Every finding on record at Avir at Converse

Based on observation record review and interview, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program for residents with newly evident or possible serious mental disorder for 3 of 13 Residents (Resident #67, #48 and #7) whose records were reviewed. The facility failed to refer Resident #67, #48 and #7 for Level I screening when diagnosed with a mental disorder. This deficient practice could affect residents with a mental diagnosis and can result in residents not receiving services as identified by PASRR. The findings were:1.Record review of Resident #67's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included: Bipolar Disorder (is a mental health condition characterized by significant mood swings, including depression), Depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest), and Hyperlipidemia (occurs when there is excessive fat in the bloodstream). Review of Resident #67's admission MDS assessment, dated 6/4/26, revealed he was admitted to the facility on [DATE]. His BIMS score was 15, which indicated intact cognition. Record review of Resident #67's PASRR I screening dated 5/28/2026 revealed no evidence or indicator of mental illness. An interview with the MDS Nurse on 6/4/2026 at 12:12 pm indicated that Resident #67 was diagnosed with bipolar disorder and that the PASRR 1 admission screening was inaccurate. As a result, the screening needed to be redone and submitted to the local health authority. The MDS Nurse explained that Resident #67 risked not receiving state services for his diagnosis, and the facility could lose Medicaid reimbursement for each day Resident #67 remained without a proper PASRR I. She also noted she had not had the opportunity to audit all residents' charts before the state survey to ensure compliance. Interview with Resident #67 on 6/4/2026 at 7:15 AM revealed that he has had a diagnosis of bipolar disorder since being discharged from the military. Interview on 06/4/2026 at 2:30 PM with the ADON revealed that the MDS Nurse was responsible for referring all residents for level I PASRR screening if they had a mental illness. He further stated not referring residents with a mental illness for a Level 1 evaluation could result in Residents not benefiting from resources available. ADON stated he would be monitoring this task at random and ensure a complete audit was done of all Residents in the facility. 2. Review of Resident #48's face sheet, dated 6/4/26, revealed he was admitted to the facility on [DATE] with diagnoses including schizophrenia unspecified (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania), bipolar disorder (mental health condition characterized by significant mood swings, including manic (or hypomanic) episodes and depressive episode), borderline personality disorder (is a serious mental health condition characterized by intense emotional instability, impulsive behaviors, and difficulties in interpersonal relationships) and post-traumatic stress disorder (serious mental health condition that can develop after an individual experiences or witnesses a traumatic event). Review of Resident #48's PASRR Level I Screening, dated 12/5/25, revealed there was evidence that he had a mental illness. Review of Resident #48's admission MDS assessment, dated 12/12/25, revealed his BIMS score was 15 of 15 reflective that he did not have cognitive impairment. Further review revealed Resident #48 received antipsychotic and antidepressant medications on a regular basis. Observation and interview on 6/01/2026 at 10:54 AM with Resident #48 revealed he was lying in bed. He stated he was not feeling well related to diagnosis of PTSD. Resident #48 stated he usually stayed in his room but knew he should get out more. Interview on 6/4/26 at 5:15 PM with the MDS Coordinator/RN E revealed she had been in charge of processing PASRR applications for about 9 months. She stated Resident #48 was diagnosed with schizophrenia unspecified, bipolar disorder and borderline personality disorder. MDS Coordinator/RN E stated she had inaccurately coded that Resident #48 had a mental illness on the PASRR Level Screening, dated 12/5/25. She stated his primary diagnosis was Dementia. Upon reviewing Resident #48's face sheet she stated his primary diagnosis was Parkinsonism. She stated Resident #48's diagnoses were all in fact qualifying diagnoses and should have referred Resident #48 to the local authority for a PASRR evaluation. MDS Coordinator/RN E stated not following through could result in Resident #48 not receiving services that could improve his quality of life. 3. Review of Resident #7's face sheet, dated 6/4/26, revealed he was admitted to the facility on [DATE] with diagnosis including post-traumatic stress disorder (a mental health condition triggered by experiencing or witnessing a traumatic event, leading to severe anxiety, flashbacks, and emotional distress). Review of Resident #7's PASRR Level I screening, dated 6/2/25 revealed he did not have a mental illness. Review of Resident #7's annual MDS assessment, dated 5/2/26 revealed his BIMS score indicated he was moderately cognitively impaired. Interview on 6/4/26 at 5:15 PM with the MDS Coordinator/RN E revealed Resident #7 had a diagnosis of post-traumatic stress disorder which was reflective of a mental illness. She stated she should have completed another PASRR Level I screening to reflect mental illness and referred Resident #7 to the local authority for a PASRR evaluation. MDS Coordinator/RN E stated not following through could result in Resident #7 not receiving services that could improve his quality of life. Review of facility policy, Policy for PASSR, dated 1/20/2026, reflected When it is determined a PASRR is filled out incorrectly, the MDS coordinator will reach out to the corresponding case worker and ask them to correct the form.

Based on the interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, that medical records were accurately maintained for each resident, as documented for 1 of 4 residents (Resident #28) whose medical records were reviewed for accuracy. The facility failed to ensure that documentation on Resident #28's face sheet ccurately reflected the diagnosis of pain. This failure could place residents at risk of receiving improper care. Findings included: Record review of Resident #28's face sheet, dated 2/17/2026, revealed a [AGE] year old male admitted to the facility on [DATE] and remitted on 7/23/2025 with diagnoses that included: Bipolar Disorder (is a mental disorder characterized by periods of depression and abnormally elevated mood), Dementia (a loss of memory, thinking, reasoning, and other mental abilities), and Diabetes (disease in which the body can not properrtly control the amount in sugar in your blood). Record review of face sheet for Resident #28, dated 6/3/26, revealed no diagnosis for pain. Record review of Resident #28's BIMS assessment, completed 5/13/26, revealed a BIM score of 14, which indicated intact cognition. Record review of Resident #28's history and physical, dated 4/23/2025, revealed a diagnosis of pain. Record review of Resident #28's care plan, updated 12/20/2022, revealed a care plan with a focus on Pain. Record review of Resident #28's June 2026 monthly physician orders revealed an order for Morphine Sulfate ( pain medication ) 30 mg, to be administered as one tablet twice a day. Interview with Resident # 28 on 6/2/2026 at 9:44 am revealed that he has had pain for years due to an old military back injury. Interview with the MDS nurse on 6/3/2026 at 9:15 AM revealed that she was responsible for entering diagnoses on face sheets and that resident #28's pain diagnosis was not entered on the face sheet. The MDS Nurse said omitting this diagnosis may have affected staff awareness of the Resident's condition and the provision of appropriate care and services. She also said she had not yet audited the residents' diagnoses against the corresponding histories and physicals, which was why the information was not correlating. During an interview on 6/3/2026 at 10:25 a.m., the ADON stated he had been in his role for two months and had not yet audited all prior admissions for face sheet accuracy. He noted that omitting a pain diagnosis from the face sheet could cause confusion for providers and may result in Resident #28 not receiving appropriate care. He explained that the MDS Nurse is responsible for this task, while he conducts random monitoring. Record review of the facility's policy charting and documentation, dated 2001, revealed: Documentation in the medical record will be objective, complete, and accurate.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food and nutrition services. The facility failed to ensure dietary staff used facial hair restraints properly during meal preparation and dish washing. The facility failed to ensure the dietary staff used proper hand hygiene during plate preparation. These failures could place residents at risk for food borne illness. The findings included:During an observation on 06/02/2026 at 11:57 a.m. Dietary Aide A was observed assisting [NAME] B by preparing a cheese burger, placing cheese on the burger, placing the cheese burger on bun and giving the plate to [NAME] B while he was wearing a beard restraint only covering his beard hair to his chin and side of face with the restraint not pulled over his mustache. During an observation on 06/02/2026 at 12:04 p.m. [NAME] B was observed leaving the serving line to go to the pantry while wearing gloves, opening the pantry door, returning to the line with bag of chips, opening the bag of chips, reaching into the bag of chips with a gloved hand, placing chips on a plate, covering the plate, and putting it on a tray. [NAME] B did not change gloves or wash hands when she returned to the serving line. [NAME] B continued to serve plates for the lunch service. During an observation on 06/02/2026 at 12:15 p.m. Dietary Aide A was observed in the dish washing room putting the following items through the dish washing machine: meal trays, steam table pans, and cooking utensils with mustache exposed and beard restraint only covering his chin. During an interview on 06/02/2026 at 12:19 p.m. Dietary Aide A stated he had taken a drink and forgot to pull the beard restraint back over his mustache. Dietary Aide A stated the beard restraint should have been covering his mustache. Dietary Aide A further stated the beard restraint was supposed to keep hair from falling in the food and could cause cross contamination. Dietary Aide A stated if the hair was to fall in food it could possibly cause someone to get sick and could possibly cause vomiting. Dietary Aide A stated he should have the beard restraint over his facial hair when he was working in the kitchen. During an interview on 06/02/2026 at 12:22 p.m. [NAME] B stated she should have changed her gloves and washed her hands when she returned to the kitchen with the bag of chips and put new gloves on to continue serving. [NAME] B stated by not removing the gloves and washing her hands it could cause cross contamination and people could get sick. During an interview on 06/02/2026 at 12:25 p.m. the Dietary Manager stated hair restraints should be put on prior to entering the kitchen. The Dietary Manager further stated beard restraints should be worn to cover all facial hair. The Dietary Manager stated that by not wearing hair restraint properly hair could fall and contaminate food or dishes causing cross contamination. The Dietary Manager stated hair could get lodged in a resident's throat, and bacteria could be on the facial hair which could cause or make someone sick. The Dietary Manager stated [NAME] B should have removed her gloves when leaving the line, washed her hands and put on new gloves when returning to the line. The Dietary Manager further stated that by not doing this it could cause cross-contamination and could put residents at risk of becoming sick from contamination. During an interview on 06/03/2026 at 3:44 p.m. the Administrator stated hair restraints/beard restraints should be always worn when in the kitchen. The Administrator stated not wearing hair/beard restraints could cause cross contamination during meal prep or kitchen duties. The Administrator stated cross contamination could cause food borne illness. The Administrator stated kitchen staff should change gloves and wash hands when they walk into the kitchen, touch their face/clothing, when eating, toileting, or touching unclean surfaces to prevent contamination of food or causing food borne illnesses. Review of facility's policy, Food Safety and Sanitation, dated 2023, read Policy: All local, state, and federal standards and regulations will be followed to assure a safe and sanitary food and nutrition services department. Procedure: 2. Employees: c. Employees are required to. [NAME] nets are required when facial hair is visible. d. Employees will wash their hands just before they start to work in the kitchen and after smoking, sneezing, using the restroom.and touching face, hair, other people or surfaces or items with potential for contamination. Review of facility's policy, Employee Hygiene for Food Safety, dated 2023, read Policy: All food and nutrition services employees will practice good personal hygiene and safe food handling procedures. Procedure: All employees will: 1. Wear hair restraints (hair, hat, and/or beard restraint) to prevent hair from contacting exposed food.6. Use utensils to handle food, avoiding bare hand contact with food. Disposable gloves are a single use item and should be discarded after each use. Hands must be washed prior to using gloves and after removing gloves. Review of facility's policy, Personal Hygiene and Health Reporting, dated 2023, read Policy: All food and nutrition services employee will be trained in appropriate personal hygiene and health reporting. Procedure: 2. Personal hygiene criteria to follow include the following: c. Beards and mustaches should be closely cropped and neatly trimmed. When near exposed foods, beards must be restrained using beard covers. Review of facility's policy, Hand Washing, dated 2023, read Policy: Employees will wash their hands as frequently as needed throughout the day using proper hand washing procedures.Procedure: Hands and exposed portions of arms (or surrogate prosthetic devices) should be washed immediately before engaging in food preparation. 1. When to wash hands: f. After handling soiled equipment or utensils. g. During food preparation, as often as necessary to remove soil or contamination and prevent cross contamination when changing tasks. j. After engaging in other activities that contaminate the hands. Review of facility's policy, Bare Hands Contact with Food and Use of Plastic Gloves, dated 2023, read Policy: Single use gloves or other barriers will used when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited. Procedure: 6. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched the gloves must be changed and hands must be washed. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-301.14, When to Wash, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTNESILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks;.

Based on observation, interview and record review the facility failed to provide food that accommodated resident preferences for 1 of 8 Residents (Resident #53) whose records were reviewed. The facility failed to provide Resident #53 the option to receive a regular diet (non-mechanically altered food) per her preference. This deficient practice could result in residents not having the freedom of making their own food choices. The findings were:Review of Resident #53's face sheet, dated 6/2/26, revealed she was admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis (joint damage), post-traumatic stress disorder (is a mental health condition triggered by experiencing or witnessing a traumatic event, leading to severe anxiety, flashbacks, and emotional distress) and major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems) recurrent. Review of Resident #53's quarterly MDS assessment, dated 4/14/26, revealed her BIMS score was 15 of 15 reflective of not having cognitive impairment. Further review revealed Resident #53 received a mechanically altered diet and it did not reflect she had a swallowing problem. Review of Resident #53's Care Plan, dated 2/13/26, revealed she was at risk of increased depression and one of the interventions included for staff to encourage and allow resident to verbalize needs and concerns; she was at nutritional risk. On a regular diet, mechanical soft (consists of foods that are chopped, mashed, pureed, or blended to make chewing and swallowing easier), thin liquids. Interventions included honor residents' meal choices and observe meal intake, record and offer alternative if eats less than 50 % of meal. Review of Resident #53's Multidisciplinary Care Conference, dated 4/22/26, revealed she C/O (complained) of DIET TEXTURE. WILL F/U (follow up). Observation and interview on 6/1/26 at 11:18 AM with Resident #53 revealed she was lying in bed. Resident #53 stated she had lived at the facility for years. Observation revealed Resident #53 did not have any teeth. Resident #53 stated she could not stand the food because staff insisted on serving her a mechanical blended diet. She stated she ordered her own food and would have the CNAs prepare instant oatmeal for breakfast, pasta, and other items. Resident #53 stated she had asked over and over for a regular food but staff basically ignored her. She stated staff acted like she could not chew. She commented she had been eating a regular diet for years without any problems. Observation and interview on 6/3/26 at 12:45 PM revealed CNA D was passing out lunch trays. She stated Resident #53's tray was the last one and CNA D presented Resident #53's lunch tray including beef Tator tot casserole, mixed vegetables and a smoothie. The beef Tator tot casserole was blended. CNA D stated she would present the meal tray to Resident #53 and the resident would let her know whether she wanted the tray or not. CNA D stated Resident #53 never accepted her meal trays. She stated Resident #53 would sometimes accept some of the drinks. Observation revealed CNA D delivered the tray to Resident #53 and then returned with the tray with all food items except the smoothie. CNA D stated Resident #53 accepted the smoothie served with the meal tray. CNA D stated she had worked at the facility for a couple of months and initially she let the charge nurse know Resident #53 was not accepting the food. CNA D stated Resident #53 would have her prepare some macaroni and cheese or other easy to prep foods and she would eat that instead of what was served. Interview on 6/3/26 at 1PM with LVN E revealed she had worked at the facility for about 11 years and stated Resident #53 was already living in the facility. She stated Resident #53 had always bought her own food and did not eat the facility food. LVN E stated she had never personally talked to Resident #53 about why she did not eat the food and again stated Resident #53 had always eaten whatever she wanted. Interview on 6/4/26 at 11:30 AM with the ADON and DOR revealed Resident #53 was not on caseload with rehabilitation services at this time. The DOR stated at one point the ST worked with Resident #53 and the primary concerns was that Resident #53 did not want to sit up during meals including having the head of her bed upright while she ate. In addition, Resident #53 would scoop the food from the plate into her mouth while lying down in bed. The DOR stated Resident #53 did not want staff to feed her. The ADON and DOR expressed concern that she could possibly choke, although they stated she had eaten whatever she wanted for as long as they had known Resident #53. The DOR and the ADON stated they were not aware Resident #53 having any choking incidents. Both the DOR and ADON stated Resident #53 had the right to choose her diet plan even if she was at risk for aspiration. They stated the facility had a waiver staff could have Resident #53 sign in order to release the facility of any liability. They stated they had not offered it to Resident #53. The DOR stated she had not contact with Resident #53 because she had not been on caseload for several months. The ADON stated he was not aware that Resident #53 wanted a diet upgrade. He stated he talked to Resident #53 often, was aware that she refused to eat the facility food but had never had a discussion with Resident #53 about her preferences. The ADON stated he could imagine Resident #53 might be frustrated about the situation. Interview on 6/4/26 at 5:15 PM with the MDS Coordinator revealed she remembered the Care Conference meeting held on 4/22/26 and Resident #53 wanted her diet upgraded to a regular diet. The MDS Coordinator stated Resident #53 reported she had a swallow study and was able to eat regular food. The MDS Coordinator stated the DOR was not present for the Care Conference meeting and let Resident #53 know they would get back with her. She stated this was discussed during the morning meeting on 4/23/26 and her request for a diet upgrade was denied without further discussion. The MDS Coordinator stated she had not met with Resident #53 about the outcome. She stated Resident #53 probably felt like nobody was listening to her and that what she wanted did not matter. Review of a facility policy, Resident Rights read in part 1. Federal and state laws guarantee the residents certain basic rights to all residents of this facility. These rights include the resident's right to: a. dignified existence and self-determination.

Based on observation, interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments for 1 (Resident #42) of 8 residents reviewed for care plan revisions. The facility failed to ensure Resident #42's care plan was revised to reflect resident no longer required the use of a foley catheter and resident being occasionally incontinent of urine. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included:Record review of Resident #42's face sheet, dated 06/03/2026 revealed Resident #42 was admitted to the facility on [DATE] with diagnoses which included: local infection of the skin and subcutaneous tissue, unspecified, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, skin transplant status and encounter for fitting and adjustment of urinary device. Record review of Resident #42's Quarterly 5-day MDS assessment, dated 05/04/2026, revealed Resident #42's BIMS score was 15 indicating cognition was intact and Section H-Bladder and Bowel H0100 Appliances was coded as none of the above for use of appliances and H0300 Urinary Continence was coded as 1 for occasionally incontinent (less than 7 episodes of incontinence). Record review of Resident #42's care plan, target date of 07/12/2026, revealed Resident #42 had a focus of [resident name] has an ADL self-care performance deficit r/t impaired mobility and intervention of TOILET USE: The resident requires assistance by (1-2) staff with toileting and managing foley catheter. Record review of Resident #42's care plan, target date of 07/12/2026, revealed Resident #42 had a focus of [resident name] has Indwelling Catheter and goal of The resident will be/remain free from catheter-related trauma. Record review of Resident #42's physician order summary dated 06/03/2026, revealed no orders for foley catheter or the care of a catheter. Record review of Resident #42's physician order recap report dated, 06/03/2026, read, FOLEY CATHETER 16 FRENCH/10 ML BALLOON with a discontinued effective date of 03/15/2026. Observation on 06/01/2026 at 10:42 a.m. revealed Resident #42 in her room and was observed transferring herself to the bed from her wheelchair and adjusting her covers free of difficulty with no Foley catheter present. During an interview and observation on 06/04/2026 at 1:42 p.m. the MDS Coordinator reviewed Resident #42's EMR and stated Resident #42 did not have an active order for a Foley catheter and further stated it was discontinued in March of 2026. The MDS Coordinator stated Foley catheter was still active in Resident #42's care plan, and she had not resolved it in the care plan. The MDS Coordinator stated that care plans were revised when the MDS assessments were due or quarterly. The MDS Coordinator further stated Resident #42's care plan for the catheter should have been revised in April. The MDS Coordinator stated when she was reviewing the care plan for Resident #42, she just did not see it and did not hit resolve the care plan. The MDS Coordinator reviewed Resident #42's Task in the EMR and stated resident was mostly continent according to the task and was 95% continent. The MDS Coordinator stated as she reviewed Resident #42's EMR that she only saw 1 or 2 incontinent episodes in the last 2 weeks. The MDS Coordinator stated the way the care plan was the staff members would assume Resident #42 had catheter care, but Resident #42 did not have a catheter so the staff would check on Resident #42 during their rounds. The MDS Coordinator stated she did not feel it would affect the care of Resident #42. The MDS Coordinator stated Resident #42's care plan should have been revised to show her toileting needs. The MDS Coordinator stated the purpose of the care plan was to inform the staff how to care for the resident and was a type of guidance for caring for residents. During an interview on 06/04/2026 at 2:37 p.m. the Administrator stated the MDS Coordinator was responsible for care plan accuracy. The Administrator stated care plans should be revised during clinical discussions, weekly, and daily as things change with a resident. The Administrator stated the best practice would be as soon as it was known that a change had occurred, the care plan should have been revised. The Administrator stated the care plan directed how the care of a resident was to be provided, what the residents' needs were and how the care was to be provided to the resident. Record review of facility's Care Plans, Comprehensive Person-Centered policy, revision date March 2022, read, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and residents' conditions changes.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 Residents (Resident #7) whose records were reviewed. The MDS Coordinator failed to include Resident #7's diagnosis of PTSD in his comprehensive care plan including care and services the facility would provide. This deficient practice could result in residents not receiving the care and services needed. The findings were:Review of Resident #7's face sheet, dated 6/4/26, revealed he was admitted to the facility on [DATE] with diagnosis including PTSD, post-traumatic stress disorder (a mental health condition triggered by experiencing or witnessing a traumatic event, leading to severe anxiety, flashbacks, and emotional distress). Review of Resident #7's annual MDS assessment, dated 5/2/26 revealed his BIMS score indicated he was moderately cognitively impaired and he had a diagnosis of PTSD. Review of Resident #7's, Comprehensive Care Plan, dated 4/10/26 did not reflect that he had a diagnosis of PTSD and it did not address how staff would assist Resident #7 in managing his condition. Observation and attempted interview on 6/03/2026 at 12 PM revealed Resident #7 was sitting at one of the dining rooms tables. Attempted interview with Resident #7 revealed he did not engage in conversation and propelled away. Interview on 6/4/26 at 5:15 PM with the MDS Coordinator revealed she was responsible for completing resident care plans. She stated Resident #7 had a diagnosis of PTSD and his Comprehensive Plan did not reflect this diagnosis, care or services he would receive. She stated the Care Plan did not accurately describe Resident #7's mental status and could result in staff not knowing how to address behaviors associated with PTSD. Review of facility policy, Care Plans, Comprehensive Person-Centered read in part 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. the comprehensive person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, including: (3) which professional services are responsible for each element of care.

Based on observation, interview and record review the facility failed to provide residents with a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 8 Residents (Resident #53 ) whose restrooms were observed for safety. The facility failed to ensure Resident #53 sink faucet was functional and did not spray water onto the floor. This deficient practice could prevent residents from using the sink in the restroom and could cause avoidable accidents. The findings were:Review of Resident #53's face sheet, dated 6/2/26, revealed she was admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis (joint damage), post-traumatic stress disorder ( is a mental health condition triggered by experiencing or witnessing a traumatic event, leading to severe anxiety, flashbacks, and emotional distress) and major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems) recurrent. Review of Resident #53's quarterly MDS assessment, dated 4/14/26, revealed her BIMS score was 15 of 15 reflective of not having cognitive impairment and she was dependent on staff for personal hygiene. Review of Resident #53's Care Plan, dated 4/4/26, revealed she had an ADL self-care performance deficit related to impaired mobility and she required assistance by 1 staff for oral care management and personal hygiene. Observation and interview on 6/1/26 at 11:18 AM with Resident #53 revealed she was lying in bed. Resident #53 stated she had lived at the facility for years. She stated she used her power motorized wheelchair for mobility but had chosen not to get out of bed for some weeks. She stated previously, she would get out of bed and use the sink in the bathroom but the water sprayed out directly from the faucet instead of spraying down. She stated it was an inconvenience for her and commented it was annoying. Resident #53 stated the faucet had not been working for months and had told a few of the CNA's but the faucet had not been fixed. Observation in Resident #53's bathroom revealed the sink faucet sprayed outward instead of downward. When the pressure was turned up the water sprayed onto the floor. Further observation revealed there was a wet towel on the floor in front of the sink. Interview on 6/3/26 at 12:45 PM with CNA D revealed Resident #53 mentioned to her the water from the sink faucet would spray outward onto the floor. She stated she reported it to her charge nurse a few weeks ago. CNA D stated she had also noted it herself when using the sink. Interview on 6/4/26 at 4:50 PM with the MD revealed he had worked for the facility for a few months. He stated he received a work order on 5/8/26 on the facility internal program from one of the nurses who reported the sink faucet in Resident #53's bathroom needed repairs. The MD stated he had not looked at it or repaired it because he had other repairs that were a higher priority. He stated he did not have an assistant, and he was the only one to complete all repairs. Observation and interview on 6/4/26 at 5:00 PM revealed the MD turned on the cold water at the sink in Resident #53's bathroom. The water sprayed straight outwards. He gradually turned the pressure higher, and the water started spraying out of the sink onto the floor. The MD stated it was probably inconvenient for Resident #53 and someone could slip and fall on the wet floor. Review of a facility policy, Resident Rights read in part 1. Federal and state laws guarantee the residents certain basic rights to all residents of this facility. These rights include the resident's right to: a. dignified existence and self-determination.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 2 medication carts (Medication Cart 300/400) reviewed for storage of drugs and biologicals. The facility failed to ensure the medication cart for hall 300/400 did not have a vial of unlabeled insulin in it. These deficient practices could place residents at risk of receiving the wrong medication, misuse of medication or drug diversion.The findings included: During an observation and interview on 3/5/26 at 11:14 a.m., observation of the 300/400-hall medication cart had a vial of insulin, without a box, without a name or pharmacy prescription label on it and with an open date. Interview with LPN A she stated they were responsible for the 300/400 medication cart. LPN A stated if medication does not have a label on it they usually will either discard the medication or contact the nurse who was in charge of the medication cart pervious to them. LPN A stated that residents' names should be on their medications to know who's running out and so the medication is not shared amongst residents because everyone can have different reactions to medication. During an interview on 3/5/26 at 4:55 p.m., the DON stated insulin should be labeled with the medication name, residents name, directions and when it is opened if it is opened. The DON stated the nurse is in charge of the medication cart. The DON stated the pharmacy is responsible for labeling the medications and if the medication does not have a label, staff will need to contact the pharmacy for one. The DON stated an unlabeled insulin could have a risk of giving the wrong person the wrong insulin. Record review of the facility document titled Medication Labeling and Storage, with a revision date February 2023, reflected: Medication Labeling2. the medication label includes, at a minimum:a. medication name (generic and/or brand);b. prescribed does;c. strength;d. expiration date, when applicable;e. resident's name;f. route of administration; andg. appropriate instructions and precautions.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 5 residents (Resident #1, Resident #2 and Resident #3) reviewed for infection control: 1.The facility failed to ensure Resident #1's pure wick tubing was not on the floor. 2.The facility failed to ensure Resident #2 had enhanced barrier precaution signage and supplies by Resident #2's door. 3.The facility failed to ensure Resident #3 had enhanced barrier precaution signage and supplies by Resident #3's door. These failures could place residents at-risk for infection due to improper care practices.The findings included: 1. Record review of Resident #1's face sheet dated 2/3/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing), diabetes (a chronic medical condition in which the body has trouble regulating blood sugar), chronic kidney disease, cognitive communication deficit and muscle weakness. Record review of Resident #1's most recent reentry MDS assessment dated [DATE] reflected the resident was severely impaired, did not have an external catheter, and was always incontinent of bowel and bladder. Record review of Resident #1's Order Summary Report dated 2/3/2026 reflected the following: - Change pure wick device (device used to manage urinary incontinence) q12 hours and pm: two times a day for urinary output supplies provided in room by family with an order date 1/4/2026 and no end date. Record review of Resident #1's comprehensive care plan with initiation date 1/4/2026 reflected the resident had a PURE WICK urinary system and at risk for UTI with interventions that included providing urinary catheter care, assessing for abnormal urine and emptying and recording output every shift and PRN. During an observation on 2/3/2026 at 12:40 p.m. Resident #1's bedroom entry revealed a sign which indicated the resident was on Enhanced Barrier Precautions. Resident #1 was observed in bed, and the pure wick catheter was sitting to the right of the bed, on a pad. Resident #1's pure wick catheter tubing was touching the floor. During an observation and interview on 2/3/2026 at 12:53 p.m., CNA A stated she was assigned to care for Resident #1 as part of her assignment in the hall she was working in. CNA A stated Resident #1 had a pure wick catheter and observed the resident's pure wick catheter tubing touching the floor. CNA A stated the pure wick catheter tubing should not be touching the floor as it was an infection control issue. CNA A stated she would let the nurse know the pure wick catheter tubing was on the floor. 2. Record review of Resident #2's face sheet dated 2/3/2026 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, retention of urine, and dysphagia (difficulty swallowing). Record review of Resident #2's admission MDS assessment dated [DATE] reflected the resident had moderate cognitive impairment and had an unhealed pressure injury/ulcer. Record review of Resident #2's Order Summary Report dated 2/3/2026 reflected the following: - heels protector when in bed due to multiple unstageable wounds, every shift with order date 1/22/2026 and no end date. - unstageable wound to left heel: cleanse with ns or wound cleanser, pat dry. Apply moisturizer gauze to base of the wound. Secure with ABD, kerlix and ace bandage, every day shift every Mon, Wed, Fri with order date 1/22/2026 with no end date. -unstageable wound to right heel: cleanse with ns or wound cleanser, pat dry. Apply moisturizer gauze to base of the wound. Secure with ABD, kerlix and ace bandage every day shift every Mon, Wed, Fri with order date 1/22/2026 with no end date. - left thigh, upper anterior hematoma (collection of blood outside a blood vessel), cleanse with ns or wound cleanser, pat dry with betadine moistened gauze to wound base, cover with bordered gauze every day shift Mon, Wed, Fri order date 1/30/2026 and start date of 2/2/2026 with no end date. Record review of Resident #2's comprehensive care plan with revision date 1/22/2026 reflected the resident admitted with pressure ulcers (r/t Hx of ulcers, immobility) unstable right heel and unstageable left heel with interventions that include administering treatments as ordered and monitor for effectiveness. 3. Record review of Resident #3's face sheet dated 2/3/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included pressure ulcer to part of back, stage 3, pressure ulcer to part of back, stage 4, pressure ulcer of right heel, pressure ulcer of left heel. Record review of Resident #3's admission MDS assessment dated [DATE] reflected the resident had moderate cognitive impairment and had an unhealed pressure injury/ulcer. Record review of Resident #3's Order Summary Report dated 2/3/2026 reflected the following: - Stage IV sacrum pressure ulcer/injury: cleanse with wound cleanser/normal saline. Apply gentell blue to base of wound. Secure with superabsorbent dressing, every day shift with order date 1/16/2026 with no end date. -unstageable wound to lower back: cleanse with ns or wound cleanser, pat dry. Apply betadine to base of wound, leave open to air, every day shift with order date 1/16/2026 with no end date. -heel up boots when in bed due to multiple unstageable wounds, every shift with order date 1/22/2026 and no end date. -stage III wound to caudal space (base of spine) to lower back: cleanse with ns or wound cleanser, pat dry, apply collagen, calcium alginate to base of the wound. Secure with silicone bordered superabsorbent dressing, every day shift with order date 1/22/2026 with no end date. -unstageable wound to right heel: cleanse with ns or wound cleanser, pat dry. Apply betadine moistened gauze to base of the wound. Secure with ABD, kerlix and secure with tape, every day shift every Mon, Wed, Fri with order date 1/22/2026 with no end date. -unstageable wound to left heel: cleanse with ns or wound cleanser, pat dry. Apply betadine moistened gauze to base of the wound. Secure with ABD, kerlix and secure with tape, every day shift every Mon, Wed, Fri with order date 1/22/2026 with no end date. -unstageable wound to left lateral ankle: cleanse with ns or wound cleanser, pat dry. Apply Hydrogel Gauze to the base of the wound and secure with bordered gauze dressing, every day shift every Mon, Wed, Fri with order date 1/22/2026 with no end date. -unstageable wound to right lateral ankle: cleanse with ns or wound cleanser, pat dry. Apply Collagen to base of the wound, then betadine moistened gauze over collagen and secure with ABD, Kerlix, and ace bandage, every day shift every Mon, Wed, Fri with an order date of 1/20/2026 with no end date. Record review of Resident #3's comprehensive care plan with revision date 1/22/2026 reflected the resident admitted with pressure ulcers (r/t Hx of ulcers, immobility) unstable right heel and unstageable left heel with interventions that include administering treatments as ordered and monitor for effectiveness. During an observation on 2/3/2026 at 1:10 p.m. revealed Resident #2 and Resident #3 resided in the same room. Resident #2 and Resident #3's bedroom entry revealed lack of signage of EBP and supplies. During an observation and interview on 2/3/2026 at 1:16 p.m., LVN C stated any residents with open wounds would need to be on EBP. LVN C stated staff would know if a resident was on EBP if they had a sign stating so and a cart with supplies alongside it. When asked if Resident #2 or/and Resident #3 would need to be on EBP, LVN C stated LVN C wasn't sure and would need to ask the DON. LVN C stated if staff do not know a resident is on EBP there could be a risk of cross contamination or/and spreading infectious diseases. During an interview on 2/3/26 at 1:26 p.m., LVN D stated any residents with wounds would need to be on EBP. LVN D stated staff would know if a resident was on EBP if there were a sign and cart by their room. LVN D stated Resident #2 and Resident #3 should have had EBP signage and supplies due to both Residents having wounds. LVN D stated the risk of not having EBP or signage/using would be infections in the wound. During an interview on 2/3/2026 at 1:54 p.m., LVN B stated she oversaw Resident #1's care as she oversaw the hall Resident #1 was in. LVN B stated Resident #1's pure wick catheter tubing should not be on the floor. LVN B stated the risk could be contamination. During an interview on 2/3/2026 2:52 p.m., the DON stated residents were placed on EBP if they have indwelling catheters or chronic wounds. The DON stated staff know if a resident was on EBP if they had signs outside their door saying so and a cart. The DON stated the purpose of EBP was to prevent transmission of bacteria. The DON stated catheter tubing should not be on the floor due to the risk of bacteria being on the outside of the tube. Record review of the facility document titled Enhanced Barrier Precautions Program with revision date March 2024, reflected:5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization a. Wounds generally include chronic wounds (i.e. pressure ulcers.) b. indwelling medical devices include central lines, urinary catheters.

Based on observations, interviews, and record reviews the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 5 medication carts, (the 100-hall medication cart) reviewed for locked compartments. LVN A left the medication cart she was assigned, unlocked outside of a resident's room while she was in the room with the door shut. This deficient practice could place residents at risk for unauthorized persons having access to medications not approved for them.The Findings included:During an observation on 9/2/2025 at 8:47 AM revealed a medication cart on the 100-hallway with the drawers facing the hallway, unlocked, unattended, with staff, the public, and residents ambulated by the cart. During an observation and interview on 9/2/2025 at 9:10 AM revealed the medication cart continued on the 100-hallway with the drawers facing the hallway, unlocked, unattended, with staff, the public, and residents ambulated by the cart. The Administrator and the Director of Nursing (DON) witnessed the unlocked medication cart and identified LVN A as the nurse assigned to the medication cart. LVN A was summoned by the DON and LVN A stated she was in a resident's room providing care and could not see her cart. LVN A stated she had left her cart unattended and unlocked. The DON stated the expectation was for all medications to be secured when not being utilized and the potential negative outcome could be loss of control of residents' medications. A record review of the facility's policy titled Medication Labeling and Storage dated 2001 revealed, the facility stores all medications and biologicals and locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to the keys. Policy interpretation and implementation: medication storage: . compartments, including but not limited to; drawers, cabinets, rooms, refrigerators, carts, and boxes containing medications and biologicals are locked when not in use and trays or carts used to transport such items are not left unattended if opened or otherwise potentially available to others.

