Every finding on record at Gates Health and Rehabilitation Center

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.

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, 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.

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.

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 on ce 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 on ce 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.

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 dated 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 dated 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 dated 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 dated 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 1/4 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 1/4 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.

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.

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 admitted [DATE]. She stated Resident #32 had contacted her on the day before expected admission (3/30/23) 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 admitted [DATE]. 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.

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.

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 reviews and staff interviews the facility failed to implement their abuse policy and procedure by not reporting Resident to Resident altercation to the facility Administrator immediately for 2 of 2 Residents reviewed (Resident #151 & #41) for abuse. The findings included: The facility's policy titled Abuse, Neglect, and Exploitation updated on 10/22/20 stated reporting of all alleged events will be made to the facility Administrator immediately. Resident #41 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #151 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His Minimum Data (MDS) dated [DATE] indicated he was severely cognitively impaired. A telephone interview was completed on 3/15/22 at 3:10pm with Nurse #5. She indicated she was coming down the hallway at approximately 9:45pm on 12/26/21 and heard Resident #41 yelling. She went towards his room to investigate and at that point she saw both Residents (Residents #151 and #41) in the doorway of Resident #41's room. Nurse #5 indicated Resident #151 proceeded to strike Resident #41 on the side of the face with his closed hand. She continued to state Resident #41's wheelchair rolled out from under him, and he sat down on the floor and Resident #151 became unsteady and fell on his stomach. Nurse #5 indicated he did not hit his head, nor complain of pain after the fall. She stated she attempted to get to Resident #151 to redirect him before he acted out but was not fast enough. Nurse #5 stated Resident #151 had no complaints of pain after the fall. She escorted him back to his room and assisted him into a reclining chair to rest. She stated she notified the Residents' responsible parties, the former Director of Nursing (DON), and the Physician. Nurse #5 stated she was instructed by the DON to observe both Residents the rest of her shift. She stated she overlooked writing a progress note regarding the incident between Resident #151 and #41 and felt she was following the correct steps with notifying the DON regarding the event and was not aware she needed to contact anyone else. A telephone interview was completed on 3/16/22 at 4:10pm with the former Director of Nursing. She indicated she was not notified by Nurse #5 during the evening of 12/26/21 regarding the Resident-to-Resident altercation. An interview was completed with the Administrator on 3/15/22 at 9:30am. The Administrator stated Nurse #5 did not notify her when the event took place on 12/26/21. She indicated she was not made aware of the incident until she arrived at the facility on 12/27/21. She stated once she was fully aware of the event's details, it was around 5:00pm on 12/27/21.

