Every finding on record at Broward Oaks Nursing and Rehabilitation

Based on observations, interviews and record reviews, the facility failed to follow the professional standards of practice for the care and management of an indwelling urinary catheter and failed to follow their own policy for catheter care for 2 of 2 residents reviewed for urinary care (Resident #1 and Resident #3). The findings included:According to the Center for Disease Control and Prevention (CDC), in the non-acute care setting. Properly secure indwelling catheters after insertion to prevent movement and urethral traction. (p.12). Education and performance feedback regarding appropriate use, hand hygiene, and catheter care (p.15). https://www.cdc.gov/infection-control/media/pdfs/Guideline-CAUTI-H.pdf According to the facility's policy titled, Catheter Care, implemented on 12/17/17, it documented that it is the policy of this facility to ensure that residents with indwelling catheter receive appropriate care and maintain their dignity and privacy when indwelling catheters are in use. Catheter care will be performed every shift and as needed by nursing personnel. 1) A record review revealed Resident #1 was admitted to the facility on [DATE] and was transferred to a hospital on 9/26/25. The admitting diagnoses included in part, Cerebral Aneurysm, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Reflux Uropathy, Essential Hypertension and Spondylosis without Myelopathy or Radiculopathy of the Lumbar region. A review of admission Minimum Data Set (MDS) assessment dated [DATE] under Section C for the Brief Interview of Mental Status (BIMS) revealed a score of 14, indicating Resident #1 had no cognitive impairment. Section GG documented this resident was staff dependent on eating, personal hygiene, toileting, and upper and lower body dressing. Section H revealed a yes response to indwelling catheter. An additional review of physician order dated 8/4/25, documented to provide (Foley) indwelling catheter care, every shift, and secure catheter with a holder to prevent migration, every shift. A further review of orders did not include Enhanced Barrier Precaution (EBP), when the urinary catheter care was ordered. A record review of facility's EBP policy with implementation date of 11/20/21 revealed an order for EBP will be obtained for residents with wounds and or indwelling medical devices (e.g. urinary catheter) regardless of Multiple Drug-Resistant Organism (MDRO) colonization status. In an interview conducted with the Infection Control Licensed Practical Nurse on 10/07/25 at 1:35 PM, when she was asked if a resident with a urinary catheter should be under EBP guidelines, she responded, Yes. When she was asked when the resident will be under EBP guidelines, she responded, as soon as the resident was ordered to have a urinary catheter. A further review of nursing care plan revealed that the EBP focus related to urinary catheter was not initiated until 9/26/25, indicating it was added approximately 7 weeks after Resident #1's admission to the facility. 2) A record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Non-Traumatic Intracerebral Hemorrhage affecting the Left Nondominant Side, Obstructive and Reflux Uropathy, Hypertensive Chronic Kidney Disease and Cognitive Social and Emotional Deficit following Nontraumatic Intracerebral Hemorrhage. A review of the quarterly MDS assessment dated [DATE], under Section C, revealed a BIMS score of 12, indicating Resident #3 had moderate cognitive impairment. Section H revealed a yes response to indwelling catheter. An electronic record review of physician orders dated 8/12/25, documented indwelling urinary catheter of size 16, with inflation balloon of 10 ml (milliliter) sterile water for the diagnosis of Obstructive Uropathy. An additional review of physician order dated 8/4/25, documented to provide (Foley) indwelling catheter care, every shift, and secure catheter with a holder to prevent migration, every shift. During a urinary care observation and interview conducted on 10/7/25 at 2:58 PM, with Staff G, a Restorative Certified Nursing Assistant (CNA), and Staff I, another CNA, who when asked about the color and the urine consistency, both stated the color was pinkish, cloudy and with sediments noted in the urinary tubing. Additional observation revealed Resident #3's catheter was not secured on the thigh but freely moving when the resident moved. Both staff CNAs stated that the secure lock was not secured and not dated. When Staff I, a CNA was asked if she frequently provides urinary catheter care to Resident #3, she responded, Yes, every time I am assigned to him. When she was asked if the secure system is always attached to the resident's, she responded, Sometimes. When she was asked if she reattaches the secure system (anchor)when it becomes detached, she responded, Nurses do that. When she was asked if she will tell the staff Nurse regarding the detachment of the secure system, she responded, I always tell the Nurse. During the same urinary care observation, Staff I, CNA did not change her gloves from beginning until the end. When she was asked why she kept the same gloves for cleaning the resident's urinary