after they left. An interview was conducted on 5/09/23 at 11:30 am with the Social Worker who stated she was not notified that Resident #32 was no longer accepted at the receiving facility. A nursing progress note dated 3/31/23 at 11:39 pm by Nurse #2 revealed Resident #32 was received back at the facility via facility transportation and returned to his previous room. Resident #32 reported pain and was administered his pain medication. Multiple attempts to interview Nurse #2 were unsuccessful. Record review of the Medication Administration Record dated April 2023 revealed Resident #32 was administered oxycodone 30 mg for pain at midnight on 4/01/23 for reported pain level of 5 out of 10. During an interview on 5/08/23 at 12:47 pm Resident #32 reported he was notified by the Social Worker and Administrator #1 on 3/30/31 that he was accepted at the receiving facility, and he would be discharging on 3/31/23. He stated when he arrived at the facility, he was told by the receiving facility's Administrator, Administrator #2, that he was not accepted for admission, and he would need to return to the facility he came from. He stated the receiving facility did not allow him to enter the building and made him stay outside with his belongings, they did not administer any medications, they did not provide any meals during the time at facility and did not allow him to use the bathroom to empty his colostomy bag or catheter bag. Resident #32 stated he was independent for his care needs and was able to transfer without help so he did not need anyone to do anything for him. Resident #32 stated he was in pain when he returned and was not given medication for his pain until the morning of 4/01/23. During a follow-up interview on 5/09/23 at 3:05 pm Resident #32 revealed he agreed to go to the receiving facility after he spoke to admission Director #2 (from the receiving facility) and she confirmed he would be able to smoke. He stated he now recalled that at some point during his time at the receiving facility they allowed him to enter the building for about 30 minutes to use the bathroom but did not allow him to stay in the building. Resident #32 reported that he now recalled the receiving facility had given him a pizza and a drink during his time there but did not administer any medications. During a telephone interview on 5/09/23 at 8:41 am the State Ombudsman revealed Resident #32 reported he was discharged from the facility on 3/31/23 to another facility. He stated when he arrived, he was notified that he was not accepted for admission by the Receiving Facility Administrator. She stated Resident #32 reported he was not given food, drink, did not have the opportunity to use the bathroom while he was enroute to and while at the receiving facility, and had to wait 12 hours to return to the facility. A telephone interview was conducted on 5/09/23 at 1:20 pm with admission Director #2 from the receiving facility who revealed she had received the admission referral for Resident #32, and he was accepted to the facility with expected admission date of 3/31/23. She stated Resident #32 had contacted her on the day before expected admission [DATE]) to confirm he would be able to smoke at the facility and she notified Resident #32 that the facility was non-smoking, but he was able to sign himself out and smoke off the property. admission Director #2 stated she felt she did not receive all the information about Resident #32 but was unable to state what information she felt was omitted. She stated she was not at the facility on the date of transfer (3/31/23) and was unable to state why Administrator #2 denied admission. An interview was conducted on 5/10/23 at 11:07 am with the Medical Director who revealed Resident #32 sitting in a van seat for transport was not a concern due to his ability to normally spend the day sitting in his wheelchair or laying on his sacrum. He stated Resident #32 was non-complaint with offloading of his pressure ulcer and would not let staff complete his pressure ulcer treatments often. The Medical Director stated Resident #32's missed doses of medication while he was at the receiving facility caused no negative outcome as Resident #32 was able to take his next dose of medication when he returned to the facility. He stated Resident #32's pain reported when he returned to the facility was normal for him because he continuously reported pain. The Medical Director reported Resident #32 was administered his scheduled pain medication when he returned to the facility. During a telephone interview on 5/10/23 at 11:39 am the Wound Physician stated Resident #32 was able to reposition independently and would be able to offload while sitting. The Wound Physician stated Resident #32 was