Based on record review, staff, Resident and Physician interviews the facility failed to provide supervision to prevent a severely cognitively impaired Resident (Resident #151) from wandering into another Resident's room (Resident #41) resulting in an altercation and Resident #151 sustaining a right humeral (upper arm bone) fracture. This was for 1 of 2 Residents reviewed for supervision to prevent accidents. The findings included: Resident #151 was admitted to the facility on [DATE] with diagnoses that included history of seizures, stroke like episode, and [CONDITION(S)]. The Minimum Data Set (MDS) dated [DATE] indicated Resident #151 was severely cognitively impaired. There were no behaviors, verbal or physical, noted toward others in the 7 day assessment period of the MDS. Resident #151 wandered on 1 to 3 days and ambulated to and from areas outside of his room with the assistance of 1 staff member. A Physician Encounter Summary dated for 12/15/21 revealed Resident #151 was seen for agitation and [CONDITION(S)]. The facility Physician gave an order for [MEDICATION(S)] (antianxiety) 1milligrams (mg) 3 times daily and [MEDICATION(S)] (antipsychotic medication) 10mg at bedtime to treat. A progress noted dated 12/26/21 written by Nurse #3 revealed Resident #151 was out of his room ambulating down the facility hallways during the 7am-7pm shift. Staff was successful at times with redirection. A 24 Hour Initial Allegation Report dated 12/27/21 revealed that on 12/26/21 at 9:45pm Resident #151 attempted to enter the room of Resident #41. Resident #41 made him aware he was not to enter his room. Resident #151 struck Resident #41 in the face. Resident #41 put his hand up and pushed Resident #151 to the ground in attempt to stop any further altercation. Both Residents fell to the floor. The hall Nurse heard the altercation but was unsuccessful in reaching the Residents in time. She assessed both Residents for injuries. Resident #41 complained of some pain but declined any medical attention and Resident #151 had no complaints of pain when assessed on 12/26/21 following the incident. The MDS dated [DATE] indicated Resident #41 was cognitively intact. An interview was completed on 3/15/22 at 10:05am with Resident #41. He indicated the evening of 12/26/22 he was sitting in his wheelchair in the doorway of his room. He saw Resident #151 walking up the hallway. He arrived at Resident #41's doorway and attempted to enter his room. Resident #41 stated when he told Resident #151 that wasn't his room and leave, Resident #151 hit him on the side of the face. Resident #41 stated he put his right hand out to protect himself from Resident #151 and ended up pushing him on his right shoulder. Resident #41 continued to state at that point his wheelchair rolled out from under him and he sat down on the floor and Resident #151 fell forward. He indicated he was not hurt in the altercation and refused any x-rays or further assessments. A telephone interview was completed on 3/15/22 at 3:10pm with Nurse #5. She indicated she was coming down the hallway at approximately 9:45pm on 12/26/21 and heard Resident #41 yelling. She went towards his room to investigate and at that point she saw both Residents (Residents #151 and #41) in the doorway of Resident #41's room. Nurse #5 indicated Resident #151 proceeded to strike Resident #41 on the side of the face with his closed hand. She continued to state Resident #41's wheelchair rolled out from under him, and he sat down on the floor and Resident #151 became unsteady and fell on his stomach. Nurse #5 indicated he did not hit his head, nor complain of pain after the fall. She stated she attempted to get to Resident #151 to redirect him before he acted out but was not fast enough. Nurse #5 stated Resident #151 had no complaints of pain after the fall. She escorted him back to his room and assisted him into a reclining chair to rest. She stated she notified the Residents' responsible parties, the former Director of Nursing, and the Physician. She was instructed to observe the Residents the rest of the shift. Nurse #5 indicated during the rest of her shift Resident #151 rested in the reclining chair in her line of vision. She also stated she had never witnessed Resident #151 being violent towards Residents. Nurse #5 stated prior to evening of 12/26/21 Resident #151 would ambulate short distances down the hallways and she would keep an eye on him and redirect if he attempted to go in other Residents' rooms. She also stated Resident #41 normally stayed in his room unless he was going out to smoke. Nurse #5 stated Resident #41 normally didn't talk to other Residents. A telephone interview was completed on 3/16/22 at 1:10pm with Nursing Assistant (NA) #6. She indicated she was working at the facility on 12/26/21 on the 7pm-7am shift but was unable to remember what Resident care assignment she had that shift. She stated she did not witness the exchange between Resident #41 and Resident #151 but did see Nurse #5 assisting the Residents after the event. She continued to state Resident #151 stayed in the reclining chair and bed the rest of the night within eyesight of a staff member. She further indicated she had never witnessed Resident #151 be aggressive towards staff or Residents. She stated prior to 12/26/21, Resident #151 was unsteady with walking and only able to walk a short distance. NA #6 continued to state she would use redirection attempts when he was wandering the hallway at night. She stated she had never witnessed Resident #151 go into other Residents' rooms. A progress note dated 12/27/21 written by Nurse #7 stated when she arrived for her 7am shift she assessed Resident #151 and noted he had swelling, bruising, and pain to his right upper arm. The note further stated he had suffered a fall on the night of 12/26/21. The Physician was contacted and made aware of the new onset of symptoms and an order was received for a mobile x-ray of the right arm. emergency room notes dated 12/27/21 indicated Resident #151 was seen for a right humeral (upper arm bone) fracture. During the hospital stay, the Resident had no complaints of pain in his arm. A splint was applied to the right arm and Resident #151 was discharged back to the facility 12/27/21. A telephone interview was completed on 3/16/22 at 10:25am with Nurse #7. She indicated she worked with Resident #151 on 12/27/21for the 7am-7pm shift. She stated when she assessed the Resident he was complaining of pain in his right arm. Upon assessment, she stated she noticed swelling and bruising to the upper arm area. Nurse #7 stated she contacted the Physician and received an order for an in-facility x-ray. Nurse #7 stated the x-ray came back positive for a fracture of the right humerus bone, and she received an order from the Physician to send the Resident to the hospital for treatment. She further stated once Resident #151 returned to the facility he was always within eyesight of a staff member. Nurse #7 stated the Resident mainly stayed in the reclining chair or in bed, but when he came out of his room into the dining area or common area he was in the eyesight of staff. Nurse #7 further stated she had never witnessed Resident #151 exhibiting signs of aggressiveness towards Residents. A telephone interview was completed on 3/16/22 at 11:52am with Nurse #6. She indicated she was very familiar with Resident #151. Nurse #6 stated she had never witnessed the Resident exhibit any signs of aggressive behaviors towards staff or Residents. She stated he was confused at times and had to be reoriented to time and place. She stated prior to the 12/26/21 incident, Resident #151 would walk and wander short distances down the hallways and attempted to go in other Residents' rooms. Nurse #6 stated when this happened, she walked along with him, redirected him with a snack or something to drink and assist him back to bed. She indicated he normally slept the remainder of her shift after this. An interview was completed with the Administrator on 3/15/22 at 9:30am. She indicated when she was made aware of the incident on 12/27/21, she immediately made sure staff were making sure Resident #151 was able to be viewed by a staff member when he was out of his room. She indicated this was passed on at each Nursing report. She stated she started having staff sign off on a 15 minute safety log on 12/30/21-1/8/22. She stated the Resident was no longer walking at that time, so she felt comfortable discontinuing the checks. The Administrator indicated there were no other incidents. An interview was completed on 3/15/22 at 10:05am with the facility Physician. He indicated he was notified of the altercation between Resident #151 and Resident #41. He stated he felt the facility had no indication Resident #151 would have acted out towards another Resident in the manner he did. The Physician stated due to Resident #151's extensive medical history that included poor nutrition and history of a stroke led to brittle bones and any fall could have led to a fracture. He stated he felt the facility did everything possible to keep Residents safe.