meatus, penis, inner thighs, catheter tubing, bed cover, bed remote control, call light and gown, she did not respond. During another observation on 10/08/25 at 1:30 PM, with Staff F, a Restorative CNA, the same urinary secure system was still detached and not secured to resident's thigh. When the resident was asked if Nurses attached it to him, he responded, No. When the resident was asked if staff perform hand washing before providing him urinary care, he responded, No. A review of September 2025 Medication Administration Record and Treatment Administration Record (TAR) revealed that on 9/24/25 and 9/26/25 during the day shifts, securement of catheter was not done by staff per physician order. A review of physician order dated 10/7/25 at 3:08 PM revealed Cefdinir Capsule 300 milligram (MG), give 1 capsule by mouth every 12 hours for Urinary Tract Infection (UTI) for 7 Days. In an interview conducted with Staff J, a Licensed Practical Nurse (LPN) on 10/08/25 at 2:45 PM, when she was asked if she provides urinary catheter care to Resident #3, she responded, Yes. When she was asked when the last time urinary care was provided for this resident, she responded, I work from 7:00 AM to 3:00 PM, and I still have not provided urinary care for this resident since the beginning of my shift. When she was asked what time she will provide urinary catheter care, she responded, A few minutes before I go home. When she was asked if she had assessed the color and consistency of urine for Resident #3, she responded, 'I have not done it yet. An electronic record review of nursing care plan revealed that catheter care was not initiated until 8/11/25, indicating it was done 7 days later after the physician ordered a urinary catheter for Resident #3, on 8/4/25. An additional review of nursing care plan did not include an EBP intervention for urinary catheter. A further review of September 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that on 9/24/25 and 9/26/25 during day shifts, securement of catheter was not done by staff per physician order. A review of physician order dated 10/7/25 (first day of survey) at 3:08 PM, it revealed Cefdinir Capsule 300 milligram (MG), to give 1 capsule by mouth every 12 hours, for Urinary Tract Infection (UTI) for 7 Days. In an interview conducted with Staff B, an LPN on 10/7/25 at 12:41 PM, when she was asked regarding urinary catheter care and management for residents, she responded, The catheter will be flushed as ordered, and I made sure I follow the facility's policy for catheter care. The urinary catheter care is done by staff, and I must perform them for my assigned residents. She added that she monitors the resident for possible UTI by monitoring symptoms like confusion and complaining of burning in the area. She added that the facility does not wait for fever to occur to indicate infection. She monitors the urine output color, and consistency and encourages resident to drink or make sure to have adequate fluid intake. She added she monitors the catheter frequently during her shift.

Based on observations, interviews, and record reviews, the facility failed to follow the professional standards for the care and management of pressure ulcers for 1 of 2 residents reviewed for wound care (Resident #1). The findings included: According to the Center for Medicare and Medicaid Services (CMS), avoidable pressure ulcer injury means the resident developed a pressure ulcer/injury, and the staff failed to do one or more of the following : Evaluate the resident's clinical condition and risk factors. Define and implement interventions that are consistent with resident needs and goals and follow professional standards of practice. Monitor and evaluate the impact of the interventions. Revise interventions as appropriate. A record review revealed Resident #1 was admitted to the facility on [DATE] and was transferred to a hospital on 9/26/25. The admitting diagnoses included in part, Cerebral Aneurysm, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Reflux Uropathy, Essential Hypertension and Spondylosis without Myelopathy or Radiculopathy of the Lumbar region. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] under Section C for the Brief Interview for Mental Status (BIMS) revealed a score of 14, indicating Resident #1 had no cognitive impairment. Section GG documented this resident was staff dependent on eating, personal hygiene, toileting, and upper and lower body dressing. Section M documented a no response to the presence of a pressure ulcer or injury, and pressure ulcer and injury care. An additional review of electronic nursing care plan with focus on skin integrity related to history of healed wound was initiated on 8/20/25. On 9/1/25, another focus indicating the old pressure ulcer was reopened and treatment was initiated; and an additional focus was added on 9/10/25, with a note documenting the wound worsened, reevaluated, and changed. An electronic nursing care plan review documented the intervention for wound care consult was added on 9/8/25, approximately 4 weeks after Resident #1's admission to the facility. Additional review of nursing interventions documented that the air mattress was added on 