Based on interview and record review, the facility failed to ensure CNA received the required minimum 12 hours annual in-service for 3 of 6 CNAs (CNA G, CNA K, CNA L) reviewed for training. The facility failed to provide the required 12 hours of annual training to CNA G, CNA K, CNA L. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for CNA G revealed a hire date of 07/31/2023. Review of a training in-services for CNA G from the previous 12 months, provided by the HR Coordinator revealed no evidence that the facility provided the required 12 hours of in-service trainings including communication training, QAPI training or ethics training being provided annually. Record review of the personnel records for CNA K revealed a hire date of 01/29/2024. Review of a training in-services for CNA K from the previous 12 months, provided by the HR Coordinator revealed no evidence that the facility provided the required 12 hours of in-service trainings including ethics training, falls training, restraint training or emergency preparedness training being provided annually. Record review of the personnel records for CNA L revealed a hire date of 03/18/2022. Review of a training in-services for CNA L from the previous 12 months, provided by the HR Coordinator revealed no evidence that the facility provided the required 12 hours of in-service trainings including ethics training being provided annually. Interview with the HR Coordinator on 04/04/2025 at 1:34 PM, revealed she initiates in-service trainings every month and every month was a different topic. The HR Coordinator stated she presented the in-services to the department heads, and they present them to their staff. The HR Coordinator stated it was the responsibility of the department heads to complete the in-services and her responsibility to verify all staff have completed the assigned in-service each month. The HR Coordinator stated staff were notified they need to complete in-service trainings only when department heads present the trainings to them. The HR Coordinator stated she followed an on-boarding checklist for new employees that includes trainings. The HR Coordinator stated she was not sure why all Dietary Manager's trainings were not completed upon hire. The HR Coordinator stated it was important that staff received their initial and annual trainings to ensure they are providing quality care to the residents. The HR Coordinator stated this could affect the residents leaving them vulnerable to abuse, neglect, and exploitation. Interview with the DON on 04/04/2025 at 2:34 PM, revealed she received the in-services from the HR Coordinator monthly and presented them to her staff. The DON stated it is the responsibility of department heads to present the in-services to their staff. The DON stated once the in-services were complete the HR Coordinator verifies all employees had completed the in-service. The DON stated completing the in-services was important to ensure staff had the knowledge to complete their jobs effectually and safely. The DON stated if staff were not trained annually, it could leave resident's vulnerable to receiving poor care. Interview with the Administrator 04/04/2025 at 2:43 PM revealed the facility provides staff with an in-service each month and each month the in-service reflected a different required training topic. The Administrator stated HR Coordinator initiated each in-service and provided them to the department heads so that they could train their staff. The Administrator stated it was the responsibility of department heads to train their staff each month and the responsibility of the HR Coordinator to verify each staff completed the in-services. The Administrator stated having untrained staff could lead to negative outcomes such as staff not knowing how to comminate or care for residents properly. A policy addressing required minimum 12 hours annual in-service for CNA was requested from the HR Coordinator on 04/04/2025 at 1:34 PM but was not provided prior to exit. A policy addressing required minimum 12 hours annual in-service for CNA was requested from the DON on 04/04/2025 at 2:34 PM but was not provided prior to exit. A policy addressing required minimum 12 hours annual in-service for CNA was requested from the Administrator on 04/04/2025 at 2:43 PM but was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 5 of 8 residents (Residents ##28, #25, #37, #31. and #38) reviewed for pharmacy services. 1. Resident #28's insulin flex pen (Humalog) for diabetes had an open date of [DATE] found inside the ,d+[DATE]-hall nursing cart on [DATE]. It should have been discarded 28 days after opening. 2. Resident #25's insulin (Lispro) for diabetes had an open date of [DATE] found inside the ,d+[DATE]-hall nursing cart on [DATE]. It should have been discarded 28 days after opening. 3. Resident #37's insulin (Novolog) for diabetes had an open date of [DATE] found inside the ,d+[DATE]-hall nursing cart on [DATE]. It should have been discarded 28 days after opening. 4. Resident #31's insulin (Novolog) for diabetes had an open date of [DATE] found inside the ,d+[DATE]-hall nursing cart on [DATE]. It should have been discarded 28 days after opening. 5. The facility nurses did not administer Resident #38's Lorazepam 0.5 mg oral one tablet at bedtime for anxiety on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (total 10 days) because the medication was not available, and nurses did not re-order it on time. These failures could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: 1. Record review of Resident #28's face sheet, dated [DATE], revealed Resident #28 was a [AGE] year-old female and admitted to the facility [DATE] with diagnoses of schizoaffective disorder (mental health problem psychosis as well as mood symptoms), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), muscle weakness, dysphagia (difficulty of swallowing), and hyperlipidemia (high level of fat). Record review of Resident #28's Quarterly MDS assessment, dated [DATE], revealed the resident's BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment, and the resident was receiving insulin injections every day as ordered. Record review of Resident #28's physician's order, dated [DATE], revealed the resident had the order of Humalog Kwik Pen subcutaneous Solution Pen Injector 100 unit/ml (insulin Lispro) inject as per sliding scale: if ,d+[DATE]=no insulin, ,d+[DATE]=1 units, ,d+[DATE]=2 units, ,d+[DATE]=3 units, ,d+[DATE]= 4 units, if blood sugar over 350 5 units, subcutaneously before meals for diabetes. Record review of Resident #28's medication administration record, dated from [DATE] to [DATE], revealed Resident #28 was receiving Humalog Kwik Pen subcutaneous Solution Pen Injector 100 unit/ml (insulin Lispro) inject as per sliding scale at 7:00 am, 11:00 am, and 4:00 pm. Observation on [DATE] at 2:41 p.m. revealed Resident #28's insulin Kwik pen (Lispro=Humalog) for diabetes with open date of [DATE] inside the ,d+[DATE]-hall nursing cart. Interview on [DATE] at 2:41 a.m. with LVN-D stated Resident #28's insulin Kwik pen (Lispro=Humalog) for diabetes with open date of [DATE] inside the ,d+[DATE]-hall nursing cart. Further interview, LVN-D said Resident #28's insulin Kwik pen (Lispro=Humalog) for diabetes should have been discarded 28 days after opening, which was [DATE] because the nurses opened it on [DATE]. LVN-D did not know what reason the nurses did not discard the insulin pen. 2. Record review of Resident #25's face sheet, dated [DATE], revealed Resident #25 was an [AGE] year-old male and admitted to the facility [DATE] with diagnoses of type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), neurocognitive disorder (decreased mental function), psychosis, and hyperlipidemia (high level of fat). Record review of Resident #25's Quarterly MDS assessment, dated [DATE], revealed the resident's BIMS score was 7 out of 15, which indicated the resident had severe cognitive impairment, and the resident was receiving insulin injections every day as ordered. Record review of Resident #25's physician's order, dated [DATE], revealed the resident had the order of Insulin Lispro injection solution subcutaneous - inject as per sliding scale: if ,d+[DATE]=no insulin, ,d+[DATE]=2 units, ,d+[DATE]=4 units, ,d+[DATE]=6 units, ,d+[DATE]= 8 units, ,d+[DATE]=10 units if blood sugar over 400 give 12 units and notify doctor, subcutaneously two times a day for diabetes. Record review of Resident #25's medication administration record, dated from [DATE] to [DATE], revealed Resident #25 was receiving Insulin Lispro subcutaneous Solution - inject as per sliding scale at 8:00 am and 8:00 pm. Observation on [DATE] at 2:41 p.m. revealed Resident #25's insulin (Lispro) for diabetes with open date of [DATE] inside the ,d+[DATE]-hall nursing cart. Interview on [DATE] at 2:41 a.m. with LVN-D stated Resident #25's insulin (Lispro) for diabetes with open date of [DATE] inside the ,d+[DATE]-hall nursing cart. Further interview, LVN-D said Resident #25's insulin (Lispro) for diabetes should have been discarded 28 days after opening, which was [DATE] because the nurses opened it on [DATE]. LVN-D did not know what reason the nurses did not discard the insulin pen. 3. Record review of Resident #37's face sheet, dated [DATE], revealed Resident #37 was a [AGE] year-old male and admitted to the facility [DATE] and readmitted to the facility [DATE] with diagnoses of paraplegia (inability to voluntarily move the lower parts of the body), radiculopathy (injury or damage to nerve roots in the area where they leave the spine), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), and muscle weakness. Record review of Resident #37's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15, which indicated the resident's cognition was intact, and the resident was receiving insulin injections every day as ordered. Record review of Resident #37's physician's order, dated [DATE], revealed the resident had the order of Insulin Novolog injection solution subcutaneous - inject 16 units subcutaneously before meals for diabetes. Record review of Resident #37's medication administration record, dated from [DATE] to [DATE], revealed Resident #37 was receiving Insulin Novolog injection solution subcutaneous - inject 16 units subcutaneously before meals for diabetes at 7:00 am, 11:00 am, and 4:00 pm. Observation on [DATE] at 2:41 p.m. revealed Resident #37's insulin (Novolog) for diabetes with open date of [DATE] inside the ,d+[DATE]-hall nursing cart. Interview on [DATE] at 2:41 p.m. with LVN-D stated Resident #37's insulin (Novolog) for diabetes with open date of [DATE] inside the ,d+[DATE]-hall nursing cart. Further interview, LVN-D said Resident #37's insulin (Novolog) for diabetes should have been discarded 28 days after opening, which was [DATE] because the nurses opened it on [DATE]. LVN-D did not know what reason the nurses did not discard the insulin pen. 4. Record review of Resident #31's face sheet, dated [DATE], revealed Resident #31was a [AGE] year-old female and admitted to the facility [DATE] and readmitted to the facility [DATE] with diagnoses of type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), and muscle weakness. Record review of Resident #31's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 1 out of 15, which indicated the resident had severe cognitive impairment, and the resident was receiving insulin injections every day as ordered. Record review of Resident #31's physician's order, dated [DATE], revealed the resident had the order of Insulin Aspart (Novolog) injection solution subcutaneous - inject as per sliding scale: if ,d+[DATE]=4 units, ,d+[DATE]=8 units, ,d+[DATE]=12 units, ,d+[DATE]=16 units, ,d+[DATE]= 20 units and notify doctor, subcutaneously every 6 hours for diabetes. Record review of Resident #31's medication administration record, dated from [DATE] to [DATE], revealed Resident #31 was receiving Insulin Aspart (Novolog) injection solution subcutaneous - inject as per sliding scale: if ,d+[DATE]=4 units, ,d+[DATE]=8 units, ,d+[DATE]=12 units, ,d+[DATE]=16 units, ,d+[DATE]= 20 units and notify doctor, subcutaneously every 6 hours for diabetes at 2:00 am, 8:00 am, 4:00 pm, and 8:00 pm. Observation on [DATE] at 2:41 p.m. revealed Resident #31's insulin (Novolog) for diabetes with open date of [DATE] inside the ,d+[DATE]-hall nursing cart. Interview on [DATE] at 2:41 p.m. with LVN-D stated Resident #31's insulin (Novolog) for diabetes with open date of [DATE] inside the ,d+[DATE]-hall nursing cart. Further interview, LVN-D said Resident #31's insulin (Novolog) for diabetes should have been discarded 28 days after opening, which was [DATE] because the nurses opened it on [DATE]. LVN-D did not know what reason the nurses did not discard the insulin pen. Interview on [DATE] at 2:42 p.m. the DON stated facility nurses should have discarded insulins for diabetes to 28 days after opening and it was nurse's responsibility. The DON said DON and ADON sometimes reviewed nursing carts, but they did not know what reason these insulins were in the nursing cart. The potential harm was the insulins might be less effective. 5. Record review of Resident #38's face sheet, dated [DATE], revealed the resident was a [AGE] year-old male, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnosis of hypertension (high blood pressure), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), hypokalemia (low level of potassium in the blood), anxiety disorder, muscle weakness, and insomnia (difficulty of sleeping). Record review of Resident #38's Annual MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15, which indicated the resident's cognitive function was intact and receiving antianxiety medication every day as ordered. Record review of Resident #38's comprehensive care plan, revised [DATE], revealed At risk for side effects to medications, increased anxiety and anxiousness related to his anxiety. For intervention - encourage and remind resident to ask for and provide assistance as needed and monitor for side effects to medications. Record review of Resident #38's physician order, dated [DATE], revealed the resident had the order of Lorazepam oral tablet 0.5 mg - Give one tablet by mouth at bedtime for anxiety. Record review of Resident #38's medication administration record, dated from [DATE] to [DATE], revealed the resident was taking Lorazepam 0.5 mg one tablet by mouth at bedtime for anxiety at 7:00 pm as ordered. However, the resident did not receive his Lorazepam 0.5 mg one tablet by mouth at bedtime for anxiety at 7:00 pm on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (total 10 days) because of no medication. Further record review of the medication administration record revealed Resident #38 did not have any anxiety episode and side effect of anti-anxiety medication such as agitation or appetite change for [DATE]. Record review of Resident #38's primary care physician's progress note, dated [DATE], revealed Anxiety - on Lorazepam. Will continue on it. No increased anxiety noted. Will monitor for any worsening symptoms and No specific pain issues noted. Interview on [DATE] at 8:53 a.m. with Resident #38 stated that he was supposed to receive his Lorazepam every day for his anxiety but did not receive it some days in [DATE] because nurses said they did not have the medication. However, he was receiving his Lorazepam every day in [DATE] without any issues. Further interview with the resident said he did not have any anxiety or side effects in [DATE]. Interview on [DATE] at 3:00 p.m. with LVN-B stated that LVN-B received the list of Resident #38's medications that needed to have refill and gave the list to ADON on [DATE]. The medication aide reported to LVN-B that the medication aide could not give Resident #38's Lorazepam on [DATE] to the resident because the medication was not available. LVN-B re-ordered it by calling to the pharmacy. LVN-B stated per the facility policy, nurses had responsibility to reorder medications before medications ran out. LVN-B did not know what reason nurses did not reorder it before Resident #38's Lorazepam ran out. Resident #38 did not have any sign or symptom related to anxiety. Interview on [DATE] at 3:15 p.m. with ADON stated she did not receive the list of Resident #38's medications that needed to have refill. Per the facility policy, medication aides should click reorder button on the electronic medication administration record before medications ran out. If medications were not delivered on time, medication aides should report it to charge nurses, and charge nurse should contact physician or pharmacy to make sure reorder and gave medications to residents from emergency kit located in the medication room if the emergency kit had medications. Further interview with ADON said lack of communication among nurses and medication aides might cause missing administrations of Resident #38's Lorazepam for 10 days in [DATE]. Interview on [DATE] at 3:16 p.m. with DON said DON became aware of missing administrations of Resident #38's Lorazepam for 10 days in [DATE] on [DATE] because the medication was not available. The DON called the primary care physician and reported it, and Resident #38's primary care physician visited and assessed the resident on face to face on [DATE] and noted the resident did not have any problem or negative outcomes regarding missing administrations of Resident #38's Lorazepam for 10 days in [DATE]. There was Resident #38's Lorazepam in the medication aide cart now, and medication aides administered it to the resident as ordered without any problem. However, it was medication error. The facility nurses should have contacted physician or pharmacy before the medication ran out. The DON said not receiving the medication may cause anxiety to Resident #38. Record review of the facility policy, titled Administering medications, undated, revealed . 7. For unavailable, missing or missed medications: a. Notify the charge nurse. b. Unavailable medication: charge nurse will check the ekit to see if dose is available. If not in the ekit, the charge nurse will reach out to facility pharmacy to initiate emergency refill of the cutoff time has already passed for the next scheduled delivery. Record review of the facility's policy, titled Insulin Expiration, undated, revealed . 2. All insulin, once opened or removed from the refrigerator must be dated. 3. All insulin, once or removed from refrigerator expired in 28 days and must be taken out of use and be replaced.

Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 11 of 23 (Housekeeper N, CMA F, CNA G, LVN H, Dietary Aide I, RN J, CNA K, CNA L, LVN M, LVN/MDS, Dietary Manager) employees reviewed for training requirements. The facility failed to implement and maintain a training program that ensured Housekeeper N, CMA F, CNA G, LVN H, Dietary Aide I, RN J, CNA K, CNA L, LVN M, LVN/MDS, Dietary Manager received required trainings annually. The facility failed to implement and maintain a training program that ensured Dietary Manager received required trainings upon hire. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of the personnel records for Housekeeper N revealed a hire date of 10/04/2016. Review of a training in-services for Housekeeper N from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training, QAPI training, ethics training, or falls training being provided annually. Record review of the personnel records for CMA F revealed a hire date of 01/27/2020. Review of a training in-services for CMA F from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training, QAPI training, HIV training, restraint training or emergency preparedness training being provided annually. Record review of the personnel records for CNA G revealed a hire date of 07/31/2023. Review of a training in-services for CNA G from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training, QAPI training or ethics training being provided annually. Record review of the personnel records for LVN H revealed a hire date of 09/14/2023. Review of a training in-services for LVN H from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training being provided annually. Record review of the personnel records for Dietary Aide I revealed a hire date of 12/08/2022. Review of a training in-services for Dietary Aide I from the previous 12 months, provided by the HR Coordinator revealed no evidence of QAPI training or behavioral health training being provided annually. Record review of the personnel records for RN J revealed a hire date of 02/17/2023. Review of a training in-services for RN J from the previous 12 months, provided by the HR Coordinator revealed no evidence of QAPI training or Ethics training being provided annually. Record review of the personnel records for CNA K revealed a hire date of 01/29/2024. Review of a training in-services for CNA K from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training, falls training, restraint training or emergency preparedness training being provided annually. Record review of the personnel records for CNA L revealed a hire date of 03/18/2022. Review of a training in-services for CNA L from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually. Record review of the personnel records for LVN M revealed a hire date of 02/10/2015. Review of a training in-services for LVN M from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually. Record review of the personnel records for LVN/MDS revealed a hire date of 03/18/2022. Review of a training in-services for LVN/MDS from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training, HIV training, or emergency preparedness training being provided annually. Record review of the personnel records for Dietary Manager revealed a hire date of 10/23/2024. Review of a training in-services for Dietary Manager from the previous 12 months, provided by the HR Coordinator revealed no evidence of behavior health training or HIV training being provided upon hire. Interview with the HR Coordinator on 04/04/2025 at 1:34 PM, revealed she initiates in-service trainings every month and every month was a different topic. The HR Coordinator stated she presented the in-services to the department heads, and they present them to their staff. The HR Coordinator stated it was the responsibility of the department heads to complete the in-services and her responsibility to verify all staff have completed the assigned in-service each month. The HR Coordinator stated staff were notified they need to complete in-service trainings only when department heads present the trainings to them. The HR Coordinator stated she followed an on-boarding checklist for new employees that includes trainings. The HR Coordinator stated she was not sure why all Dietary Manager's trainings were not completed upon hire. The HR Coordinator stated it was important that staff received their initial and annual trainings to ensure they are providing quality care to the residents. The HR Coordinator stated this could affect the residents leaving them vulnerable to abuse, neglect, and exploitation. Interview with the DON on 04/04/2025 at 2:34 PM, revealed she received the in-services from the HR Coordinator monthly and presented them to her staff. The DON stated it is the responsibility of department heads to present the in-services to their staff. The DON stated once the in-services were complete the HR Coordinator verifies all employees had completed the in-service. The DON stated completing the in-services was important to ensure staff had the knowledge to complete their jobs effectually and safely. The DON stated if staff were not trained annually, it could leave resident's vulnerable to receiving poor care. Interview with the Administrator 04/04/2025 at 2:43 PM revealed the facility provides staff with an in-service each month and each month the in-service reflected a different required training topic. The Administrator stated HR Coordinator initiated each in-service and provided them to the department heads so that they could train their staff. The Administrator stated it was the responsibility of department heads to train their staff each month and the responsibility of the HR Coordinator to verify each staff completed the in-services. The Administrator stated having untrained staff could lead to negative outcomes such as staff not knowing how to comminate or care for residents properly. Record review of facility policy titled In-Service Education, undated, revealed 1. Each year the administration or other designee will develop and implement an educational calendar to include (but not limited to) the following topics: 1. Range of Motion 2. Communication 3. QAPI Program 4. Sensory and Communication Impairments 5. Dementia Care/ Alz management (Quarterly: see Dementia Education Policy 20.01) 6. Resident Rights 7. Skin Care and Pressure Ulcer Prevention 8. Universal/Standard Precautions 9. AED Training (Nurses Quarterly; use manufacturers recommendation) I 0. Fire Safety 11. Toileting Programs 12. Incontinence 13. Disaster Plan/Emergency Preparedness 14. Wandering/Elopement 15. General Safety Precautions 16. Smoking Policy 17. Infection Control Program 18. Grievance Policy 19. Incidents and Accidents 20. Mechanical Transfers and Lifts (use manufacturers recommendation) 21. Falls and Fall Prevention 22. Infection Diseases (TB Hep B overview incl. vaccinations) 23. Sexual Harassment 24. Professional & Appropriate Communication 25. Geriatric Pharmacology (Nurses/CMAs) 26. Advanced Directive and Guardianship 27. Pain Assessment and Management 28. ADL's 29. Catheter Care 30. Urinary and Fecal Incontinence 3 I. Workplace Violence 32. Constipation 33. HIV/AIDS 34. UTIs 35. Unusual Occurrences Policy 36. Material Safety Data Sheets (MSDS) 37. Nutrition and Hydration 38. HIPAA 39. Abuse, Neglect, Exploitation Prevention and Reporting Program 40. Compliance and Ethics Program 41. Behavior Interventions 42. Intellectual/Mental Disability 43. Trauma Informed Care 44. Hand Washing Return Demonstration 45. Appropriate use of PPE 46. Restraints 47. Antibiotic Stewardship Policy 48. HR 49 - 1105B - Elder Justice Act 49. Facility Assessment 50. Respiratory and Trach Care (Nurses) 51. Narcan (naloxone) (Nurses) 52. Enhanced Barrier Precautions 53. Psychological Changes of Aging 54. Common Emergencies in Geriatrics 55. IV Therapy (Nurses) 56. Assisting Residents with Eating

Based on interview and record review, the facility failed to provide communications training for 4 of 23 employees (Housekeeper N, CMA F, CNA G, LVN H) reviewed for training, in that: The facility failed to ensure effective communication training was provided to Housekeeper N, CMA F, CNA G and LVN H annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of the personnel records for Housekeeper N revealed a hire date of 10/04/2016. Review of a training in-services for Housekeeper N from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training being provided annually. Record review of the personnel records for CMA F revealed a hire date of 01/27/2020. Review of a training in-services for CMA F from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training being provided annually. Record review of the personnel records for CNA G revealed a hire date of 07/31/2023. Review of a training in-services for CNA G from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training being provided annually. Record review of the personnel records for LVN H revealed a hire date of 09/14/2023. Review of a training in-services for LVN H from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training being provided annually. Interview with the HR Coordinator on 04/04/2025 at 1:34 PM, revealed she initiates in-service trainings every month and every month was a different topic. The HR Coordinator stated she presented the in-services to the department heads, and they present them to their staff. The HR Coordinator stated it was the responsibility of the department heads to complete the in-services and her responsibility to verify all staff have completed the assigned in-service each month. The HR Coordinator stated staff were notified they need to complete in-service trainings only when department heads present the trainings to them. The HR Coordinator stated she followed an on-boarding checklist for new employees that includes trainings. The HR Coordinator stated she was not sure why all Dietary Manager's trainings were not completed upon hire. The HR Coordinator stated it was important that staff received their initial and annual trainings to ensure they are providing quality care to the residents. The HR Coordinator stated this could affect the residents leaving them vulnerable to abuse, neglect, and exploitation. Interview with the DON on 04/04/2025 at 2:34 PM, revealed she received the in-services from the HR Coordinator monthly and presented them to her staff. The DON stated it is the responsibility of department heads to present the in-services to their staff. The DON stated once the in-services were complete the HR Coordinator verifies all employees had completed the in-service. The DON stated completing the in-services was important to ensure staff had the knowledge to complete their jobs effectually and safely. The DON stated if staff were not trained annually, it could leave resident's vulnerable to receiving poor care. Interview with the Administrator 04/04/2025 at 2:43 PM revealed the facility provides staff with an in-service each month and each month the in-service reflected a different required training topic. The Administrator stated HR Coordinator initiated each in-service and provided them to the department heads so that they could train their staff. The Administrator stated it was the responsibility of department heads to train their staff each month and the responsibility of the HR Coordinator to verify each staff completed the in-services. The Administrator stated having untrained staff could lead to negative outcomes such as staff not knowing how to comminate or care for residents properly. Record review of facility policy titled In-Service Education, undated, revealed 1. Each year the administration or other designee will develop and implement an educational calendar to include (but not limited to) the following topics: 2. Communication

Based on interview and record review the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of it's QAPI program for 5 of 23 employees (Housekeeper N, CNA G, Dietary Aide I, CMA F, RN J) employees reviewed for training requirements. The facility failed to ensure required QAPI trainings was provided to Housekeeper N, CNA G, Dietary Aide I, CMA F, and RN J annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of the personnel records for Housekeeper N revealed a hire date of 10/04/2016. Review of a training in-services for Housekeeper N from the previous 12 months, provided by the HR Coordinator revealed no evidence of QAPI training being provided annually. Record review of the personnel records for CMA F revealed a hire date of 01/27/2020. Review of a training in-services for CMA F from the previous 12 months, provided by the HR Coordinator revealed no evidence of QAPI training being provided annually. Record review of the personnel records for CNA G revealed a hire date of 07/31/2023. Review of a training in-services for CNA G from the previous 12 months, provided by the HR Coordinator revealed no evidence of QAPI training being provided annually. Record review of the personnel records for Dietary Aide I revealed a hire date of 12/08/2022. Review of a training in-services for Dietary Aide I from the previous 12 months, provided by the HR Coordinator revealed no evidence of QAPI training being provided annually. Record review of the personnel records for RN J revealed a hire date of 02/17/2023. Review of a training in-services for RN J from the previous 12 months, provided by the HR Coordinator revealed no evidence of QAPI training being provided annually. Interview with the HR Coordinator on 04/04/2025 at 1:34 PM, revealed she initiates in-service trainings every month and every month was a different topic. The HR Coordinator stated she presented the in-services to the department heads, and they present them to their staff. The HR Coordinator stated it was the responsibility of the department heads to complete the in-services and her responsibility to verify all staff have completed the assigned in-service each month. The HR Coordinator stated staff were notified they need to complete in-service trainings only when department heads present the trainings to them. The HR Coordinator stated she followed an on-boarding checklist for new employees that includes trainings. The HR Coordinator stated she was not sure why all Dietary Manager's trainings were not completed upon hire. The HR Coordinator stated it was important that staff received their initial and annual trainings to ensure they are providing quality care to the residents. The HR Coordinator stated this could affect the residents leaving them vulnerable to abuse, neglect, and exploitation. Interview with the DON on 04/04/2025 at 2:34 PM, revealed she received the in-services from the HR Coordinator monthly and presented them to her staff. The DON stated it is the responsibility of department heads to present the in-services to their staff. The DON stated once the in-services were complete the HR Coordinator verifies all employees had completed the in-service. The DON stated completing the in-services was important to ensure staff had the knowledge to complete their jobs effectually and safely. The DON stated if staff were not trained annually, it could leave resident's vulnerable to receiving poor care. Interview with the Administrator 04/04/2025 at 2:43 PM revealed the facility provides staff with an in-service each month and each month the in-service reflected a different required training topic. The Administrator stated HR Coordinator initiated each in-service and provided them to the department heads so that they could train their staff. The Administrator stated it was the responsibility of department heads to train their staff each month and the responsibility of the HR Coordinator to verify each staff completed the in-services. The Administrator stated having untrained staff could lead to negative outcomes such as staff not knowing how to comminate or care for residents properly. Record review of facility policy titled In-Service Education, undated, revealed 1. Each year the administration or other designee will develop and implement an educational calendar to include (but not limited to) the following topics: 3. QAPI Program

Based on interview and record review, the facility failed to provide mandatory ethics training for 7 of 23 employees (Housekeeper N, CNA G, RN J, CNA K, CNA L, LVN M, LVN/MDS) employees reviewed for training, in that: The facility failed to ensure ethics training was provided to Housekeeper N, CNA G, RN J, CNA K, CNA L, LVN M, and LVN/MDS annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for Housekeeper N revealed a hire date of 10/04/2016. Review of a training in-services for Housekeeper N from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually. Record review of the personnel records for CNA G revealed a hire date of 07/31/2023. Review of a training in-services for CNA G from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually. Record review of the personnel records for RN J revealed a hire date of 02/17/2023. Review of a training in-services for RN J from the previous 12 months, provided by the HR Coordinator revealed no evidence of Ethics training being provided annually. Record review of the personnel records for CNA K revealed a hire date of 01/29/2024. Review of a training in-services for CNA K from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually. Record review of the personnel records for CNA L revealed a hire date of 03/18/2022. Review of a training in-services for CNA L from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually. Record review of the personnel records for LVN M revealed a hire date of 02/10/2015. Review of a training in-services for LVN M from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually. Record review of the personnel records for LVN/MDS revealed a hire date of 03/18/2022. Review of a training in-services for LVN/MDS from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually. Interview with the HR Coordinator on 04/04/2025 at 1:34 PM, revealed she initiates in-service trainings every month and every month was a different topic. The HR Coordinator stated she presented the in-services to the department heads, and they present them to their staff. The HR Coordinator stated it was the responsibility of the department heads to complete the in-services and her responsibility to verify all staff have completed the assigned in-service each month. The HR Coordinator stated staff were notified they need to complete in-service trainings only when department heads present the trainings to them. The HR Coordinator stated she followed an on-boarding checklist for new employees that includes trainings. The HR Coordinator stated she was not sure why all Dietary Manager's trainings were not completed upon hire. The HR Coordinator stated it was important that staff received their initial and annual trainings to ensure they are providing quality care to the residents. The HR Coordinator stated this could affect the residents leaving them vulnerable to abuse, neglect, and exploitation. Interview with the DON on 04/04/2025 at 2:34 PM, revealed she received the in-services from the HR Coordinator monthly and presented them to her staff. The DON stated it is the responsibility of department heads to present the in-services to their staff. The DON stated once the in-services were complete the HR Coordinator verifies all employees had completed the in-service. The DON stated completing the in-services was important to ensure staff had the knowledge to complete their jobs effectually and safely. The DON stated if staff were not trained annually, it could leave resident's vulnerable to receiving poor care. Interview with the Administrator 04/04/2025 at 2:43 PM revealed the facility provides staff with an in-service each month and each month the in-service reflected a different required training topic. The Administrator stated HR Coordinator initiated each in-service and provided them to the department heads so that they could train their staff. The Administrator stated it was the responsibility of department heads to train their staff each month and the responsibility of the HR Coordinator to verify each staff completed the in-services. The Administrator stated having untrained staff could lead to negative outcomes such as staff not knowing how to comminate or care for residents properly. Record review of facility policy titled In-Service Education, undated, revealed 1. Each year the administration or other designee will develop and implement an educational calendar to include (but not limited to) the following topics: 40. Compliance and Ethics Program

Based on interview and record review, the facility failed to provide behavioral health training consistent with the requirements at S483.40 and as determined by the facility assessment at S483.71 for 2 of 28 (Dietary Aide I and Dietary Manager) employees reviewed for training, in that: The facility failed to ensure behavioral health training was provided to Dietary Aide I annually. The facility failed to ensure behavioral health training was provided to Dietary Manager upon hire. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for Dietary Aide I revealed a hire date of 12/08/2022. Review of a training in-services for Dietary Aide I from the previous 12 months, provided by the HR Coordinator revealed no evidence of behavioral health training being provided annually. Record review of the personnel records for Dietary Manager revealed a hire date of 10/23/2024. Review of a training in-services for Dietary Manager from the previous 12 months, provided by the HR Coordinator revealed no evidence of behavior health training being provided upon hire. Interview with the HR Coordinator on 04/04/2025 at 1:34 PM, revealed she initiates in-service trainings every month and every month was a different topic. The HR Coordinator stated she presented the in-services to the department heads, and they present them to their staff. The HR Coordinator stated it was the responsibility of the department heads to complete the in-services and her responsibility to verify all staff have completed the assigned in-service each month. The HR Coordinator stated staff were notified they need to complete in-service trainings only when department heads present the trainings to them. The HR Coordinator stated she followed an on-boarding checklist for new employees that includes trainings. The HR Coordinator stated she was not sure why all Dietary Manager's trainings were not completed upon hire. The HR Coordinator stated it was important that staff received their initial and annual trainings to ensure they are providing quality care to the residents. The HR Coordinator stated this could affect the residents leaving them vulnerable to abuse, neglect, and exploitation. Interview with the DON on 04/04/2025 at 2:34 PM, revealed she received the in-services from the HR Coordinator monthly and presented them to her staff. The DON stated it is the responsibility of department heads to present the in-services to their staff. The DON stated once the in-services were complete the HR Coordinator verifies all employees had completed the in-service. The DON stated completing the in-services was important to ensure staff had the knowledge to complete their jobs effectually and safely. The DON stated if staff were not trained annually, it could leave resident's vulnerable to receiving poor care. Interview with the Administrator 04/04/2025 at 2:43 PM revealed the facility provides staff with an in-service each month and each month the in-service reflected a different required training topic. The Administrator stated HR Coordinator initiated each in-service and provided them to the department heads so that they could train their staff. The Administrator stated it was the responsibility of department heads to train their staff each month and the responsibility of the HR Coordinator to verify each staff completed the in-services. The Administrator stated having untrained staff could lead to negative outcomes such as staff not knowing how to comminate or care for residents properly. Record review of facility policy titled In-Service Education, undated, revealed 1. Each year the administration or other designee will develop and implement an educational calendar to include (but not limited to) the following topics: 41. Behavior Interventions