noncompliant with his sacral pressure ulcer which include not allowing a dressing to be applied and history of picking at his sacral pressure ulcer so she was unable to state if sitting in a vehicle for the drive to and from the facility would have caused damage to the pressure ulcer. A telephone interview was conducted on 5/11/23 at 9:33 am with Administrator #2, the receiving facility's Administrator, revealed she did not feel comfortable accepting Resident #32 because he was a smoker and did not have an intention to stop smoking. She stated her facility was a non-smoking facility and she did not feel it was safe for him to cross the street in his wheelchair to smoke. She reported she notified the Transportation Aide and the Wound Nurse but Resident #32 was left at the facility. Administrator #2 stated she contacted Administrator #1 on the phone, and he stated he would send the Wound Nurse and Transportation Aide back to pick up Resident #32. Administrator #2 stated Resident #32 was allowed to enter the facility and she provided food, drinks, and use of bathroom but the facility did not administer any medication due to Resident #32 not being accepted for admission. She stated Resident #32 remained in the facility until the Wound Nurse and Transportation Aide returned. Administrator #2 stated the Wound Nurse and the Transportation Aide did come back and pick up Resident #32, but she felt they should not have left him when they were notified that he was no longer accepted for admission. An interview was conducted with Administrator #1 on 5/11/23 at 2:50 pm who revealed he drove along with admission Director #1 to deliver Resident #32's belongings to the receiving facility on 3/31/23. He stated he was in contact with Administrator #2 at the receiving facility throughout the five-hour drive to provide updates on travel time since it was a far distance away. He stated at no time during the drive or while he was at the facility did Administrator #2 tell him she had changed her mind and would no longer accept Resident #32 at her facility. Administrator #1 stated he received a phone call from the Wound Nurse that drove Resident #32 to the receiving facility, and he did tell them it was okay to leave Resident #32 because they had accepted him, and his belongings were in the facility. He stated he then spoke to Administrator #2 by phone who stated Resident #32 needed to be picked back up because they were not able to care for him and she stated she did not know he was a smoker. She stated she did not feel comfortable accepting Resident #32. Administrator #1 stated he contacted the Wound Nurse and notified them they needed to return and bring Resident #32 back to the facility. Administrator #1 stated the facility managed the discharge of Resident #32 properly by sending the required information during the referral process, transporting Resident #32 and his belongings including medications, and giving report to receiving nurse at the facility. Administrator #1 stated the receiving facility was notified of the smoking background during the referral process and they accepted him with that knowledge, so he was unable to state why the receiving facility changed their mind once Resident #32 arrived for admission. Administrator #1 stated the facility managed the discharge of Resident #32 properly by sending the required information during the referral process, transporting Resident #32 and his belongings including medications, and giving report to receiving nurse at the facility. Administrator #1 stated the receiving facility was notified of the smoking background during the referral process and they accepted him with that knowledge, so he was unable to state why the receiving facility changed their mind once Resident #32 arrived for admission. 2. Resident #23 was admitted to the facility on [DATE]. Resident #23 was discharged to another facility on 4/27/23. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was cognitively intact and used tobacco. The Nursing Home Notice of Transfer/discharge date d 3/22/23 revealed Resident #23 was issued a 30-day discharge notice with date of transfer listed as 4/21/23. The notice was signed by Resident #23. An interview was conducted on 5/09/23 at 11:30 am with the Social Worker who revealed she sent Resident #23's referral packet to the receiving facility and she had received an email on 3/22/23 that Resident #23 was accepted for admission. The Social Worker stated she sent all required information in the referral which included Resident #23's smoking status. She stated admission Director #2, the receiving facility's admission Director, stated they would be able to go off campus to smoke. The Social Worker stated Resident #23 had requested to be