9/10/25, and the wedge cushion to reposition and off load to be placed under the back every shift was initiated on 9/25/25, indicating both air mattress and wedge cushions were added approximately 5, and 7 weeks after Resident #1's admission to the facility. In an interview conducted with Wound Care Licensed Practical Nurse (LPN) on 10/7/25 at 11:20 AM, when she was asked the process of skin assessment during admission, she responded, If no skin issues are found, but if there are risks. she will initiate an air mattress order for preventative measure. She added that the resident might get the air mattress in a couple of hours after admission. If admitted before 4:30 PM, the mattress will be issued within the first 2 hours of admission to the facility. If admitted late at night, the mattress will be provided to the resident on the following day. She added that the facility has uploaded wedges, pillows, donut and cushion for wheelchairs. All the Inter Disciplinary Team (IDT) members, Central Supply personnel and Therapy staff will coordinate the care of a resident who has skin risk assessment for pressure ulcer and they will decide which preventative measures would be appropriate. She stated that within 2 days after admission, a resident who is at risk for skin breakdown will have the necessary supplies to prevent the development of pressure ulcer. She added that they have weekly skin check, where the Nurse will go in and observe the body for any new areas forming and document the findings in the computer, on skin observation under the assessment tab. When she was asked if it is possible to have stage 4 pressure ulcer after a month of staying in the facility, she stated that it would first start with visible skin issues like redness, excoriation, deteriorating, then stage 1, but usually not stage 4 right away. She had not witnessed a resident who did not have any skin opening during admission and then a month later turned into stage 4 pressure ulcer. When she was asked if there was a facility acquired pressure ulcer in September 2025, she responded, Resident #1, because this resident came in with scar tissue on the sacrum, which was closed, and with no drainage. I did not take a picture of the sacrum during admission, and I wrote buttocks on her nursing admission skin assessment which was electronically submitted on 8/20/25. I performed the skin assessment on 8/20/25, but I corrected the word buttocks into sacrum later. She added that she initiated preventive measures like barrier cream, offloading measures, wedges and air mattress, but wedges and air mattress were not provided to Resident #1 because the resident had no open wound on admission. When she was asked if there were risk for the development of pressure ulcer for this resident, she responded that this resident had a risk of developing pressure ulcer. She ordered the air mattress and wedges on 09/09/25, which was approximately 3 weeks after Resident #1's admission to the facility. She ordered them because the resident was not thriving. The resident was refusing to eat, drink, refusing clean up, and frequently with closed mouth. The resident had sacral excoriation only on 9/9/25, then stage 1 within the same week, according to Wound Care LPN. On 9/18/25, staff stated Resident #1's sacral wound was Stage 4. Staff added that the exacerbation of sacral wound was related to generalized decline of resident, and it was according to the wound physician. The doctor did not stage the wound of Resident #1 according to the Wound Care LPN. She admitted that she did not intervene immediately at admission. She added that according to the wound physician, no amount of intervention can prevent the occurrence of Stage 4 pressure ulcer, a few weeks after admission to the facility. On 8/20/25, she wrote the admission skin assessment, but she did not see the resident again until 9/2/25. She admitted that she wrote 3 late entries in the nursing progress notes. She added that she saw the resident after a nurse called her that Resident #1's skin on the sacral area was starting to break down. When she was asked why there were 3 late entries in the nursing progress notes regarding her skin assessment, she responded, Because I was not doing my weekly skin notes. When she was asked why she was not doing the weekly skin notes, she responded, I do not know. In an interview conducted with Staff B, an LPN on 10/7/25 at 12:42 PM, when she was asked regarding Resident #1's pressure ulcer, she stated she did not remember, but she remembered this resident was refusing care frequently, although she did not remember when Resident #1 started to refuse care. When she was asked if she monitored the skin weekly, she responded, Yes. When she was asked how she prevents pressure ulcer development, she responded, I follow the facility's policy, use barrier cream, wash and dry the sacral area, and perform incontinent change often. I will ask the staff CNAs to turn and reposition the resident. She added that she will use pillows to take pressure off the sacral area and any bony prominences. When she was asked if she monitors the CNAs when they were doing the turning and repositioning tasks, she responded, Sometimes.