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 4 of 8 residents (Residents #37, #49, #31, and #54) reviewed for storage. 1. Resident #37's insulin Glargine (Lantus) for diabetes had no open date, found inside ,d+[DATE]-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened. 2. Resident #49's insulin Glargine (Lantus) for diabetes had no open date, found inside ,d+[DATE]-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened. 3. Resident #31's insulin Glargine (Lantus) for diabetes had no open date, found inside ,d+[DATE]-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened. 4. Resident #54's insulin (Novolog) for diabetes had no open date, found inside ,d+[DATE]-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened. These failures could place residents at risk of having not therapeutic effects by using old insulins. The findings were: 1. Record review of Resident #37's face sheet, dated [DATE], revealed Resident #37 was a [AGE] year-old male and admitted to the facility [DATE] and readmitted to the facility [DATE] with diagnoses of paraplegia (inability to voluntarily move the lower parts of the body), radiculopathy (injury or damage to nerve roots in the area where they leave the spine), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), and muscle weakness. Record review of Resident #37's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 15 out of 15, which indicated the resident's cognition was intact, and the resident was receiving insulin injections every day as ordered. Record review of Resident #37's physician's order, dated [DATE], revealed the resident had the order of Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 50 unit subcutaneously two times a day for type 2 diabetes mellitus. Record review of Resident #37's medication administration record, dated from [DATE] to [DATE], revealed the resident was receiving Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 50 unit subcutaneously two times a day for type 2 diabetes mellitus at 8:00 am and 8:00 pm. Observation on [DATE] at 2:47 p.m. revealed Resident #37's insulin Glargine (Lantus) for diabetes with no open date inside the ,d+[DATE]-hall nursing cart. Interview on [DATE] at 2:51 p.m. LVN-D stated Resident #37's insulin Glargine (Lantus) for diabetes with no open date was inside the ,d+[DATE]-hall nursing cart. Further interview, LVN-D said Resident #37's insulin Glargine (Lantus) for diabetes should have been discarded 28 days after opening per the label. However, LVN-D did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-D did not know when the facility nurses opened Resident #37's insulin pen. 2. Record review of Resident #49's face sheet, dated [DATE], revealed Resident #49 was a [AGE] year-old male and admitted to the facility [DATE] and readmitted to the facility [DATE] with diagnoses of atherosclerosis of coronary artery bypass graft (over time arteries can become narrowed and hardened by the build-up of fatty called plaques), hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), and hypertension (high blood pressure). Record review of Resident #49's Annual MDS, dated [DATE], revealed the resident's BIMS score was 13 out of 15, which indicated the resident's cognition was intact, and the resident was receiving insulin injections every day as ordered. Record review of Resident #49's physician's order, dated [DATE], revealed the resident had the order of Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 15 unit subcutaneously at bedtime for type 2 diabetes mellitus. Record review of Resident #49's medication administration record, dated from [DATE] to [DATE], revealed the resident was receiving Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 15 unit subcutaneously at bedtime for type 2 diabetes mellitus at 8:00 pm. Observation on [DATE] at 2:47 p.m. revealed Resident #49's insulin Glargine (Lantus) for diabetes with no open date inside the ,d+[DATE]-hall nursing cart. Interview on [DATE] at 2:51 p.m. LVN-D stated Resident #49's insulin Glargine (Lantus) for diabetes with no open date was inside the ,d+[DATE]-hall nursing cart. Further interview, LVN-D said Resident #49's insulin Glargine (Lantus) for diabetes should have been discarded 28 days after opening per the label. However, LVN-D did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-D did not know when the facility nurses opened Resident #49's insulin pen. 3. Record review of Resident #31's face sheet, dated [DATE], revealed Resident #31 was a [AGE] year-old female and admitted to the facility [DATE] and readmitted to the facility [DATE] with diagnoses of type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), and muscle weakness. Record review of Resident #31's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 1 out of 15, which indicated the resident had severe cognitive impairment, and the resident was receiving insulin injections every day as ordered. Record review of Resident #31's physician's order, dated [DATE], revealed the resident had the order of Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 10 unit subcutaneously two times a day for type 2 diabetes mellitus. Record review of Resident #31's medication administration record, dated from [DATE] to [DATE], revealed the resident was receiving Insulin Glargine (Lantus) subcutaneous solution pen-injector 100 unit/ml - inject 10 unit subcutaneously two times a day for type 2 diabetes mellitus at 10:00 am and 4:00 pm. Observation on [DATE] at 2:47 p.m. revealed Resident #31's insulin Glargine (Lantus) for diabetes with no open date inside the ,d+[DATE]-hall nursing cart. Interview on [DATE] at 2:51 p.m. LVN-D stated Resident #31's insulin Glargine (Lantus) for diabetes with no open date was inside the ,d+[DATE]-hall nursing cart. Further interview, LVN-D said Resident #31's insulin Glargine (Lantus) for diabetes should have been discarded 28 days after opening per the label. However, LVN-D did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-D did not know when the facility nurses opened Resident #31's insulin pen. 4. Record review of Resident #54's face sheet, dated [DATE], revealed Resident #54 was a [AGE] year-old female and admitted to the facility [DATE] and readmitted to the facility [DATE] with diagnoses of senile degeneration of brain (progressive decline in cognitive function, impacting memory, and reasoning), pneumonia (infection to the lung), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), and muscle weakness. Record review of Resident #54's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 4 out of 15, which indicated the resident had severe cognitive impairment, and the resident was receiving insulin injections every day as ordered. Record review of Resident #54's physician's order, dated [DATE], revealed the resident had the order of Novolog injection solution 100 unit/ml - inject per sliding scale subcutaneously before meals for type 2 diabetes mellitus. Record review of Resident #54's medication administration record, dated from [DATE] to [DATE], revealed the resident was receiving Novolog injection solution 100 unit/ml - inject per sliding scale subcutaneously before meals for type 2 diabetes mellitus at 7:00 am, 11:00 am, and 4:00 pm. Observation on [DATE] at 2:47 p.m. revealed Resident #54's insulin Novolog for diabetes with no open date inside the ,d+[DATE]-hall nursing cart. Interview on [DATE] at 2:51 p.m. LVN-D stated Resident #54's insulin Novolog for diabetes with no open date was inside the ,d+[DATE]-hall nursing cart. Further interview, LVN-D said Resident #54's insulin Novolog for diabetes should have been discarded 28 days after opening per the label. However, LVN-D did not know if he should discard the insulin pen because the insulin pen did not have open date. The LVN-D did not know when the facility nurses opened Resident #54's insulin pen. Interview on [DATE] at 2:57 p.m. the DON said the facility nurses should have written open dates on insulins when they opened them to discard them 28 days after opened. Nurses would not know when they have to discard insulins if insulins did not have open dates, and it might cause improper use, and residents might not have therapeutic effects. DON said that it was nurse' responsibility, and DON and ADON sometimes reviewed nursing carts, but they did not know what reason nurses did not write the open dates. Record review of the facility's policy, titled Insulin Expiration, undated, revealed . 2. All insulin, once opened or removed from the refrigerator must be dated. 3. All insulin, once or removed from refrigerator expired in 28 days and must be taken out of use and be replaced.

Based on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 8 residents (Resident #18) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #18. This failure could affect any resident and keep them from calling for help as needed. The findings were: Record review of Resident #18's face sheet, dated 04/02/2025, revealed he was admitted to the facility on [DATE] with diagnoses which included: epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), unspecified, not intractable, with status epilepticus (a seizure that lasts longer than 5 minutes or when seizures occur in rapid succession without the person regaining consciousness between them), essential hypertension (high blood pressure), muscle weakness generalized, and unspecified dementia (a group of symptoms affecting memory, thinking and social abilities, unspecified severity, without behavioral disturbance, psychotic disturbance and anxiety. Record review of Resident #18's Quarterly MDS assessment, dated 02/21/2025, revealed the resident's BIMS score was 00, which indicated severe cognitive impairment. The Quarterly MDS assessment further revealed Resident #18 was dependent (helper does all of the effort) for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, personal hygiene, putting on/taking off footwear, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, tub/shower transfer, and roll left and right. Record review of Resident #18's care plan, last care plan review completed date of 03/31/2025, revealed Resident #18 had a focus of [resident's name] is at risk for fall due to periods of unsteady gait, resident also noncompliant with staff assistance. and interventions read Call light in reach in room and answered promptly. Encourage and remind him to use call light to ask for assistance. Observation on 04/01/2025 at 10:50 a.m. revealed Resident #18 sleeping in his bed, bed in the lowest position to the floor with call light clipped to privacy curtain. Observation on 04/02/2025 at 9:36 a.m. revealed Resident #18 sleeping in his bed, bed in the lowest position to the floor, lying on his side with the call light clipped to the privacy curtain. Observation and interview on 04/02/2025 at 9:57 a.m. CNA E stated Resident #18 would scream a lot at times and would yell for things. CNA E further stated normally he does not use his call light, but she goes in there to check on him during her rounds. CNA E revealed Resident #18 would not have been able to reach the call light if he needed it. CNA E then removed the call light from the curtain and clipped to his blanket and explained to him what she was doing when he began yelling as he was resting in the bed. CNA E stated to Resident #18 I'm giving you your call light, and Resident #18 responded okay as he went back to sleep. CNA E stated the call light was used for residents to ask for help if they needed her and it was her responsibility to place it where he could reach it. During interview on 04/04/2025 at 2:17 p.m. the DON stated the call light should be near the resident where they can grab it. The DON further stated when in the bed it should be always accessible. The DON stated the CNA and the nurse on the floor were responsible for placing it within reach and when they went in the room, they should have seen it and corrected it. The DON stated by being out of reach the resident would not be able to press it if they needed assistances. During an interview on 04/04/2025 at 2:21 p.m. the administrator stated staff in general were responsible for call light placement, but usually the CNA. The administrator further stated when anyone went in or during rounds anyone can place within reach. The administrator stated by not having the call light a resident might not get their needs met. The administrator stated he believed Resident #18 did not use it and the staff rounded on him frequently. Record review of facility's Call Lights policy, no date, read The purpose of this procedure is to respond to the resident's requests and needs., General Guidelines .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 16 residents (Resident #6) reviewed for MDS transmission. Resident #6's discharge MDS assessment was not completed and transmitted within 14 days of completion. This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required. The findings were: Review of Resident #6's face sheet, dated 04/04/2025, revealed an admitted [DATE] with diagnoses that included: chronic systolic (congestive) heart failure, respiratory failure, unspecified, unspecified whether with hypoxia (state of insufficient oxygen supply to the body's tissues, leading to a deficiency in oxygen delivery) or hypercapnia (occurs when the body's ability to eliminate carbon dioxide through breathing is impaired, leading to a buildup of carbon monoxide in the blood), essential hypertension (high blood pressure), atherosclerotic heart disease of native coronary artery without angina pectoris (symptom, not a disease itself, that indicates a problem with blood flow to the heart muscle), and unspecified dementia, unspecified severity, without behavioral disturbance, mood disturbance and anxiety. Review of Resident #6's Discharge MDS Assessment, dated 01/02/2025, revealed the assessment had not been completed and transmitted to CMS. During an interview on 04/04/2025 at 2:58 p.m. the MDS coordinator revealed the Discharge MDS assessment was open for Resident #6, but it was not finished. The MDS coordinator further stated the Discharge MDS assessment should have been done right away after the resident discharged . The MDS coordinator stated it should be completed by day 14. The MDS coordinator was not sure why it was not completed for Resident #6 after her discharge on 01/02/2025. The MDS coordinator stated she did not really know how was overlooked. The MDS Coordinator stated it was her responsibility to complete the Discharge MDS assessment. The MDS coordinator stated the MDS assessments were for CMS tracking, CMS reporting and by not completing the MDS assessment could affect possibly the QMs (quality measures). The MDS coordinator stated she kept a calendar and clinicals there was a schedule that would give a list. During an interview on 04/04/2025 at 3:10 p.m. the DON stated the MDS coordinator was responsible for the accuracy and completion of MDS assessments. The DON stated monitoring was done by the MDS coordinator, ADON, DON and administrator in the stand-up meeting. The DON was not sure why Resident #6's Discharge MDS assessment would have been missed. The DON did not believe there was another system other than PCC to track the MDS assessments. During an interview on 04/04/2025 at 3:19 p.m. the administrator stated the MDS coordinator was responsible for completion of the MDS assessments and the tracking of the MDS assessments. The administrator further stated there was a MDS in progress report in PCC and for some reason Resident #6's Discharge MDS assessment was not showing on the in-progress report in PCC when she pulled up the report. The administrator stated by not completing and submitting the MDS assessments could affect the quality measures of the facility. Record review of facility's policy titled Implementation of the Minimum Data Set (MDS), no date, read It is the policy of this facility to ensure a comprehensive assessment of each resident is completed and submitted according to the RAI guidelines manual set forth by CMS. Procedure: Monitor the schedule of the MDS. Complete a comprehensive, quarterly, significant change or other appropriate MDS according to the guidelines of the RAI manual set forth by CMS.

Based on interview and record review the facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 6 residents (Resident #1) whose records were reviewed for code status. The facility failed to ensure nursing staff followed emergency protocol and failed to ensure staff provided Resident #1, who had a Full Code in place, CPR, after the resident was found unresponsive with no pulse or respirations, according to professional standards of practice. On [DATE] at 4:51 p.m., and Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 4:05 p.m., the facility remained out of compliance due to the facility continuing to monitor the implementation and effectiveness of its Plan of Removal (POR). This failure could place residents at risk of not receiving life-saving measures, decline in health resulting in serious injury and or death. The findings included: Record review of Resident #1's face sheet, dated [DATE], reflected she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses to include cerebral infarction (a disruption in the brain's blood flow), dysphagia (inability to speak), hyperlipidemia (high fat levels in the blood) and malignant neoplasm of the colon (tumor). Resident #1's face sheet listed her as a full code. Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected her BIMS score was 11 indicating moderate cognitive impairment and was usually able to understand others and be understood by others. She required substantial assistance for ADL's. The MDS did not reflect the code status. Record review of Resident #1's care plan, dated [DATE], reflected Resident/Family are requesting full code status. The goal stated resident/family wishes will be honored through next review and CPR will be initiated as needed through next review. The goal had a date initiated [DATE], revision date [DATE] and target date [DATE]. The care plan interventions included: activate EMS as indicated, if transferred out of the facility notify receiving facility and EMS of full code, initiate CPR as indicated, mark chart per facility policy, observe for changes in condition and notify MDs and RP, resident is a full code, observe for change when assisting with care and notify the nurse, review code status with resident/family quarterly and prn. Interventions had an initiation date of [DATE]. Record review of Resident #1's admission notes, created by the DON on [DATE] with an effective date of [DATE], reflected Resident #1 was a full code resident and stated resident/family reports code status as full code. Record review of Resident #1's active physician orders for [DATE] reflected she had an order for full code with original date [DATE]. In addition, Resident #1's orders reflected an order to admit to hospice with original date [DATE]. Record review of Resident #1's Social Service admission assessment dated [DATE] stated Resident #1 was a full code status and did not have and out of hospital do not resuscitate form, advanced directives or a medical/financial power of attorney. The assessment reflected resident rights were explained to Resident #1. Record review of Resident #1's Social Service quarterly assessment, dated [DATE], reflected Resident #1 was a full code and did not have an out of hospital do not resuscitate form. Record review of Resident #1's [DATE] MAR reflected Advanced Directive: Full Code listed on the top of each page of Resident #1's MAR. Record review of Resident #1's EMR profile reflected Code Status: Full Code listed at top of the profile page directly under resident name, status, physician, and allergies. Record review of Resident #1's paper chart reflected a yellow binder with a green sheet in the front of the chart that stated, Full Code and a copy of Resident #1's face sheet that stated full code. Record review of Resident #1's progress note, dated [DATE] at 10:02 p.m., authored by LVN A read as follows was called to resident room. No breathes assess. No pulse. Call out to [hospice company name]. Awaiting call back. DON informed. Record review of Resident #1's progress note, dated [DATE] at 10:40 p.m., authored by LVN A read as follows upon retrieving residents face sheet out of resident chart, this nurse realized that resident was a full code. Contacted [hospice company name] in regard to code status. They stated they thought she was a DNR and was looking through their paperwork and stated to wait until hospice RN arrived at facility. [10:46 p.m.] Contacted DON in reference to code status. While on phone with DON, [hospice company name] nurse [name]RN entered facility and was informed of code status. She stated she would need to contact her supervisor to see what needed to be done. Hospice Nurse [name] then called 911 per directions of her supervisor and EMS came to the facility. Initiated life saving measures and resident was then pronounced deceased at 12:01 a.mXXX[DATE]. During an interview on [DATE] at 4:54 p.m., the Hospice Executive Director revealed the Hospice Triage RN received a call from LVN A at 10:06 p.m. on [DATE] and was told there was a patient death at the facility. Hospice triage RN told LVN A than an RN would be headed to the facility as soon as she finished another case. The Hospice Executive Director stated the Hospice RN arrived at the facility at 10:58 p.m., spoke to LVN A who was on the phone with the Hospice Triage RN again, and said LVN A told them the patient was a full code, and she did not start CPR and did not know what to do. The Hospice Executive Director said the Hospice RN spoke to the DON who stated she was twenty minutes away and did not know what to do. The Hospice RN called 911 at 11:10 p.m. and then called and reported the incident to the Hospice Executive Director at 11:17 p.m. The Executive Director stated Resident #1 admitted to hospice services on [DATE] and was a full code status from the time of admission. The Hospice Executive Director stated a full code status means a resident should be resuscitated. During an interview, [DATE] at 4:48 p.m., the Law Enforcement Officer stated the police department received a call regarding a deceased female around 11:30 p.m. on [DATE]. The Officer stated when he arrived, he was told by EMS staff that the facility nurse said she thought Resident #1 was a DNR and did not initiate CPR since she was on hospice. The Officer stated the Hospice RN and EMS said no one had initiated CPR at the facility for Resident #1 until the EMS personnel arrived around 11:30 p.m. The Officer stated he was notified by a staff member, Resident #1 had been checked on around 9 p.m. prior to being found unresponsive at 10 p.m. on [DATE]. During an interview, [DATE] at 5:36 p.m., the Hospice RN revealed she received a text from the Hospice Triage RN stating there was a death at this facility. The Hospice RN stated she finished providing care to another patient and then arrived at this facility at 10:58 p.m. on [DATE]. When she arrived, she stated LVN A was on the phone and very distraught and said, I didn't realize the patient was a full code and I called your office again to find out what to do. Hospice RN said she asked LVN A what the facility protocol was, and LVN A said she did not know and the DON was on the way. LVN A called the DON and Hospice RN spoke to the DON and asked her what the protocol was when this happens and Hospice RN said the DON said, I am not sure. The Hospice RN said she told the DON, I am not comfortable with this and I am calling EMS, and the DON said ok. Hospice RN said she called EMS and notified them of the situation and that Resident #1 had been passed away for over an hour. Hospice RN stated EMS arrived at the facility at 11:23 p.m., ran a lead (refers to the process of attaching and monitoring electrocardiogram leads on a patient) on Resident #1 at 11:29 p.m. The result revealed the patient was deceased . Hospice RN stated EMS called their EMS command and were instructed to initiate CPR. Hospice RN said EMS performed CPR for 31 minutes and then the EMS physician pronounced Resident #1 deceased at 12:01 a.m. on [DATE]. Hospice RN stated hospice records reflect Resident #1 was a full code and Resident #1 was listed as a full code at the facility and had a yellow binder with a green sheet in the front indicating Resident #1 was a full code. Hospice RN stated the facility should have initiated CPR for Resident #1. During an interview, [DATE] at 11:49 a.m., CNA D revealed she had checked on Resident #1 around 9:35 p.m. and Resident #1 was lying in bed and CNA D said, she looked ok, and I made sure she was clean and dry. CNA D said she made a final round at 10:00 p.m. and when she entered Resident #1's room, CNA D observed blackish brown liquid emesis on Resident #1's chest and CNA D said Resident #1 looked like she was gone. CNA D stated she yelled for LVN A to come to the room and when LVN A entered the room CNA D said, I gave LVN A space to check on her and I stepped out of the room. CNA D said she did not recall how long LVN A was in the room but said LVN A exited the room and said, she's gone. CNA D said she was aware Resident #1 was a full code and said a resident's code status is located in the EMR chart. CNA D was asked if anyone performed CPR and she said I don't know if anyone did, I went to get items to clean her up. All I know is I was told she was gone and that's it. When asked if she had received any training on code status or been contacted by leadership to discuss the incident she responded no. CNA D said full code status meant that a resident should get CPR if unresponsive. During an interview, [DATE] at 12:12 p.m., the Hospice Triage RN stated she received a call from the answering service at 10:02 p.m. on [DATE] and was notified to contact LVN A. The Hospice Triage RN called LVN A at 10:04 p.m. and LVN A said a resident on hospice services passed away. She said the conversation was very brief and they did not discuss code status because the Hospice Triage Nurse said, we would send a nurse out regardless of code status, so the facility is responsible for following their protocol for code status, and LVN A did not mention code status or CPR. The Hospice Triage RN notified the Hospice RN and the Hospice RN she would go to the facility as soon as she finished care with another patient. The Hospice Triage RN revealed another call came in around 10:48 p.m. to the answering service. The Hospice Triage RN said she called the facility back and spoke to LVN A at 10:55 p.m., at which time, LVN A told the Hospice Triage RN that Resident #1 was a full code, and she did not start CPR or call EMS. The Hospice Triage RN said she told LVN A she needed to follow facility protocol and LVN A said the Hospice RN had arrived and hung up the phone. The Hospice Triage RN revealed that Hospice RN called her at 10:59 p.m. and said Resident #1 was a full code and the Hospice Triage RN said she told her to hang up and call 911 and notify the Hospice Director of the incident and that the facility did not follow their protocol. When asked what a licensed nurse should do if they find a hospice patient unresponsive, the Hospice Triage RN said they should follow their facility protocol for responding to DNR and full code status and stated a full code resident should receive full resuscitation. Record review of the facility active staff roster, dated [DATE], reflected LVN A's name, position, status, hire date and phone number were not listed. During an interview, [DATE] at 12:25 p.m., the Administrator was asked by the surveyor why LVN A's name was not listed on the employee roster. The Administrator stated, that is because she was terminated. The Administrator stated LVN A was terminated on [DATE] and provided the surveyor LVN A's phone number. During an interview on [DATE] at 12:44 p.m., the DON revealed she received a call around 10 p.m. on [DATE] from LVN A who notified her that Resident #1 was deceased , and hospice was on the way to pronounce Resident #1. The DON stated she received another call from LVN A approximately 40 minutes later and LVN A said, I made a mistake. The DON said she asked LVN A what she meant and LVN A revealed Resident #1 was a full code and then hung up the phone stating the Hospice RN had arrived. The DON said she left her home to go to the facility and when she arrived, EMTs were performing CPR on Resident #1 and pronounced her deceased at 12:01 a.m. on [DATE]. The DON stated no one performed CPR for Resident #1 from 10:02 p.m. until the EMT's arrive and started CPR at 11:30 p.m. The DON was asked what the facility protocol was for finding a resident unresponsive and the DON stated the nurse should verify the resident code status, go to the room and assess the resident, and initiate CPR if the resident is a full code, and instruct another person to call 911. When asked if LVN A checked Resident #1's code status at the time she was found unresponsive, the DON said LVN A reported she did not check Resident #1's EMR or chart for the correct code status. The DON stated the resident code status is listed on the resident profile in the EMR, on the face sheet, MAR/TAR, care plan and in the paper binder labeled with a red or green sheet as a code status identifier. When asked why it is important for staff to adhere to a resident's code status preference, the DON stated, because the resident has the right to choose whether we perform CPR or not. The DON was asked about prior code status training for the licensed nurses, and she stated the licensed nurses had received training in February 2024 on code status, how to respond to a code, where to find code status in resident charts and where to input the order so it populates throughout the EMR. The DON stated she suspended LVN A after the incident on [DATE] and terminated LVN A's employment on [DATE] for not performing CPR on a full code resident. The DON was asked if the facility completed an investigation or gathered statements of the incident and the DON said no. Record review of facility document titled Employee Disciplinary Action Form, dated [DATE], reflected LVN A was terminated on [DATE] for failure to follow facility policy regarding code status and to provide full code response for a resident that was found unresponsive. The document was signed by the DON and Administrator. The document stated LVN A refused to sign. Record review of LVN A's CPR certification reflected LVN A had successfully completed the requirements in accordance with American Health Care Academy's curriculum for the course, Healthcare Provider CPR/AED: Adult, Child, Infant and First Aide (BLS). The certification was completed [DATE] and valid until [DATE]. Record review of an in-service training attendance roster, dated [DATE], reflected the topic of the in-services was patient code status and how to enter a code in the EMR. The in-service also included a document that stated every resident's code status is located in the EMR toward the top of the screen under allergies and provided visual references of the EMR. The in-service was signed by LVN A. Record review of facility document titled Cardiopulmonary Resuscitation (CPR), undated, listed steps for licensed nurses that included 1. Determine unresponsiveness by tapping or gently shaking resident and shouting are you ok? If you suspect a neck or spinal injury, do not shake the resident. 2. If the resident does not respond, call out for help. 3. Delegate a specific individual to check the resident's orders and care plan for CPR or no CPR order, have individual call paramedics, attending physician and administrative personnel per facility procedure and report back to you as soon as possible. 4. Do not start cardiopulmonary resuscitation (CPR) if the resident is breathing and has a pulse. 5. Place the resident on his or her back, supporting head and neck, on a hard surface. Perform CPR if the resident is unresponsive and not breathing or no normal breathing (i.e., only gasping). This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:51 p.m. The Administrator was notified at 4:51 p.m. and was provided with the IJ template on [DATE]. During an interview, [DATE] at 6:15 p.m., LVN A verified she was the charge nurse for Resident #1 on [DATE]. LVN A said the last time she observed Resident #1 was around 8 p.m. when she administered a medication and said Resident #1 spoke to her and her vitals were within normal limits. LVN A said CNA D came to her at 10 p.m. and said she needed to go check on Resident #1 and CNA D said she did not think Resident #1 was breathing. LVN A said she entered the room and observed the patient with no pulse and no breath. LVN A said she thought Resident #1 was a DNR and did not go and check her code status. LVN A said she called the DON and hospice and proceeded with doing an end of shift report. LVN A said about 40 minutes later, she went to Resident #1 chart to document and realized Resident #1 was a full code and that I never started CPR. LVN A said she called hospice and was told to wait for the RN to arrive. LVN A said the Hospice RN arrived and LVN A told her what happened, and Hospice RN called 911. LVN A said she called the DON again and was informed that the DON was on her way to the facility. LVN A said, I don't know why I did not do anything, when I realized it, it was too late. LVN A was asked what the facility protocol was for finding a resident unresponsive and/or without a pulse and she said, we are supposed to look at the chart and the computer to verify code status. LVN A said she received training on code status around February or March. LVN A was asked what the facility protocol was if a resident is found unresponsive and is a full code and she said I should of verified the code status and I should have started CPR but it had already been 40 minutes by that time. I was pulling out her face sheet to make a copy and that is when I noticed the error I made LVN A stated she was CPR certified and just renewed my certification last week. LVN A said she was suspended on [DATE] and quit on [DATE]. LVN A stated she was aware that a patient can be on hospice and be a full code. The following Plan of Removal (POR) was accepted on [DATE] at 12:20 p.m. and indicated the following: Events Leading to the Alleged Deficient Practice (narrative format): On [DATE], State Surveyor entered [Facility name] at 8:22am on a Complaint investigation. IJ was called at 4:51pm for the following as quoted on the IJ template: F678 Quality of Life The facility failed to provide a full code resident (Resident #1) with CPR when resident was observed without a pulse from 10:02pm till EMS arrived at 11:23pm. The alleged failure is as follows (summary format, bullet points) 1. Failed to initiate Full Code procedures timely when Nurse found resident unresponsive. The Medical Director, [Physician name] was notified at 12:02pm on [DATE]. No additional instructions or plans obtained. Facilities response was discussed. What action was taken for the staff directly involved in the failure? Nurse was terminated. Staff will be educated/trained in regard to Resident Code Status and Hospice Services and initiating CPR timely for resident who are a Full Code. A 100% audit of Resident Code Status for all residents was completed by [name], Director of Nursing in which Code status on Resident Face Sheet was verified by order for code status and if code status is a DNR the executed OOHDNR document was verified in Miscellaneous section in [EMR name] and copy verified in Resident hard chart. An audit will be completed monthly by the Director of Nursing. Alleged Failure #1 - Failed to follow facility policy regarding code status and initiate CPR/Full Code procedures timely when resident was found unresponsive. In-servicing/education provided in response (bullet point narrative): Start/stop time and date: On [DATE] at 12:30pm education began for Nurses (LVN and RN) staff in regards to Resident Code Status and Hospice Services and initiating CPR timely for resident who are a Full Code. Education Code Status and Hospice: Hospice residents can elect to be a Full Code. Resident with no pulse or respirations: Nurse will check code status in, [EMR name] call the Code Blue, initiate CPR and have another staff call 911. Flow chart of How to respond when a resident has no pulse or is unresponsive is posted at the nurses station as a reminder. When to provide CPR. When resident has no pulse or no respirations, Nurses are to check code status in [EMR name] which will determine how to respond appropriately. What will you do for staff not present? Nurses that aren't present will be in-serviced before the start of their next regularly scheduled shift What will you do with newly hired staff? The education/in-service of facility policy regarding Code Status and Hospice Services and initiating CPR timely for resident who are a Full Code. Who did the education/in-servicing? The education will be completed by [name] Director of Nursing What time did the education/in-servicing complete? All the education on this topic will be complete [DATE] by 5:00pm for Nurse staff present. A 4 question post-test will be given to verify retention of knowledge related Hospice Services and Code Status and initiating CPR timely for resident who are a Full Code. How will you monitor for effectiveness of the Plan of Removal? Administrator will randomly issue post test regarding education/in-service on Hospice Services and Code Status and initiating CPR timely for resident who are a Full Code for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. Director of Nursing will randomly request a Nurse to communicate Code Status on a resident on Hospice and initiating CPR timely for resident who are a Full Code for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. Nurse responses will be documented on a Response LOG that will identify staff name, date, shift, answer/response and if correct, resident name. The facility's POR verification was as follows: During an interview with the DON, [DATE] at 2:19 p.m., the DON stated LVN A was terminated from the facility on [DATE]. The DON stated the Medical Director was notified of the incident on [DATE] at 12:02 p.m. and the Medical Director did not give any additional instructions. The DON stated staff training was initiated on [DATE] and was completed on the morning of [DATE]. The training was provided to 100% of licensed nurses and covered the topics of where to find resident code status in the resident chart, importance of verifying code status if a resident is found unresponsive, what actions to take if a resident is a full code or DNR and hospice resident's right to be full code. During an interview with the Administrator, [DATE] at 2:28 pm, the Administrator stated LVN A was terminated on [DATE]. The Administrator stated the Medical Director was notified of the incident at [DATE] at 12:02 pm and provided no further guidance. The Administrator stated training for licensed nurses was initiated on [DATE] and was completed on the early morning on [DATE] and the training was completed by the DON. Record review of document labeled, Employee Disciplinary Action Form, dated [DATE], revealed the name of LVN A, type of offense is listed as violation of company policy. The document revealed LVN A as suspended on [DATE] at 11 pm and was terminated due to the result of the event on [DATE]. Record review of staff roster dated [DATE] reflected 13 licensed nurses (11 full time nurses and 2 prn nurses). Record review of an in-service training attendance roster, dated [DATE], reflected the in-service topics included hospice resident and code status, resident rights and where to find code status. The instructor was facility DON and roster was signed by 16 nurses (3 agency employees). Documents attached to the in-service included an action tree describing how to respond when a resident is found with no pulse or unresponsive and listed the first action as go to [EMR name] and check code status. Record review of a document titled Hospice Residents/Code Status/Resident Rights Post Test listed 4 questions which included 1. What do you immediately check when a patient is found unresponsive? 2. Can you be on hospice and still be a full code? 3. Where do you find the code status? 4. Resident has the right to decide their code status True or False?. There are 18 (13 facility nurses and 5 agency nurses) completed posttests by nurses. Record review of a Hospice list, dated [DATE], reflected 10 resident names. 3 residents are listed as full code. Record Review of a document labeled [facility name] Ordering Listing Report, dated [DATE] at 8:03am, reflected a list of all facility residents and their code status. The document revealed there are 28 residents with orders for DNR and 31 residents with Full code orders. Record review of resident roster, dated [DATE], reflected 59 resident names. Record review of 59 resident face sheets, dated [DATE], reflected code status on the resident face sheets matched the resident physician order for code status. Interviews conducted with 10 of 11 full time licensed nurse employees (5 -6 a.m.-2p.m., 1- 2 p.m.-10 p.m., 1 - 10 p.m.-6 a.m., 3- double weekends 6 a.m.-10 p.m.). Interviews conducted with 2 agency LVNs (1- 6 a.m.-2 p.m. and 1- 2 p.m.-10 p.m.). 2 PRN employees were unable to be reached by phone and were not on the schedule. The employees interviewed revealed they had received training from the DON regarding where a resident's code status is located in the chart, when to verify code status, what to do if a resident is a full code or DNR and hospice patients can be a full code. The licenses nurses were all able to answer the questions correctly, validating understanding of the in-service topic. During an interview with the Administrator, [DATE] at 2:28 p.m., the Administrator stated the DON would provide training to new hires during the orientation process and would provide training to agency employees prior to their assigned shift. The Administrator stated random post tests would be given to licensed nurses, weekly for 4 weeks, starting on [DATE] by the Administrator. The test would include questions regarding code status and initiating CPR timely for residents that are a full code. During an interview with the DON, [DATE] at 2:19 p.m., the DON stated new hires would receive training on code status, hospice and full code, and what to do when a resident is DNR or full code, during the orientation process and the DON would provide the education. DON stated agency staff would be educated on code status prior to beginning their shift and the DON would be providing the education. DON stated she had created an audit log and would conduct random audits with the licensed nurses. The audit would include asking the nurse to identify the residents code status, identify if the patient is on hospice, identify if the resident is a full code and how the nurse would respond to the code status. Record review of a document titled Monitoring for Knowledge Retention, undated, listed the names of all facility nurses and had a section for agency staff. There are 4 forms listed as week 1, 2, 3, and 4 and stated it will be conducted by the Administrator. Record review of audit logs labeled Week 1, undated, listed date, shift, nurse, resident, code status, hospice y/n, correctly identified code status y/n and correct response of what to do if full code y/n. There were 5 blank audit lines per sheet. There are 3 additional correlating documents labeled Week 2, Week 3 and Week 4. The audit would be completed by the DON. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying their POR had been initiated and/or completed. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 4:05 p.m. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that was not an Immediate Jeopardy and a scope of isolated, due to the facility was still monitoring the effectiveness of their Plan of Removal.