transferred to be closer to his family and friends since his admission and she had sent multiple referrals to facilities in the area he wished to be transferred to but had not been able secure a location for his transfer. She stated when a bed became available at the receiving facility Resident #23 was asked if he wanted to transfer there and he stated he would like to transfer to the receiving facility. The Social Worker stated Resident #23 did not have many visitors while at the facility, so he was excited to be closer to his friends and family members. A discharge planning note dated 3/30/23 at 5:21 pm by the Social Worker revealed Resident #23 was accepted for admission at the receiving facility on 3/22/23 and transportation would be provided by the facility with a discharge date planned on 3/31/23. A nursing note dated 3/31/23 at 2:48 pm by Nurse #1 revealed nursing report was called to the receiving facility nurse. During a telephone interview on 5/10/23 at 5:47 pm with Nurse #1 who discharged Resident #23 from the facility on 3/31/23 stated she called the receiving facility and gave the nurse a report and they did not state Resident #23 was not being accepted for admission. A discharge progress note dated 3/31/23 at 3:35 pm by the Social Worker revealed Resident #23 was discharged from the facility and was transported by facility van. Resident #23 left the facility with his belongings. During an interview on 5/09/23 at 3:45 pm the Wound Nurse revealed she accompanied Resident #23 during the transfer to the receiving facility on 3/31/23. She stated Resident #23's personal items were taken by the Administrator, Administrator #1, and admission Director, admission Director #1, in a private car that followed the facility van. She stated when they arrived at the receiving facility Resident #23 was taken into the facility and she completed nurse to nurse report and gave Resident #23's medications to the nurse at the facility. The Wound Nurse stated Administrator #1 and admission Director #1 left the receiving facility after Resident #32's personal items were taken to his room. The Wound Nurse stated as she prepared to leave the facility the receiving facility's Administrator, Administrator #2, stated they needed to take Resident #23 back because she was no longer accepting him. The Wound Nurse stated she called Administrator #1 and was instructed that she was able to leave the receiving facility without Resident #23 because the facility had accepted him as a resident, so they left the facility without Resident #23. She stated the ride to the receiving facility was about 5 hours with the stop to use the bathroom and they were about halfway back to their facility when she received the call from her Administrator, Administrator #1, to go back and pick up Resident #23. The Wound Nurse reported Resident #23 did not report pain during the time back to the facility. An interview was conducted on 5/09/23 at 3:38 pm with the Transportation Aide who revealed she drove Resident #23 to the receiving facility, which took about 5 hours one way, on 3/31/23 with the Wound Nurse. She stated when they arrived at the receiving facility, she took Resident #23 into the facility in his wheelchair and assisted him to use the restroom. She stated his belongings were placed in the room that was assigned to him. The Transportation Aide reported that as she was leaving Administrator #2, the receiving facility's Administrator, told her and the Wound Nurse that the facility had changed their mind and would no longer be able to admit Resident #23 and that they needed to take him back. She stated they did stop one time on the drive to the receiving facility to use the restroom for Resident #23. The Transportation Aide stated when they returned to pick up Resident #23, he had a pizza and a drink that was given to him by the receiving facility. She stated during the ride to and from the receiving facility Resident #23 did not report pain or a need for an additional stop. admission Director #1 reported during an interview on 5/09/23 at 4:35 pm that she drove with Administrator #1 to the receiving facility with Resident #23's personal items because they were unable to fit in the facility van. admission Director #1 stated when she left the receiving facility Resident #23 was inside the facility and his belongings were in his assigned room. She stated Administrator #2, the receiving facility Administrator, did not notify her before she left that Resident #23 was not accepted at the facility, but she did contact her Administrator, Administrator #1, on the phone after they left. An interview was conducted on 5/09/23 at 11:30 am with the Social Worker who revealed she was not notified that Resident #23 was no