Based on record review and staff interviews the facility failed to schedule an Registered Nurse (RN) for at least 8 consecutive hours per day for 6 of 76 days reviewed for sufficient staffing. (1/29/22, 1/30/22, 2/26/22, 2/27/22, 3/12/22, and 3/13/22). Findings included: A record review of the facility ' s Daily Staffing Sheet was conducted on 3/17/22. The Daily Staffing Sheets revealed the facility had not scheduled an RN for at least 8 consecutive hours a day on 1/29/22, 1/30/22, 2/26/22, 2/27/22, 3/12/22, and 3/13/22. During an interview on 3/17/22 at 12:58 PM the Scheduler confirmed there was not an RN in the facility for at least 8 consecutive hours on 1/29/22, 1/30/22, 2/26/22, 2/27/22, 3/12/22, and 3/13/22. She revealed the facility was required to have an RN scheduled every day for a minimum of 8 hours, but she was unable to find RN coverage for those dates. She stated she was unable to remember if she notified the Director of Nursing (DON) or Administrator that the facility did not have an RN scheduled for those days. During an interview on 3/17/22 at 1:30 PM the Administrator revealed the DON and the Scheduler were expected to meet and review staffing. She stated she was not aware the facility was without RN coverage for at least 8 consecutive hours on those days. During an interview on 3/17/22 at 2:42 PM the DON stated she did meet with the Scheduler and review staffing but stated she was a new hire in February. She sated she was unable to comment on the dates 1/29/22 and 1/30/22 but stated she was not aware there was not an RN scheduled for at least 8 consecutive hours on 2/26/22, 2/27/22, 3/12/22, and 3/13/22.

Based on record review and staff interview, the facility failed to prevent a significant medication error by not following a physician's order to administer an anticoagulant for 1 of 2 residents reviewed for anticoagulation therapy (Resident #106). The finding included: Resident #106 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the hospital discharge summary dated 3/10/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's order dated 3/10/22 revealed Resident 106 was to receive [MEDICATION(S)] 2.5 milligrams (mg) one tablet two times daily. The order was in confirmation pending status on the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #106's MAR for March 2022 revealed that [MEDICATION(S)] was not administered as ordered on the following dates: -3/10/22 -3/11/22 -3/12/22 -3/13/22 -3/14/22 A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #106 was cognitively intact and received an anticoagulant 3 days of the look back period. An interview was conducted with the Wound Nurse on 3/14/22 at 3:13 PM. The nurse stated that all admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse stated that Resident #106's orders had not been reviewed in the clinical morning meeting. The morning clinical meeting had not been occurring consistently. An interview was conducted with Nurse #4 on 3/14/22 at 10:27 AM. Nurse #4 stated that [MEDICATION(S)] did not show on the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] 2.5 mg order was listed under the orders pending status on the orders page of the EMAR. Nurse #4 stated that the nurse should check the EMAR for pending orders and accept them. An interview was conducted with Resident #106's primary care physician on 3/16/22 at 12:41 PM. The physician stated that he had been made aware that Resident #106 had missed doses of [MEDICATION(S)]. He stated that labs were ordered, and the medication order was updated. The physician stated he had assessed Resident #106 on 3/16/22 and there was no negative outcome. An interview was conducted with the Corporate Clinical Nurse Consultant on 3/17/22 at 3:40 PM. The Nurse Consultant stated that she expected the orders would be confirmed during medication pass and the nurse would notify the Director of Nursing if there was a concern.

Based on observation, record review and staff interview the facility failed to assess a resident for self-administration of medication for 1 of 1 resident observed to have medication in the room. (Resident #26) The findings included: Resident #26 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan dated 1/20/22 did not include the self-administration of medication. There was not an assessment of Resident #26 in the medical record to determine if it was safe for the resident to self-administer medications. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact and required limited to extensive assistance with most activities of daily living (ADLs) and was independent with eating. On 3/14/22 at 10:21 AM Resident #26 was observed lying on the bed with a cup containing 3 tablets sitting on the bedside table. Resident #26 stated he had asked the nurse to sit the cup on the table and he told her he would take them. An interview was conducted with Nurse #4 on 3/14/22 at 10:27 AM. Nurse #4 stated Resident #26 was sitting up on the side of the bed and took all his medications in her presence. Nurse #4 stated Resident #26 must have spit some of his pills back into the cup. Nurse #4 stated that she should have stood at the resident's bedside to make sure that he swallowed all the medication. An entry on Resident #26's care plan dated 3/14/22 noted the following resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Check mouth after medications given to ensure swallowed. An interview with the Director of Clinical Nurse Services on 3/17/22 at 3:39 PM revealed that she expected that the nurse would not have set the medications in a cup at the bedside. The Clinical Services Director further stated that the nurse should have ensured that Resident #26 swallowed the medication.