47564 Based on observation, record review, and interviews, the facility failed to provide adequate supervision, for 1 of 4 residents (Resident #3) reviewed for accidents, hazards, and supervision. Resident #3 walked out of the facility through an alarming door without staff responding. This deficient practice placed residents at risk for being unsupervised, accidents, and injury. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 4/8/2024 at 2:05 PM. While the immediacy was removed on 4/9/2024, the facility remained out of compliance at a severity level of potential for more than minimal harm that was not an Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal. The findings included: Record review of Resident #3's admission record, dated 03/09/2024, reflected an [AGE] year-old resident with an admitted [DATE], and diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors) and dementia (group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #3's Annual MDS, dated [DATE], reflected Resident #3 had not exhibited behaviors of wandering, and that the residents BIMS score was a 4, indicating the resident was severely cognitively impaired. Record review of Resident #3's Wandering Risk Assessment History of Outcomes, dated 03/09/2024, reflected that Resident #3 had consistently scored in the category of being a Moderate Risk of wandering on Resident #3's Wandering Risk Assessments completed on the following dates: 11/26/2020, 03/11/2021, 03/11/2022, 03/10/2023, 06/13/2023, 09/18/2023, 12/19/2023, and 03/07/2024. Record review of Resident #3's Comprehensive Person-Centered Care Plan, dated 03/09/2024, reflected Resident loves to wander around facility with/without purpose d/t her cognitive impairment and 3/7/24 Resident to utilize wander guard with interventions that included if wandering increases and place resident at risk for injury, or leaving facility, Notify MD, RP, ADMIN, DON, SS and assess, discuss possible need for secure unit. In an interview on 03/09/2024 at 4:03 PM, [NAME] C stated that she was taking a break in the smoking area outside when she heard banging and the alarm going off at the fire exit door. [NAME] C stated that when she looked up after a while, she noticed Resident #3 was standing next to her. [NAME] C stated that at this point, the Maintenance Director came over and proceeded to redirect the resident, and that the alarm had been going off for probably 3 or 4 minutes before she or the Maintenance Director noticed. [NAME] C then went on to state they had not had an elopement training at this facility. In an interview on 03/09/2024 at 4:12 PM, Maintenance Director stated that while walking up to the facility building from his workshop, which was not connected to the main building of the facility he noticed Resident #3 was standing outside pushing her wheelchair and using it as a walker. The Maintenance Director stated that this is when he realized he heard the door alarm going off, he proceeded to help the resident sit back in her wheelchair and brought her back inside. The Maintenance Director then stated that he brought the resident to the nurses' station and asked the nurses if they heard the alarm, to which they responded no. The Maintenance Director stated that the alarm was easy to hear at the nurses' station, and he was not sure why the nurses did not respond to it. The maintenance director stated he believed the staff may have chosen to ignore the alarm, as it goes off at times while staff members take residents out for smoking break. In an interview on 03/09/2024 at 4:37 PM, CNA D stated that on the date Resident #3 walked out of the facility, she was providing a shower to a resident in a closed shower room down the 100 hallway and heard the alarm going off but did not feel comfortable leaving the resident alone in the shower room to respond to the alarm. CNA D stated that the alarm was loud and easy to hear, and it should be easily heard at the nurse's station. CNA D stated that Resident #3 walked around a lot, but that she has not observed exit seeking behavior from the resident. In an interview on 03/09/2024 at 4:40 PM, CNA E stated that while Resident #3 walked out of the facility, he was with a resident when he heard the alarm going off and was unable to respond to it. CNA E stated the alarm was loud, and you could hear it well from most common areas as it was near the dining room and nurse's station. CNA E stated that Resident #3 walked around a lot and they sometimes had to bring her wheelchair to her because she would walk to another area of the building without it. Otherwise, she has never seen her try to exit the facility. CNA E stated that usually someone was always near Resident #3, so they were able to help her if necessary. Observation on 03/09/2024 at 4:50 PM revealed Resident #3 resting in her bedroom wearing a wander guard. In an interview on 03/10/2024 at 11:06 AM, LVN F stated she was at the nurse's station when Resident #3 walked out of the door, looked at the doors in and out of the facility when the alarm went off until the maintenance director brought Resident #3 inside. LVN F stated she heard the alarm, and that Resident #3 had not tried to exit seek before but would walk around the facility a lot. In an interview on 03/10/2024 at 1:09 PM, the DON stated that the expectation was that if staff heard the door alarm, they need to investigate why the alarm went off. The DON stated they have not had an in-service training relating to elopement since the event. She then stated that RN I was unavailable for interview and that RN I would call as soon as she was available for an interview. The DON stated that they did not treat this as a true elopement. She stated they did not notify the physician or the resident's representative as the resident did not leave the property, and thus did not create an incident report. The DON stated a true elopement was when the resident leaves the property entirely. The DON stated they assessed the resident when she returned inside the facility, and this was when the wander guard was placed. In an interview on 03/10/2024 at 1:18 PM, the Administrator stated that the expectation was that all staff who heard the door alarm were to respond to it and investigate as to why it went off. The administrator stated they did not treat this as a true elopement and did not notify the physician or the resident's representative as the resident did not get very far outside. The administrator stated there was no incident report made. In an interview on 03/10/2024 at 1:40 PM, RN I stated she was at the nurses' station when Resident #3 walked out of the door. RN I stated that she and LVN F were documenting in residents charts and realized they had been hearing a beeping. RN I stated this was when she began to look around for a moment and saw the maintenance director bring in Resident #3. RN I stated that she and LVN F were caught up in report and talking that by the time they realized the alarm was going off, the maintenance director was bringing Resident #3 back inside. RN I stated it was the expectation that when any beeping or any kind of alarm was going off you were to answer it. Record review of a policy titled, Elopement, undated, reflected Nursing personnel must report and investigate all reports of missing residents. This was determined to be an Immediate Jeopardy (IJ) on 4/8/2024 at 2:05 PM The facility Administrator and the DON were notified. The Adminsitrator was provided with the IJ template on 4/8/2024 at 2:05 PM. The following Plan of Removal submitted by the facility was accepted on [4/9/2024 at 5:09 PM ]: Plan of Removal Guidelines Events Leading to the Alleged Deficient Practice: On 04/08/2024, Surveyor entered the facility to change an IJ issued on 3/22/24 to a current IJ. IJ was called at 2:05pm for the following as quoted on the IJ template: F689 The facility failed to ensure Resident #3 was as free of accident hazards as was possible and received adequate supervision to prevent accidents in that Resident #3 walked out of the facility through an alarming door without staff responding. The alleged failure is as follows (summary format, bullet points) 1. Staff failed to respond to a door alarm when a resident was exiting out the door. The Medical Director, was notified at 2:20pm on 4/8/2024. No additional instructions or plans obtained. Facilities response was discussed. Medical Director was notified of the incident regarding Resident#3 on March 9th, 2024. What action was taken for the staff directly involved in the failure? Staff will be educated/trained on door alarm response. Alleged Failure #1 - Staff failed to respond to a door alarm that was activated by a resident. In-servicing/education provided in response (bullet point narrative): - Start/stop time and date: - On 3/11/2024 at 9:00am education began for all staff in regards to responding to a door alarm. - What will you do for staff not present? o Staff that aren't present will be in-serviced before the start of their next regularly scheduled shift - What will you do with newly hired staff? o The education/in-service for Door Alarm Response will be included in the new hire process for all staff. - Who did the education/in-servicing? o The education will be completed by Administrator. - What time did the education/in-servicing complete? o All the education on this topic was completed by 3/22/2024. How will you monitor for effectiveness of the Plan of Removal? - Administrator will randomly perform door alarm testing for staff response. o Start date March 11, 2024, Weekly on various shifts for 6 weeks, ending April 20th, 2024. What will be the procedure in the event the door alarm is activated? o Staff will respond by going to the door in which the alarm is activated. Who will be the point of contact to report door alarm activity. o The staff member(s) that respond to the alarmed door and they will notify the Administrator or the Director of Nursing. Verification of Plan: Observations: Observations on 3/22/2024 at 3:30 PM and 5:09 PM revealed no door alarms were sounding and no residents were outside in front or side of the building. Observations on 4/8/2024 at 1 PM revealed no door alarms were sounding and no residents were outside in front or side of the building. Observations on 4/9/2024 at 9 AM revealed no door alarms were sounding and no residents were outside in front or side of the building. Observation on 4/9/2024 at 10:51 AM revealed a mock door alarm was opened in the dining area by the Administrator and 5 staff immediately responded and went towards the door. Records: Resident #3 was discharged on [DATE] to a facility with a secure unit. Record review of Resident #3's consolidated physician orders and care plan for wander guard was dated 3/7/2024. In-service sheets with staff signature. In service dated 3/11/2024 Door Alarm Response, Elopement (nursing personnel must report and investigate all reports of missing residents). Record review of In-services signed by staff: 73 out of 74 of their staff were in-serviced. (part-time and full time). One staff person was out on FMLA and when they return to work, they will be in-serviced. 8 out of 11 therapy staff have been in-serviced. The other 3 staff had not been to work. 5 out of 6 agency staff that had worked had been in-serviced. One agency staff that normally worked has not been into work. Staff interviews: Interview on 4/9/2024 at 4:07 PM with MD stated the facility did notify her of the current IJ and when Resident #3 had left out a door in the facility. MD stated she was not sure why it was a an IJ. MD she had nothing else to say. Interviewed a total of 18 out of 74 regular staff. Interviewed all 3 shifts, including 2 CMA, 7 CNA's, 4 LVNS, 1 RN, 2 dietary aide, 1 housekeeper, and 1 staffing coordinator, 3 therapy staff, and 2 agency staff. Interviewed a total of 23 staff on all 3 shifts, prn, weekends, therapy, and agency staff that have been on the schedule since 3/7/ 2024. In an interview on 3/22/2024 at 5:28 PM with CNA A (6-2 PM, 2-10 PM) he stated he was in-serviced on door alarms, immediate check if alarm doors sounded, and make sure residents were not trying to go out. If resident does go out, staff were to bring back the resident. Staff were to guide the resident back safely and notify the Administrator or charge nurse. In an interview on 3/22/2024 at 5:34 PM with dietary aide B (6-2 PM) stated she was in-serviced on the door alarm and if a resident leaves the facility via the door. Dietary aide B stated if she heard the alarm sound, she would go check the door, and look to see if the resident left the facility. Dietary aide B stated she would bring the resident back in the facility and notify the nurse or DON. In an interview on 3/22/2024 at 5:36 PM with housekeeper C (3-8 PM, prn) stated she was in-serviced when she started her shift at the facility. Housekeeper C stated the in-service was about making sure no residents go out the door and they did a demonstration of the process. She was to notify the DON/nurse/manager of any residents leaving through the doors. In an interview on 3/22/2022 at 5:43 PM with RN D (6-2 PM) stated she did receive the in-service for checking the door if it alarms, immediately go see if a resident was nearby or had left the facility. If they did see a resident, bring back the resident inside the SNF and notify the Administrator. The nurses have a daily reminder to check for residents that were trying to go out the door. In an interview on 3/22/2022 at 5:47 PM with LVN E (2-10 PM) he stated he had been in-serviced on checking the door alarm if a resident had gone out, go over to resident, and re-direct the resident if the resident did not want to come into the facility. LVN E stated he would notify the Administrator, RP, and MD and document event. In an interview on 3/22/2022 at 6 PM with CNA F (2-10 PM) she stated she was in-serviced on if an alarm door sounds, she will go see which door it was, see if resident had gone out of the facility, and bring them back in the facility. CNA F stated if the resident did not want to come back in, CAN F would re-direct the resident back inside, stay with the resident to make sure they don' t go back outside, and notify the nurse. In an interview on 3/22/2022 at 6:06 PM with CMA G (2-10PM) she stated she was in-serviced on the door alarm. If she heard the alarm, she would locate the door, and see if a resident went outside. If she did see that a resident was outside, or near the door, she would re-direct the resident back inside into a safe place. CMA G stated she would notify the nurse. In an interview on 3/22/2022 at 6:09 PM with LVN H (agency) (6-2 PM, 2-10 PM) she stated she was in-serviced when she first started her shift on the door alarms. LVN H stated she would go see where the sound was coming from, she would immediately see if resident went out, and if a resident did re-direct them. LVN H stated she would assess the resident for an injury, if no injury re-direct them back to the SNF. If the resident had an injury, she would call 911, notify the charge nurse that resident left out the door and document. In an interview on 3/22/2022 at 6:16 PM with CNA I (2-10 PM) she stated she was in-serviced on the door alarm, if it alarms, she would walk towards the door to see if the resident went outside or not. If the resident did bring them back in, give them something to eat or drink and notify the nurse. In an interview on 3/22/2022 at 6:20 PM with MA J (2-10 PM) she stated she was in-serviced on the door alarm. MA J stated if she heard the door alarm, go see if resident went outside, and if so bring them back in. If resident refused, let the nurse know and stay with resident. In an interview on 3/22/2022 at 6:34 PM with CNA K (2-10 PM) he stated he was in-serviced on the door alarm. CNA K stated he would go outside immediately to door that was alarming, to see if the resident went outside. If the resident did go outside, he would bring the resident back inside. He would make sure the resident was safe and notify the nurse. In an interview on 3/22/2022 at 6:37 PM with HR coordinator L (8-5 PM) she stated she was in-serviced on door alarms. If a door alarm were heard she would go towards the door, to see if the resident went outside the facility. If the resident did go outside the facility, she would bring them back, and notify the nurse and/or the DON/Administrator. In an interview on 3/22/2022 at 7:30 PM with LVN M (2-10 PM) she stated she was in-serviced for door alarms. LVN M would immediately go to door to see if the resident was outside, bring the resident back in, she would notify the Administrator, the MD/family, and document. In an interview on 3/22/2022 at 7:31 PM with Staffing Coordinator N (8:30-5:30 PM) she stated she was in-serviced on door alarms, exit doors alarms (15 minutes egress alarm), and to go to door to see if resident was outside of the door. If resident was outside, go out immediately and secure the resident, bring the resident back in, and notify the DON. In an interview on 3/22/2022 at 7:35 PM with ADON O (7-4 PM) she stated she had an in-service training on door alarms. Staff should get up immediately if they heard the alarm and make sure all the residents were in the building. Check to see if a resident got out, then bring the resident back, re-direct the resident, staff stay out there with the resident, notify Administrator, the nurse, family, the DON, the ADON, the STATE, and the MD. In an interview on 3/22/2022 at 7:39 PM with CNA P (10-6 AM) she stated she was in-serviced on the door alarms. CNA P was to check all exit doors and secure the doors and make sure no residents were outside. If a resident was outside, bring them back in and notify the nurse. In an interview on 3/22/2022 at 7:41PM with CNA Q (10-6 AM) he stated he had training on the door alarms. To make sure residents did not get out of the building, re-direct into building, keep the resident safe, and notify the nurse and management. In an interview on 4/9/2024 at 11:41 AM with LVN R (6-2pm, prn) she stated she worked as needed at the facility. LVN R stated she had training on the door alarm and stated he would go to door and make sure a resident did not exit. LVN R stated all staff should check where the alarm was sounding and watch the exit doors. LVN R stated she would to make sure resident does not go out, and, if resident was outside, she would bring the resident back inside the facility. LVN R stated she would notify the chain of command, the Administrator, DON, family, charge nurse and document. In an interview on 4/9/2024 at 11:51 AM with CNA S (6-2 PM) stated she was in-serviced on the door alarms. CNA S stated she would see which door it was and look to see if a resident went outside. CNA S stated if resident went outside, she would go outside with resident and would bring them back into the facility. CNA S would notify the nurse and the Administer/DON. Interview on 4/9/2024 at 12:06 PM with CNA T (agency) (6-2 Pm, 2-10 PM) stated she was in serviced when she started work on the floor on door alarms. CNA T stated she would go to door that was alarming, see if resident were near the door or outside. CAN T stated if she saw a resident outside, she would bring them back to their room, and notify the nurse. In an interview on 4/9/2024 at 5:01 PM with the DON/Administrator stated the expectations for the door alarms were if it should sound all staff were responsible for immediately going to the door that was alarming. If staff were busy with resident care, there were other staff in the building that could respond to the alarm from the exit doors. When the door alarms alarm, the staff should notify the DON/Administrator about why the door alarm was sounding and what they did. They stated they would notify the resident physician and family if a resident was to elope. The Admin/DON stated they were responsible for ensuring staff were educated/trained on door alarms and ensuring residents were safe. The DON stated the risk of if a resident eloped would be that they would get hurt. The Administrator provided a copy of the Random Door Alarm testing LOG. In an interview on 4/9/2024 at 4:40 PM with the Administrator she stated, education was started for staff on 3/11/2024 responding to the door alarm. The Administrator/DON stated as staff were hired and work on the floor, she would educate the staff and the new hire process would include the door alarm response education/training. The Administrator stated she had a door alarm record log that she kept for the random door alarm checks on staff. The Administrator stated when the door alarm sounds, staff were to go to the door that was sounding off. She stead the egress exits doors have a 15 second delay. The staff were educated on making the response to the door alarm urgent and immediately. The Administrator stated any staff should go to door that was alarming and all staff must respond unless caring for a resident. The Administrator stated all staff were to notify the Administrator/DON if a false alarm or why the alarm sounded and what they did. The Administrator stated she would provide oversight to her staff in regard to the door alarms and responses. The Administrator and the DON were in charge of the training /education of staff. If not here the point of contact was the charge nurse, then the charge nurse would notify the Administrator/DON. The Medical Director would be contacted if the resident was harmed or impacted. The Administrator stated she notified the Medical Director of the IJ. The Administrator was informed the Immediate Jeopardy was removed on 4/9/2024 at 5:09 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.

Based on interviews and record reviews, the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in experimental research, and to formulate an advance directive for 1(Resident #69) of 24 residents reviewed for advanced directives. The facility failed to honor the rights of Resident #69's wishes to die a dignified death by failing to honor a signed OOH DNR order on [DATE] at 9:30 AM when Resident #69 was found unresponsive without a pulse and had a full code initiated to include CPR for approximately 25 minutes. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:55 p.m. While the IJ was removed on [DATE] at 2:55 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to evaluate the plan of removal. This facility failure placed residents at risk of not having their rights honored, to include pain, fractures, psychological and physical harm. The findings included: Record review of Resident #69's electronic face sheet dated [DATE] reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: diabetes mellitus (a disease of inadequate control of blood glucose levels), cognitive communication deficit (difficulty with thinking and how someone uses language), chronic kidney disease (when the kidneys have become damaged over time (for at least 3 months) and have a hard time doing all their functions), CVA (cerebral vascular accident or brain attack) and osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection. Resident #69's electronic face sheet reflected he had Full Code (desired CPR) status. Record review of Resident #69's significant change MDS assessment dated [DATE] reflected he scored a ,d+[DATE] on his BIMS which signified he was cognitively intact. He could usually understand others and could usually be understood. He required extensive assistance with his ADL's. Record review of Resident #1's comprehensive care plan revised on [DATE] reflected Focus, the resident/family are requesting DNR status, Goal, resident/family wishes will be honored through next review, Interventions/Tasks, Activate EMS as indicated, if transferred out of facility, notify receiving facility and EMS of DNR status, initiate CPR as indicated. Record review of Resident #69's readmission assessment dated [DATE] reflected resident desired to have DNR status under advanced directives. Record review of Resident #69's Order Details dated [DATE] reflected Admit to .under .Hospice, DX. CVA, Code Status: DNR. Record review of the facility shift change report dated [DATE] from the night shift nurse (LVN B) to the day shift nurse (LVN C) reflected ADMISSIONS: Resident #69 admitted at 01:00 AM to .Hospice, on pleasure feedings, regular diet, multiple breakdowns noted. No mention of Code Status. Record review of Resident #69's progress notes written by LVN E dated [DATE] at 10:45 AM, reflected Resident #69 was found unresponsive without a pulse. PCC checked and resident listed as Full Code status. Crash cart was brought into room, Resident #69 placed on the floor. CPR was initiated at 09:28 AM, no respirations, no pulse, no BP, pupils fixed and dilated, skin cool to touch, non-responsive, EMS arrived at 09:45 AM and took over CPR, artificial airway placed. CPR stopped at 09:53 AM after electronic DNR located and provided to EMT's. Pronounced at 09:59 AM via phone by MD for EMS Fire/EMS, and local police. Record review of Resident #69's progress notes dated [DATE] at 1:21 PM, reflected that during an interview with the local police, LVN A located an OOH DNR for Resident #69 under the miscellaneous tab in PCC. Record review of Resident #69's OOH DNR reflected it was signed and dated on [DATE], prior to his readmission to the facility. Interview on [DATE] at 10:46 AM with LVN C, she stated she and LVN A initiated the code for Resident #69. LVN C stated that LVN A found him, called for help, and came out of his room and they checked PCC and found Full Code status was noted on his electronic face sheet. LVN C stated she did not check his orders. LVN C stated the police and EMS was notified and they arrived within 5 minutes. LVN C stated she was trained on how to put a resident's code status and orders into PCC. LVN C stated she did not recall being told Resident #69 was admitted with DNR status from LVN B. LVN C stated it was important to honor a resident's wishes for advanced directives otherwise their rights would be violated. Interview on [DATE] at 10:58 AM with LVN A, she stated she found Resident #69 and called for help. LVN A stated she and LVN C checked his EMR and found he was full code status in PCC. LVN A stated she did not check his admission orders. LVN A stated when a police officer asked her about his medications, she looked under his miscellaneous tab in PCC and saw the OOH DNR. LVN A stated she felt bad when that happened and immediately took the OOH DNR to show to the EMT responders and they stopped CPR. LVN A stated Resident #69 was pronounced deceased by the MD. Interview on [DATE] at 11:44 AM with LVN B, she stated she was the nurse that did the admission assessment for Resident #69. LVN B stated she put his information into PCC, to include his code status, and she did not know why it was not reflected on Resident #69's face sheet because she felt like she did everything right. LVN B stated his code status was reflected in his admission orders and she communicated it to the night shift nurse LVN C. LVN B stated it was important for the resident's rights and advanced directive desires to be noted and communicated to the nursing staff because if he had a cardiac event, he did not want to be resuscitated. Interview on [DATE] at 12:00 PM with the DON, she stated she was called by LVN A, and she told her to check Resident #69's chart. The DON stated she did not realize that Resident #69 received a full course of CPR, and when she realized what had happened, she knew she needed to in-service the nurses on the PCC order entry process. The DON stated LVN B must have failed to discontinue the previous full code order, and this resulted in the change of code status not populating onto the face sheet. Interview on [DATE] at 12:15 PM with the Administrator, she stated she reported Resident #69's death as required under long term care death notifications for a death within 24 hours of transfer, however she did not realize the issue with Resident #69's advanced directives not being honored, or she would have reported it to HHSC right away. Record review of the facility policy and procedure titled Resident Rights (undated) reflected Purpose, to ensure the resident rights are respected and protected. Further review of the policy and procedure reflected, The resident has a right: To a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Record review of the facility pamphlet (undated) titled Treatment Choices reflected Code Status Policy. Purpose, to provide each resident/responsible party with the education and opportunity to make an informed decision regarding their code status. The facility will maintain a system of clearly identifying, documenting, and communicating the resident's code status decisions to essential facility personnel. The Administrator was notified of an IJ on [DATE] at 5:55 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on [DATE] at 2:55 p.m. and included the following: Alleged Failure #1 - Failed to properly input code status in the Point Click Care (PCC) Electronic Medical Record (EMAR) upon admission. Alleged Failure #2 - Failed to honor the rights of Resident # 1's wishes to die a dignified death by failing to honor a signed out of hospital do not resuscitate (DNR). Director of Nursing completed an audit of all resident code statuses on [DATE], 8:00pm, and all were found to be accurate. In-servicing/education provided in response (bullet point narrative): -Start/stop time and date: -On [DATE] at 6:30pm education began for Nurses (LVN and RN) staff in regards to properly complete Order Entry of code status in the PCC/EMAR of a resident. Nurses will reference PCC in the event of an emergency situation. -o Nurses that aren't present will be in-serviced by the DON before the start of their next regularly scheduled shift, utilizing a staff roster to ensure training and ensure a passing score on Post Test. -o The education/in-service of Order Entry of Code Status in a Resident PCC/EMAR will be included in the new hire process for all Nurses. o The education will be completed by the DON -o All the education on this topic will be complete [DATE] by 10:00pm for Nurse staff present. o A 4 question post-test will be given to verify retention of knowledge related Order Entry of code status into resident PCC/EMAR. -Administrator will randomly issue post test regarding education/in-service on Order Entry of code status into PCC/EMAR provided for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. -Director of Nursing will randomly request a Nurse to perform order entry of code status into PCC/EMAR and will document competence for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. Record reviews of sampled residents #9, #14, #22, #23, #26, #33, #35, #36, #38, #43, #44 and #56 EMR's and face sheets reflected code status was accurate. Verification of the POR Record review of facilities incident response binder revealed the facility completed the in-service with nursing staff on topics where to find the resident's code, how to enter resident's code status for new admissions and status changes, the purpose of code status, and resident's rights-choosing their code status. -Record review of facilities incident response binder revealed the facility conducted a post test for each nursing staff that received the in-service. Facility has documented 100% of their nursing (all 19 nurses) staff have completed the posttest and received a 100% on the post test. Interview on [DATE] at 1:05 p.m. with the DON revealed she in-serviced 100% (all 19 nurses) staff were on [DATE] after 6 PM and the remainder were in serviced on [DATE]. OUT OF 19 TOTAL NURSES-16 WERE INTERVIEWED FOR VERIFICATION (84%) Phone interview with RN N at 9:40 AM on [DATE]. She stated she received training on [DATE] on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Administrator will randomly issue posttest regarding education/in-service on Order Entry of code status into PCC/EMAR provided for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. -Director of Nursing will randomly request a Nurse to perform order entry of code status into PCC/EMAR and will document competence for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. -5 DAY SHIFT NURSES -Interview with LVN D on [DATE] at 12:21 p.m. revealed she had training on code status, how to put in the code status and to respect their rights. -Interview with the DON, RN at 9:51 AM on [DATE]. RN conducted the training with all nursing staff. RN started training on [DATE] and completed training on [DATE]. RN had all staff complete a posttest to ensure they understood the in-service. -Interview with MDS Nurse at 10:42 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN E ADON, at 11:02 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN F on [DATE] at 11:52 AM revealed she just had training on DNR and how to put in the code status into PCC. We also check the chart. It is important because it is the resident rights. -4 EVENING SHIFT NURSES -Interview with LVN G, on [DATE] at 11:39 AM, and I went in this am and had training. The training was how to find the code status of a resident. Why code status is important because it is their rights. We also were advised to check the chart. -Interview with LVN C, at 10:46 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN H on [DATE] at 11:45 AM, she stated she had code training on updating the code, and we check the orders. We check the paper chart. Respect wishes of resident. -Interview with LVN I at 11:36 AM on [DATE]. She stated she received training yesterday on DNR status and full code. We went over where to find the code status and how to change it in PCC. We would check the chart also. -2 NIGHT SHIFT NURSES -Interview with LVN J at 11:25 AM on [DATE]. Received training today at 08:00 a.m. [DATE]. The training was on DNR and code status, how to enter PCC properly. What the code status means. We were trained to also check the chart. The importance of code status indicates the resident's rights. -Interview with LVN B on [DATE] at 11:47 AM she stated she had code training on updating the code and we check the orders. We check the paper chart. It is important because it is their rights. -Interview with RN K on [DATE] at 11:58 AM revealed she had training on code status. Following the resident wishes. How to change in PCC. It is their rights. -Interview with RN L, at 11:06 AM on [DATE]. She received training on [DATE], of how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN M, at 11:11 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN A, at 10:58 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Phone interview with RN N at 9:40 AM on [DATE]. Received training on [DATE] on how to enter the code status, where to enter the code status and the importance11:36 of ensuring the code status is accurate. Interview on [DATE] at 1:32 PM, with the DON, she stated the auditing for the effectiveness of the Plan of Removal will begin on Monday [DATE]. Nurses will be randomly selected, and observed and evaluated with the post test, and this will continue for 4 weeks. Record Review of facilities incident response binder revealed the facility has implemented a procedure to make random observations with licensed nursing staff by DON for the next 4 weeks starting [DATE]. Post observation the Administrator will administer a posttest to ensure staff understand they understand the training. On [DATE] at 08:48 AM, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to monitor the implementation and effectiveness of its plan of removal.

Based on interviews and record reviews, the facility failed to provide basic life support , including CPR, to a resident requiring such emergency care prior to the arrival of medical personnel and subject to related physician orders and the resident's advanced directives for 1(Resident #69) of 24 residents reviewed for advanced directives. The facility failed to provide emergency care subject to physician orders and the resident's advanced directives when Resident #69 was readmitted to the facility. On [DATE] at 09:30 AM Resident #69 was found unresponsive without a pulse and had a full code initiated to include CPR for approximately 25 minutes when he had an OOH DNR. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:55 p.m. While the IJ was removed on [DATE] at 2:55 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to evaluate the plan of removal. This facility failure placed residents at risk of not having their rights honored, to include pain, fractures, psychological and physical harm. The findings included: Record review of Resident #69's electronic face sheet dated [DATE] reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: diabetes mellitus (a disease of inadequate control of blood glucose levels), cognitive communication deficit (difficulty with thinking and how someone uses language), chronic kidney disease (when the kidneys have become damaged over time (for at least 3 months) and have a hard time doing all their functions), CVA (cerebral vascular accident or brain attack) and osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection. Resident #69's electronic face sheet reflected he had Full Code (desired CPR) status. Record review of Resident #69's significant change MDS assessment dated [DATE] reflected he scored a ,d+[DATE] on his BIMS which signified he was cognitively intact. He could usually understand others and could usually be understood. He required extensive assistance with his ADL's. Record review of Resident #1's comprehensive care plan revised on [DATE] reflected Focus, the resident/family are requesting DNR status, Goal, resident/family wishes will be honored through next review, Interventions/Tasks, Activate EMS as indicated, if transferred out of facility, notify receiving facility and EMS of DNR status, initiate CPR as indicated. Record review of Resident #69's readmission assessment dated [DATE] reflected resident desired to have DNR status under advanced directives. Record review of Resident #69's Order Details dated [DATE] reflected Admit to .under .Hospice, DX. CVA, Code Status: DNR. Record review of the facility shift change report dated [DATE] from the night shift nurse (LVN B) to the day shift nurse (LVN C) reflected ADMISSIONS: Resident #69 admitted at 01:00 AM to .Hospice, on pleasure feedings, regular diet, multiple breakdowns noted. No mention of Code Status. Record review of Resident #69's progress notes written by LVN E dated [DATE] at 10:45 AM, reflected Resident #69 was found unresponsive without a pulse. PCC checked and resident listed as Full Code status. Crash cart was brought into room, Resident #69 placed on the floor. CPR was initiated at 09:28 AM, no respirations, no pulse, no BP, pupils fixed and dilated, skin cool to touch, non-responsive, EMS arrived at 09:45 AM and took over CPR, artificial airway placed. CPR stopped at 09:53 AM after electronic DNR located and provided to EMT's. Pronounced at 09:59 AM via phone by MD for EMS Fire/EMS, and local police. Record review of Resident #69's progress notes dated [DATE] at 1:21 PM, reflected that during an interview with the local police, LVN A located an OOH DNR for Resident #69 under the miscellaneous tab in PCC. Record review of Resident #69's OOH DNR reflected it was signed and dated on [DATE], prior to his readmission to the facility. Interview on [DATE] at 10:46 AM with LVN C, she stated she and LVN A initiated the code for Resident #69. LVN C stated that LVN A found him, called for help, and came out of his room and they checked PCC and found Full Code status was noted on his electronic face sheet. LVN C stated she did not check his orders. LVN C stated the police and EMS was notified and they arrived within 5 minutes. LVN C stated she was trained on how to put a resident's code status and orders into PCC. LVN C stated she did not recall being told Resident #69 was admitted with DNR status from LVN B. LVN C stated it was important to honor a resident's wishes for advanced directives otherwise their rights would be violated. Interview on [DATE] at 10:58 AM with LVN A, she stated she found Resident #69 and called for help. LVN A stated she and LVN C checked his EMR and found he was full code status in PCC. LVN A stated she did not check his admission orders. LVN A stated when a police officer asked her about his medications, she looked under his miscellaneous tab in PCC and saw the OOH DNR. LVN A stated she felt bad when that happened and immediately took the OOH DNR to show to the EMT responders and they stopped CPR. LVN A stated Resident #69 was pronounced deceased by the MD. Interview on [DATE] at 11:44 AM with LVN B, she stated she was the nurse that did the admission assessment for Resident #69. LVN B stated she put his information into PCC, to include his code status, and she did not know why it was not reflected on Resident #69's face sheet because she felt like she did everything right. LVN B stated his code status was reflected in his admission orders and she communicated it to the night shift nurse LVN C. LVN B stated it was important for the resident's rights and advanced directive desires to be noted and communicated to the nursing staff because if he had a cardiac event, he did not want to be resuscitated. Interview on [DATE] at 12:00 PM with the DON, she stated she was called by LVN A, and she told her to check Resident #69's chart. The DON stated she did not realize that Resident #69 received a full course of CPR, and when she realized what had happened, she knew she needed to in-service the nurses on the PCC order entry process. The DON stated LVN B must have failed to discontinue the previous full code order, and this resulted in the change of code status not populating onto the face sheet. Interview on [DATE] at 12:15 PM with the Administrator, she stated she reported Resident #69's death as required under long term care death notifications for a death within 24 hours of transfer, however she did not realize the issue with Resident #69's advanced directives not being honored, or she would have reported it to HHSC right away. Record review of the facility policy and procedure titled Resident Rights (undated) reflected Purpose, to ensure the resident rights are respected and protected. Further review of the policy and procedure reflected, The resident has a right: To a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Record review of the facility pamphlet (undated) titled Treatment Choices reflected Code Status Policy. Purpose, to provide each resident/responsible party with the education and opportunity to make an informed decision regarding their code status. The facility will maintain a system of clearly identifying, documenting, and communicating the resident's code status decisions to essential facility personnel. The Administrator was notified of an IJ on [DATE] at 5:55 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on [DATE] at 2:55 p.m. and included the following: Alleged Failure #1 - Failed to properly input code status in the Point Click Care (PCC) Electronic Medical Record (EMAR) upon admission. Alleged Failure #2 - Failed to honor the rights of Resident # 1's wishes to die a dignified death by failing to honor a signed out of hospital do not resuscitate (DNR). Director of Nursing completed an audit of all resident code statuses on [DATE], 8:00pm, and all were found to be accurate. In-servicing/education provided in response (bullet point narrative): -Start/stop time and date: -On [DATE] at 6:30pm education began for Nurses (LVN and RN) staff in regards to properly complete Order Entry of code status in the PCC/EMAR of a resident. Nurses will reference PCC in the event of an emergency situation. -o Nurses that aren't present will be in-serviced by the DON before the start of their next regularly scheduled shift, utilizing a staff roster to ensure training and ensure a passing score on Post Test. -o The education/in-service of Order Entry of Code Status in a Resident PCC/EMAR will be included in the new hire process for all Nurses. oThe education will be completed by the DON -o All the education on this topic will be complete [DATE] by 10:00pm for Nurse staff present. oA 4 question post-test will be given to verify retention of knowledge related Order Entry of code status into resident PCC/EMAR. -Administrator will randomly issue post test regarding education/in-service on Order Entry of code status into PCC/EMAR provided for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. -Director of Nursing will randomly request a Nurse to perform order entry of code status into PCC/EMAR and will document competence for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. Record reviews of sampled residents #9, #14, #22, #23, #26, #33, #35, #36, #38, #43, #44 and #56 EMR's and face sheets reflected code status was accurate. Verification of the POR Record review of facilities incident response binder revealed the facility completed the in-service with nursing staff on topics where to find the resident's code, how to enter resident's code status for new admissions and status changes, the purpose of code status, and resident's rights-choosing their code status. -Record review of facilities incident response binder revealed the facility conducted a post test for each nursing staff that received the in-service. Facility has documented 100% of their nursing (all 19 nurses) staff have completed the posttest and received a 100% on the post test. Interview on [DATE] at 1:05 p.m. with the DON revealed she in-serviced 100% (all 19 nurses) staff were on [DATE] after 6 PM and the remainder were in serviced on [DATE]. OUT OF 19 TOTAL NURSES-16 WERE INTERVIEWED FOR VERIFICATION (84%) Phone interview with RN N at 9:40 AM on [DATE]. She stated she received training on [DATE] on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Administrator will randomly issue posttest regarding education/in-service on Order Entry of code status into PCC/EMAR provided for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. -Director of Nursing will randomly request a Nurse to perform order entry of code status into PCC/EMAR and will document competence for 4 weeks to ensure knowledge has been maintained and compliance has been achieved. -5 DAY SHIFT NURSES -Interview with LVN D on [DATE] at 12:21 p.m. revealed she had training on code status, how to put in the code status and to respect their rights. -Interview with the DON, RN at 9:51 AM on [DATE]. RN conducted the training with all nursing staff. RN started training on [DATE] and completed training on [DATE]. RN had all staff complete a posttest to ensure they understood the in-service. -Interview with MDS Nurse at 10:42 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN E ADON, at 11:02 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN F on [DATE] at 11:52 AM revealed she just had training on DNR and how to put in the code status into PCC. We also check the chart. It is important because it is the resident rights. -4 EVENING SHIFT NURSES -Interview with LVN G, on [DATE] at 11:39 AM, and I went in this am and had training. The training was how to find the code status of a resident. Why code status is important because it is their rights. We also were advised to check the chart. -Interview with LVN C, at 10:46 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN H on [DATE] at 11:45 AM, she stated she had code training on updating the code, and we check the orders. We check the paper chart. Respect wishes of resident. -Interview with LVN I at 11:36 AM on [DATE]. She stated she received training yesterday on DNR status and full code. We went over where to find the code status and how to change it in PCC. We would check the chart also. -2 NIGHT SHIFT NURSES -Interview with LVN J at 11:25 AM on [DATE]. Received training today at 08:00 a.m. [DATE]. The training was on DNR and code status, how to enter PCC properly. What the code status means. We were trained to also check the chart. The importance of code status indicates the resident's rights. -Interview with LVN B on [DATE] at 11:47 AM she stated she had code training on updating the code and we check the orders. We check the paper chart. It is important because it is their rights. -Interview with RN K on [DATE] at 11:58 AM revealed she had training on code status. Following the resident wishes. How to change in PCC. It is their rights. -Interview with RN L, at 11:06 AM on [DATE]. She received training on [DATE], of how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN M, at 11:11 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Interview with LVN A, at 10:58 AM on [DATE]. Received training yesterday, [DATE], on how to enter the code status, where to enter the code status and the importance of ensuring the code status is accurate. -Phone interview with RN N at 9:40 AM on [DATE]. Received training on [DATE] on how to enter the code status, where to enter the code status and the importance11:36 of ensuring the code status is accurate. Interview on [DATE] at 1:32 PM, with the DON, she stated the auditing for the effectiveness of the Plan of Removal will begin on Monday [DATE]. Nurses will be randomly selected, and observed and evaluated with the post test, and this will continue for 4 weeks. Record Review of facilities incident response binder revealed the facility has implemented a procedure to make random observations with licensed nursing staff by DON for the next 4 weeks starting [DATE]. Post observation the Administrator will administer a posttest to ensure staff understand they understand the training. On [DATE] at 08:48 AM, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to monitor the implementation and effectiveness of its plan of removal.