Based on observations, interviews and record review, the facility failed to identify a significant weight loss in a timely manner and failed to prevent further significant weight loss for 1 of 4 residents sampled for nutrition (Resident #35). The findings included: A review of the facility's policy titled, Weight Assessment and Interventions revised in September 2008 showed the following: The nursing staff will measure Resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian, and verbal notification must be confirmed in writing. The Dietitian will respond within 24 hours of receipt of written notification. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month-5% of weight loss is significant, and greater than 5% is severe. 3 months-7.5% of weight loss is significant; greater than 7.5% is severe. 6 months-10/% of weight loss is significant; greater than 10% is severe. A review of the facility's policy titled, Weight-Height Monitoring Policy reviewed on 09/14/24, showed the following: Residents with weight loss monitor to weight weekly and the Dietitian will review and record all weight in the electronic system tandem with restorative. A record review showed Resident #35 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes, End Stage Renal Disease, Anemia, and dependence on Dialysis. The Minimum Data Set (MDS) dated [DATE] revealed Resident #35 with a Brief Interview of Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. In an observation conducted on 5/5/25 at 1:13 PM, Resident #35 was eating his lunch meal. The meal ticket noted a Mechanical Soft Liberal Renal Diet with No Concentrated Sweets. Resident #35 ate 80% of his lunch meal. In an observation conducted on 5/6/25 at 12:30 PM, Resident #35 was in his room eating his lunch meal. He was observed eating about 75% of his meal. A review of the weight log for Resident #35 showed the following weights: 4/17/2025, a weight of 137.2 pounds. 3/6/2025, a weight of 148.4 pounds. 2/13/2025, a weight of 148.4 pounds. 1/16/2025, a weight of 147.6 pounds. 1/6/2025, a weight of 149.6 pounds. 12/30/2024, a weight of 148.0 pounds. 12/23/2024, a weight of 146.0 pounds. 12/15/2024, a weight of 152.0 pounds. 12/13/2024, a weight of 148.0 pounds. 12/6/2024, a weight of 146.0 pounds. 11/29/2024, a weight of 144.0 pounds. This showed Resident #35 had a 7.5% severe weight loss from 3/6/25 to 4/17/24. A Nutrition Risk assessment dated [DATE] revealed the following: Resident #35's Body Mass Index (BMI) showed a score of 20.1 which is in the normal range. The Resident is at 84% of his Ideal Body Weight and needs to be elevated for wound healing and Hemodialysis. A ProStat (protein supplement) of 30 milliliters was recommended 3 times a day for wound healing. It showed to continue monitoring the intake of meals to meet estimated needs and monitor skin integrity and weight. A review of the monthly nutrition progress noted dated 2/13/25 showed the following: The Resident's weight is relatively stable, and it was recommended that the protein supplement be decreased to once a day. The Mini Nutritional assessment, which was conducted on 3/6/25, showed that Resident #35 was at risk for malnutrition, with a score of 10. A score between 0 and 7 indicates malnutrition. A care plan note dated 3/27/25 revealed that Resident #35's weight was 148 pounds, and a 2-pound weight gain was noted in the last 3 months. The Resident's Ideal Body Weight is around 160 pounds based on his height of 71 inches. Further review of the Nutrition progress notes or assessments did not show that the Clinical Dietitian addressed the Severe 7.5% weight loss that was identified on 4/17/25. The care plan initiated on 12/4/24 for Resident #35 showed the following: Resident #35 has nutritional problems or potential for nutritional problems related to Hemodialysis and multiple medical diagnoses. The Resident will maintain adequate nutrition stats as evidenced by maintaining weight within the usual weight range of 147-152 pounds. It further revealed that the Clinical Dietitian will evaluate and make diet changes as needed. This care plan showed that Resident #35 was on Megace (appetite stimulant) from 12/24/24 and was discontinued on 2/21/25. The documented percentage of meal eaten for the last 30 days showed Resident #35 ate mostly 75% of meals. In a phone interview conducted on 5/7/25 at 11:00 AM with the current Clinical Dietitian, she said she started working for the facility about a week ago. Residents who are on nutritional support, have stage 2 pressure ulcers, significant weight loss, and are on Dialysis would be considered at high nutritional risk. When asked about the facility weight policy, she stated residents' weights are taken on admission, 72 hours, weekly for 4 weeks, and monthly thereafter. The facility has a weekly weight binder that is later