Based on observation, record review and staff interview, the facility failed to develop a comprehensive care plan for 1 of 2 residents (Resident #103) with an indwelling urinary catheter. The findings included: Resident #103 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #103's admission minimum data set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment, required extensive assistance to total dependence for activities of daily living (ADLs) from staff except for eating. He had an indwelling catheter and was frequently incontinent of bowel. A review of the Care Area Assessment with an assessment reference date (ARD) of 3/14/22 indicated that the urinary catheter should have been addressed in the care plan. An observation of Resident #103 was conducted on 3/14/22 at 9:43 AM. Resident #103 had an indwelling urinary catheter. An interview was conducted with the MDS (Minimum Data Set) nurse on 3/17/22 at 11:00 AM. The MDS nurse stated that the urinary catheter should have been included in Resident #103's care plan. An interview was conducted with the Regional Director of Clinical Services on 3/17/22 at 3:53 PM. The Clinical Director stated the urinary catheter should have been included in Resident #103's care plan.

Based on record review, Responsible Party (RP) interview, and staff interviews, the facility failed to invite the RP to a care plan meeting for 1 of 24 residents reviewed for care plan. (Resident #45). Findings included: Resident #45 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed an initial care plan meeting was completed on 11/12/21 with Resident #45 ' s RP. Record review of Minimum Data Set (MDS) Admission assessment dated [DATE] revealed Resident #45 had severe cognitive impairment. During an telephone interview on 3/15/22 at 9:46 AM Resident #45 ' s Responsible Party (RP) revealed that she participated in an initial care plan meeting on the day of admission but was not aware of a care plan meeting was scheduled since the initial meeting. The RP stated that she was told that the facility would schedule a full care plan meeting with other departments in approximately 3 weeks. Resident #45 ' s RP stated she did not hear from the facility to schedule the meeting and was not aware if the meeting had taken place. During an interview on 3/15/22 at 3:44 PM the Social Worker revealed the MDS Nurse was responsible to schedule the care conferences. She stated she sent care plan invitation once the schedule was received by MDS. The Social Worker stated she was unable to find an invitation for care plan meeting for Resident #45 ' s RP and she was unable to remember or locate documentation that a care plan meeting took place as required for Resident #45. During an interview on 3/15/22 at 4:03 PM the MDS Nurse stated Resident #45 ' s care plan meeting was to be scheduled around 12/9/21 based on the date of the MDS Admission Assessment. She stated she wrote his name on her list to schedule but was unable to state if she sent the information to the Social Worker to send out the invitation to Resident #45 ' s RP. The MDS Nurse was unable to remember or locate information that a care plan meeting was held since the 11/12/21 meeting for Resident #45. During an interview on 3/17/22 at 4:45 PM the Administrator revealed the Social Worker and the MDS Nurse were to coordinate and ensure the meetings were completed as required.

Based on observation, record review and staff interview, the facility failed to obtain and include physician orders in the medical record for 1 of 2 sampled residents (Resident #103) with indwelling urinary catheters. The findings included: Resident #103 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #103's admission minimum data set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. He had an indwelling catheter. A review of the 2/2/22 hospital discharge summary revealed Resident #103 had an indwelling urinary catheter. An observation of Resident #103 was conducted on 3/14/22 at 9:43 AM. Resident #103 had an indwelling urinary catheter. A review of Resident #103's physician's orders did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An interview conducted with the Wound Nurse on 3/16/22 at 10:40 AM. The Wound Nurse stated that the admitting nurse was responsible for ensuring there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/17/21 at 11:30 AM an interview was conducted with Nurse #4. Nurse #4 stated it was important to have a physician's order for a catheter so that the facility knew the size of the catheter and balloon. Nurse #4 stated that the resident had a to have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with the Regional Director of Clinical Services on 3/17/22 at 3:35 PM. The Director of Clinical Services stated that she expected there would be orders for the urinary catheter.