longer accepted at the receiving facility. A nursing progress note dated 3/31/23 at 11:21 pm by Nurse #2 revealed Resident #23 returned to the facility via facility transport and was admitted to his previous room. Resident #23 reported pain and was administered medication. Multiple attempts to interview Resident #23 (no longer a resident at this facility) by phone were unsuccessful. During a telephone interview on 5/09/23 at 8:41 am the State Ombudsman revealed Resident #23 reported he was discharged from the facility on 3/31/23 to another facility. He stated when he arrived the facility declined to admit him. She stated Resident #23 reported he was not given lunch or dinner and he did not have his blood sugar checked or scheduled insulin. Resident #23 did not report any negative outcome. A telephone interview was conducted on 5/09/23 at 1:20 pm with admission Director #2 from the receiving facility who revealed she had received the admission referral for Resident #23, and he was accepted to the facility with expected admission date of 3/31/23. She stated she knew Resident #23 was a smoker. admission Director #2 stated she felt she did not receive all the information about Resident #23 in their referral but was unable to state what information she felt was omitted. She stated she was not at the facility on the date of transfer (3/31/23) and was unable to state why Administrator #2 denied admission to Resident #23. During an interview on 5/10/23 at 11:07 am the Medical Director revealed Resident #23 did not have any negative effect from missing his prescribed medication times and being in the vehicle for an extended period on 3/31/23. The Medical Director stated Resident #23 was able to take his evening medications when he returned to the facility and did not have any negative outcome due to the missed doses while he was at the receiving facility. A telephone interview was conducted on 5/11/23 at 9:33 am with Administrator #2, the receiving facility Administrator, who revealed she did not feel comfortable accepting Resident #23 because he was a smoker and did not have an intention to stop smoking. She stated her facility was a non-smoking facility and she did not feel it was safe for him to cross the street in his wheelchair to smoke. She reported she notified the Transportation Aide and the Wound Nurse but Resident #23 was left at the facility. Administrator #2 stated she contacted Administrator #1 on the phone, and he stated he would send the Wound Nurse and Transportation Aide back to pick up Resident #23. Administrator #2 stated Resident #23 was allowed to enter the facility and she provided food, drinks, and use of bathroom but the facility did not administer any medication or check his blood sugar due to Resident #23 not being accepted for admission. She stated Resident #32 remained in the facility until the Wound Nurse and Transportation Aide returned. Administrator #2 stated the Transportation Aide and Wound Nurse should not have left Resident #23 when they were notified that he was no longer accepted for admission. An interview was conducted with Administrator #1 on 5/11/23 at 2:50 pm who revealed he drove along with the admission Director #1 to deliver Resident #23's belongings to the receiving facility on 3/31/23. He stated he was in contact with Administrator #2 at the receiving facility throughout the five-hour drive to provide updates on travel time since it was a far distance away. He stated at no time during the five-hour drive or while he was at the facility did Administrator #2 tell him she had changed her mind and would no longer accept Resident #23 at her facility. Administrator #1 stated he received a phone call from the Wound Nurse who drove Resident #23 to the receiving facility, and he did tell them it was okay to leave Resident #23 because they had accepted him, and his belongings were in the facility. He stated he then spoke to Administrator #2 by phone who stated Resident #23 needed to be picked back up because they were not able to care for him and she stated she did not know he was a smoker. She stated she did not feel comfortable accepting him. Administrator #1 stated he contacted the Wound Nurse and the Transportation Aide and notified them they needed to return and bring Resident #23 back to the facility. Administrator #1 stated the facility managed the discharge of Resident #23 properly by sending the required information during the referral process, transporting Resident #23 and his belongings including medications, and giving report to receiving nurse at the facility. Administrator #1 stated the receiving facility was notified of the smoking background during the referral process and they accepted him with that knowledge, so he was unable to