recorded in the electronic system, and a weight alert will be displayed on the dashboard, letting staff know of any significant weight triggers or changes. This is based on previous weights recorded or the time frame of 30/90/180 days. The electronic system will show a trigger for any residents who have lost weight. There is also a report she can pull to see any weight changes in all residents. According to the Clinical Dietitian, a significant weight loss is considered for the following ranges: 5% weight loss in 30 days, 7.5% in 90 days, and 10% weight loss in 180 days. For any residents with significant weight loss she will intervene as soon as possible between 24 to 48 hours. A note will be written in the progress notes section talking about the weight variances, the root cause, the plan, and the interventions in place. She will also place the residents on a weekly weight. The Clinical Dietitian stated that the former Clinical Dietitian should have addressed the severe weight loss after it was noted on 4/17/25 and could not give an answer as to why it was not. The Clinical Dietitian said that the weights on Resident #35 are also taken during Dialysis and that she will need to review the communication sheets to verify the weight loss reported. An interview was conducted on 5/7/25 at 11:22 AM with the Dietary Technician who reported starting her position in the facility about one month ago. She reviews significant weight losses and emails the list to the Clinical Dietitian as needed. She reviews the weight log twice a week, and the staff will also leave a list of residents who have lost weight in her mailbox. A new weight was taken on 5/8/25 at 12:00 PM as requested by this Surveyor, and it showed that Resident #35 was 128 pounds. The Resident lost an additional severe weight loss of 6.7% in less than a month. Resident #35 was now at 80% of his Ideal Body Weight range. In an interview conducted on 5/8/25 at 12:08 PM with Staff N, a Certified Nursing Assistant (CNA) stated that she takes the weight once a month for dialysis residents. It is done upon admission, 72 hours after admission, and once a month thereafter. The dialysis team takes the weights of Resident #35 before and after the dialysis treatment. She has a weight book from the 1st of the month to the 10th of the month that is later given to the current Clinical Dietitian. If she sees any weight loss, she will report it to the Charge Nurse and the Restorative Nurse. In an interview conducted on 5/8/25 at 12:12 PM, Staff M, CNA, stated that Resident #35 eats between 75% and 100% of his meals. He can eat on his own and does not need assistance from staff. In an interview conducted on 5/8/25 at 12:15 PM with Resident #35, he stated that his appetite is not so good today and that sometimes he does not eat all the food on the tray because he does not like the food choices. He further said that he likes nutritional supplements and would drink them if they were given. He likes both vanilla and chocolate flavors. A review of the Dialysis communication sheets showed that the following weights were recorded: On 5/7/25, a pre-weight of 157.7 pounds and post-weight of 154.3 pounds. On 5/5/25, a pre-weight of 157.3 pounds and post-weight of 154 pounds. On 5/2/25, a pre-weight of 157.96 pounds and post-weight of 154 pounds. On 4/30/25, a pre-weight of 156.2 pounds and post-weight of 154 pounds. On 4/18/25 a pre-weight of 156.2 pounds and post-weight of 154 pounds. On 3/7/25 a pre-weight of 156.2 pounds and post-weight of 154 pounds. In an interview conducted on 5/8/25 at 12:30 PM with the Administrator, he stated that he had received calls in the past from staff letting him know of some issues with the scales, with one showing an error message. He even used one of the scales to weigh himself, which did not show an accurate reading. He decided to reach out to an outside company to come and calibrate all the facility ' s scales. They came out last week to calibrate the two Hoyer lift scales and the two stationary scales. In an interview conducted on 5/8/25 at 12:45 PM with the facility's Director of Nursing (DON), she stated that the dialysis team is the one that takes the weights of the dialysis residents before and after treatments. This Surveyor expressed concerns about the discrepancies in the weights taken by the facility team and the dialysis team during Dialysis. The DON said the dialysis team uses the facility's scales to take the residents' weights. She has observed the team taking the weights on some residents but not each time during their dialysis treatments. In this interview, this Surveyor expressed concern that the clinical team did not address the severe weight loss and that no further interventions or nutritional supplements were considered to prevent the further weight loss identified on 5/7/25.