Based on observation, interviews and record reviews the facility failed to immediately inform the physician of a significant change of condition to a resident's physical status for 1 of 8 residents (Resident#1) reviewed for change in condition in that: The facility failed to implement their process for ongoing monitoring of residents on oxygen and notify the physician when Resident #1's O2 saturations remained at 81% on oxygen. This change of condition resulted in Resident #1 expiring. This failure resulted in identification of Immediate Jeopardy (IJ) on [DATE] at 12:18 p.m. The IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as an isolated pattern until the facility has completed all in-service and monitoring interventions. This deficient practice place residents with a change in condition at-risk for harm and quality of life. The findings were: Record review of Resident #1's face sheet, dated [DATE], revealed an admitted [DATE] and diagnoses that included: morbid (severe) obesity due to excess calories, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), and dependence on supplemental oxygen. Record review of Resident #1's Care Plan (start date of [DATE]) for risk of shortness of breath, respiratory distress, and increased anxiety due to a diagnosis of chronic obstructive pulmonary disease revealed interventions which included Resident #1 was known to be non-compliant with wearing oxygen at times and Observe for SOB (shortness of breath), respiratory distress, wheezing, fatigue, increased anxiety and implement appropriate ordered interventions and notify MD (doctor of medicine) if interventions are not effective. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a Brief Interview for Mental Status (MDS) score of 11, which indicated the resident had moderate cognitive impairment, and the resident required supervision of one staff member physical assistance with transfers, dressing, and hygiene. Review of Resident #1's Clinical Physician Orders, dated [DATE] revealed the resident had order for oxygen at ,d+[DATE] liters per minute via nasal cannula as needed to keep O2 saturations above 92%, with a start date of [DATE]. There was another order with a start date of [DATE] to monitor O2 saturations every shift for shortness of breath. Record review of Resident #1's oxygen saturations (O2) for September and [DATE] revealed they ranged between ,d+[DATE]% on room air or oxygen via nasal cannula. On [DATE] the resident's O2 was at 78% on room air, on [DATE] the resident's O2 was at 88% on room air, on [DATE] the resident's O2 was at 89% on room air, on [DATE] the resident's O2 was at 88% on c-pap, and on [DATE] the resident was at 87% on room air. Additional O2 saturations for Resident #1 during the month of November and [DATE] was ,d+[DATE]%. Record review of Nurse Practitioner's (NP) progress note, dated [DATE], revealed the resident was wheezing on exam, denied any cough, chest pain or shortness of breath, and continued to be a daily smoker. The progress note revealed the NP ordered chest x-ray, 2 views. Record review of a nurses' progress note dated [DATE] at 10:02 p.m. revealed Resident #1's chest x-ray showed prominent intestinal lung markings which may be due to pulmonary edema or atypical pneumonitis and the physician ordered Prednisone (a steroid used to treat conditions especially associated with inflammation) 40 mg by mouth 2 times a day for 5 days for shortness of breath and abnormal chest x-ray. Review of a nurses' progress note, dated [DATE] at 11:12 p.m., revealed Resident #1's oxygen saturations were at 92% on 2 liters via nasal cannula. Record review of nurses' progress note, dated [DATE] at 5:50 a.m. by LVN A, revealed at 5:20 a.m. she entered resident #1's room to reposition the resident with LVN B's assistance and reapplied her oxygen at 2 liters per nasal cannula for chronic COPD. The nurse further reported she returned to the resident's room at 5:42 a.m. and checked Resident #1's O2 saturations which was at 81%. The nurse documented she left the resident's room to allow privacy while CNA C provided peri-care and that, There were only two nurses and two CNAs in the building this nurse stayed on the floor to continue monitoring the other residents. Record review of nurses' progress note, dated [DATE] at 6:27 a.m. by LVN A, revealed Resident #1 was lying with her neck pressed against the bed. Her face was turning blue and this nurse and the other nurse on duty were able to convince the resident to wear her oxygen and lay with her head sitting up. Review of a nurses' progress note, dated [DATE] at 1:17 p.m. by LVN D, revealed around 7:,d+[DATE]:30 a.m. the LVN went to check Resident #1's blood sugar and found the resident on her right side, the resident's face noted blueish and when she shook the resident, there was no response, and the resident was not breathing. LVN D called for assistance, Cardiopulmonary resuscitation (CPR) was started, and 911 was called. The LVN documented the automated external defibrillator (AED) pads were placed on the resident's chest and the AED advised no shock. The facility continued CPR until EMS arrived and EMS personnel took over. LVN D documented the resident passed at 8:34 a.m. Record review of Resident #1's Provider Investigative Report, dated [DATE], revealed the resident was found by LVN A at 5:21 a.m. laying on her side with blue lips, pallor, oxygen was off. The LVN requested assistance from LVN B to reposition the resident. The report revealed Resident#1 was somewhat responsive and after she was repositioned up right and oxygen was applied at 2 liters per nasal cannula the resident was responsive and alert. LVN A encouraged the resident to do deep breathing exercises and then left the room. LVN A returned to the resident's room at 5:42 a.m. to assist CNA C with peri-care and at that time LVN A checked Resident #1's oxygen saturations and it was at 81% on two liters per nasal cannula. The nurse indicated she would continue to monitor and left the room. LVN D came on duty for the following shift. LVN D had gone into Resident #1's room at approximately 8:00 a.m. and found the resident unresponsive, not breathing and her oxygen was laying on the floor. CPR was initiated by LVN D, EMS was called, and they continued CPR, however Resident #1 expired at 8:34 a.m. Review of LVN A's progress note dated [DATE] at 5:50 a.m. revealed the LVN applied Resident #1's oxygen at 2 liters per nasal cannula after the resident was sat upright. The LVN documented the resident was non-compliant with her oxygen and her c-pap. The LVN reported she left the room but returned at 5:42 a.m. and checked the resident's O2 saturations and the resident was stating at 81%. LVN A told the resident to take deep breaths and left the room. The LVN documented there were only 2 nurses and 2 CNAs, and she would stay on the floor to continue monitoring the other residents. Review of LVN A's progress note, dated [DATE] at 6:27 a.m., revealed when the LVN had found the resident in bed without oxygen, and the resident's face was turning blue. Review of LVN D's progress note dated[DATE] at 1:17 p.m. revealed when she entered Resident #1's room around 7:,d+[DATE]:30 a.m. The resident was laying on her side and her face was bluish. The LVN shook the resident, but there was no response, and the resident was not breathing. The LVN called for assistance from other staff began CPR and 911 was called. EMS continued CPR after they arrived on the scene, but the resident was pronounced dead at 8:34 a.m. Review of Resident #1's Record of Death, located in the resident's medical record confirmed the resident passed away on [DATE] at 8:34 a.m. Review of a written statement by CNA D (undated) revealed Resident #1 refused peri-care so she contacted LVN A. The nurse was able to convince the resident to allow the CNA to change her. The CNA's statement revealed the resident was awake and talking the entire time the CNA was in the room and the resident thanked the CNA afterwards. Review of a written statement by CNA E (undated) revealed she went into Resident #1's room at 6:56 a.m. and found the resident sleeping on her side, facing the window and in no distress. During an interview on [DATE] at 9:59 a.m., the Administrator reported Resident #1 had an order to use oxygen and had a history on non-compliance with the oxygen. The Administrator also reported LVN A did not pass on Resident #1's condition during the overnight shift to the oncoming shift, LVN D, on the morning the resident passed away. An interview on [DATE] at 10:58 a.m. with LVN A revealed she had verbally told the oncoming shift LVN, LVN D, about Resident #1's condition during the overnight shift, including that she had found the resident without her oxygen off and she was turning blue. LVN A revealed staff had to frequently reposition Resident #1 to sit up and replace her oxygen, and that the night before the resident passed, was not the first time the LVN found the resident without her oxygen and having some blue color to her and around her lips. LVN A stated when she reported to the oncoming staff how she had found the resident without her oxygen and turning blue, They all agreed this was the resident's normal condition. The LVN reported when they gave report, they wrote some things down but the report she gave to LVN D was mostly verbal because they did not see Resident #1's condition as a change in condition since this was the usual habits of the resident. The LVN reported she was aware Resident #1 recently had an abnormal x-ray of her chest and was started on new medication. LVN A revealed, again, that she and the on-coming nurse, LVN D, did not think anything unusual about what had happened the evening before the resident passed, because that was the resident's usual condition. An interview on [DATE] at 11:07 a.m. with LVN B revealed she worked the overnight shift with LVN A and assisted LVN A with repositioning Resident #1. LVN B reported when she entered the room to assist LVN A to reposition Resident #1 she noted the resident was blue ashen (paleness or gray tint) in color. The LVN stated the resident was initially resistive to rolling over on her back but eventually agreed and they were able to sit her up and place her O2 on that she had removed. The LVN stated when the O2 was placed she noted the resident cognition improved. LVN B stated the resident frequently lay on her side, removed her oxygen, and refused to wear her c-pap. The LVN stated Resident #1 was gaining her color back and responding the last time she saw her. LVN B stated she had never seen Resident #1 with the blue ashen color she was the night before she passed. LVN B stated typically in situations such as this, the LVN would notify her supervisors and the resident's physician about the resident's condition. LVN B stated she thought LVN A had notified Resident #1's physician. The LVN stated the resident frequently removed her oxygen and they kept an eye on her during the overnight shift. LVN B stated they were short of staff that evening but did not think that had anything to do with what was going on with Resident #1. During an interview on [DATE] at 11:36 a.m., LVN D reported when she came on duty on the morning of [DATE], she received report from off-going nurse, LVN A. LVN D reported LVN A stated during the overnight shift, she had found Resident #1 without her oxygen and her face turning blue and LVN A had repositioned her, applied her oxygen and that the resident was doing good. LVN D stated she had never seen Resident #1's face turned blue as LVN A described. LVN D stated she did not check on Resident #1 immediately, because LVN A stated the resident was doing good. LVN D stated the CNAs were on the floor and no CNAs reported any concerns. LVN D stated when she entered Resident #1's room, she found the resident laying on her side, she was blue without her oxygen or c-pap on. The LVN stated Resident #1 removed her oxygen and c-pap. LVN D stated when she entered the resident's room to check her blood sugar level, the resident's face was discolored so she shook her, and the resident did not respond. LVN D stated she called for help from the other staff, and they began CPR and EMS was called. The LVN stated she was not aware Resident #1 had started new medication related to a chest x-ray. LVN D reported LVN A acted as if it was not an emergency and stated Resident #1 was good to go and never in any distress. LVN D stated anyone with their saturations in their 80's, she would place oxygen on the resident, call the primary care physician, and send the resident out to the hospital. An interview on [DATE] at 12:02 p.m. with the DON revealed when a resident had oxygen saturations that were low, staff were instructed to place the oxygen on the resident to get them stabilized with oxygen saturations above 90%. The DON went on to say if the resident's saturations did not increase then the staff should call 911. The DON reported the resident had COPD, was obstinate about taking her O2 off and the resident always had an ill appearance. The DON stated it was hard to say if ashen color meant the resident was in distress because everyone was different, but blue around the lips was concerning and should have been reported to the physician. The DON reported during the overnight shift prior to Resident 1's passing, they were short on nurses' aides but not on nurses. The DON reported she had never had any previous complaints about LVN A. An interview on [DATE] at 2:07 p.m. with CNA E revealed when she came on duty on the morning Resident #1 passed, no one had shared information with her about the resident's condition during the overnight shift. The CNA revealed she had wished the facility shared information about the resident's during the change of shift because she did not know who fell or any other changes during the previous shift. CNA E stated when she checked on Resident #1 around 7:00 a.m. that morning the resident was lying on her side facing the window and thought she was asleep. The CNA revealed she did not see the resident's face, could not confirm if the resident was wearing her oxygen and could not confirm if the resident was still alive and breathing. During an interview on [DATE] at 12:12 p.m. with the Medical Director, she revealed, typically, she was notified when a resident's O2 saturations was less than 91% but the physician was available anytime a nurse had concerns about a resident's condition. When questioned what may have contributed to Resident #1's passing, the Medical Director stated she could not confirm anything at that time as she had not had a chance to review all of Resident #1's medical record. Review of the Order Listing Report, dated [DATE], revealed there were 29 residents with orders for oxygen. Review of the facility policy, Notification to Physician, Family and Others, not dated, revealed, The facility will inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative and document in the resident's medical record were applicable, when there is: A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) The Administrator was notified of an IJ on [DATE] at 12:18 p.m. and was given a copy of the IJ Template and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] at 7:16 p.m. and included the following: Plan of Removal [DATE] Immediate Action #1 - Medical Director was notified on [DATE] at 12:19 p.m. about the incidents surrounding the passing of Resident #1 and the facility response was discussed. - LVN A was terminated [DATE]. - on [DATE] at 1:30 p.m. education began for all LVNs and CNAs in-regards to completing walking rounds and/or bedside rounds at shift change. - LVNs and CNAs not already in-serviced would be in-serviced before the start of their next regularly scheduled shift. - These in-services would be included in the new hire process for LVNs and CNAs. - A post-test would be given to verify retention of knowledge related to walking rounds. - All education on this topic would be completed on [DATE] by 3:00 p.m. for LVNs and CNAs present. Monitoring: - At shift change LVNs and CNAs would sign off on 24-hour report acknowledging they received information regarding each resident on their assignment. - The signed-off 24-hour report would be reviewed by the Director of Nursing or Administrator for 4 weeks until compliance had been achieved. - The Administrator would randomly view video footage and/or be present during shift change 5 times a week to assure walking rounds were completed for 4 weeks until compliance had been achieved and maintained. Immediate Action #2 - On [DATE] at 1:30 p.m. education for LVNs and CNAs began in-regards to notifying the physician/Medical Director for a significant change in a resident's condition and nursing best practice of when to follow up on vital signs out of parameters. - LVNs and CNAs that were not already in-serviced would be in-serviced before the start of their next regular shift. - These in-services would be included in the new hire process for LVNs and CNAs. - A post-test would be given to verify retention of knowledge related to notification of the physician for a significant change in the resident and follow up for vital signs out of parameters. - All the education on this topic would be completed on [DATE] by 3:00 p.m. for LVNs and CNAs. Monitoring: - Director of Nursing would review 10% of resident charts weekly for all significant events for physician notification and would be documented on monitoring log. - Monitoring would continue for 4 weeks until compliance had been achieved and maintained. Verification of the Plan of Removal was as follows: a. Reviewed in-service training on [DATE] for all nursing staff. The nursing staff were in-serviced on when to report to the physician for notification of changes of a resident. b. Reviewed in-service training on [DATE] for all nursing staff. The nursing staff were in-serviced on nurse-to-nurse-reporting and walking rounds at exchange of shift to assure communication of issues related to care of the residents from previous shift and to always ensure continuity of care. c. Reviewed in-service training on [DATE] for all nursing staff. The nursing staff were in-serviced on vital signs and best practice for follow up for vital signs out of parameters. d. Review of the post-tests for 52 nursing staff members, with 3 post tests given to each staff member related to their in-services on notification of physicians, walking rounds at change of shift and vital sign/O2 parameters revealed they had written understanding and knowledge of the in-service teachings. e. Review of the Nurse walking rounds Sign Off Sheet revealed the charge nurses and CNAs were completing rounds with the on-coming shifts on [DATE], [DATE], and [DATE] and the sheets were reviewed and signed by the Administrator. f. Review of the Chart Review Log for week 1 for dates of [DATE]-[DATE], revealed 10 resident charts would be reviewed each week by administrative nursing. g. Review of the Random Video History Review revealed random observations of shift change both in person and viewed on video would be conducted 5 times a week for 4 weeks. h. Observation on [DATE] at shift ,d+[DATE] shift change revealed off-going staff were exchanging information on the residents' condition to on-coming staff. i. In an interview between [DATE] at 8:54 a.m. to [DATE] at 10:12 a.m. 2 nurses (LVN F and LVN G) from ,d+[DATE] shift, 2 nurses (LVN H and LVN I) from ,d+[DATE] shift, 2 nurses (LVN B and LVN J) from ,d+[DATE] shift, 3 medication aides (MA K, MA L, and MA M) from ,d+[DATE] and ,d+[DATE] shifts, 2 CNAs (CNA E and CNA N) from ,d+[DATE] shift, 2 CNAs (CNA O and CNA P) from ,d+[DATE] shift, 4 CNAs (CNA Q, CNA R, CNA S, and CNA T) from ,d+[DATE] shift, 1 prn (as needed) CNA (U) , 1 CNA/van driver (CNA V) 3 administrative staff/LVN (HR W, LVN X, LVN Y) and 3 agency CNA's (CNA Z), CNA AA, and CNA BB) were interviewed (with a total of 25 nursing staff interviewed) regarding the in-servicing provided by the facility as part of the plan of removal and all had knowledge and understanding of the in-services provided. j. During an interview with the Administrator on [DATE] at 7:56 a.m. the Administrator confirmed the new logging and tracking were being implemented this date. k. During an interview on [DATE] with the Administrator she confirmed the new logging and tracking worksheets for Chart Review and Random Video History Review were being implemented this date. The Administrator reported she had been able to visually monitor staff shift change with exchange of resident information since the incident occurred on [DATE]. l. During an interview on [DATE] at 7:56 a.m. the Administrator reported she believed the incident occurred because LVN A had lack of experience with only 3 years as a nurse. The Administrator reported the LVN had worked only the overnight shift. The Administrator revealed the facility required anybody working the overnight shift had to work the day shift a couple of days first so they could get the training needed. The Administrator reported LVN A had worked for the facility before, left and came back and the Administrator did not think LVN A did the day training when she returned because she had worked at the facility before. The Administrator reported any new nurse hired was shadowed by an experienced nurse for 3 days and if they still felt the nurse was not ready then they would continue training. The Administrator revealed they were starting new training program next week with all the nurses, to include general nurses training, change of condition and a Nurse Educator Toolkit that was provided by Texas Health and Human Services. The Administrator revealed as far as what they could have done different to prevent the incident was to implement nurse training and one-on-one with instructors. The Administrator reported because they did not recognize LVN A's weaknesses and her level of critical thinking skills they were at fault as well. While the IJ was removed on [DATE] the facility remained out of compliance at a level of actual harm with a scope identified as isolated until all staff was in-serviced and showed proficiency on vital sign parameters, notification of physician and change of condition, walking rounds through monitoring of change of shift observations and chart reviews.

Based on observations, interviews, and record reviews, the facility failed to implement respiratory care services to prevent residents from respiratory failure for 1 of 8 residents (Residents #1) whose care was reviewed for quality of care, in that: The facility failed to have structures in place to ensure Resident #1 received oxygen to maintain O2 saturations at 92% as per physician orders. This change of condition resulted in Resident #1 expiring. This failure resulted in identification of Immediate Jeopardy (IJ) on [DATE] at 12:18 pm. The IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as an isolated pattern until the facility has completed all in-service and monitoring interventions. This deficient practice place residents requiring oxygen at-risk for harm and quality of life. The findings were: Record review of Resident #1's face sheet, dated [DATE], revealed an admitted [DATE] and diagnoses that included: morbid (severe) obesity due to excess calories, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), and dependence on supplemental oxygen. Record review of Resident #1's Care Plan (start date of [DATE]) for risk of shortness of breath, respiratory distress, and increased anxiety due to a diagnosis of chronic obstructive pulmonary disease revealed interventions which included Resident #1 was known to be non-compliant with wearing oxygen at times and Observe for SOB (shortness of breath), respiratory distress, wheezing, fatigue, increased anxiety and implement appropriate ordered interventions and notify MD (doctor of medicine) if interventions are not effective. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a Brief Interview for Mental Status (MDS) score of 11, which indicated the resident had moderate cognitive impairment, and the resident required supervision of one staff member physical assistance with transfers, dressing, and hygiene. Review of Resident #1's Clinical Physician Orders, dated [DATE] revealed the resident had order for oxygen at ,d+[DATE] liters per minute via nasal cannula as needed to keep O2 saturations above 92%, with a start date of [DATE]. There was another order with a start date of [DATE] to monitor O2 saturations every shift for shortness of breath. Record review of Resident #1's oxygen saturations (O2) for September and [DATE] revealed they ranged between ,d+[DATE]% on room air or oxygen via nasal cannula. On [DATE] the resident's O2 was at 78% on room air, on [DATE] the resident's O2 was at 88% on room air, on [DATE] the resident's O2 was at 89% on room air, on [DATE] the resident's O2 was at 88% on c-pap, and on [DATE] the resident was at 87% on room air. Additional O2 saturations for Resident #1 during the month of November and [DATE] was ,d+[DATE]%. Record review of Nurse Practitioner's (NP) progress note, dated [DATE], revealed the resident was wheezing on exam, denied any cough, chest pain or shortness of breath, and continued to be a daily smoker. The progress note revealed the NP ordered chest x-ray, 2 views. Record review of a nurses' progress note dated [DATE] at 10:02 p.m. revealed Resident #1's chest x-ray showed prominent intestinal lung markings which may be due to pulmonary edema or atypical pneumonitis and the physician ordered Prednisone (a steroid used to treat conditions especially associated with inflammation) 40 mg by mouth 2 times a day for 5 days for shortness of breath and abnormal chest x-ray. Review of a nurses' progress note, dated [DATE] at 11:12 p.m., revealed Resident #1's oxygen saturations were at 92% on 2 liters via nasal cannula. Record review of nurses' progress note, dated [DATE] at 5:50 a.m. by LVN A, revealed at 5:20 a.m. she entered resident #1's room to reposition the resident with LVN B's assistance and reapplied her oxygen at 2 liters per nasal cannula for chronic COPD. The nurse further reported she returned to the resident's room at 5:42 a.m. and checked Resident #1's O2 saturations which was at 81%. The nurse documented she left the resident's room to allow privacy while CNA C provided peri-care and that, There were only two nurses and two CNAs in the building this nurse stayed on the floor to continue monitoring the other residents. Record review of nurses' progress note, dated [DATE] at 6:27 a.m. by LVN A, revealed Resident #1 was lying with her neck pressed against the bed. Her face was turning blue and this nurse and the other nurse on duty were able to convince the resident to wear her oxygen and lay with her head sitting up. Review of a nurses' progress note, dated [DATE] at 1:17 p.m. by LVN D, revealed around 7:,d+[DATE]:30 a.m. the LVN went to check Resident #1's blood sugar and found the resident on her right side, the resident's face noted blueish and when she shook the resident, there was no response, and the resident was not breathing. LVN D called for assistance, Cardiopulmonary resuscitation (CPR) was started, and 911 was called. The LVN documented the automated external defibrillator (AED) pads were placed on the resident's chest and the AED advised no shock. The facility continued CPR until EMS arrived and EMS personnel took over. LVN D documented the resident passed at 8:34 a.m. Record review of Resident #1's Provider Investigative Report, dated [DATE], revealed the resident was found by LVN A at 5:21 a.m. laying on her side with blue lips, pallor, oxygen was off. The LVN requested assistance from LVN B to reposition the resident. The report revealed Resident#1 was somewhat responsive and after she was repositioned up right and oxygen was applied at 2 liters per nasal cannula the resident was responsive and alert. LVN A encouraged the resident to do deep breathing exercises and then left the room. LVN A returned to the resident's room at 5:42 a.m. to assist CNA C with peri-care and at that time LVN A checked Resident #1's oxygen saturations and it was at 81% on two liters per nasal cannula. The nurse indicated she would continue to monitor and left the room. LVN D came on duty for the following shift. LVN D had gone into Resident #1's room at approximately 8:00 a.m. and found the resident unresponsive, not breathing and her oxygen was laying on the floor. CPR was initiated by LVN D, EMS was called, and they continued CPR, however Resident #1 expired at 8:34 a.m. Review of LVN A's progress note dated [DATE] at 5:50 a.m. revealed the LVN applied Resident #1's oxygen at 2 liters per nasal cannula after the resident was sat upright. The LVN documented the resident was non-compliant with her oxygen and her c-pap. The LVN reported she left the room but returned at 5:42 a.m. and checked the resident's O2 saturations and the resident was stating at 81%. LVN A told the resident to take deep breaths and left the room. The LVN documented there were only 2 nurses and 2 CNAs, and she would stay on the floor to continue monitoring the other residents. Review of LVN A's progress note, dated [DATE] at 6:27 a.m., revealed when the LVN had found the resident in bed without oxygen, and the resident's face was turning blue. Review of LVN D's progress note dated[DATE] at 1:17 p.m. revealed when she entered Resident #1's room around 7:,d+[DATE]:30 a.m. The resident was laying on her side and her face was bluish. The LVN shook the resident, but there was no response, and the resident was not breathing. The LVN called for assistance from other staff began CPR and 911 was called. EMS continued CPR after they arrived on the scene, but the resident was pronounced dead at 8:34 a.m. Review of Resident #1's Record of Death, located in the resident's medical record confirmed the resident passed away on [DATE] at 8:34 a.m. Review of a written statement by CNA D (undated) revealed Resident #1 refused peri-care so she contacted LVN A. The nurse was able to convince the resident to allow the CNA to change her. The CNA's statement revealed the resident was awake and talking the entire time the CNA was in the room and the resident thanked the CNA afterwards. Review of a written statement by CNA E (undated) revealed she went into Resident #1's room at 6:56 a.m. and found the resident sleeping on her side, facing the window and in no distress. During an interview on [DATE] at 9:59 a.m., the Administrator reported Resident #1 had an order to use oxygen and had a history on non-compliance with the oxygen. The Administrator also reported LVN A did not pass on Resident #1's condition during the overnight shift to the oncoming shift, LVN D, on the morning the resident passed away. An interview on [DATE] at 10:58 a.m. with LVN A revealed she had verbally told the oncoming shift LVN, LVN D, about Resident #1's condition during the overnight shift, including that she had found the resident without her oxygen off and she was turning blue. LVN A revealed staff had to frequently reposition Resident #1 to sit up and replace her oxygen, and that the night before the resident passed, was not the first time the LVN found the resident without her oxygen and having some blue color to her and around her lips. LVN A stated when she reported to the oncoming staff how she had found the resident without her oxygen and turning blue, They all agreed this was the resident's normal condition. The LVN reported when they gave report, they wrote some things down but the report she gave to LVN D was mostly verbal because they did not see Resident #1's condition as a change in condition since this was the usual habits of the resident. The LVN reported she was aware Resident #1 recently had an abnormal x-ray of her chest and was started on new medication. LVN A revealed, again, that she and the on-coming nurse, LVN D, did not think anything unusual about what had happened the evening before the resident passed, because that was the resident's usual condition. An interview on [DATE] at 11:07 a.m. with LVN B revealed she worked the overnight shift with LVN A and assisted LVN A with repositioning Resident #1. LVN B reported when she entered the room to assist LVN A to reposition Resident #1 she noted the resident was blue ashen (paleness or gray tint) in color. The LVN stated the resident was initially resistive to rolling over on her back but eventually agreed and they were able to sit her up and place her O2 on that she had removed. The LVN stated when the O2 was placed she noted the resident cognition improved. LVN B stated the resident frequently lay on her side, removed her oxygen, and refused to wear her c-pap. The LVN stated Resident #1 was gaining her color back and responding the last time she saw her. LVN B stated she had never seen Resident #1 with the blue ashen color she was the night before she passed. LVN B stated typically in situations such as this, the LVN would notify her supervisors and the resident's physician about the resident's condition. LVN B stated she thought LVN A had notified Resident #1's physician. The LVN stated the resident frequently removed her oxygen and they kept an eye on her during the overnight shift. LVN B stated they were short of staff that evening but did not think that had anything to do with what was going on with Resident #1. During an interview on [DATE] at 11:36 a.m., LVN D reported when she came on duty on the morning of [DATE], she received report from off-going nurse, LVN A. LVN D reported LVN A stated during the overnight shift, she had found Resident #1 without her oxygen and her face turning blue and LVN A had repositioned her, applied her oxygen and that the resident was doing good. LVN D stated she had never seen Resident #1's face turned blue as LVN A described. LVN D stated she did not check on Resident #1 immediately, because LVN A stated the resident was doing good. LVN D stated the CNAs were on the floor and no CNAs reported any concerns. LVN D stated when she entered Resident #1's room, she found the resident laying on her side, she was blue without her oxygen or c-pap on. The LVN stated Resident #1 removed her oxygen and c-pap. LVN D stated when she entered the resident's room to check her blood sugar level, the resident's face was discolored so she shook her, and the resident did not respond. LVN D stated she called for help from the other staff, and they began CPR and EMS was called. The LVN stated she was not aware Resident #1 had started new medication related to a chest x-ray. LVN D reported LVN A acted as if it was not an emergency and stated Resident #1 was good to go and never in any distress. LVN D stated anyone with their saturations in their 80's, she would place oxygen on the resident, call the primary care physician, and send the resident out to the hospital. An interview on [DATE] at 12:02 p.m. with the DON revealed when a resident had oxygen saturations that were low, staff were instructed to place the oxygen on the resident to get them stabilized with oxygen saturations above 90%. The DON went on to say if the resident's saturations did not increase then the staff should call 911. The DON reported the resident had COPD, was obstinate about taking her O2 off and the resident always had an ill appearance. The DON stated it was hard to say if ashen color meant the resident was in distress because everyone was different, but blue around the lips was concerning and should have been reported to the physician. The DON reported during the overnight shift prior to Resident 1's passing, they were short on nurses' aides but not on nurses. The DON reported she had never had any previous complaints about LVN A. An interview on [DATE] at 2:07 p.m. with CNA E revealed when she came on duty on the morning Resident #1 passed, no one had shared information with her about the resident's condition during the overnight shift. The CNA revealed she had wished the facility shared information about the resident's during the change of shift because she did not know who fell or any other changes during the previous shift. CNA E stated when she checked on Resident #1 around 7:00 a.m. that morning the resident was lying on her side facing the window and thought she was asleep. The CNA revealed she did not see the resident's face, could not confirm if the resident was wearing her oxygen and could not confirm if the resident was still alive and breathing. During an interview on [DATE] at 12:12 p.m. with the Medical Director, she revealed, typically, she was notified when a resident's O2 saturations was less than 91% but the physician was available anytime a nurse had concerns about a resident's condition. When questioned what may have contributed to Resident #1's passing, the Medical Director stated she could not confirm anything at that time as she had not had a chance to review all of Resident #1's medical record. Review of the Order Listing Report, dated [DATE], revealed there were 29 residents with orders for oxygen. Record review of HHF Safety-Communication with the Physician: Parameters dated [DATE] and provided by the facility revealed, under the heading, Considerations, staff should alert the physician if O2 Saturations are less than 92% and 5. Clinicians are always expected to adhere to professional practice standards and to use sound clinical judgement in assessing patients and making determinations of need to contact the physician. Review under the heading, Procedure, revealed f. Compare patient's measurements against normal parameters and g. If parameters are outside normal parameters (or agency's parameter policy), notify the physician. The Administrator was notified of an IJ on [DATE] at 12:18 p.m. and was given a copy of the IJ Template and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] at 7:16 p.m. and included the following: Plan of Removal [DATE] Immediate Action #1 - Medical Director was notified on [DATE] at 12:19 p.m. about the incidents surrounding the passing of Resident #1 and the facility response was discussed. - LVN A was terminated [DATE]. - on [DATE] at 1:30 p.m. education began for all LVNs and CNAs in-regards to completing walking rounds and/or bedside rounds at shift change. - LVNs and CNAs not already in-serviced would be in-serviced before the start of their next regularly scheduled shift. - These in-services would be included in the new hire process for LVNs and CNAs. - A post-test would be given to verify retention of knowledge related to walking rounds. - All education on this topic would be completed on [DATE] by 3:00 p.m. for LVNs and CNAs present. Monitoring: - At shift change LVNs and CNAs would sign off on 24-hour report acknowledging they received information regarding each resident on their assignment. - The signed-off 24-hour report would be reviewed by the Director of Nursing or Administrator for 4 weeks until compliance had been achieved. - The Administrator would randomly view video footage and/or be present during shift change 5 times a week to assure walking rounds were completed for 4 weeks until compliance had been achieved and maintained. Immediate Action #2 - On [DATE] at 1:30 p.m. education for LVNs and CNAs began in-regards to when to follow up on vital signs out of parameters. - LVNs and CNAs that were not already in-serviced would be in-serviced before the start of their next regular shift. - These in-services would be included in the new hire process for LVNs and CNAs. - A post-test would be given to verify retention of knowledge related to follow up for vital signs out of parameters. - All the education on this topic would be completed on [DATE] by 3:00 p.m. for LVNs and CNAs. Monitoring: - Director of Nursing would review 10% of resident charts weekly for all significant events for physician notification and would be documented on monitoring log. - Monitoring would continue for 4 weeks until compliance had been achieved and maintained. Verification of the Plan of Removal was as follows: a. Reviewed in-service training on [DATE] for all nursing staff. The nursing staff were in-serviced on nurse-to-nurse-reporting and walking rounds at exchange of shift to assure communication of issues related to care of the residents from previous shift and to always ensure continuity of care. b. Reviewed in-service training on [DATE] for all nursing staff. The nursing staff were in-serviced on vital signs, oxygen parameters, and best practice for follow up for vital signs out of parameters. c. Review of the post-tests for 52 nursing staff members, with 3 post tests given to each staff member related to walking rounds at change of shift and vital sign/O2 parameters revealed they had written understanding and knowledge of the in-service teachings. d. Review of the Nurse walking rounds Sign Off Sheet revealed the charge nurses and CNAs were completing rounds with the on-coming shifts on [DATE], [DATE], and [DATE] and the sheets were reviewed and signed by the Administrator. e. Review of the Chart Review Log for week 1 for dates of [DATE]-[DATE], revealed 10 resident charts would be reviewed each week by administrative nursing. f. Review of the Random Video History Review revealed random observations of shift change both in person and viewed on video would be conducted 5 times a week for 4 weeks. g. Observation on [DATE] at shift ,d+[DATE] shift change revealed off-going staff were exchanging information on the residents' condition to on-coming staff. h. In an interview between [DATE] at 8:54 a.m. to [DATE] at 10:12 a.m. 2 nurses (LVN F and LVN G) from ,d+[DATE] shift, 2 nurses (LVN H and LVN I) from ,d+[DATE] shift, 2 nurses (LVN B and LVN J) from ,d+[DATE] shift, 3 medication aides (MA K, MA L, and MA M) from ,d+[DATE] and ,d+[DATE] shifts, 2 CNAs (CNA E and CNA N) from ,d+[DATE] shift, 2 CNAs (CNA O and CNA P) from ,d+[DATE] shift, 4 CNAs (CNA Q, CNA R, CNA S, and CNA T) from ,d+[DATE] shift, 1 prn (as needed) CNA (U) , 1 CNA/van driver (CNA V) 3 administrative staff/LVN (HR W, LVN X, LVN Y) and 3 agency CNA's (CNA Z), CNA AA, and CNA BB) were interviewed (with a total of 25 nursing staff interviewed) regarding the in-servicing provided by the facility as part of the plan of removal and all had knowledge and understanding of the in-services provided. i. During an interview with the Administrator on [DATE] at 7:56 a.m. the Administrator confirmed the new logging and tracking were being implemented this date. j. During an interview on [DATE] with the Administrator she confirmed the new logging and tracking worksheets for Chart Review and Random Video History Review were being implemented this date. The Administrator reported she had been able to visually monitor staff shift change with exchange of resident information since the incident occurred on [DATE]. k. During an interview on [DATE] at 7:56 a.m. the Administrator reported she believed the incident occurred because LVN A had lack of experience with only 3 years as a nurse. The Administrator reported the LVN had worked only the overnight shift. The Administrator revealed the facility required anybody working the overnight shift had to work the day shift a couple of days first so they could get the training needed. The Administrator reported LVN A had worked for the facility before, left and came back and the Administrator did not think LVN A did the day training when she returned because she had worked at the facility before. The Administrator reported any new nurse hired was shadowed by an experienced nurse for 3 days and if they still felt the nurse was not ready then they would continue training. The Administrator revealed they were starting new training program next week with all the nurses, to include general nurses training, change of condition and a Nurse Educator Toolkit that was provided by Texas Health and Human Services. The Administrator revealed as far as what they could have done different to prevent the incident was to implement nurse training and one-on-one with instructors. The Administrator reported because they did not recognize LVN A's weaknesses and her level of critical thinking skills they were at fault as well. While the IJ was removed on [DATE] the facility remained out of compliance at a level of actual harm with a scope identified as isolated until all staff was in-serviced and showed proficiency on vital sign parameters, notification of physician and change of condition, walking rounds through monitoring of change of shift observations and chart reviews.