state why the receiving facility changed their mind once Resident #23 arrived for admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to implement an individualized person-centered care plan for a resident with a diagnosis of Alzheimer's Disease and usage of a hypnotic medication for 1 of 2 residents reviewed for Dementia Care (Resident #4). The findings included: Resident #4 was admitted to the facility on [DATE]. Resident #4 had diagnoses which included Alzheimer's Disease and insomnia. A physician order dated 1/04/23 for Zolpidem Tartrate (Ambien) 5 milligram (mg) tablet at bedtime for insomnia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #4 was coded for Alzheimer's Disease and use of a hypnotic medication. The care plan last reviewed on 3/23/23 revealed no care plan for Alzheimer's/Dementia care or diagnosis and no care plan for the use of a hypnotic medication. During an interview on 5/10/23 at 4:16 pm with the previous Director of Nursing (DON) revealed she would at times update or enter a care plan, but the MDS Nurse was responsible to ensure Resident #4's care plan was accurate. She stated the care plan was reviewed every three months and with a significant change but was unable to state how the care plan for Alzheimer's Disease and the use of a hypnotic medication was missed for Resident #4. A telephone interview was conducted on 5/11/23 at 9:30 am with the MDS Nurse who revealed she had assisted the facility with MDS assessments remotely and would add care plan updates when she could. The MDS Nurse stated a care plan was required for Resident #4's diagnosis of Alzheimer's Disease and his use of a hypnotic medication. The MDS Nurse stated she did not participate in the clinical meetings at the facility, so she was unable to state how the care plan for Resident #4's Alzheimer's Disease and Ambien was missed during clinical reviews. An interview was conducted on 5/11/23 at 2:32 pm with the Administrator who revealed the MDS Nurse was required to update Resident #4's care plan as needed. He stated reviews were done in the clinical meetings, but he was unable to determine why the care plans for Resident #4 did not reflect his Alzheimer's Disease and use of a hypnotic medication.

Based on record review and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions the committee put into place following the 1/29/21 complaint investigation and the 3/17/22 complaint and recertification survey. This was for a recited deficiency on the current complaint and recertification survey of 5/11/23 in care plan development and implementation (F656). The continued failure during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F656 Based on record review and staff interviews the facility failed to implement an individualized person-centered care plan for a resident with a diagnosis of Alzheimer's Disease and usage of a hypnotic medication for 1 of 2 residents reviewed for Dementia Care (Resident #4). During the complaint investigation survey of 1/29/21 the facility was cited for failing to develop a resident centered care plan for a resident with an indwelling urinary catheter. During the complaint and recertification survey on 3/17/22 the facility was cited for failure to develop a comprehensive care plan for a resident with an indwelling urinary catheter. An interview was completed on 5/11/23 at 2:48 pm with the Administrator. The Administrator reported the QAA committee meets monthly to discuss the facility's ongoing performance improvement plans. The Administrator revealed there were no ongoing performance improvement plans regarding care plan development and implementation. He stated the facility had multiple staff members trying to assist with care plan development and implementation and that it led to deficient practice. The Administrator stated it was the responsibility of the QAA to identify deficient practice and create performance improvement plans to correct the deficient practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interviews the facility failed to establish a frequency of smoking times to meet the residents' choices for 4 of 10 residents (Resident # 38, Resident #10, Resident #34, and Resident # 5) who were identified as smokers. The findings included: During the Group Resident Council meeting held on 5/9/23 at 1:32 PM, the resident group stated they used to have six smoke breaks a day and now they were down to four times a day. The group indicated that if they missed a smoke break due to an appointment, staff would take them out. The group indicated it was a long time to wait overnight for their next cigarette at 10:00 AM and with the weather getting warmer it would be nice to go back to the six smoking times a day. On 5/8/23 the facility