Based on observations, interviews, and record reviews, the facility failed to follow the Enhanced Barrier Precautions (EBP) guidelines for 2 out of 23 residents reviewed (Resident #93 and Resident #26). The findings included: A review of facility policy titled, Catheter Care, implemented on 12/17/17 revealed the procedure for female catheter care is as follows: labia will be separated to expose the urinary meatus; wipe from front to back with moistened towel, with a new moistened cloth, starting at the urinary meatus moving out, then wipe the catheter. 1) Record review for Resident #26 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Hemiplegia, Hemiparesis, Muscle Weakness, Aphasia, Type 2 Diabetes Mellitus Dysphagia, and Chronic Kidney Disease. A review of the quarterly Minimum Data Set (MDS) assessment for Resident # 26 dated 03/17/25, under Section C revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. A review of Nursing care plan initiated on 12/17/24 revealed a focus on Enhanced Barrier Precautions related to indwelling catheter. The interventions included Staff must wear gown and gloves for high contact care areas which include changing briefs and urinary catheter . During observation conducted on 05/07/25 at 12:08 PM, Staff W, and Staff X, both Certified Nursing Assistants (CNAs) stated We will perform urinary catheter care for Resident #26. Both Staff CNAs gathered supplies after washing their hands, then donned on gloves, but did not don on gowns. Staff W, CNA, loosened Resident #26's brief and exposed the urinary catheter tubing. Resident #26 moaned as soon as the urinary catheter tube was touched and lifted from the perineal area. With gloved hands, Staff W, CNA started wiping the outside part of urinary catheter tube first, before wiping the part closer to the urinary meatus, inner vagina, vaginal folds and the rest of the front perineum. Staff W, CNA, used the same set of gloves during wiping, spraying of the hand-held soap to wet cloth towels, dipping cloth towels into the water basin, and drying both the front and back perineal areas. Staff W, CNA changed her gloves before applying the A and D ointment to the back areas. Staff X, CNA assisted with stabilizing Resident #26 when she was turned to the right side for the cleaning of the back area. When the urinary catheter care was completed, Staff W removed Resident #26's brief and replaced it with a fresh one. In an interview with Staff W, CNA who when asked what EBP means, responded, EBP is when Staff use gloves and gown for residents with tube feeding and urinary catheter. When asked why she did not don on a gown, she responded I forgot. When asked where are the post signage and EBP supplies for Resident #26, she responded, Resident #26's closet door has a EBP post, and the supplies are located on top of Resident #26's bedside table. Staff W, CNA pointed to plastic bags with blue gowns inside Resident #26's room. In an interview with Staff X, CNA, on 05/07/25 at 1:00 PM, who when asked why she did not don on a gown before performing urinary catheter care, responded, I forgot. 41837 2. Record review for Resident #93 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on 06/01/24 with diagnoses that included in part the following: Muscle Weakness (Generalized), Dysphagia, Expressive Language Disorder, and Adult Failure to Thrive. The Minimum Data Set, dated dated dated [DATE] documented in Section C a Brief Interview of Mental Status was not attempted due to the resident is rarely/never understood. On 05/05/25 at 10:10 AM observation of Resident #93 receiving tube feeding. There was no Enhanced Barrier Precaution (EBP) sign posted in room or on door. During an interview conducted on 05/05/25 at 10:34 AM with Staff A, Registered Nurse (RN), who stated he has worked at the facility for just over 1 year. When asked about Enhanced Barrier Precautions (EBP) he said he does not have any residents on EBP on his assignment today. When asked what the criteria for someone to have EBP is he said he would have to check on that. The RN never got back to the surveyor. The RN was assigned to care for Resident #75 who a had dialysis access port. During an interview conducted on 05/05/25 at 10:19 AM with Staff B Certified Nursing Assistant (CNA), who stated she has worked at the facility for [AGE] years. When asked about Enhanced Barrier Precautions (EBP) she said she does not have any residents assigned to her on EBP. When asked if she knew why a resident would have EBP or what the criteria is for EBP, she said she did not know. During an interview conducted on 05/05/25 at 10:25 AM with Staff C, Certified Nursing Assistant, who stated she has worked at the facility for [AGE] years. When asked about Enhanced Barrier Precautions (EBP) she said she does not have any residents on EBP. When asked what the requirement was for a resident to be on EBP, she said I think if they have falls. During an interview conducted on 05/06/25 at 2:14 PM with Staff A, Registered Nurse (RN), who was asked about Enhanced Barrier Precautions (EBP) and which type of residents would have the EBP or meet criteria