Based on observation, interview, and record review the facility failed to ensure that residents receive adequate supervision to minimize falls for 1 residents (Residents # 6) of 16 residents reviewed for supervision related to falls: Resident # 6 did not receive physical therapy screenings nor was provided with restorative care to minimize accidents or falls. Resident #6 fell 9 times over a 6 month period (April-October, 2017). This deficient practice could affect 12 residents with falls in the 400 Hall. The findings were: Record review of Resident # 6's face sheet revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation at 8:38 am on 10/24/17 revealed Resident #6 to be sitting up in wheelchair in room eating breakfast. On contact isolation for ESBL (extended spectrum beta lactamase) in the urine. Bedside table in front her eating breakfast on disposable products. Observation at 1:12 pm on 10/24/17 revealed Resident #6, lying in bed awake. Fall mats in place. Observation at 8:07 am on 10/25/17 revealed Resident # 6 sitting up in wheelchair bedside table in frond of her. Observation at 8:17 am on 10/26/17 reveled Resident #6 to be sitting up in wheelchair in her room. Alert to self only. Confused . Unable to answer questions. Non-Interviewable. Record review of Resident's # 6 Significant Change MDS dated [DATE] revealed Brief Interview for Mental Status (BIMS) 3 (0-7) is severely impaired. Record review of Resident #6's Incident Report dated 04/15/17 at 10:10 am revealed: Resident # 6 had an unwitnessed fall, found in room between bed and window no injuries. Post-fall risk assessment score 15 (high risk). Recommendation Physical Therapy (PT) screening. Record review of Resident #6's Incident Report dated 04/15/17 at 11:40 am revealed Resident # 6 had an unwitnessed fall, in dining room. Found in dining room sitting on buttocks with head bent down. Laceration to face and fracture to nose. Post-fall risk assessment score 16 (high risk). Resident started on Occupational Therapy (OT) on 04/16/17. Record review of OT evaluation and plan of treatment dated 04/26/17 revealed Resident # 6 started OT services on 04/25/17 three times a week for four weeks for self care management training, therapeutic activities, neuromuscular reeducation, and therapeutic exercise. Record review of PT screening dated 05/05/17 revealed on hold to continue skills services to address fall. Currently on hold for approval. Record review of Resident #6's Incident Report dated 05/19/17 at 10:19 pm Resident #6 had a witness fall. Resident was in closet sorting through clothes attempted to step back and slid down to the floor (assisted by CNA to floor) with no injuries. Post-fall risk assessment score 16 (high risk). Recommendations PT to screen. Further record review revealed no record of PT screen. Record review of Resident #6's Incident Report dated 06/20/17 at 5:23 am revealed Resident #6 was siting on the edge of the chair when asked resident to sit back resident began to slide off chair down to the floor. No injuries. Post-fall risk assessment score 15 (high risk). Recommendations PT screen. OT & DON assess chair for appropriate fit. Further record review revealed no record of PT screen. Record review of Resident #6's Incident Report dated 06/25/17 at 5:29 am revealed witness fall. Nurse observed resident sitting on foot end of her bed sliding towards the floor. Post-fall risk assessment 17 (high risk). Recommendation scoop mattress applied. Record review of physical therapy notes revealed therapy was initiated 07/06/17- 08/14/17. for bilateral lower extremely strength and gait training. Record review of Resident # 6's Incident Report dated 07/18/17 at 4:30 am revealed Resident #6 had a witnessed fall. CNA saw resident slide from bed to floor sitting on her bottom on floor with back against her bed. Post-fall risk assessment 17 (high risk). Recommendations for PT three times a week for twelve weeks. Record review of Resident #6's Incident Report dated 09/21/17 at 5:30 pm revealed Resident # 6 had unwitnessed fall, found sitting on floor back against bed facing window bare-footed. Recommendations fall mats. Encouraged and educated on call light usage. Record review of Resident #6's Incident Report dated 10/05/17 at 10:10 am revealed Resident #6 had a witnessed fall with injury sustained a laceration above right eyebrow requiring sutures. Resident was sitting by nurses station when nurse saw the resident stand up out of her wheelchair and fell forward on to her stomach and hit her head on the floor. Post-fall risk assessment 18. Recommendations referred to therapy services. Record review of therapy notes revealed last day of service was 08/15/17 no new screening found. Record review of Resident #6's nursing restorative care note for October, 2017 revealed restorative was discontinued on 10/20/17 due to isolation. Record review of Resident #6's Incident Report dated 10/21/17 at 10:22 am revealed Resident #6 had unwitnessed fall found sitting on mat next to her bed in room. Recommendation Resident to use non-skid socks. Record review of Resident #6's care plan revealed last revision for falls was completed 07/18/17. During interview at 12:15 pm on 10/26/17 with the Administrator he revealed they could have initiated restorative while they were pending authorization for PT/OT services. During interview at 12:15 pm on 10/26/17 with the DON confirmed care plan should be updated post fall. Confirmed there were no other therapy screens documentation. During interview at 3:43 pm on 10/27/17 with PT G revealed Resident #6 received physical therapy services from 07/06/17-08/15/17, and then discharged to nursing for restorative program. PT G further revealed Resident #6 was referred to restorative for moderate assist mod cycle, and ambulating with bars then nursing takes over. Record review of facility's policy Fall and Post-Fall Management (no date) revealed under goals: 2. Initiate preventative approach. 3. Provide appropriate strategies and interventions directed to resident, environmental factors, and staff. 5. Monitor and reevaluate resident outcome. Post-fall procedures 5. update interventions as necessary. 8. Take an interdisciplinary approach to identify any new interventions or need to change in interventions. Based on information provided by facility on 10/27/17 there were 12 residents with falls in the 400 hall for October, 2017.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was as free of accident hazards as was possible and that each resident received adequate supervision to prevent accidents for 17 of 23 residents (Resident #s 8, 6, 7, 24, 5, 11, 1, 27, 50, 51, 52, 53, 22, 45, 54, 55, and 42) whose care was reviewed for safe smoking, for 2 of 20 residents (Resident #s 12 and 22) whose care was reviewed for safe eating/drinking, for 1 of 3 residents (Resident #12) reviewed for bed/chair alarms on the 400 hall, on 1 (the 100 hall) of 4 observed hallways, and for 3 of 3 residents (Resident #s 13, 44, and 23) residing in rooms with unsecured razors in that: A. 1. Resident #8 had cigarette burns on his fingers. The facility did not investigate these burns, assess Resident #8 for safe smoking according to his care plan, and provide smoking safety equipment/supervision/storage according to his care plan. He was not supervised while smoking, was not wearing a smoking apron or using a cigarette holder, and had his cigarettes and his lighter on him. 2. Resident #6 had cigarette burns on his left hip and upper thigh. The facility did not investigate these burns, assess Resident #6 for safe smoking, and provide smoking safety equipment/supervision/storage according to his care plan. He was not supervised while smoking, was not wearing a smoking apron, and had his cigarettes and his lighter on him. 3. Resident #7 had cigarette burn holes in his clothing and was smoking unsupervised and without a smoking apron on. The facility did not assess Resident #7 for safe smoking, care plan his smoking, and provide needed smoking safety equipment/supervision/storage. 4. Resident #24 was caught smoking in his room, outside which there was an oxygen tank, in April. The facility did not assess Resident #24 for safe smoking and provide a needed smoking apron once he was assessed to need one. 5. The facility had not assessed Resident #5 for safe smoking since 2/9/15, and this 2/9/15 safe smoking assessment was incomplete. The facility did not assess Resident #5 for safe smoking according to her care plan and did not provide smoking supervision/storage according to her care plan. Resident #5 knew the access code to the designated smoking area, had her cigarettes and lighter on her, and was smoking unsupervised (against the facility's smoking policy). 6. The facility did not provide needed smoking supervision and storage for Resident #11 (according to the facility's smoking policy). Resident #11 knew the access code to the designated smoking area, had her cigarettes and lighter on her, and was smoking unsupervised. 7. The facility did not assess Resident #s 1 and 27 for safe smoking according to the facility's smoking policy. 8. The facility did not enforce its smoking policy for unidentified residents and residents were smoking unsupervised in the designated smoking area. They had their cigarettes and lighters on them and knew the access code into/out of the building. 9. The facility did not provide a safe environment for residents. Cigarette butts were found in grassy areas and outside of the designated smoking area. The designated area for resident smoking included ash trays not approved by the National Fire Protection Association and trash cans being used for trash and cigarette butts. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on 8/11/15. While the IJ was removed on 8/12/15, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was not an immediate jeopardy due to the facility not yet completing in-service training for all staff on enforcement of the smoking policy and not having all residents who smoked sign a safe smoking agreement. B. 1. Resident #12 had coffee burns to her right upper thigh and her abdomen. The facility did not investigate these burns and assess Resident #12 for her ability to drink hot liquids safely. Hot coffee (over 170 degrees Fahrenheit) was left in the dining room for residents to serve themselves and was unsupervised. 2. Resident #22 spilled hot coffee on his left thigh area. The facility did not investigate this burn and assess Resident #22 for his ability to drink hot liquids safely. Hot coffee (over 170 degrees Fahrenheit) was left in the dining room for residents to serve themselves and was unsupervised. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on 8/12/15. While the IJ was removed on 8/19/15, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was not an immediate jeopardy due to the facility not yet evaluating the incident/accident reports, investigating them thoroughly, and putting corrective measures in place to prevent reoccurrence. C. The facility did not assess Resident #12 for fall risk before taking off her assistive devices. D. A large container of PDI Super Sani-Cloth Germicidal Disposable Wipes was sitting on the PPE Equipment cart outside of Room #104. E. An electric razor was plugged into the electric outlet and lying on the restroom sink, and a disposable razor was lying on top of the paper towel dispenser in the restroom of Resident #s 44 and 23. F. Two disposable razors were on top of the paper towel dispenser in Resident #13's restroom. These failures could result in fire hazard with injury and could affect 23 residents at the facility who smoked, could result in burns and could affect 54 residents who liked to drink hot liquids, could result in falls with/without injury for 3 residents on the 400 hall requiring bed/chair alarms, could place 4 confused and disoriented residents walking/ambulating on the 100 hall at risk for adverse reactions to the chemicals in the Germicidal Disposable Wipes, and could result in electrical shock and/or cuts to the 3 residents living in the rooms with unsecured razors. The findings were: A. 1. Record review of Resident #8's facesheet (dated 8/11/15) revealed that he was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the assessments section of Resident #8's clinical record revealed that he was last evaluated for safe smoking on 7/8/14. At this time, he was assessed to be potentially unsafe and to need a safe smoking care plan. Smoking in unsupervised areas, being careless with smoking materials, and providing smoking materials to others were noted as being severe problems. Record review of Resident #8 ' s health status note (dated 6/21/15) revealed that he was seen outside by staff picking up used cigarette butts and then trying to smoke them. Documentation revealed that he was educated on the risks of burning himself but that no other interventions were made. Record review of Resident #8 ' s skin/wound note (dated 7/13/15) revealed that he continue(d) to smoke (unsafe smoker) tip of fingers charred over at times. All nursing staff/ADON/DON/ADM aware of situation with this resident and smoking issues . There was no accompanying incident/accident report. Record review of Resident #8's quarterly MDS assessment (ARD 7/14/15) revealed that he scored an 11 on the BIMS (indicating that he was cognitively intact). Record review of Resident #8 ' s care plan (reviewed 7/15/15) revealed that he was at risk for skin breakdown related to being an unsafe and noncompliant smoker. Interventions included wearing protective clothing and being supervised when smoking. His care plan called for his smoking ability to be reassessed quarterly and after reports of unsafe practices and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Record review of Resident #8's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that he needed a smoking apron, a cigarette holder, and supervision while smoking and needed the facility to store his lighter and cigarettes. Observation on 8/11/15 at 7:28 a.m. revealed Resident #8 sitting in his wheelchair outside on the covered patio smoking. Resident #8 was noted to have 8 round holes in the crotch of his navy sweatpants and 3 round holes on the pant leg. There were no staff supervising Resident #8, and he was not wearing a smoking apron. During an interview with Resident #8 on 8/11/15 at 7:30 a.m., he reported that he went in and out alone to smoke. Resident #8 said staff did not go outside when residents were outside smoking on the covered patio. During an interview with Resident #8 in his room at 11:00 a.m. on 8/13/15, he reported that he had burned himself while smoking at the facility. Resident #8 was observed to have burn holes all over his pants. 2. Record review of Resident #6's facesheet (dated 8/11/15) revealed an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6 ' s skin/wound note (dated 12/15/14) revealed left upper thigh, 0.9 x 0.5 x 0 epitheliazed with yellowish like tissue covering 100% of the wound bed, edges slightly epiboly. Slight redness notes to periwound, round in shape, dry. No induration or pain or warmth noted. (Resembles cigarette burn), resident clothing noted to have cigarette burn holes in them, both t-shirt and warm-ups have holes in them from previous smoking session. Area cleansed and dressed with transparent film. Nurse in charge made aware of wound and will follow up . Record review of Resident #6 ' s 12/15/14 incident/accident report revealed Shower aid reported that when showering resident he had a 0.9 centimeter x 0.5 centimeter area to his left upper thigh. Periwound is reddened and surface shows that skin is trying to heal. There is no noted bleeding or draining to area. He denies any pain or discomfort. Area looks like he may have burned himself while smoking. His t-shirt also had burned circles as well. Resident is not able to state what happened but did state he did remember dropping cigarette ash on his pants a long while back . Notes were Resident is now being accompanied by CNA staff member when resident requests to smoke outside. I did tell resident that he is advised to wear a smoking apron for his safety, but he got really upset and stated he is not a ' damn baby ' or a ' child ' . He refuses to wear smoking apron but allowed staff member to accompany him when smoking outside for safety monitoring . Record review of Resident #6 ' s skin/wound note (dated 4/28/15) revealed left hip with 3.0 x 4.0 area open blister with reddened periwound (fresh) denies pain. Trauma caused by cigarette burn as evident by wheelchair padding, cigarette burn marks on cushion to left side of chair. Nurse informed of skin condition . There was no accompanying incident/accident report. Record review of Resident #6's medication administration note (dated 5/20/15) revealed left hip open blisters - clean with normal saline, pat dry - apply TAO, cover with transparent dressing - every day shift every Monday, Wednesday, Friday for trauma blisters (cigarette) . There was no accompanying incident/accident report. Record review of Resident #6's quarterly MDS assessment (ARD 6/9/15) revealed that he scored a 4 on the BIMS (indicating that he had severe cognitive impairment). Record review of Resident #6 ' s care plan (last reviewed 6/23/15) revealed that he required supervision with smoking, that his smoking ability should be reassessed quarterly and after reports of unsafe practices, and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Review of Resident #6 ' s clinical record revealed no safe smoking assessments. Record review of Resident #6's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that he needed a smoking apron and supervision while smoking and needed the facility to store his lighter and cigarettes. Observation of Resident #6 in the designated smoking area at 7:30 a.m. on 8/12/15 revealed that he was smoking, had a lighter in his pouch, and was not wearing a smoking apron. Psychologist HH was out with Resident #6, but then came back inside the facility - leaving Resident #6 outside unsupervised and smoking. During an interview with Psychologist HH at 7:32 a.m. on 8/12/15, he stated I didn't follow the rules. I let them out. Psychologist HH reported that he had been educated on the smoking policy that morning but had allowed Resident #6 to go out and smoke unsupervised. During an interview with Resident #6 in his room at 9:51 a.m. on 8/13/15, he reported that he was able to carry his cigarettes and lighter with him and to smoke unsupervised as he pleased until the surveyors came. 3. Record review of Resident #7's facesheet (dated 8/11/15) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the assessments section of Resident #7's clinical record revealed that he was last evaluated for safe smoking on 7/8/14. At this time, he was assessed to be safe, to not require supervision while smoking, and ro be able to carry his own cigarettes and lighter. Record review of Resident #7's smoking care plan (last reviewed 8/1/14) revealed that he was an independent smoker, should be assessed for safe smoking quarterly and with a change in condition, and should be monitored for unsafe smoking practices. Record review of Resident #7's quarterly MDS assessment (ARD 7/3/15) revealed that he scored a 10 on the BIMS (indicating moderate cognitive impairment). Record review of Resident #7's care plan (last reviewed 7/8/15) revealed that smoking was not addressed. Record review of Resident #7's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that he needed a smoking apron and supervision while smoking and needed the facility to store his lighter and cigarettes. Observation on 8/11/15 at 7:25 a.m. revealed Resident #7 walking independently in the facility corridor. Resident #7 was noted to have a dark blue jacket with 2 round holes approximately the same circumference as a cigarette on the front. During an interview with Resident #7 at 5:40 p.m. on 8/11/15, he reported that he never had to wear a smoking apron, had been able to smoke when he pleased, and was able to carry his cigarettes and lighter on him before the surveyors showed up. When asked about the burn holes on his clothes, Resident #7 reported that cigarette ashes had fallen on him. Observation of Resident #7 smoking in the designated area at 7:30 a.m. on 8/12/15 revealed that he was not wearing a smoking apron. Psychologist HH was out with Resident #7, but then came back inside the facility - leaving Resident #7 outside unsupervised and smoking. During an interview with Psychologist HH at 7:32 a.m. on 8/12/15, he stated I didn't follow the rules. I let them out. Psychologist HH reported that he had been educated on the smoking policy that morning but had allowed Resident #7 to go out and smoke unsupervised. 4. Record review of Resident #24 ' s electronic facesheet (not dated) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #24 ' s health status note (dated 4/27/15) revealed that he was caught smoking in his room. Resident is in (room) which is close to the door outside which there was an oxygen tank, that belonged to another resident. (Resident) stated that his roommate (Resident #1) gave him the lighter to light his cigarette . Incident/accident reports were reviewed, and there were no incident/accident reports pertaining to Resident #24 smoking in his room. Record review of Resident #24's annual MDS assessment (ARD 6/11/15) revealed that he scored a 4 on the BIMS (indicating that he had severe cognitive impairment). Record review of Resident #24's care plan (reviewed 7/23/15) revealed that he required supervision with smoking, that his smoking ability should be reassessed quarterly and after reports of unsafe practices, and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Review of Resident #24 ' s clinical record revealed no safe smoking assessments. Record review of Resident #24's safe smoking assessment (after surveyor intervention - dated 8/15/15) revealed that he needed a smoking apron and supervision while smoking. Observation of Resident #24 at 11:41 a.m. on 8/18/15 revealed that he was smoking without an apron on. 5. Record review of Resident #5's facesheet (dated 8/11/15) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5 ' s clinical record revealed that her last safe smoking assessment was done on 2/9/15 and was still in progress . During an interview with LVN N on 8/11/15 at 3:00 p.m., she reported that Resident #5 had not had a smoking assessment completed since her admission on 2/9/15. Record review of Resident #5's significant change MDS assessment (ARD 6/24/15) revealed that she scored a 6 on the BIMS (indicating that she had moderate cognitive impairment). Record review of Resident #5's care plan (reviewed 6/29/15) revealed that she required supervision with smoking, that her smoking ability should be reassessed quarterly and after reports of unsafe practices, and that her cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Record review of Resident #5's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that she could light her own cigarette, did not need to be supervised when smoking, and did not need the facility to store her cigarettes or lighter. Observation on 8/10/15 at 6:00 p.m. revealed Resident #5 self-propelling her wheelchair outside to the covered patio and smoking a cigarette. No staff was supervising the smoking and/or outside on the covered patio. During an interview with Resident #5 on 8/10/15 at 6:05 p.m., she reported that she was allowed to keep her cigarettes and lighter in her room. Observation on 8/11/15 at 6:08 a.m. revealed Resident #5 in her bed sleeping. Two packages of cigarettes and one lighter were observed on her over bed table. Observation on 8/11/15 at 10:40 a.m. revealed Resident #5 self-propelling her wheelchair, utilizing the keypad, going outside to the covered patio, and smoking. No staff were supervising the patio. 6. Record review of Resident #11's facesheet (dated 8/13/15) revealed that she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #11's quarterly MDS assessment (ARD 6/5/15) revealed that she scored a 7 on the BIMS (indicating moderate cognitive impairment). Record review of Resident #11's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that she could light her own cigarette, did not need to be supervised when smoking, and did not need the facility to store her cigarettes or lighter. Observation of the designated smoking area on 8/11/15 at 6:13 a.m. revealed 3 residents (including Resident #11) smoking without supervision. Resident #11 was observed walking with the assistance of a rolling walker. She used the door keypad and punched in the security code to gain access to the inside of the facility. Observation on 8/11/15 at 8:02 a.m. revealed Resident #11 using her rolling walker to ambulate past the nurses ' station, utilizing the keypad, and letting herself outside to the designated smoking area. No staff were observed supervising the resident. Resident #11 then lit her cigarette. Resident #11 handed this surveyor her lighter and asked if this surveyor would light another resident ' s cigarette because he was blind and her legs hurt too bad to get up and assist him. This surveyor took the lighter from Resident #11 as LVN N walked outside to the covered patio and handed this surveyor a piece of paper. This surveyor handed LVN N the lighter. LVN N said, The smoking policy has been implemented and walked inside with the lighter. Observation of Resident #52 at 9:01 a.m. on 8/12/15 revealed that she exited the facility with half of a cigarette (unlit) in her hand. When asked where she got the cigarette, Resident #52 reported that she got it from her friend and pointed to Resident #11. Resident #11 stated I had it. I saved it from yesterday. One of the ladies - a worker - told me to put it in my purse . Resident #11 reported that she had last smoked at the 7:00 p.m. break on 8/11/15. 7. Record review of Resident #1's facesheet (dated 8/11/15) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's annual MDS assessment (ARD 6/30/15) revealed that he scored a 9 on the BIMS (indicating that he had moderate cognitive impairment) and was a smoker. Record review of Resident #1's care plan (reviewed 7/23/15) revealed that he required supervision with smoking, that his smoking ability should be reassessed quarterly and after reports of unsafe practices, and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Review of Resident #1's clinical record revealed no safe smoking assessment. Observation of Resident #1 at 11:41 a.m. on 8/18/15 revealed that he was smoking in the designated smoking area with staff supervision. Record review of Resident #27's electronic facesheet (not dated) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #27's admission MDS assessment (ARD 6/29/15) revealed that she scored a 3 on the BIMS (indicating that she had severe cognitive impairment). Record review of Resident #27's progress notes revealed that she was caught smoking in her room on 8/17/15. Record review of Resident #27's care plan (revised 8/20/15) revealed that she required supervision with smoking, that her smoking ability should be reassessed quarterly and after reports of unsafe practices, and that her cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Review of Resident #27 ' s clinical record revealed no safe smoking assessment. 8. Observation of the designated smoking area on 8/11/15 at 6:55 a.m. revealed four unidentified male residents smoking. No staff were supervising them. Observation of the designated smoking area on 8/11/15 at 7:01 a.m. revealed one unidentified male resident smoking. No staff were supervising him. Observation of the designated smoking area on 8/11/15 at 8:36 a.m. revealed 8 unidentified residents smoking. No staff were supervising them. During an interview with Resident #50 at 5:13 p.m. on 8/11/15, she reported that she had been at the facility for 2 weeks and had been able to smoke unsupervised until today. During an interview with Resident #51 at 5:15 p.m. on 8/11/15, she reported that she had been at the facility for 3 months and had been able to smoke unsupervised until today. Resident #51 had 2 lit cigarettes in her hand at this time. The cigarette in her left hand was almost finished but still smoking. Resident #51 was holding the cigarette between her pointer finger and her thumb, and her left hand was shaking. The ashes were observed to fall onto her clothes but did not burn them. Observation of the designated smoking area at 5:05 p.m. on 8/12/15 revealed that Resident #53 was smoking without an apron on. The administrator was observed to light Resident #22 ' s cigarette (that Resident #22 was holding) before he put an apron on Resident #22. Resident #45 was observed pulling an unlit cigarette out of his shirt pocket. He asked Resident #51 for a light, and Resident #51 started searching in her purse. Resident #51 then noticed the surveyor and told Resident #45 that he needed to get his cigarette lit by the staff. Resident #54 was observed with 2 lit cigarettes in her hand at the same time. During an interview with Resident #45 at 5:05 p.m. on 8/12/15, he reported that he kept the cigarette in his pocket from an earlier smoke break. Observation of the designated smoking area at 7:00 p.m. on 8/12/15 revealed that Resident #55 lit Resident #24 ' s cigarette with her lit cigarette. Resident #24 had a smoking apron on, and Resident #55 was assessed by the facility to be a safe smoker. Resident #45 lit his second cigarette with his first lit cigarette. Observation of Resident #51 in her room at 10:07 a.m. on 8/13/15 revealed that she was covered with a blanket with a cigarette burn hole. During an interview with Resident #51 at this time, she reported that she didn ' t smoke in her room. Observation of Resident #42 at 9:05 a.m. on 8/14/15 revealed that he had burn holes on his pants. During an interview with Resident #42 at 9:06 a.m. on 8/14/15, he reported that he had the burned pants from cigarette ashes. Resident #42 also reported that, when he smoked a cigarette and the cigarette would be near his pants and the wind would blow, the ashes dropped on his pants. 9. Observations of the designated smoking area at 5:03 p.m. on 8/11/15 revealed 6 cigarette butts in a plastic planter bucket that also contained dry leaves and strips of paper. There were cigarette butts scattered on the dry, grassy area to the left of the exit door and on the rocky, dry-leaved area to the right of the exit door. Further observation of the designated smoking area at 5:03 p.m. on 8/11/15 revealed a metal ash tray containing an empty cigarette box and plastic wrapping along with cigarette butts. At 5:06 p.m. on 8/11/15, the administrator was observed putting trash in the box ash tray and not removing the trash that was already there. Observation of Resident #5 at 5:16 p.m. on 8/11/15 revealed that she was using a metal ash tray with toilet paper in it to dispose of her cigarette ashes. Observation of the designated smoking area at 5:18 p.m. on 8/11/15 revealed a chimney tower ash tray with cigarette butts on the ground around it. Observation of 3 unidentified staff smoking at 5:18 p.m. on 8/11/15 revealed that they were putting their cigarette ashes on the ground and not using ash trays. Observation of Resident #54 at 5:22 p.m. on 8/11/15 revealed that she put her cigarette out in a red metal trash can containing plastic. The trash can was left open, and smoke was coming out of it. The maintenance man was then observed putting water in the red metal trash can, and the administrator told the residents, Please use the ash trays for cigarettes and the trash cans for trash . Observation of the designated smoking area at 3:00 p.m. on 8/12/15 revealed scattered cigarette butts on the grass and in planters. Observation of the designated smoking area at 5:05 p.m. on 8/12/15 revealed 5 cigarette butts in a non self-closing ash tray. Observation of the designated smoking area at 12:18 p.m. on 8/17/15 revealed cigarette butts on the grass and in a trash can with trash (styrofoam cups and cigarette packs). During an interview with the Maintenance Supervisor at 12:19 p.m. on 8/17/15, he confirmed the above observations. Observation of the designated smoking area at 12:20 p.m. on 8/17/15 revealed cigarette butts in a non self-closing trash can. Observation outside of the main entrance to the facility (not the designated smoking area) at 1:55 p.m. on 8/18/15 revealed cigarette butts scattered on the concrete and the Corporate CMI Coordinator smoking. During an interview with Resident #14 at 10:12 a.m. on 8/13/15, she reported that the designated smoking area was a pig sty and stated Residents throw trash and cigarette butts on the ground. Staff, when they are out there, tell them not to but staff aren ' t always out there . Resident #14 reported that, in the winter time, she had accidentally burned some of her clothes while smoking unsupervised outside because she had so many layers on. In an interview with LVN A on 8/11/15 at 7:55 a.m., she reported that residents were allowed to keep their personal cigarettes in their rooms. LVN A said residents were supposed to keep their lighters at the desk. She said a CNA would usually light the residents ' cigarettes for them. LVN A said staff used their own judgement as to whether a resident was safe to smoke independently. She said the facility did not have a list of residents who were safe to smoke independently. In an interview with the DON on 8/11/15 at 8:15 a.m., he reported that, as far as smoking went, some residents come and go back in . The DON said that staff were always collecting lighters from residents and that he had received two lighters that morning. He said that residents were supposed to have a staff member supervise them while smoking but confirmed that staff were not monitoring residents ' smoking. The DON said residents knew the code to get outside. He said staff and residents were to follow the smoking schedule. He reported that he did not mind residents having their own cigarettes but that they were not supposed to keep their lighters. The DON said that the former ADON was responsible for completing resident smoking assessments, but that he knew he was ultimately responsible for making sure smoking assessments were completed. The DON said staff were not to give the keypad code to residents. The DON said Resident #6 ' s fingers looked charred off and on from smoking. In an interview with the AD on 8/11/15 at 8:50 a.m., she reported that the residents who smoked just want to smoke all day. She said residents who smoked were not supervised, adding that the monitoring had gone by the wayside. In an interview with the ADON on 8/11/15 at 1:06 p.m., she reported that she had not been trained on resident safety with smoking. She reported that she knew residents were going in and out of the building and smoking but that she didn ' t know whether or not residents were going out to smoke by themselves. She reported that she had never done a safe smoking assessment and that there were never clear assignments as to who does what . During an interview with the administrator at 2:11 p.m. on 8/11/15, he reported that smoke breaks were now being monitored by staff. He reported that the former ADON was in charge of the safe smoking assessments and stated Smoking fell through the cracks . He reported that no issues pertinent to smoking were brought to the attention of QA because the new ADON picked smoking up when she started . When asked who was monitoring to make sure that the DON and ADON were doing their jobs, the administrator stated I was . When asked how he found out what was really going on in the facility, the administrator stated Uh huh, uh huh . When asked what he would expect staff to do if they saw residents with the code to the exit door, the administrator stated The paraphernalia should be in a locked box. Staff should be getting residents ' cigarettes and lighters and putting them in this box . The administrator stated We just got laxed on the smoking. We saw it happening out of the corner of ou