Based on observation, record review, staff and physician interviews, the facility failed to obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident #3). Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3 ' s Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed he had severe cognitive impairment. Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] An observation on 3/14/22 at 10:49 AM Resident #3 had oxygen via nasal canula (NC) at 3 liters per minute in place. An observation on 3/15/22 at 8:24 AM Resident #3 had oxygen via NC at 3 liters per minute in place. During an interview on 3/15/22 at 2:59 PM Nurse #3 revealed that a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 3/16/22 at 12:41 PM the Physician revealed he was aware Resident #3 was on oxygen, but the order may have slipped through the cracks. During an interview on 3/17/22 at 2:34 PM the Director of Nursing revealed she was aware Resident #3 used oxygen. She stated a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/17/22 at 2:45 PM the Clinical Regional Nurse revealed the nursing department was expected to maintain and follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 3/17/22 at 4:33 PM the Administrator stated nursing was responsible to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and staff and resident interviews, the facility failed to assess and put in interventions to prevent a resident from lying on a catheter tubing on 1 of 1 resident (Resident #33) sampled with a urinary catheter which led to the discovery of a stage 4 pressure wound on the left thigh. Findings include: Resident #33 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of Resident #33's admission Minimum Data Set (MDS) assessment, dated 12/27/09 documented Resident #33 had no short term or long term memory problem, was independent with daily decision making ability, had no behavioral symptoms and did not resist any care. Resident #33 required extensive assistance from one staff member for bed mobility, extensive assistance from two staff members for transfers, and was non-ambulatory. The assessment documented Resident #33 had functional range of motion impairment on both sides of the upper and lower extremities and had an indwelling urinary catheter. Under the SKIN CONDITION section of the assessment, it was documented Resident #33 had 2 stage 2 and 1 stage 4 pressure ulcers and a history of resolved ulcers in the past 90 days. Resident Assessment Protocol (RAP) summary documentation dated 12/27/09 indicated Resident #33 had been admitted with a stage 4 wound on the left ishium and 2 stage 2 wounds present on the right inner and outer buttocks. Resident #33 was identified at risk for pressure ulcer development. A review of a physician's verbal order for Resident #33, dated 01/20/10, documented a new order for Santyl (topical debridement medication) to be applied to the left posterior thigh daily. A review of PROGRESS NOTES for Resident #33 documented an entry on 01/20/10 at 1:55 PM that the resident's physician had been in to see the resident and new orders had been written. There was no entry regarding a wound on Resident #33's posterior thigh area found in the progress notes. Review of Resident #33's Treatment Sheet for January 2010 indicated Resident #33 received treatment of [REDACTED]. Review of a physician's progress note, dated 01/27/10, documented Resident #33 had another wound to his leg where he had been sitting on a urinary catheter. The wound was described as being approximately 5cm (centimeter) long and about 2cm wide with an eschar (black tissue). Review of a SKIN GRID - PRESSURE sheet for Resident #33 documented on 01/29/10 a stage 4 wound present on the left thigh which measured 6cm by 2.5 cm with a small amount of serous drainage and slough present. In an interview with Resident #33 on 01/05/11 at 2:20 PM, Resident #33 declined to have his wound care observed. Resident #33 stated he had been admitted to the facility with wounds present on his left and right ischial areas. Resident #33 said he developed a wound shortly after admission from lying on the urinary tubing on the back of his left thigh which has since healed. In an interview with the Rehab Manager on 01/06/10 at 2:20 PM, The Rehab Manager said she had worked with Resident #33 in the past. The Rehab Manager said Resident #33 had developed an area on his posterior left thigh from lying on his catheter tubing. The Rehab Manager said Resident #33 experienced muscle spasms in his lower extremities which caused him to have movement which might of caused him to lie on the tubing. In an interview with Nurse #2 on 01/06/11 at 2:32 PM, Nurse #2 said Resident #33 urinary catheter had to be monitored as he had been found lying on the tubing. Nurse #2 said she had found a reddened non-opened area present on Resident #33's left thigh about one month ago. Nurse #2 said the area improved within a few days. Nurse #2 did not recall a previous wound on Resident #33's left posterior thigh. In an interview with the Director of Nurses (DON) on 01/06/11 at 4:50 PM, she identified the left posterior thigh wound, documented 01/29/10, on Resident #33 as a pressure wound as result of Resident #33 lying on his urinary catheter. The DON stated it was her expectation that a resident's urinary catheter would be assessed and monitored regularly to prevent a stage 4 wound from being found.