provided a list of the active smokers. The form listed Residents #38, #10, #34, and #5 as smokers. The facility also provided the designated smoking times list as 10:00 AM, 2:00 PM, 4:00 PM and 7:30 PM. 1. Resident #38 was admitted to the facility on [DATE]. The most recent quarterly Minimum Data Set, dated [DATE] revealed Resident #38 as cognitively intact. Resident #38 was coded as independent with his activities of daily living and was coded for smoking. The care plan updated on 4/3/23 for Resident #38 indicated that he required supervision while smoking. The interventions included instruct the resident about smoking risks and hazards and about smoking cessation aids that are available. Instruct resident about the facility policy on smoking: locations, times, safety concerns., Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Observe clothing and skin for signs of cigarette burns. The resident requires SUPERVISION while smoking. Review of the most recent smoking assessment dated [DATE] revealed Resident #38 was assessed as a supervised smoker, due to noncompliance with the smoking policy. On 5/9/23 at 2:10 PM the smoking attendant stated residents used to have 6 smoke breaks a day and when the new company took over the breaks were decreased. During an interview with Resident #38 on 5/11/23 at 9:21 AM he stated there used to be 6 smoking times a day, but new management decreased the number to 4 times a day. He said it was a long stretch from 7:30 PM until 10:00 AM and he missed the late-night smoke break. In an interview on 5/11/23 at 9:58 AM the Administrator stated that they used to have six smoking times a day with the last smoke break at 9:30 PM. He revealed when the new company took over, he did a resident survey and from those results they combined the smoke breaks down and discontinued the 9:30 PM smoke break. The Administrator stated there were four smoke breaks a day, with the last break at 7:30 PM. He revealed if a resident was out to an appointment and missed their smoking break, staff were available to take the resident out to smoke. 2. Resident #10 was readmitted to the facility on [DATE]. The most recent quarterly Minimum Data Set, dated [DATE] revealed Resident #10 as cognitively intact. Resident # 10 was coded as required limited assistance with bed mobility, transfers, and extensive assistance with dressing. He was coded for smoking. The care plan dated 4/11/23 for Resident #10 indicated that he required supervision while smoking. The interventions were to Instruct resident about the facility policy on smoking: locations, times, safety concerns. Notify the charge nurse immediately if it is suspected resident has violated facility smoking policy. The resident requires SUPERVISION while smoking. The residents' smoking supplies are stored. Review of the most recent smoking assessment dated [DATE] revealed Resident #10 was assessed as a supervised smoker, due to noncompliance with the smoking policy. On 5/9/23 at 2:10 PM the smoking attendant stated residents used to have 6 smoke breaks a day and when the new company took over the breaks were decreased. In an interview with Resident #10 on 5/11/23 at 9:34 AM he stated it was a long time from the nighttime to the 10:00 AM smoke break and it would be nice if there were more smoke breaks. Resident #10 indicated there was nothing he could do about the smoking times. In an interview on 5/11/23 at 9:58 AM the Administrator stated that they used to have six smoking times a day with the last smoke break at 9:30 PM. He revealed when the new company took over, he did a resident survey and from those results they combined the smoke breaks down and discontinued the 9:30 PM smoke break. The Administrator stated there were four smoke breaks a day, with the last break at 7:30 PM. He revealed if a resident was out to an appointment and missed their smoking break, staff were available to take the resident out to smoke. 3.Resident #34 was admitted to the facility on [DATE]. The most recent quarterly Minimum Data Set, dated [DATE] revealed Resident #34 was cognitively intact. Resident #34 required supervision for bed mobility, transfers, limited assistance with dressing and extensive assistance with personal hygiene. He was coded for smoking. The care plan updated on 3/16/23 for Resident #34 indicated he needed supervision for smoking. The interventions included instruct the resident about smoking risks and hazards and about smoking cessation aids that are available. Instruct the resident about the facility policy on smoking: locations, times, safety concerns. Notify the charge nurse immediately if it is suspected resident has violated facility smoking policy. Observe clothing and skin for signs of cigarette burns. The resident