Based on observation, interview, and record review, the facility failed to implement policies and procedures that prohibit neglect of residents for 17 of 23 residents (Resident #s 8, 6, 7, 24, 5, 11, 1, 27, 50, 51, 52, 53, 22, 45, 54, 55, and 42) whose care was reviewed for safe smoking, for 2 of 20 residents (Resident #s 12 and 22) whose care was reviewed for safe eating/drinking, and for one of 6 incidents (Incident #1 involving Resident #10) reviewed for implementation or procedures in that: A. 1. Resident #8 had [MEDICAL CONDITION] his fingers. There was no evidence that [MEDICAL CONDITION] investigated. Resident #8 had not been assessed for safe smoking in over a year and was assessed to be potentially unsafe at that time. His care plan called for supervised smoking, protective equipment while smoking, smoking safety reassessments quarterly and after reports of unsafe practices, and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. He was not supervised while smoking, was not wearing a smoking apron or using a cigarette holder, and had his cigarettes and his lighter on him. 2. Resident #6 had [MEDICAL CONDITION] his left hip and upper thigh. There was no evidence that 2 of [MEDICAL CONDITION] investigated. Resident #6 was not assessed for safe smoking. His care plan called for supervised smoking, smoking safety reassessments quarterly and after reports of unsafe practices, and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. He was not supervised while smoking, was not wearing a smoking apron, and had his cigarettes and his lighter on him. 3. Resident #7 had cigarette burn holes in his clothing and was smoking unsupervised and without a smoking apron on. He had not been assessed for safe smoking in over a year and was assessed to be safe and to carry his own cigarettes and lighter at this time. Resident #7's care plan did not address smoking. 4. Resident #24 was caught smoking in his room, outside which there was an oxygen tank, in April. Resident #24 was not assessed for safe smoking. He was observed smoking without a smoking apron on after being assessed to need one. 5. Resident #5 had not been assessed for safe smoking since 2/9/15, and this safe smoking assessment was incomplete. Resident #5 knew the access code to the designated smoking area, had her cigarettes and lighter on her, and was smoking unsupervised (against the facility's smoking policy). 6. Resident #11 knew the access code to the designated smoking area, had her cigarettes and lighter on her, and was smoking unsupervised (against the facility's smoking policy). 7. Resident #s 1 and 27 smoked and were not assessed for safe smoking according to the facility's smoking policy. 8. The facility's smoking policy was not being enforced for unidentified residents and residents were smoking unsupervised in the designated smoking area. They had their cigarettes and lighters on them and knew the access code into/out of the building. 9. Cigarette butts were found in grassy areas and outside of the designated smoking area. 10. The designated area for resident smoking included ash trays not approved by the National Fire Protection Association and trash cans being used for trash and cigarette butts. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on 8/11/15. While the IJ was removed on 8/12/15, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was not an immediate jeopardy due to the facility not yet completing in-service training for all staff on enforcement of the smoking policy and not having all residents who smoked sign a safe smoking agreement. B. 1. Resident #12 had [MEDICAL CONDITION] her right upper thigh and her abdomen. There was no evidence that [MEDICAL CONDITION] investigated. Resident #12 was not assessed for her ability to drink hot liquids safely. Hot coffee was left in the dining room for residents to serve themselves and was unsupervised. 2. Resident #22 spilled hot coffee on his left thigh area. There was no evidence that this incident was investigated. Resident #22 was not assessed for his ability to drink hot liquids safely. Hot coffee was left in the dining room for residents to serve themselves and was unsupervised. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on 8/12/15. While the IJ was removed on 8/19/15, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was not an immediate jeopardy due to the facility not yet evaluating the incident/accident reports, investigating them thoroughly, and putting corrective measures in place to prevent reoccurrence. C. Resident #10's incident investigation (arm fracture) was not reported to the state for 2 days after the incident occurred and staff were not interviewed by the facility. These facility failures could result in fire hazard with injury and could affect 23 residents at the facility who smoked; could result [MEDICAL CONDITION] could affect 54 residents who liked to drink hot liquids; and could contribute to continued abuse and neglect for 14 residents with incidents in August of 2015. The findings were: A. 1. Record review of Resident #8's face sheet (dated 8/11/15) revealed that he was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the assessments section of Resident #8's clinical record revealed that he was last evaluated for safe smoking on 7/8/14. At this time, he was assessed to be potentially unsafe and to need a safe smoking care plan. Smoking in unsupervised areas, being careless with smoking materials, and providing smoking materials to others were noted as being severe problems. Record review of Resident #8' s health status note (dated 6/21/15) revealed that he was seen outside by staff picking up used cigarette butts and then trying to smoke them. Documentation revealed that he was educated on the risks of burning himself but that no other interventions were made. Record review of Resident #8 ' s skin/wound note (dated 7/13/15) revealed that he continue(d) to smoke (unsafe smoker) tip of fingers charred over at times. All nursing staff/ADON/DON/ADM aware of situation with this resident and smoking issues . There was no accompanying incident/accident report. Record review of Resident #8's quarterly MDS assessment (ARD 7/14/15) revealed that he scored an 11 on the BIMS (indicating that he was cognitively intact). Record review of Resident #8's care plan (reviewed 7/15/15) revealed that he was at risk for skin breakdown related to being an unsafe and noncompliant smoker. Interventions included wearing protective clothing and being supervised when smoking. His care plan called for his smoking ability to be reassessed quarterly and after reports of unsafe practices and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Record review of Resident #8's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that he needed a smoking apron, a cigarette holder, and supervision while smoking and needed the facility to store his lighter and cigarettes. Observation on 8/11/15 at 7:28 a.m. revealed Resident #8 sitting in his wheelchair outside on the covered patio smoking. Resident #8 was noted to have 8 round holes in the crotch of his navy sweatpants and 3 round holes on the pant leg. There were no staff supervising Resident #8, and he was not wearing a smoking apron. During an interview with Resident #8 on 8/11/15 at 7:30 a.m., he reported that he went in and out alone to smoke. Resident #8 said staff did not go outside when residents were outside smoking on the covered patio. During an interview with Resident #8 in his room at 11:00 a.m. on 8/13/15, he reported that he had burned himself while smoking at the facility. Resident #8 was observed to have burn holes all over his pants. 2. Record review of Resident #6's face sheet (dated 8/11/15) revealed an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's skin/wound note (dated 12/15/14) revealed left upper thigh, 0.9 x 0.5 x 0 [MEDICATION NAME] with yellowish like tissue covering 100% of the wound bed, edges slightly epiboly. Slight redness notes to periwound, round in shape, dry. No induration or pain or warmth noted. (Resembles cigarette burn), resident clothing noted to have cigarette burn holes in them, both t-shirt and warm-ups have holes in them from previous smoking session. Area cleansed and dressed with transparent film. Nurse in charge made aware of wound and will follow up . Record review of Resident #6's 12/15/14 incident/accident report revealed Shower aid reported that when showering resident he had a 0.9 centimeter x 0.5 centimeter area to his left upper thigh. Periwound is reddened and surface shows that skin is trying to heal. There is no noted bleeding or draining to area. He denies any pain or discomfort. Area looks like he may have burned himself while smoking. His t-shirt also had burned circles as well. Resident is not able to state what happened but did state he did remember dropping cigarette ash on his pants a long while back . Notes were Resident is now being accompanied by CNA staff member when resident requests to smoke outside. I did tell resident that he is advised to wear a smoking apron for his safety, but he got really upset and stated he is not a ' damn baby ' or a ' child ' . He refuses to wear smoking apron but allowed staff member to accompany him when smoking outside for safety monitoring . Record review of Resident #6's skin/wound note (dated 4/28/15) revealed left hip with 3.0 x 4.0 area open blister with reddened periwound (fresh) denies pain. Trauma caused by cigarette burn as evident by wheelchair padding, cigarette burn marks on cushion to left side of chair. Nurse informed of skin condition . There was no accompanying incident/accident report. Record review of Resident #6's medication administration note (dated 5/20/15) revealed left hip open blisters - clean with normal saline, pat dry - apply TAO, cover with transparent dressing - every day shift every Monday, Wednesday, Friday for trauma blisters (cigarette) . There was no accompanying incident/accident report. Record review of Resident #6's quarterly MDS assessment (ARD 6/9/15) revealed that he scored a 4 on the BIMS (indicating that he had severe cognitive impairment). Record review of Resident #6 's care plan (last reviewed 6/23/15) revealed that he required supervision with smoking, that his smoking ability should be reassessed quarterly and after reports of unsafe practices, and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Review of Resident #6 's clinical record revealed no safe smoking assessments. Record review of Resident #6's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that he needed a smoking apron and supervision while smoking and needed the facility to store his lighter and cigarettes. Observation of Resident #6 in the designated smoking area at 7:30 a.m. on 8/12/15 revealed that he was smoking, had a lighter in his pouch, and was not wearing a smoking apron. Psychologist HH was out with Resident #6, but then came back inside the facility - leaving Resident #6 outside unsupervised and smoking. During an interview with Psychologist HH at 7:32 a.m. on 8/12/15, he stated I didn't follow the rules. I let them out. Psychologist HH reported that he had been educated on the smoking policy that morning but had allowed Resident #6 to go out and smoke unsupervised. During an interview with Resident #6 in his room at 9:51 a.m. on 8/13/15, he reported that he was able to carry his cigarettes and lighter with him and to smoke unsupervised as he pleased until the surveyors came. 3. Record review of Resident #7's face sheet (dated 8/11/15) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the assessments section of Resident #7's clinical record revealed that he was last evaluated for safe smoking on 7/8/14. At this time, he was assessed to be safe, to not require supervision while smoking, and to be able to carry his own cigarettes and lighter. Record review of Resident #7's smoking care plan (last reviewed 8/1/14) revealed that he was an independent smoker, should be assessed for safe smoking quarterly and with a change in condition, and should be monitored for unsafe smoking practices. Record review of Resident #7's quarterly MDS assessment (ARD 7/3/15) revealed that he scored a 10 on the BIMS (indicating moderate cognitive impairment). Record review of Resident #7's care plan (last reviewed 7/8/15) revealed that smoking was not addressed. Record review of Resident #7's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that he needed a smoking apron and supervision while smoking and needed the facility to store his lighter and cigarettes. Observation on 8/11/15 at 7:25 a.m. revealed Resident #7 walking independently in the facility corridor. Resident #7 was noted to have a dark blue jacket with 2 round holes approximately the same circumference as a cigarette on the front. During an interview with Resident #7 at 5:40 p.m. on 8/11/15, he reported that he never had to wear a smoking apron, had been able to smoke when he pleased, and was able to carry his cigarettes and lighter on him before the surveyors showed up. When asked about the burn holes on his clothes, Resident #7 reported that cigarette ashes had fallen on him. Observation of Resident #7 smoking in the designated area at 7:30 a.m. on 8/12/15 revealed that he was not wearing a smoking apron. Psychologist HH was out with Resident #7, but then came back inside the facility - leaving Resident #7 outside unsupervised and smoking. During an interview with Psychologist HH at 7:32 a.m. on 8/12/15, he stated I didn't follow the rules. I let them out. Psychologist HH reported that he had been educated on the smoking policy that morning but had allowed Resident #7 to go out and smoke unsupervised. 4. Record review of Resident #24 ' s electronic face sheet (not dated) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #24 ' s health status note (dated 4/27/15) revealed that he was caught smoking in his room. Resident is in (room) which is close to the door outside which there was an oxygen tank, that belonged to another resident. (Resident) stated that his roommate (Resident #1) gave him the lighter to light his cigarette . Incident/accident reports were reviewed, and there were no incident/accident reports pertaining to Resident #24 smoking in his room. Record review of Resident #24's annual MDS assessment (ARD 6/11/15) revealed that he scored a 4 on the BIMS (indicating that he had severe cognitive impairment). Record review of Resident #24's care plan (reviewed 7/23/15) revealed that he required supervision with smoking, that his smoking ability should be reassessed quarterly and after reports of unsafe practices, and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Review of Resident #24 's clinical record revealed no safe smoking assessments. Record review of Resident #24's safe smoking assessment (after surveyor intervention - dated 8/15/15) revealed that he needed a smoking apron and supervision while smoking. Observation of Resident #24 at 11:41 a.m. on 8/18/15 revealed that he was smoking without an apron on. 5. Record review of Resident #5's face sheet (dated 8/11/15) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5 's clinical record revealed that her last safe smoking assessment was done on 2/9/15 and was still in progress . During an interview with LVN N on 8/11/15 at 3:00 p.m., she reported that Resident #5 had not had a smoking assessment completed since her admission on 2/9/15. Record review of Resident #5's significant change MDS assessment (ARD 6/24/15) revealed that she scored a 6 on the BIMS (indicating that she had moderate cognitive impairment). Record review of Resident #5's care plan (reviewed 6/29/15) revealed that she required supervision with smoking, that her smoking ability should be reassessed quarterly and after reports of unsafe practices, and that her cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Record review of Resident #5's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that she could light her own cigarette, did not need to be supervised when smoking, and did not need the facility to store her cigarettes or lighter. Observation on 8/10/15 at 6:00 p.m. revealed Resident #5 self-propelling her wheelchair outside to the covered patio and smoking a cigarette. No staff was supervising the smoking and/or outside on the covered patio. During an interview with Resident #5 on 8/10/15 at 6:05 p.m., she reported that she was allowed to keep her cigarettes and lighter in her room. Observation on 8/11/15 at 6:08 a.m. revealed Resident #5 in her bed sleeping. Two packages of cigarettes and one lighter were observed on her over bed table. Observation on 8/11/15 at 10:40 a.m. revealed Resident #5 self-propelling her wheelchair, utilizing the keypad, going outside to the covered patio, and smoking. No staff were supervising the patio. 6. Record review of Resident #11's face sheet (dated 8/13/15) revealed that she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #11's quarterly MDS assessment (ARD 6/5/15) revealed that she scored a 7 on the BIMS (indicating moderate cognitive impairment). Record review of Resident #11's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that she could light her own cigarette, did not need to be supervised when smoking, and did not need the facility to store her cigarettes or lighter. Observation of the designated smoking area on 8/11/15 at 6:13 a.m. revealed 3 residents (including Resident #11) smoking without supervision. Resident #11 was observed walking with the assistance of a rolling walker. She used the door keypad and punched in the security code to gain access to the inside of the facility. Observation on 8/11/15 at 8:02 a.m. revealed Resident #11 using her rolling walker to ambulate past the nurses ' station, utilizing the keypad, and letting herself outside to the designated smoking area. No staff were observed supervising the resident. Resident #11 then lit her cigarette. Resident #11 handed this surveyor her lighter and asked if this surveyor would light another resident ' s cigarette because he was blind and her legs hurt too bad to get up and assist him. This surveyor took the lighter from Resident #11 as LVN N walked outside to the covered patio and handed this surveyor a piece of paper. This surveyor handed LVN N the lighter. LVN N said, The smoking policy has been implemented and walked inside with the lighter. Observation of Resident #52 at 9:01 a.m. on 8/12/15 revealed that she exited the facility with half of a cigarette (unlit) in her hand. When asked where she got the cigarette, Resident #52 reported that she got it from her friend and pointed to Resident #11. Resident #11 stated I had it. I saved it from yesterday. One of the ladies - a worker - told me to put it in my purse . Resident #11 reported that she had last smoked at the 7:00 p.m. break on 8/11/15. 7. Record review of Resident #1's face sheet (dated 8/11/15) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's annual MDS assessment (ARD 6/30/15) revealed that he scored a 9 on the BIMS (indicating that he had moderate cognitive impairment) and was a smoker. Record review of Resident #1's care plan (reviewed 7/23/15) revealed that he required supervision with smoking, that his smoking ability should be reassessed quarterly and after reports of unsafe practices, and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Review of Resident #1's clinical record revealed no safe smoking assessment. Observation of Resident #1 at 11:41 a.m. on 8/18/15 revealed that he was smoking in the designated smoking area with staff supervision. Record review of Resident #27's electronic face sheet (not dated) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #27's admission MDS assessment (ARD 6/29/15) revealed that she scored a 3 on the BIMS (indicating that she had severe cognitive impairment). Record review of Resident #27's progress notes revealed that she was caught smoking in her room on 8/17/15. Record review of Resident #27's care plan (revised 8/20/15) revealed that she required supervision with smoking, that her smoking ability should be reassessed quarterly and after reports of unsafe practices, and that her cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Review of Resident #27 's clinical record revealed no safe smoking assessment. 8. Observation of the designated smoking area on 8/11/15 at 6:55 a.m. revealed four unidentified male residents smoking. No staff were supervising them. Observation of the designated smoking area on 8/11/15 at 7:01 a.m. revealed one unidentified male resident smoking. No staff were supervising him. Observation of the designated smoking area on 8/11/15 at 8:36 a.m. revealed 8 unidentified residents smoking. No staff were supervising them. During an interview with Resident #50 at 5:13 p.m. on 8/11/15, she reported that she had been at the facility for 2 weeks and had been able to smoke unsupervised until today. During an interview with Resident #51 at 5:15 p.m. on 8/11/15, she reported that she had been at the facility for 3 months and had been able to smoke unsupervised until today. Resident #51 had 2 lit cigarettes in her hand at this time. The cigarette in her left hand was almost finished but still smoking. Resident #51 was holding the cigarette between her pointer finger and her thumb, and her left hand was shaking. The ashes were observed to fall onto her clothes but did not burn them. Observation of the designated smoking area at 5:05 p.m. on 8/12/15 revealed that Resident #53 was smoking without an apron on. The administrator was observed to light Resident #22 ' s cigarette (that Resident #22 was holding) before he put an apron on Resident #22. Resident #45 was observed pulling an unlit cigarette out of his shirt pocket. He asked Resident #51 for a light, and Resident #51 started searching in her purse. Resident #51 then noticed the surveyor and told Resident #45 that he needed to get his cigarette lit by the staff. Resident #54 was observed with 2 lit cigarettes in her hand at the same time. During an interview with Resident #45 at 5:05 p.m. on 8/12/15, he reported that he kept the cigarette in his pocket from an earlier smoke break. Observation of the designated smoking area at 7:00 p.m. on 8/12/15 revealed that Resident #55 lit Resident #24 ' s cigarette with her lit cigarette. Resident #24 had a smoking apron on, and Resident #55 was assessed by the facility to be a safe smoker. Resident #45 lit his second cigarette with his first lit cigarette. Observation of Resident #51 in her room at 10:07 a.m. on 8/13/15 revealed that she was covered with a blanket with a cigarette burn hole. During an interview with Resident #51 at this time, she reported that she didn ' t smoke in her room. Observation of Resident #42 at 9:05 a.m. on 8/14/15 revealed that he had burn holes on his pants. During an interview with Resident #42 at 9:06 a.m. on 8/14/15, he reported that he had the burned pants from cigarette ashes. Resident #42 also reported that, when he smoked a cigarette and the cigarette would be near his pants and the wind would blow, the ashes dropped on his pants. 9. Observations of the designated smoking area at 5:03 p.m. on 8/11/15 revealed 6 cigarette butts in a plastic planter bucket that also contained dry leaves and strips of paper. There were cigarette butts scattered on the dry, grassy area to the left of the exit door and on the rocky, dry-leaved area to the right of the exit door. Observation of 3 unidentified staff smoking at 5:18 p.m. on 8/11/15 revealed that they were putting their cigarette ashes on the ground and not using ash trays. Observation of the designated smoking area at 3:00 p.m. on 8/12/15 revealed scattered cigarette butts on the grass and in planters. Observation of the designated smoking area at 12:18 p.m. on 8/17/15 revealed cigarette butts on the grass and in a trash can with trash (styrofoam cups and cigarette packs). During an interview with the Maintenance Supervisor at 12:19 p.m. on 8/17/15, he confirmed the above observations. Observation outside of the main entrance to the facility (not the designated smoking area) at 1:55 p.m. on 8/18/15 revealed cigarette butts scattered on the concrete and the Corporate CMI Coordinator smoking. During an interview with Resident #14 at 10:12 a.m. on 8/13/15, she reported that the designated smoking area was a pig sty and stated Residents throw trash and cigarette butts on the ground. Staff, when they are out there, tell them not to but staff aren ' t always out there . Resident #14 reported that, in the winter time, she had accidentally burned some of her clothes while smoking unsupervised outside because she had so many layers on. 10. Observation of the designated smoking area at 5:03 p.m. on 8/11/15 revealed a metal ash tray containing an empty cigarette box and plastic wrapping along with cigarette butts. At 5:06 p.m. on 8/11/15, the administrator was observed putting trash in the box ash tray and not removing the trash that was already there. Observation of Resident #5 at 5:16 p.m. on 8/11/15 revealed that she was using a metal ash tray with toilet paper in it to dispose of her cigarette ashes. Observation of the designated smoking area at 5:18 p.m. on 8/11/15 revealed a chimney tower ash tray with cigarette butts on the ground around it. Observation of Resident #54 at 5:22 p.m. on 8/11/15 revealed that she put her cigarette out in a red metal trash can containing plastic. The trash can was left open, and smoke was coming out of it. The maintenance man was then observed putting water in the red metal trash can, and the administrator told the residents, Please use the ash trays for cigarettes and the trash cans for trash . Observation of the designated smoking area at 5:05 p.m. on 8/12/15 revealed 5 cigarette butts in a non self-closing ash tray. Observation of the designated smoking area at 12:20 p.m. on 8/17/15 revealed cigarette butts in a non self-closing trash can. In an interview with LVN A on 8/11/15 at 7:55 a.m., she reported that residents were allowed to keep their personal cigarettes in their rooms. LVN A said residents were supposed to keep their lighters at the desk. She said a CNA would usually light the residents ' cigarettes for them. LVN A said staff used their own judgement as to whether a resident was safe to smoke independently. She said the facility did not have a list of residents who were safe to smoke independently. In an interview with the DON on 8/11/15 at 8:15 a.m., he reported that, as far as smoking went, some residents come and go back in . The DON said that staff were always collecting lighters from residents and that he had received two lighters that morning. He said that residents were supposed to have a staff member supervise them while smoking but confirmed that staff were not monitoring residents ' smoking. The DON said residents knew the code to get outside. He said staff and residents were to follow the smoking schedule. He reported that he did not mind residents having their own cigarettes but that they were not supposed to keep their lighters. The DON said that the former ADON was responsible for completing resident smoking assessments, but that he knew he was ultimately responsible for making sure smoking assessments were completed. The DON said staff were not to give the keypad code to residents. The DON said Resident #6 ' s fingers looked charred off and on from smoking. In an interview with the AD on 8/11/15 at 8:50 a.m., she reported that the residents who smoked just want to smoke all day. She said residents who smoked were not supervised, adding that the monitoring had gone by the wayside. In an interview with the ADON on 8/11/15 at 1:06 p.m., she reported that she had not been trained on resident safety with smoking. She reported that she knew residents were going in and out of the building and smoking but that she didn ' t know whether or not residents were going out to smoke by themselves. She reported that she had never done a safe smoking assessment and that there were never clear assignments as to who does what . During an interview with the administrator at 2:11 p.m. on 8/11/15, he reported that smoke breaks were now being monitored by staff. He reported that the former ADON was in charge of the safe smoking assessments and stated Smoking fell through the cracks . He reported that no issues pertinent to smoking were brought to the attention of QA because the new ADON picked smoking up when she started . When asked who was monitoring to make sure that the DON and ADON were doing their jobs, the administrator stated I was . When asked how he found out what was really going on in the facility, the administrator stated Uh huh, uh huh . When asked what he would expect staff to do if they saw residents with the code to the exit door, the administrator stated The paraphernalia should be in a locked box. Staff should be getting residents ' cigarettes and lighters and putting them in this box . The administrator stated We just got laxed on the smoking. We saw it happening out of the corner of our eyes, but nothing bad is happening yet. It ' s homelike. People smoke at home . The administrator reported that the DON was aware that residents had lighters. He reported that the staff were being in-serviced on smoking policy enforcement and changes. He reported that he depended on the DON to complete assignments that the former ADON did not complete. Record review of the facility's Smoking - Permitted with Limitations policy (reviewed 10/18/14) revealed 2. Smoking is prohibited in all common areas. 3. Smoking is permitted in designated areas. Residents who smoke must be able to handle their smoking apparatus safely. 4. Smoking in bed is not permitted at any time. 5. Residents must be supervised by staff or

Based on observation, interview, and record review, the facility failed to implement policies and procedures that prohibit neglect of residents for 17 of 23 residents (Resident #s 8, 6, 7, 24, 5, 11, 1, 27, 50, 51, 52, 53, 22, 45, 54, 55, and 42) whose care was reviewed for safe smoking, for 2 of 20 residents (Resident #s 12 and 22) whose care was reviewed for safe eating/drinking, and for one of 6 incidents (Incident #1 involving Resident #10) reviewed for implementation or procedures in that: A. 1. Resident #8 had [MEDICAL CONDITION] his fingers. There was no evidence that [MEDICAL CONDITION] investigated. Resident #8 had not been assessed for safe smoking in over a year and was assessed to be potentially unsafe at that time. His care plan called for supervised smoking, protective equipment while smoking, smoking safety reassessments quarterly and after reports of unsafe practices, and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. He was not supervised while smoking, was not wearing a smoking apron or using a cigarette holder, and had his cigarettes and his lighter on him. 2. Resident #6 had [MEDICAL CONDITION] his left hip and upper thigh. There was no evidence that 2 of [MEDICAL CONDITION] investigated. Resident #6 was not assessed for safe smoking. His care plan called for supervised smoking, smoking safety reassessments quarterly and after reports of unsafe practices, and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. He was not supervised while smoking, was not wearing a smoking apron, and had his cigarettes and his lighter on him. 3. Resident #7 had cigarette burn holes in his clothing and was smoking unsupervised and without a smoking apron on. He had not been assessed for safe smoking in over a year and was assessed to be safe and to carry his own cigarettes and lighter at this time. Resident #7's care plan did not address smoking. 4. Resident #24 was caught smoking in his room, outside which there was an oxygen tank, in April. Resident #24 was not assessed for safe smoking. He was observed smoking without a smoking apron on after being assessed to need one. 5. Resident #5 had not been assessed for safe smoking since 2/9/15, and this safe smoking assessment was incomplete. Resident #5 knew the access code to the designated smoking area, had her cigarettes and lighter on her, and was smoking unsupervised (against the facility's smoking policy). 6. Resident #11 knew the access code to the designated smoking area, had her cigarettes and lighter on her, and was smoking unsupervised (against the facility's smoking policy). 7. Resident #s 1 and 27 smoked and were not assessed for safe smoking according to the facility's smoking policy. 8. The facility's smoking policy was not being enforced for unidentified residents and residents were smoking unsupervised in the designated smoking area. They had their cigarettes and lighters on them and knew the access code into/out of the building. 9. Cigarette butts were found in grassy areas and outside of the designated smoking area. 10. The designated area for resident smoking included ash trays not approved by the National Fire Protection Association and trash cans being used for trash and cigarette butts. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on 8/11/15. While the IJ was removed on 8/12/15, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was not an immediate jeopardy due to the facility not yet completing in-service training for all staff on enforcement of the smoking policy and not having all residents who smoked sign a safe smoking agreement. B. 1. Resident #12 had [MEDICAL CONDITION] her right upper thigh and her abdomen. There was no evidence that [MEDICAL CONDITION] investigated. Resident #12 was not assessed for her ability to drink hot liquids safely. Hot coffee was left in the dining room for residents to serve themselves and was unsupervised. 2. Resident #22 spilled hot coffee on his left thigh area. There was no evidence that this incident was investigated. Resident #22 was not assessed for his ability to drink hot liquids safely. Hot coffee was left in the dining room for residents to serve themselves and was unsupervised. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on 8/12/15. While the IJ was removed on 8/19/15, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was not an immediate jeopardy due to the facility not yet evaluating the incident/accident reports, investigating them thoroughly, and putting corrective measures in place to prevent reoccurrence. C. Resident #10's incident investigation (arm fracture) was not reported to the state for 2 days after the incident occurred and staff were not interviewed by the facility. These facility failures could result in fire hazard with injury and could affect 23 residents at the facility who smoked; could result [MEDICAL CONDITION] could affect 54 residents who liked to drink hot liquids; and could contribute to continued abuse and neglect for 14 residents with incidents in August of 2015. The findings were: Record review of the facility's Prevention and Reporting of Suspected Resident Abuse and Neglect policy and procedure (not dated) revealed Rosewood Rehab has implemented the following processes in an effort to provide residents and staff a comfortable and safe environment. The administrator and DON are responsible for implementation and ongoing monitoring of abuse policies and procedures. Implementation and ongoing monitoring consist of the following policies: screening, training, prevention, identification, protection, investigation, and reporting . Neglect is defined as 'the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness'. Neglect is reportable if the injury, harm, or death of a resident was due to failure to provide services, treatment, or care to a resident. Record review of the facility ' s safety policy (not dated) revealed Purpose: Provide a safe environment for staff, residents, and visitors to work and visit . Procedure: 1. It is the intention of (facility name) to provide a safe environment for all staff to work, residents to live in, and guests to visit. 2. Safety is the responsibility of everyone and any safety concern should be reported to management . Record review of the facility's Smoking - Permitted with Limitations policy (reviewed 10/18/14) revealed 2. Smoking is prohibited in all common areas. 3. Smoking is permitted in designated areas. Residents who smoke must be able to handle their smoking apparatus safely. 4. Smoking in bed is not permitted at any time. 5. Residents must be supervised by staff or family members. 6. All cigarettes, lighters, and/or matches shall be kept at the nurse ' s station at all times . 8. A resident smoking assessment will be completed on all new residents. The assessment will determine if a resident requires a smoking apron for added protection. If it is determined that a resident is at risk for burns, a smoking apron will be placed on the resident prior to smoking . Record review of the facility ' s Smoking - Prohibited policy (no review date) revealed 1. Smoking is prohibited in all areas of the building, including resident rooms, because of health and safety hazards. 2. Visitors and guests may not smoke in the building. 3. Staff may smoke at the back courtyard which is the only designated smoking area at the facility. Cigarette butts are to be placed in the metal self-closing ashtrays provided . Record review of the facility ' s Safe Smoking Policy (not dated and presented at the same time as the plan of removal) revealed Policy: 1. The interdisciplinary team (IDT) members will determine if a resident is a safe or unsafe smoker before the resident exercises the privilege to smoke . 3. All cigarettes, lighters, matches, and smoking paraphernalia shall be kept at the nursing station. 4. Residents must be supervised by family, volunteers, in designated smoking areas. The facility will provide supervision when it does not interfere with care . Safe Smoking Procedure: 1. The IDT will be in-serviced on the safe smoking policy and safe smoking evaluation section of the nursing admission assessment. 2. The IDT or member of will review the smoking policy with the resident and/or responsible party on admission and as part of the care-planning process. 3. A resident who smokes is evaluated using the nursing admission assessment upon admission or at a significant change of condition. Assess the resident ' s cognitive status to determine if the resident is capable of safe smoking. Interview the resident to determine their ability to verbalize and understand the smoking rules. Observe the resident ' s ability to smoke in a safe manner. Determine the level of supervision required. 4. The nursing staff will re-evaluate residents that are involved in smoking accidents or incidents that occur while smoking to determine a greater degree of supervision. This may include the use of a smoking apron while smoking. 5. The first infraction of the smoking policy results in a warning. a. This may be verbal. b. This warning is given to the resident and his/her family member or responsible party. c. A safe smoking evaluation of the resident is performed. 6. The second infraction of the smoking policy results in a notice of discharge . A. 1. Record review of Resident #8's facesheet (dated 8/11/15) revealed that he was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the assessments section of Resident #8's clinical record revealed that he was last evaluated for safe smoking on 7/8/14. At this time, he was assessed to be potentially unsafe and to need a safe smoking care plan. Smoking in unsupervised areas, being careless with smoking materials, and providing smoking materials to others were noted as being severe problems. Record review of Resident #8 ' s health status note (dated 6/21/15) revealed that he was seen outside by staff picking up used cigarette butts and then trying to smoke them. Documentation revealed that he was educated on the risks of burning himself but that no other interventions were made. Record review of Resident #8 ' s skin/wound note (dated 7/13/15) revealed that he continue(d) to smoke (unsafe smoker) tip of fingers charred over at times. All nursing staff/ADON/DON/ADM aware of situation with this resident and smoking issues . There was no accompanying incident/accident report. Record review of Resident #8's quarterly MDS assessment (ARD 7/14/15) revealed that he scored an 11 on the BIMS (indicating that he was cognitively intact). Record review of Resident #8 ' s care plan (reviewed 7/15/15) revealed that he was at risk for skin breakdown related to being an unsafe and noncompliant smoker. Interventions included wearing protective clothing and being supervised when smoking. His care plan called for his smoking ability to be reassessed quarterly and after reports of unsafe practices and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Record review of Resident #8's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that he needed a smoking apron, a cigarette holder, and supervision while smoking and needed the facility to store his lighter and cigarettes. Observation on 8/11/15 at 7:28 a.m. revealed Resident #8 sitting in his wheelchair outside on the covered patio smoking. Resident #8 was noted to have 8 round holes in the crotch of his navy sweatpants and 3 round holes on the pant leg. There were no staff supervising Resident #8, and he was not wearing a smoking apron. During an interview with Resident #8 on 8/11/15 at 7:30 a.m., he reported that he went in and out alone to smoke. Resident #8 said staff did not go outside when residents were outside smoking on the covered patio. During an interview with Resident #8 in his room at 11:00 a.m. on 8/13/15, he reported that he had burned himself while smoking at the facility. Resident #8 was observed to have burn holes all over his pants. 2. Record review of Resident #6's facesheet (dated 8/11/15) revealed an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6 ' s skin/wound note (dated 12/15/14) revealed left upper thigh, 0.9 x 0.5 x 0 [MEDICATION NAME] with yellowish like tissue covering 100% of the wound bed, edges slightly epiboly. Slight redness notes to periwound, round in shape, dry. No induration or pain or warmth noted. (Resembles cigarette burn), resident clothing noted to have cigarette burn holes in them, both t-shirt and warm-ups have holes in them from previous smoking session. Area cleansed and dressed with transparent film. Nurse in charge made aware of wound and will follow up . Record review of Resident #6 ' s 12/15/14 incident/accident report revealed Shower aid reported that when showering resident he had a 0.9 centimeter x 0.5 centimeter area to his left upper thigh. Periwound is reddened and surface shows that skin is trying to heal. There is no noted bleeding or draining to area. He denies any pain or discomfort. Area looks like he may have burned himself while smoking. His t-shirt also had burned circles as well. Resident is not able to state what happened but did state he did remember dropping cigarette ash on his pants a long while back . Notes were Resident is now being accompanied by CNA staff member when resident requests to smoke outside. I did tell resident that he is advised to wear a smoking apron for his safety, but he got really upset and stated he is not a ' damn baby ' or a ' child ' . He refuses to wear smoking apron but allowed staff member to accompany him when smoking outside for safety monitoring . Record review of Resident #6 ' s skin/wound note (dated 4/28/15) revealed left hip with 3.0 x 4.0 area open blister with reddened periwound (fresh) denies pain. Trauma caused by cigarette burn as evident by wheelchair padding, cigarette burn marks on cushion to left side of chair. Nurse informed of skin condition . There was no accompanying incident/accident report. Record review of Resident #6's medication administration note (dated 5/20/15) revealed left hip open blisters - clean with normal saline, pat dry - apply TAO, cover with transparent dressing - every day shift every Monday, Wednesday, Friday for trauma blisters (cigarette) . There was no accompanying incident/accident report. Record review of Resident #6's quarterly MDS assessment (ARD 6/9/15) revealed that he scored a 4 on the BIMS (indicating that he had severe cognitive impairment). Record review of Resident #6 ' s care plan (last reviewed 6/23/15) revealed that he required supervision with smoking, that his smoking ability should be reassessed quarterly and after reports of unsafe practices, and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Review of Resident #6 ' s clinical record revealed no safe smoking assessments. Record review of Resident #6's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that he needed a smoking apron and supervision while smoking and needed the facility to store his lighter and cigarettes. Observation of Resident #6 in the designated smoking area at 7:30 a.m. on 8/12/15 revealed that he was smoking, had a lighter in his pouch, and was not wearing a smoking apron. Psychologist HH was out with Resident #6, but then came back inside the facility - leaving Resident #6 outside unsupervised and smoking. During an interview with Psychologist HH at 7:32 a.m. on 8/12/15, he stated I didn't follow the rules. I let them out. Psychologist HH reported that he had been educated on the smoking policy that morning but had allowed Resident #6 to go out and smoke unsupervised. During an interview with Resident #6 in his room at 9:51 a.m. on 8/13/15, he reported that he was able to carry his cigarettes and lighter with him and to smoke unsupervised as he pleased until the surveyors came. 3. Record review of Resident #7's facesheet (dated 8/11/15) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the assessments section of Resident #7's clinical record revealed that he was last evaluated for safe smoking on 7/8/14. At this time, he was assessed to be safe, to not require supervision while smoking, and ro be able to carry his own cigarettes and lighter. Record review of Resident #7's smoking care plan (last reviewed 8/1/14) revealed that he was an independent smoker, should be assessed for safe smoking quarterly and with a change in condition, and should be monitored for unsafe smoking practices. Record review of Resident #7's quarterly MDS assessment (ARD 7/3/15) revealed that he scored a 10 on the BIMS (indicating moderate cognitive impairment). Record review of Resident #7's care plan (last reviewed 7/8/15) revealed that smoking was not addressed. Record review of Resident #7's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that he needed a smoking apron and supervision while smoking and needed the facility to store his lighter and cigarettes. Observation on 8/11/15 at 7:25 a.m. revealed Resident #7 walking independently in the facility corridor. Resident #7 was noted to have a dark blue jacket with 2 round holes approximately the same circumference as a cigarette on the front. During an interview with Resident #7 at 5:40 p.m. on 8/11/15, he reported that he never had to wear a smoking apron, had been able to smoke when he pleased, and was able to carry his cigarettes and lighter on him before the surveyors showed up. When asked about the burn holes on his clothes, Resident #7 reported that cigarette ashes had fallen on him. Observation of Resident #7 smoking in the designated area at 7:30 a.m. on 8/12/15 revealed that he was not wearing a smoking apron. Psychologist HH was out with Resident #7, but then came back inside the facility - leaving Resident #7 outside unsupervised and smoking. During an interview with Psychologist HH at 7:32 a.m. on 8/12/15, he stated I didn't follow the rules. I let them out. Psychologist HH reported that he had been educated on the smoking policy that morning but had allowed Resident #7 to go out and smoke unsupervised. 4. Record review of Resident #24 ' s electronic facesheet (not dated) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #24 ' s health status note (dated 4/27/15) revealed that he was caught smoking in his room. Resident is in (room) which is close to the door outside which there was an oxygen tank, that belonged to another resident. (Resident) stated that his roommate (Resident #1) gave him the lighter to light his cigarette . Incident/accident reports were reviewed, and there were no incident/accident reports pertaining to Resident #24 smoking in his room. Record review of Resident #24's annual MDS assessment (ARD 6/11/15) revealed that he scored a 4 on the BIMS (indicating that he had severe cognitive impairment). Record review of Resident #24's care plan (reviewed 7/23/15) revealed that he required supervision with smoking, that his smoking ability should be reassessed quarterly and after reports of unsafe practices, and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Review of Resident #24 ' s clinical record revealed no safe smoking assessments. Record review of Resident #24's safe smoking assessment (after surveyor intervention - dated 8/15/15) revealed that he needed a smoking apron and supervision while smoking. Observation of Resident #24 at 11:41 a.m. on 8/18/15 revealed that he was smoking without an apron on. 5. Record review of Resident #5's facesheet (dated 8/11/15) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5 ' s clinical record revealed that her last safe smoking assessment was done on 2/9/15 and was still in progress . During an interview with LVN N on 8/11/15 at 3:00 p.m., she reported that Resident #5 had not had a smoking assessment completed since her admission on 2/9/15. Record review of Resident #5's significant change MDS assessment (ARD 6/24/15) revealed that she scored a 6 on the BIMS (indicating that she had moderate cognitive impairment). Record review of Resident #5's care plan (reviewed 6/29/15) revealed that she required supervision with smoking, that her smoking ability should be reassessed quarterly and after reports of unsafe practices, and that her cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Record review of Resident #5's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that she could light her own cigarette, did not need to be supervised when smoking, and did not need the facility to store her cigarettes or lighter. Observation on 8/10/15 at 6:00 p.m. revealed Resident #5 self-propelling her wheelchair outside to the covered patio and smoking a cigarette. No staff was supervising the smoking and/or outside on the covered patio. During an interview with Resident #5 on 8/10/15 at 6:05 p.m., she reported that she was allowed to keep her cigarettes and lighter in her room. Observation on 8/11/15 at 6:08 a.m. revealed Resident #5 in her bed sleeping. Two packages of cigarettes and one lighter were observed on her over bed table. Observation on 8/11/15 at 10:40 a.m. revealed Resident #5 self-propelling her wheelchair, utilizing the keypad, going outside to the covered patio, and smoking. No staff were supervising the patio. 6. Record review of Resident #11's facesheet (dated 8/13/15) revealed that she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #11's quarterly MDS assessment (ARD 6/5/15) revealed that she scored a 7 on the BIMS (indicating moderate cognitive impairment). Record review of Resident #11's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that she could light her own cigarette, did not need to be supervised when smoking, and did not need the facility to store her cigarettes or lighter. Observation of the designated smoking area on 8/11/15 at 6:13 a.m. revealed 3 residents (including Resident #11) smoking without supervision. Resident #11 was observed walking with the assistance of a rolling walker. She used the door keypad and punched in the security code to gain access to the inside of the facility. Observation on 8/11/15 at 8:02 a.m. revealed Resident #11 using her rolling walker to ambulate past the nurses ' station, utilizing the keypad, and letting herself outside to the designated smoking area. No staff were observed supervising the resident. Resident #11 then lit her cigarette. Resident #11 handed this surveyor her lighter and asked if this surveyor would light another resident ' s cigarette because he was blind and her legs hurt too bad to get up and assist him. This surveyor took the lighter from Resident #11 as LVN N walked outside to the covered patio and handed this surveyor a piece of paper. This surveyor handed LVN N the lighter. LVN N said, The smoking policy has been implemented and walked inside with the lighter. Observation of Resident #52 at 9:01 a.m. on 8/12/15 revealed that she exited the facility with half of a cigarette (unlit) in her hand. When asked where she got the cigarette, Resident #52 reported that she got it from her friend and pointed to Resident #11. Resident #11 stated I had it. I saved it from yesterday. One of the ladies - a worker - told me to put it in my purse . Resident #11 reported that she had last smoked at the 7:00 p.m. break on 8/11/15. 7. Record review of Resident #1's facesheet (dated 8/11/15) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's annual MDS assessment (ARD 6/30/15) revealed that he scored a 9 on the BIMS (indicating that he had moderate cognitive impairment) and was a smoker. Record review of Resident #1's care plan (reviewed 7/23/15) revealed that he required supervision with smoking, that his smoking ability should be reassessed quarterly and after reports of unsafe practices, and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Review of Resident #1's clinical record revealed no safe smoking assessment. Observation of Resident #1 at 11:41 a.m. on 8/18/15 revealed that he was smoking in the designated smoking area with staff supervision. Record review of Resident #27's electronic facesheet (not dated) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #27's admission MDS assessment (ARD 6/29/15) revealed that she scored a 3 on the BIMS (indicating that she had severe cognitive impairment). Record review of Resident #27's progress notes revealed that she was caught smoking in her room on 8/17/15. Record review of Resident #27's care plan (revised 8/20/15) revealed that she required supervision with smoking, that her smoking ability should be reassessed quarterly and after reports of unsafe practices, and that her cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Review of Resident #27 ' s clinical record revealed no safe smoking assessment. 8. Observation of the designated smoking area on 8/11/15 at 6:55 a.m. revealed four unidentified male residents smoking. No staff were supervising them. Observation of the designated smoking area on 8/11/15 at 7:01 a.m. revealed one unidentified male resident smoking. No staff were supervising him. Observation of the designated smoking area on 8/11/15 at 8:36 a.m. revealed 8 unidentified residents smoking. No staff were supervising them. During an interview with Resident #50 at 5:13 p.m. on 8/11/15, she reported that she had been at the facility for 2 weeks and had been able to smoke unsupervised until today. During an interview with Resident #51 at 5:15 p.m. on 8/11/15, she reported that she had been at the facility for 3 months and had been able to smoke unsupervised until today. Resident #51 had 2 lit cigarettes in her hand at this time. The cigarette in her left hand was almost finished but still smoking. Resident #51 was holding the cigarette between her pointer finger and her thumb, and her left hand was shaking. The ashes were observed to fall onto her clothes but did not burn them. Observation of the designated smoking area at 5:05 p.m. on 8/12/15 revealed that Resident #53 was smoking without an apron on. The administrator was observed to light Resident #22 ' s cigarette (that Resident #22 was holding) before he put an apron on Resident #22. Resident #45 was observed pulling an unlit cigarette out of his shirt pocket. He asked Resident #51 for a light, and Resident #51 started searching in her purse. Resident #51 then noticed the surveyor and told Resident #45 that he needed to get his cigarette lit by the staff. Resident #54 was observed with 2 lit cigarettes in her hand at the same time. During an interview with Resident #45 at 5:05 p.m. on 8/12/15, he reported that he kept the cigarette in his pocket from an earlier smoke break. Observation of the designated smoking area at 7:00 p.m. on 8/12/15 revealed that Resident #55 lit Resident #24 ' s cigarette with her lit cigarette. Resident #24 had a smoking apron on, and Resident #55 was assessed by the facility to be a safe smoker. Resident #45 lit his second cigarette with his first lit cigarette. Observation of Resident #51 in her room at 10:07 a.m. on 8/13/15 revealed that she was covered with a blanket with a cigarette burn hole. During an interview with Resident #51 at this time, she reported that she didn ' t smoke in her room. Observation of Resident #42 at 9:05 a.m. on 8/14/15 revealed that he had burn holes on his pants. During an interview with Resident #42 at 9:06 a.m. on 8/14/15, he reported that he had the burned pants from cigarette ashes. Resident #42 also reported that, when he smoked a cigarette and the cigarette would be near his pants and the wind would blow, the ashes dropped on his pants. 9. Observations of the designated smoking area at 5:03 p.m. on 8/11/15 revealed 6 cigarette butts in a plastic planter bucket that also contained dry leaves and strips of paper. There were cigarette butts scattered on the dry, grassy area to the left of the exit door and on the rocky, dry-leaved area to the right of the exit door. Observation of 3 unidentified staff smoking at 5:18 p.m. on 8/11/15 revealed that they were putting their cigarette ashes on the ground and not using ash trays. Observation of the designated smoking area at 3:00 p.m. on 8/12/15 revealed scattered cigarette butts on the grass and in planters. Observation of the designated smoking area at 12:18 p.m. on 8/17/15 revealed cigarette butts on the grass and in a trash can with trash (styrofoam cups and cigarette packs). During an interview with the Maintenance Supervisor at 12:19 p.m. on 8/17/15, he confirmed the above observations. Observation outside of the main entrance to the facility (not the designated smoking area) at 1:55 p.m. on 8/18/15 revealed cigarette butts scattered on the concrete and the Corporate CMI Coordinator smoking. During an interview with Resident #14 at 10:12 a.m. on 8/13/15, she reported that the designated smoking area was a pig sty and stated Residents throw trash and cigarette butts on the ground. Staff, when they are out there, tell them not to but staff aren ' t always out there . Resident #14 reported that, in the winter time, she had accidentally burned some of her clothes while smoking unsupervised outside because she had so many layers on. 10. Observation of the designated smoking area at 5:03 p.m. on 8/11/15 revealed a metal ash tray containing an empty cigarette box and plastic wrapping along with cigarette butts. At 5:06 p.m. on 8/11/15, the administrator was observed putting trash in the box ash tray and not removing the trash that was already there. Observation of Resident #5 at 5:16 p.m. on 8/11/15 revealed that she was using a metal ash tray with toilet paper in it to dispose of her cigarette ashes. Observation of the designated smoking area at 5:18 p.m. on 8/11/15 revealed a chimney tower ash tray with cigarette butts on the ground around it. Observation of Resident #54 at 5:22 p.m. on 8/11/15 revealed that she put her cigarette out in a red metal trash can containing plastic. The trash can was left open, and smoke was coming out of it. The maintenance man was then ob