Based on observations, record review, and resident and staff interviews the facility failed to prevent a pressure ulcer on a heel (Resident #22) , failed to prevent an avoidable stage 4 pressure ulcer on a posterior thigh obtained from lying on a urinary catheter (Resident #33); failed to implement physician recommendations for nutrition interventions on a timely basis and provide ordered treatments (Resident #20) on 3 of 3 sampled residents identified at risk for pressure ulcer development. Findings include: 1. Resident #22 was re-admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Resident #22 had no identified pressure ulcers on re-admission. Resident #22's admission Minimum Data Set (MDS) completed 12/16/10 indicated that the resident had short and long term memory problems and was severely impaired in daily decision making. Resident #22 was identified at risk for pressure ulcers on the assessment. The same assessment documented Resident #22 had no pressure ulcers on re-admission to the facility and required a pressure reducing device for the bed. Under the CARE AREA TRIGGERS (CAT's) it was noted Resident #22 had no skin breakdown but her right heel was noted as soft and tender to touch. A review of Resident #22's interim care plan dated 12/16/10 included an intervention to protect/elevate elbows and heels as needed. A review of resident #22's RESIDENT STATUS SHEET ( sheet used by the nurses aides listing instructions to care for the resident) did not indicate resident #22's heels were to be elevated or include the use of a protective device. Review of the SKIN SWEEP sheet dated 12/16/10, showed new skin impairment with a measurement of 6x5cm to Resident #22's right heel Review of Resident #22's NURSES PROGRESS NOTES revealed an entry dated 12/16/10 at 1:00 AM, indicated there was an area on Resident #22's right heel which measured 6x5 centimeters (cm). The tissue around the area was described as soft and sensitive. A Care Plan showing actual skin integrity impairment was initiated on 12/20/10 for Resident #22's right heel. The approaches showed weekly skin assessments, staff to utilize pressure relief devices as indicated (pillows, foam padding), and monitor for changes with wound and treatment. Review of the physician order [REDACTED]. Review of Resident #22's TREATMENT RECORD for December 2010 revealed a handwritten entry to float heels while in bed and protective boots when out of bed as FYI (for your information). There was no date to indicate when it was entered on the sheet and there were no initials documented to indicate if this was done on resident #22. Review of Resident #22's SKIN SWEEP sheet dated 12/26/10 revealed the area on the right heel was soft and boggy with eschar tissue. Review of Resident #22's NURSING PROGRESS NOTES dated 12/26/10 at 9:30 AM, showed the right foot skin to be intact. The heel soft and boggy with eschar tissue noted. The note indicated Resident #22's heels were floated. Review of Resident #22's TREATMENT RECORD for January 2011 showed entries for float heels while in bed and protective boots when out of bed as FYI (for your information). There were no initials documented on the record to indicate this was done on Resident #22. On review of the Weekly Wound Tracking Tool dated 1/4/11, the measurements of Resident #22's right heel blister were 6x5.5cm. It was listed as unstageable. Interventions were shown as float heels. In an observation on 1/4/11 at 5:05 PM, a pillow was observed under Resident #22's right leg. Both Resident #22's heels were observed resting directly on the bed. There were no protective devices observed in Resident #22's room. NA #4 removed Resident #22's socks and turned Resident #22 towards her right side. A large intact dark purple area was observed on Resident #22's right heel. NA #4 put Resident #22's socks back on and covered her up and left the room. Both of Resident #22's heels remained directly on the bed. In an observation on 1/5/11 at 8:35 AM, a protective boot was observed on resident #22's right leg and the heel was floating. In an interview on 1/5/11 at 10:30 AM with Licensed Nurse #3 she stated when an order for [REDACTED]. In an interview on 1/5/11 at 10:40 AM, Resident #22's physician stated that when he ordered a resident's heels to be floated, it meant anything that would take the pressure off the heel could be used except "bunny boots" . He stated the area to the right heel had started as a blood blister and was fluid filled at one time. The physician stated it was now hard and not draining. The physician said it was his expectation that the blister would be re-absorbed with time. The physician stated the wound could be due to pressure, diabetes or arterial disease. In an interview on 1/5/11 at 12:15 PM, the Director of Nursing (DON) stated that the Minimum Data Set (MDS) nurse was responsible for updating the care plans and the RESIDENT STATUS SHEETS of the residents. The DON would discuss any changes with the physician following rounds and provide the information to the MDS nurse. New orders were also discussed in the morning meetings which the MDS nurse attended. It was the expectation of the DON that the care plans and RESIDENT STATUS SHEETS would be updated based on changes to physician orders [REDACTED]. In an interview on 1/5/11 at 12:22 PM, Nurse Aide (NA) #3 stated that the RESIDENT STATUS SHEET provided the information needed for the aides to care for the residents. NA #3 said it should be reviewed when they first came on shift. NA #3 stated if there had been any changes the nurse was responsible to let the aides know. NA #3 said if a resident needed