requires Supervision while smoking. Review of the smoking assessment dated [DATE] and 4/23/23 revealed Resident #34 was assessed as a supervised smoker, due to noncompliance with the smoking policy. An interview was conducted with Resident #34 on 5/8/23 at 10:47 AM. Resident #34 stated he was a grown man and could not do what he wanted. He stated he could not go out to smoke unless it was the smoking times. On 5/9/23 at 2:10 PM the smoking attendant stated residents used to have 6 smoke breaks a day and when the new company took over the breaks were decreased. In an interview on 5/11/23 at 9:58 AM the Administrator stated that they used to have six smoking times a day with the last smoke break at 9:30 PM. He revealed when the new company took over, he did a resident survey and from those results they combined the smoke breaks down and discontinued the 9:30 PM smoke break. The Administrator stated there were four smoke breaks a day, with the last break at 7:30 PM. He revealed if a resident was out to an appointment and missed their smoking break, staff were available to take the resident out to smoke. 4. Resident #5 was admitted to the facility on [DATE]. The most recent quarterly Minimum Data Set, dated [DATE] revealed Resident #5 as cognitively intact. Resident #5 was coded as required supervision with bed mobility, transfers, and extensive assistance with dressing. He was coded for smoking. The care plan dated 2/16/23 for Resident #5 indicated that he required supervision while smoking. The interventions included instruct the resident about smoking risks and hazards and about smoking cessation aids that are available. Instruct the resident about the facility policy on smoking: locations, times, safety concerns. Notify the charge nurse immediately if it is suspected resident has violated facility smoking policy. Observe clothing and skin for signs of cigarette burns. Review of the smoking assessment dated [DATE] revealed Resident #5 was assessed as a supervised smoker, due to noncompliance with the smoking policy. On 5/9/23 at 2:10 PM the smoking attendant stated residents used to have 6 smoke breaks a day and when the new company took over the breaks were decreased. On 5/11/23 at 1:08 PM Resident #5 stated he enjoyed smoking and when they decreased the number of smoking times, it left him with nothing else to do. He stated fewer smoke breaks made him more agitated. In an interview on 5/11/23 at 9:58 AM the Administrator stated that they used to have six smoking times a day with the last smoke break at 9:30 PM. He revealed when the new company took over, he did a resident survey and from those results they combined the smoke breaks down and discontinued the 9:30 PM smoke break. The Administrator stated there were four smoke breaks a day, with the last break at 7:30 PM. He revealed if a resident was out to an appointment and missed their smoking break, staff were available to take the resident out to smoke.

Based on observation and staff interview the facility failed to maintain food service equipment clean without a debris build up on 1 of 1 convection ovens observed for cleanliness, and failed to maintain 9 of 9 sheet pans and 2 of 2 sauce pans free of dried food debris. This practice has the potential for cross contamination of food served to residents. This was evident in 2 of 2 kitchen observations. The Findings included: During the initial kitchen tour conducted on 5/8/23 at 10:29 AM, the convection oven was observed to have a buildup of grease inside the oven doors, both the right and left sides, and the bottom of the convection oven was observed with a buildup of black charred food debris. Located on the drying rack, 5 of 5 sheet pans were observed stacked ready for use with a buildup of dark dried food debris ¼ inch under the rim. Two sauce pans stored on the drying rack were observed with a buildup of grease that coated the outside of the sauce pans. A second observation of the kitchen on 5/11/23 at 10:40 AM, revealed 9 of 9 sheet pans were observed stacked ready for use with a buildup of dark dried food debris ¼ inch under the rim. Two sauce pans were observed stored on the drying rack with a buildup of grease that coated the outside of the sauce pans. The convection oven was observed to be in the same condition. Review of the Daily Cleaning Schedule for May 2023 documented the convection oven was last cleaned on 5/7/23. An interview was conducted with the Dietary Manager (DM) on 5/11/23 at 10:43 AM, she stated they deep clean the kitchen on Fridays and usually deep cleaned the convection oven every two weeks. In an interview on 5/11/23 at 11:50 AM the Administrator stated staff should clean the sheet pans or discard the items if they would not come clean.