Based on observations, interviews, and record reviews, that facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 17 of 23 residents (Resident #s 8, 6, 7, 24, 5, 11, 1, 27, 50, 51, 52, 53, 22, 45, 54, 55, and 42) whose care was reviewed for safe smoking and for 2 of 20 residents (Resident #s 12 and 22) whose care was reviewed for safe eating/drinking in that: 1. The administrator did not implement and enforce established company smoking policies and procedures, train and supervise staff and residents to ensure that the facility's smoking policy was being followed and that adequate supervision was being provided, and review incident/accident reports so that corrective measures to prevent reoccurence could be put into place. 2. The DON failed to identify and resolve smoking/coffee temperature problems in a timely manner, implement and evaluate the overall operations (including the evaluation of safety standards, reporting of hazardous conditions , and clear assignments of tasks) of the nursing services department, train and supervise staff and residents to ensure that the facility's smoking policy was being followed and that adequate supervision was being provided, and review incident/accident reports so that corrective measures to prevent reoccurence could be put into place. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on 8/11/15. While the IJ was removed on 8/12/15, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was not an immediate jeopardy due to the facility not yet completing in-service training for all staff on enforcement of the smoking policy and not having all residents who smoked sign a safe smoking agreement. These failures also resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on 8/12/15. While the IJ was removed on 8/19/15, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was not an immediate jeopardy due to the facility not yet evaluating the incident/accident reports, investigating them thoroughly, and putting corrective measures in place to prevent reoccurrence. These failures could result in fire hazard with injury and could affect 23 residents at the facility who smoked and could result [MEDICAL CONDITION] could affect 54 residents who liked to drink hot liquids The findings were: During an interview with the Corporate CMI Coordinator at 10:15 a.m. on 8/13/15, he reported that there were incident/accident reports from as far back as 8/23/14 that had not been followed up on and investigated. During an interview with the owner and the Corporate CMI Coordinator at 10:23 a.m. on 8/17/15, they reported that there were no investigations completed for Resident #12 ' s coffee burn and the [MEDICAL CONDITION] Resident #s 6 and 8. The owner stated I wasn ' t aware of the coffee burn until y ' all (the survey team) came in. We knew the coffee was too hot 2-3 weeks ago and told the administrator to take care of it. We assumed it was done . During an interview with the owner at 8:50 a.m. on 8/19/15, he stated I am scared for the residents. I have failed to do my job as an owner. The owner reported that the facility had an increased number of smokers secondary to the administrator letting anybody and everybody in. During an interview with the Corporate CMI Coordinator at 10:44 a.m. on 8/19/15, he reported that staff were not knowledgable about PCC, resulting in orders not being pushed out, incident/accident reports not being completed, items being deactivated, assessments being incomplete and inaccurate, etc. The Corporate CMI Coordinator reported that he had last in-serviced staff on PCC when the owner bought the facility approximately one year ago. During an interview with the DON at 5:53 p.m. on 8/19/15, he reported that the facility had two new medication aides and that nurses roll over all the time. During continued interview with the DON at 5:53 p.m. on 8/19/15, he reported that he had worked at the facility since 6/16/14. When asked at what point he was made aware that there was an issue with hot beverages, the DON reported that Resident #12's first burn was his first knowledge that somebody got hurt from a coffee spill. When asked at what point he was made aware that there was an issue with smoking, the DON reported that the first burn that came up was with Resident #6, was found in the shower, and was assumed to be from a cigarette. With regards to the hot beverages, the DON was asked what instructions were provided to nursing afterwards. He reported that there was no facility protocol for hot liquids and that he didn't know there was a certain temperature that coffee was supposed to be at. He stated I assumed that, coming out of the kitchen, it was safe. At the morning meeting, about a month ago, the burn was discovered in the shower. (The administrator) and (the Corporate CMI Coordinator) spoke to dietary the day the burn was discovered. On my end, after (the administrator) and (the Corporate CMI Coordinator) went to the kitchen to talk to dietary, I didn't do anything to in-service staff. I assumed they adjusted the temperature. It was a freak accident. (The Corporate CMI Coordinator) and (the administrator) did not tell me anything after they went to the kitchen. The DON reported that he didn't know about Resident #12's second burn because the nurses weren't doing their jobs as far as communicating on the 24-hour reports. The DON reported that hot liquid assessments were not implemented after the Corporate CMI Coordinator and the administrator met to discuss Resident #12's coffee burn. The DON stated After this all started, I heard (Resident #22) spilled coffee - before this week - it wasn't brought up until the IJ. The DON reported that all assessments were supposed to be completed quarterly and as-needed thereafter and stated These haven't been getting done. Since I started here, it's been a loose thing with residents keeping their cigarettes and family bringing stuff in. It was addressed by (the administrator) a few months ago for (the SW) to mail out the smoking policy. The SW said she shouldn't be doing it, so the job was given to the ADON. The ADON is no longer here. She wasn't doing a lot. The DON reported that he was aware of the smoking problems for over a year but was not aware of any resulting injuries. He reported that he did nothing regarding the enforcement of smoking policies. The DON reported that he felt the incident pertaining to Resident #12's burn should have been called in to DADS but stated (The administrator) was leading that. I didn't follow up with him to verify if he was calling it in or not. When asked what he was going to do from now on, the DON stated Better communication. All I gotta say is I gotta follow up. He (the owner) has made me risk manager, and not it's in my hands. The DON reported that he needed to do more in-servicing for staff and more quality monitoring. He reported that the nurses and aides were not communicating and stated The monthly meetings are clearly not working. We're going to have to go back to meetings twice a month. The DON stated So much that I see is so wrong right now. Yes, I dropped the ball on checking up on people, but there was a lot on my plate. The DON reported that staff had not been in-serviced on smoking or on hot liquids prior to the IJs being called. When asked how the incidents should have been addressed, the DON reported that he was not aware of any issues until [MEDICAL CONDITION]. He reported that he should have done a more thorough job of investigating the burns. He reported that nurses did not have a checks and balances system to ensure that orders weren't missed: I wasn't making sure and going behind MAs/staff to make sure (what) they were doing. He reported that information necessary for CNAs to provide appropriate care was not posted and needed to be. During an interview with the Corporate CMI Coordinator at 3:39 p.m. on 8/20/15, he stated The reason for all of this is lack of communication - lack of follow-up from the administrator on down. The Corporate CMI Coordinator stated that he trusted the facility for the input of data in order for assessments to be correct: Administrator and nursing should have taken care of it. The Corporate CMI Coordinator revealed that he was not aware of any missing information and stated that the Administrator and the DON should have followed up. During an interview with the owner at 2:37 p.m. on 8/21/15, he reported that the administrator and the DON were being replaced and that he would be more hands on at the facility for a while. He reported that he would be getting training on PCC so that he could better monitor all of his facilities. When asked how he would ensure that incidents would be investigated and that corrective measures would be put into place, the owner stated We are replacing the administrator and the DON - our 1st and 2nd breakdowns. The charge nurses and the nursing staff are all being in-serviced. The procedure worked - the administrator and the DON failed to follow through with it. The owner reported that the incident with Resident #6'[MEDICAL CONDITION] not followed through with secondary to the DON's inexperience. I was mislead when we hired (the DON). (The administrator) told me that he would be a great DON. Little did I know that he was a new nurse, had been an MDS nurse, and had no DON experience. The owner reported that both IJs were results of system failures. He stated We didn't address issues and put interventions in place. Interview on 8/20/15 at 4:10 p.m. with the Administrator revealed that he was not aware before of a problem with hot beverages and did not think it was an issue at all. He stated that after the incident with the hot coffee burn on Resident #12, the coffee pot was moved inside. The Administrator stated that he did not report the incident due to a floor nurse (did not remember name) reported that the injury was not that bad. As for the smoking, there were no incidents of burns. The administator thought that only 1 resident had reported his fingers being brown and there was no complaint due to the facility obtained a cigarette holder. In reference to monitoring the residents that smoked, the administrator stated that staff smoked in the same area and would monitor, however, staff was not aware of aprons, but believed that the staff would supervise the residents due to no incidents. The administrator stated that family members did not take the smoking paraphernalia to the nurses station upon entering the facility. The administrator stated that there were no incidents, no concerns with smoking until the IJ. He did not feel that it was neglect upon the residents, at that time, due to unsafe smoking or hot beverages: no incidents for either one. A. In an interview with the DON on 8/11/15 at 8:15 a.m., he reported that, as far as smoking went, some residents come and go back in . The DON said that staff were always collecting lighters from residents and that he had received two lighters that morning. He said that residents were supposed to have a staff member supervise them while smoking but confirmed that staff were not monitoring residents ' smoking. The DON said residents knew the code to get outside. He reported that he did not mind residents having their own cigarettes but that they were not supposed to keep their lighters. The DON said that the former ADON was responsible for completing resident smoking assessments but that he knew he was ultimately responsible for making sure smoking assessments were completed. The DON said staff were not to give the keypad code to residents. During an interview with the administrator at 2:11 p.m. on 8/11/15, he reported that smoke breaks were now being monitored by staff. He reported that the former ADON was in charge of the safe smoking assessments and stated Smoking fell through the cracks . He reported that no issues pertinent to smoking were brought to the attention of QA because the new ADON picked smoking up when she started . When asked who was monitoring to make sure that the DON and ADON were doing their jobs, the administrator stated I was . When asked how he found out what was really going on in the facility, the administrator stated Uh huh, uh huh . When asked what he would expect staff to do if they saw residents with the code to the exit door, the administrator stated The paraphernalia should be in a locked box. Staff should be getting residents ' cigarettes and lighters and putting them in this box . The administrator stated We just got laxed on the smoking. We saw it happening out of the corner of our eyes, but nothing bad is happening yet. It ' s homelike. People smoke at home . The administrator reported that the DON was aware that residents had lighters. He reported that the staff were being in-serviced on smoking policy enforcement and changes. He reported that he depended on the DON to complete assignments that the former ADON did not complete. 1. Record review of Resident #8's facesheet (dated 8/11/15) revealed that he was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the assessments section of Resident #8's clinical record revealed that he was last evaluated for safe smoking on 7/8/14. At this time, he was assessed to be potentially unsafe and to need a safe smoking care plan. Smoking in unsupervised areas, being careless with smoking materials, and providing smoking materials to others were noted as being severe problems. Record review of Resident #8 ' s health status note (dated 6/21/15) revealed that he was seen outside by staff picking up used cigarette butts and then trying to smoke them. Documentation revealed that he was educated on the risks of burning himself but that no other interventions were made. Record review of Resident #8 ' s skin/wound note (dated 7/13/15) revealed that he continue(d) to smoke (unsafe smoker) tip of fingers charred over at times. All nursing staff/ADON/DON/ADM aware of situation with this resident and smoking issues . There was no accompanying incident/accident report. Record review of Resident #8's quarterly MDS assessment (ARD 7/14/15) revealed that he scored an 11 on the BIMS (indicating that he was cognitively intact). Record review of Resident #8 ' s care plan (reviewed 7/15/15) revealed that he was at risk for skin breakdown related to being an unsafe and noncompliant smoker. Interventions included wearing protective clothing and being supervised when smoking. His care plan called for his smoking ability to be reassessed quarterly and after reports of unsafe practices and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Record review of Resident #8's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that he needed a smoking apron, a cigarette holder, and supervision while smoking and needed the facility to store his lighter and cigarettes. Observation on 8/11/15 at 7:28 a.m. revealed Resident #8 sitting in his wheelchair outside on the covered patio smoking. Resident #8 was noted to have 8 round holes in the crotch of his navy sweatpants and 3 round holes on the pant leg. There were no staff supervising Resident #8, and he was not wearing a smoking apron. During an interview with Resident #8 on 8/11/15 at 7:30 a.m., he reported that he went in and out alone to smoke. Resident #8 said staff did not go outside when residents were outside smoking on the covered patio. During an interview with Resident #8 in his room at 11:00 a.m. on 8/13/15, he reported that he had burned himself while smoking at the facility. Resident #8 was observed to have burn holes all over his pants. 2. Record review of Resident #6's facesheet (dated 8/11/15) revealed an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6 ' s skin/wound note (dated 12/15/14) revealed left upper thigh, 0.9 x 0.5 x 0 [MEDICATION NAME] with yellowish like tissue covering 100% of the wound bed, edges slightly epiboly. Slight redness notes to periwound, round in shape, dry. No induration or pain or warmth noted. (Resembles cigarette burn), resident clothing noted to have cigarette burn holes in them, both t-shirt and warm-ups have holes in them from previous smoking session. Area cleansed and dressed with transparent film. Nurse in charge made aware of wound and will follow up . Record review of Resident #6 ' s 12/15/14 incident/accident report revealed Shower aid reported that when showering resident he had a 0.9 centimeter x 0.5 centimeter area to his left upper thigh. Periwound is reddened and surface shows that skin is trying to heal. There is no noted bleeding or draining to area. He denies any pain or discomfort. Area looks like he may have burned himself while smoking. His t-shirt also had burned circles as well. Resident is not able to state what happened but did state he did remember dropping cigarette ash on his pants a long while back . Notes were Resident is now being accompanied by CNA staff member when resident requests to smoke outside. I did tell resident that he is advised to wear a smoking apron for his safety, but he got really upset and stated he is not a ' damn baby ' or a ' child ' . He refuses to wear smoking apron but allowed staff member to accompany him when smoking outside for safety monitoring . Record review of Resident #6 ' s skin/wound note (dated 4/28/15) revealed left hip with 3.0 x 4.0 area open blister with reddened periwound (fresh) denies pain. Trauma caused by cigarette burn as evident by wheelchair padding, cigarette burn marks on cushion to left side of chair. Nurse informed of skin condition . There was no accompanying incident/accident report. Record review of Resident #6's medication administration note (dated 5/20/15) revealed left hip open blisters - clean with normal saline, pat dry - apply TAO, cover with transparent dressing - every day shift every Monday, Wednesday, Friday for trauma blisters (cigarette) . There was no accompanying incident/accident report. Record review of Resident #6's quarterly MDS assessment (ARD 6/9/15) revealed that he scored a 4 on the BIMS (indicating that he had severe cognitive impairment). Record review of Resident #6 ' s care plan (last reviewed 6/23/15) revealed that he required supervision with smoking, that his smoking ability should be reassessed quarterly and after reports of unsafe practices, and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Review of Resident #6 ' s clinical record revealed no safe smoking assessments. Record review of Resident #6's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that he needed a smoking apron and supervision while smoking and needed the facility to store his lighter and cigarettes. Observation of Resident #6 in the designated smoking area at 7:30 a.m. on 8/12/15 revealed that he was smoking, had a lighter in his pouch, and was not wearing a smoking apron. Psychologist HH was out with Resident #6, but then came back inside the facility - leaving Resident #6 outside unsupervised and smoking. During an interview with Psychologist HH at 7:32 a.m. on 8/12/15, he stated I didn't follow the rules. I let them out. Psychologist HH reported that he had been educated on the smoking policy that morning but had allowed Resident #6 to go out and smoke unsupervised. During an interview with Resident #6 in his room at 9:51 a.m. on 8/13/15, he reported that he was able to carry his cigarettes and lighter with him and to smoke unsupervised as he pleased until the surveyors came. 3. Record review of Resident #7's facesheet (dated 8/11/15) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the assessments section of Resident #7's clinical record revealed that he was last evaluated for safe smoking on 7/8/14. At this time, he was assessed to be safe, to not require supervision while smoking, and ro be able to carry his own cigarettes and lighter. Record review of Resident #7's smoking care plan (last reviewed 8/1/14) revealed that he was an independent smoker, should be assessed for safe smoking quarterly and with a change in condition, and should be monitored for unsafe smoking practices. Record review of Resident #7's quarterly MDS assessment (ARD 7/3/15) revealed that he scored a 10 on the BIMS (indicating moderate cognitive impairment). Record review of Resident #7's care plan (last reviewed 7/8/15) revealed that smoking was not addressed. Record review of Resident #7's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that he needed a smoking apron and supervision while smoking and needed the facility to store his lighter and cigarettes. Observation on 8/11/15 at 7:25 a.m. revealed Resident #7 walking independently in the facility corridor. Resident #7 was noted to have a dark blue jacket with 2 round holes approximately the same circumference as a cigarette on the front. During an interview with Resident #7 at 5:40 p.m. on 8/11/15, he reported that he never had to wear a smoking apron, had been able to smoke when he pleased, and was able to carry his cigarettes and lighter on him before the surveyors showed up. When asked about the burn holes on his clothes, Resident #7 reported that cigarette ashes had fallen on him. Observation of Resident #7 smoking in the designated area at 7:30 a.m. on 8/12/15 revealed that he was not wearing a smoking apron. Psychologist HH was out with Resident #7, but then came back inside the facility - leaving Resident #7 outside unsupervised and smoking. During an interview with Psychologist HH at 7:32 a.m. on 8/12/15, he stated I didn't follow the rules. I let them out. Psychologist HH reported that he had been educated on the smoking policy that morning but had allowed Resident #7 to go out and smoke unsupervised. 4. Record review of Resident #24 ' s electronic facesheet (not dated) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #24 ' s health status note (dated 4/27/15) revealed that he was caught smoking in his room. Resident is in (room) which is close to the door outside which there was an oxygen tank, that belonged to another resident. (Resident) stated that his roommate (Resident #1) gave him the lighter to light his cigarette . Incident/accident reports were reviewed, and there were no incident/accident reports pertaining to Resident #24 smoking in his room. Record review of Resident #24's annual MDS assessment (ARD 6/11/15) revealed that he scored a 4 on the BIMS (indicating that he had severe cognitive impairment). Record review of Resident #24's care plan (reviewed 7/23/15) revealed that he required supervision with smoking, that his smoking ability should be reassessed quarterly and after reports of unsafe practices, and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Review of Resident #24 ' s clinical record revealed no safe smoking assessments. Record review of Resident #24's safe smoking assessment (after surveyor intervention - dated 8/15/15) revealed that he needed a smoking apron and supervision while smoking. Observation of Resident #24 at 11:41 a.m. on 8/18/15 revealed that he was smoking without an apron on. 5. Record review of Resident #5's facesheet (dated 8/11/15) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5 ' s clinical record revealed that her last safe smoking assessment was done on 2/9/15 and was still in progress . During an interview with LVN N on 8/11/15 at 3:00 p.m., she reported that Resident #5 had not had a smoking assessment completed since her admission on 2/9/15. Record review of Resident #5's significant change MDS assessment (ARD 6/24/15) revealed that she scored a 6 on the BIMS (indicating that she had moderate cognitive impairment). Record review of Resident #5's care plan (reviewed 6/29/15) revealed that she required supervision with smoking, that her smoking ability should be reassessed quarterly and after reports of unsafe practices, and that her cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Record review of Resident #5's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that she could light her own cigarette, did not need to be supervised when smoking, and did not need the facility to store her cigarettes or lighter. Observation on 8/10/15 at 6:00 p.m. revealed Resident #5 self-propelling her wheelchair outside to the covered patio and smoking a cigarette. No staff was supervising the smoking and/or outside on the covered patio. During an interview with Resident #5 on 8/10/15 at 6:05 p.m., she reported that she was allowed to keep her cigarettes and lighter in her room. Observation on 8/11/15 at 6:08 a.m. revealed Resident #5 in her bed sleeping. Two packages of cigarettes and one lighter were observed on her over bed table. Observation on 8/11/15 at 10:40 a.m. revealed Resident #5 self-propelling her wheelchair, utilizing the keypad, going outside to the covered patio, and smoking. No staff were supervising the patio. 6. Record review of Resident #11's facesheet (dated 8/13/15) revealed that she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #11's quarterly MDS assessment (ARD 6/5/15) revealed that she scored a 7 on the BIMS (indicating moderate cognitive impairment). Record review of Resident #11's safe smoking assessment (after surveyor intervention - dated 8/11/15) revealed that she could light her own cigarette, did not need to be supervised when smoking, and did not need the facility to store her cigarettes or lighter. Observation of the designated smoking area on 8/11/15 at 6:13 a.m. revealed 3 residents (including Resident #11) smoking without supervision. Resident #11 was observed walking with the assistance of a rolling walker. She used the door keypad and punched in the security code to gain access to the inside of the facility. Observation on 8/11/15 at 8:02 a.m. revealed Resident #11 using her rolling walker to ambulate past the nurses ' station, utilizing the keypad, and letting herself outside to the designated smoking area. No staff were observed supervising the resident. Resident #11 then lit her cigarette. Resident #11 handed this surveyor her lighter and asked if this surveyor would light another resident ' s cigarette because he was blind and her legs hurt too bad to get up and assist him. This surveyor took the lighter from Resident #11 as LVN N walked outside to the covered patio and handed this surveyor a piece of paper. This surveyor handed LVN N the lighter. LVN N said, The smoking policy has been implemented and walked inside with the lighter. Observation of Resident #52 at 9:01 a.m. on 8/12/15 revealed that she exited the facility with half of a cigarette (unlit) in her hand. When asked where she got the cigarette, Resident #52 reported that she got it from her friend and pointed to Resident #11. Resident #11 stated I had it. I saved it from yesterday. One of the ladies - a worker - told me to put it in my purse . Resident #11 reported that she had last smoked at the 7:00 p.m. break on 8/11/15. 7. Record review of Resident #1's facesheet (dated 8/11/15) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's annual MDS assessment (ARD 6/30/15) revealed that he scored a 9 on the BIMS (indicating that he had moderate cognitive impairment) and was a smoker. Record review of Resident #1's care plan (reviewed 7/23/15) revealed that he required supervision with smoking, that his smoking ability should be reassessed quarterly and after reports of unsafe practices, and that his cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Review of Resident #1's clinical record revealed no safe smoking assessment. Observation of Resident #1 at 11:41 a.m. on 8/18/15 revealed that he was smoking in the designated smoking area with staff supervision. Record review of Resident #27's electronic facesheet (not dated) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #27's admission MDS assessment (ARD 6/29/15) revealed that she scored a 3 on the BIMS (indicating that she had severe cognitive impairment). Record review of Resident #27's progress notes revealed that she was caught smoking in her room on 8/17/15. Record review of Resident #27's care plan (revised 8/20/15) revealed that she required supervision with smoking, that her smoking ability should be reassessed quarterly and after reports of unsafe practices, and that her cigarettes, lighter, and smoking paraphernalia must be kept at the nursing station. Review of Resident #27 ' s clinical record revealed no safe smoking assessment. 8. Observation of the designated smoking area on 8/11/15 at 6:55 a.m. revealed four unidentified male residents smoking. No staff were supervising them. Observation of the designated smoking area on 8/11/15 at 7:01 a.m. revealed one unidentified male resident smoking. No staff were supervising him. Observation of the designated smoking area on 8/11/15 at 8:36 a.m. revealed 8 unidentified residents smoking. No staff were supervising them. During an interview with Resident #50 at 5:13 p.m. on 8/11/15, she reported that she had been at the facility for 2 weeks and had been able to smoke unsupervised until today. During an interview with Resident #51 at 5:15 p.m. on 8/11/15, she reported that she had been at the facility for 3 months and had been able to smoke unsupervised until today. Resident #51 had 2 lit cigarettes in her hand at this time. The cigarette in her left hand was almost finished but still smoking. Resident #51 was holding the cigarette between her pointer finger and her thumb, and her left hand was shaking. The ashes were observed to fall onto her clothes but did not burn them. Observation of the designated smoking area at 5:05 p.m. on 8/12/15 revealed that Resident #53 was smoking without an apron on. The administrator was observed to light Resident #22 ' s cigarette (that Resident #22 was holding) before he put an apron on Resident #22. Resident #45 was observed pulling an unlit cigarette out of his shirt pocket. He asked Resident #51 for a light, and Resident #51 started searching in her purse. Resident #51 then noticed the surveyor and told Resident #45 that he needed to get his cigarette lit by the staff. Resident #54 was observed with 2 lit cigarettes in her hand at the same time. During an int