their heels floated it meant to elevate the heels off the bed with pillows. In an interview on 1/6/11 at 11:10 AM, the MDS nurse stated that she was responsible for the updates to the resident care plans and the RESIDENT STATUS SHEETS. Updates were made daily following morning meetings and from copies of physician orders. In an interview on 1/6/11 at 3:25 PM, the Administrator and DON stated it was the facility policy to document on wounds weekly, recording their measurements, description (including presence of odor, pain, drainage, wound bed, surrounding skin, etc), and staging on a skin grid. The DON stated that documenting measurements, descriptions, and staging was an important tool because the nurses and physician used this information to make decisions about changing wound treatments, adding or changing nutrition interventions, and adding or changing orders for pressure relief. It was her expectation that weekly measurements on wounds be taken and recorded in the chart. 2. Resident #33 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of Resident #33's admission Minimum Data Set (MDS) assessment, dated 12/27/09 documented Resident #33 had no short term or long term memory problem, was independent with daily decision making ability, had no behavioral symptoms and did not resist any care. Resident #33 required extensive assistance from one staff member for bed mobility, extensive assistance from two staff members for transfers, and was non-ambulatory. The assessment documented Resident #33 had functional range of motion impairment on both sides of the upper and lower extremities and had an indwelling urinary catheter. Under the SKIN CONDITION section of the assessment, it was documented Resident #33 had 2 stage 2 and 1 stage 4 pressure ulcers and a history of resolved ulcers in the past 90 days. Resident Assessment Protocol (RAP) summary documentation dated 12/27/09 indicated Resident #33 had been admitted with a stage 4 wound on the left ishium and 2 stage 2 wounds present on the right inner and outer buttocks. Resident #33 was identified at risk for pressure ulcer development. Review of Resident #33's December 2009 and January 2010 PHYSICIANS ORDER SHEET ' s had orders for a skin assessment weekly. Review of Resident #33's treatment Sheet for January 2010 documented a skin assessment was to be completed weekly. There were no initials documented on the sheet to indicate the assessments had been completed. There were no completed SKIN ASSESSMENT sheets found in Resident #33's clinical records for January 2010. A review of a physician's verbal order for Resident #33, dated 01/20/10, documented a new order for Santyl (topical debridement medication) to be applied to the left posterior thigh daily. A review of PROGRESS NOTES for Resident #33 documented an entry on 01/20/10 at 1:55 PM that the resident's physician had been in to see the resident and new orders had been written. There was no entry regarding a wound on Resident #33's posterior thigh area found in the progress notes. Review of Resident #33's Treatment Sheet for January 2010 indicated Resident #33 received treatment of [REDACTED]. Review of a physician's progress note, dated 01/27/10, documented Resident #33 had another wound to his leg where he had been sitting on a urinary catheter. The wound was described as being approximately 5cm (centimeter) long and about 2cm wide with an eschar (black tissue). Review of a SKIN GRID - PRESSURE sheet for Resident #33 documented on 01/29/10 a stage 4 wound present on the left thigh which measured 6cm by 2.5 cm with a small amount of serous drainage and slough present. A physician's orders [REDACTED]. In an interview with Resident #33 on 01/05/11 at 2:20 PM, Resident #33 declined to have his wound care observed. Resident #33 stated he had been admitted to the facility with wounds present on his left and right ischial areas. Resident #33 said he developed a wound shortly after admission from lying on the urinary tubing on the back of his left thigh which has since healed. Resident #33 said he was unable to feel himself lying on the catheter tubing. In an interview with the Rehab Manager on 01/06/10 at 2:20 PM, The Rehab Manager said she had worked with Resident #33 in the past. The Rehab Manager said Resident #33 had developed an area on his posterior left thigh from lying on his catheter tubing. The Rehab Manager said Resident #33 experienced muscle spasms in his lower extremities which caused him to have movement which might cause him to lie on the tubing. The Rehab Manager said Resident #33's skin was fragile and he was prone to skin breakdowns. In an interview with Nurse #2 on 01/06/11 at 2:32 PM, Nurse #2 said Resident #33 urinary catheter had to be monitored regular as he had been found lying on the tubing. Nurse #2 said she had found a reddened non-opened area present on Resident #33 ' s left thigh about one month ago. Nurse #2 said the area improved within a few days. Nurse #2 did not recall a previous wound on Resident #33's left posterior thigh. In an interview with the Director of Nurses (DON) on 01/06/11 at 4:50 PM, she identified the left posterior thigh wound, documented 01/29/10, on Resident #33 as a pressure wound as result of Resident #33 lying on his urinary catheter which should have been found before it was a stage 4 wound. The DON said it was her expectation that skin assessments were completed on residents weekly and initialed on their Treatment Record the date completed. The DON stated it was her expectation a pressure wound would be found prior to a stage 4 and interventions would have been put in place for the prevention of wounds. 3. Resident #20 was admitted on [DATE] and readmitted on [DATE] and 8/2/10. The resident's documented [DIAGNOSES REDACTED]. Resident #20's 7/31/10 2:05 PM Progress Note documented, "...Open areas x 2 noted @ (at)sacral area. 1st area measuring @ 1 x 1 cm (centimeters). 2nd area 2 x 1 cm & 0.2 cm in depth...." Record review revealed Resident #20 was hospitalized from [DATE] until 08/02/10. 08/01/10 hospital lab results documented Resident #20's [MEDICATION NAME] level was 2.0 grams/deciliter (g/dL) with normal being 3.2 - 4.6 g/dL. An order to treat Resident #20's stage II sacral decubiti with Santyl and cover with dry dressing daily was included in the resident's readmission orders [REDACTED]. Resident #20's 08/02/10 plan of care for the prevention of pressure ulcers documented "monitor nutrition and hydration" as an intervention. The resident's 08/02/10 plan of care for actual skin integrity impairment did not list nutrition as a specific intervention. However, this latter plan of care documented "tx (treat) as ordered by MD" as an approach. Resident #20's 08/03/10 2:00 PM Progress Note documented, "...tx (treatment) done to sacral areas as ordered. two separate areas noted. measurements for open areas were done as well. area @ sacral measured @ 2.2 cm x 1.4 cm & 0.6 depth. second area under sacral area measured @ 1.9 cm x 0.5 cm." In a 08/04/10 the resident's primary physician identified Resident #20's sacral decubiti as stage III. Record review revealed there was no Treatment Sheet which documented the provision of Santyl to Resident's #20's sacral decubiti form 08/02/10 through 08/10/10. A 08/11/10 physician's orders [REDACTED]. Record review revealed two treatments on 08/11/10 and on 08/12/10 were not documented as being provided to Resident #20's buttocks crease on the Treatment Sheet. The resident's 08/12/10 Admission Minimum Data Set (MDS) documented Resident #20 had two stage II ulcers. The resident's 08/12/10 Pressure Ulcers Resident Assessment Protocol (RAP) documented, "Stage II pressure ulcer to sacrum/buttocks crease and blister to right heel. He requires extensive assist with (symbol used) bed mobility, and is incont (incontinent) of b & b (bowel and bladder). Has 2 + [MEDICAL CONDITION] to bil LEs (bilateral lower extremities)-impeding circulation. Receives PT/OT (physical therapy/occupational therapy) currently. At risk for further skin breakdown and/or development of infection to wounds...." The resident's 08/12/10 Nutritional Status RAP documented, "...Currently has wound to buttocks crease/sacrum and blister to right (symbol used) heel.... He is at (symbol used) risk for poor wound healing, retention of fluid, skin breakdown, and hypo/[MEDICAL CONDITION]." Record review revealed one treatment on 08/13/10 and on 08/17/10 were not documented as being provided to Resident #20's buttocks crease on the Treatment Sheet. A 08/18/10 physician progress notes [REDACTED]. Going to put him (Resident #20) on Promod once a day followed by a couple glasses of water...." A 08/18/10 physician order [REDACTED]. Another 08/18/10 physician order [REDACTED]. Review of Resident #20's August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Resident #20's August 2010 Treatment Sheet revealed there was no documentation the resident received any treatment to the buttocks crease wound on 08/18/10 through 08/22/10. A 08/24/10 physician order [REDACTED].#20's right heel. A 08/25/10 physician progress notes [REDACTED]. Review of Resident #20's August 2010 Treatment Sheet revealed there was no documentation the resident received antibiotic ointment/dry dressing to the blister on the right heel on 08/26/10, and there was no documentation the resident received two treatments to the buttocks crease on 08/26/10 and one treatment to the buttocks crease on 08/27/10, 08/30/10, and 08/31/10. A 08/30/10 physician order [REDACTED]. Review of Resident #20's August 2010 Treatment Sheet revealed the resident still received antibiotic ointment/dry dressing to the blister on his right heel on 08/30/10 and 08/31/10. Review of Resident #20's September 2010 MAR indicated [REDACTED]. A 09/02/10 physician order [REDACTED].#20's left thigh and [MEDICATION NAME] was to be applied every five days to a new open area on the resident's right buttocks. Review of Resident #20's September 2010 Treatment Sheet revealed there was no documentation of two treatments being provided to the buttocks crease on 09/01/10 and one treatment being provided to the buttocks crease daily on 09/05/10, 09/07/10, and 09/12/10. In addition, there was no documentation that treatments were provided to the resident's right heel on 09/05/10, 09/07/10, and 09/12/10. There was no documentation of Periguard cream being applied to the resident's left thigh one time on 09/03/10, two times on 09/07/10 through 09/09/10, and one time on 09/10/10. No use of [MEDICATION NAME] to the right buttocks was documented on 09/12/10. At 3:25 PM on 01/06/11 the Administrator and Director of Nursing (DON) stated it was facility policy to document the provision of all wound treatments on the Treatment Sheets. They reported they thought the provision of vitamin C and Promod was not captured on the August 2010 MAR because the resident had so many MARs composed when he entered the facility. They explained a MAR indicated [REDACTED]. The DON stated the vitamin C and Promod were important nutrition interventions for Resident #20 who was prone to wound deterioration due to his diabetes and low [MEDICATION NAME] level. The DON commented the resident was very compromised and had problems with [MEDICAL CONDITION].