for EBP, he said he forgot to check on that. When asked if he has any residents on EBP he said, I don't think so. When asked about if he has any residents receiving dialysis or tube feeding he said yes. Staff A RN said he thinks you need to do hand hygiene, wear gloves and a gown when taking care of those residents. When asked where the gowns are kept, he said they should be in an isolation cart in the hallway. When asked about EBP signs, he said they should be on the front door of the room. On 05/06/25 at 2:30 PM a side-by-side observation was made with Staff A RN who acknowledged there was no EBP sign in the room or on the door for Resident #93 who had a PEG tube. And the EBP signage for Resident #75 (who receives dialysis) was on the closet door and was unable to be seen when the room door was opened all the way as it covered the signage. During an interview conducted on 05/06/25 at 4:51 PM with the Infection Preventionist who stated she has worked at the facility since 2020. When asked about Enhanced Barrier Precautions (EBP) the IP stated EBP is implemented for all resident with any device put there that you were not born with such as a PEG tube , dialysis port, trach, colostomy and any wounds. The IP stated the staff have to wear gown and gloves while performing resident care for those residents, and an order and care plan should be in place. There should be an EBP sign on the resident's closet door. On 05/06/25 at 5:10 PM a side- by-side observation was conducted with the Infection Preventionist (IP) who acknowledged there was no EBP signage on the door or in the room for Resident #93. The IP stated she had overheard the surveyor interview with Staff A RN regarding EBP and immediately educated the staff member.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food according to professional standards for food service safety and sanitary conditions and to prevent foodborne illnesses for 2 of 2 visits to the main kitchen. The findings included: In an observation conducted on 5/5/25 at 7:30 AM during the initial tour of the main kitchen, the following were noted: The Dietary Service Manager was noted to have no facial hairnet protection while walking around the food production area. Staff F, Diet Aide, was noted to have no facial hairnet protection while walking around the food production area. Three rolls of raw ground beef, 5 pounds each, were noted inside the sink with no running water flow. In this observation, Staff G [NAME] stated that the raw ground beef was thawing for lunch today. The reach-in refrigerator was noted to have a metal container of cooked vegetables that was partially opened and exposed. A dirty, used rag was noted in a red bucket with no sanitizing solution. Empty food boxes and dirty used gloves were noted on top of the food production area on top of a clean pot. The reach-in refrigerator was noted to have two plates of a chef salad that were not dated or labeled. In an observation conducted on 5/6/25 at 12:30 PM, the Dietary Service Manager was noted to have no facial hairnet protection while walking around the food production area. In an observation conducted on 5/7/25 at 11:45 AM, the Dietary Service Manager was noted using a facility-calibrated thermometer to measure the temperature of the cooked foods for the lunch tray line. He was observed putting the thermometer inside the different food containers without gloves.

Based on observations, review and record review, the facility failed to provide food in a form designed to meet individual needs for the Pureed diet observed during 1 of 2 visits to the main kitchen. This has the potential to affect the 20 out of 98 residents on a Pureed diet. The findings included: The International Dysphagia Diet Standardization Initiative, dated January 2019, showed the following: Pureed food should have a smooth texture with no lumps, and it should not be formed or sticky. In an observation conducted on 5/5/25 at 7:55 AM in the central kitchen during the breakfast tray line, the following was noted: A half-size 6-inch deep stainless steel steam table container with pureed pancakes. Staff G, Cook, was getting ready to start the tray line for the breakfast meal. Closer observation showed that the pureed pancakes did not have a smooth consistency and were noted to be lumpy and grainy. This Surveyor tested the pureed food consistency using a spoon, which showed that it was firm and sticky on the spoon. In an interview conducted on 5/5/25 at 8:00 AM with Staff G, she stated that she has a new blender to mix up the food for the Pureed consistency and said she will put it through the blender again for the correct consistency. She then got the new blender from the back of the kitchen. In a phone interview conducted on 5/8/25 at 9:20 AM with Staff H, the Speech Language Pathologist stated that the pureed food consistency should have a uniform texture, smooth and not lumpy. It should resemble the texture of food like pudding, apple sauce, and humus.

Based on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication error related to expired insulin, for one of 5 sampled residents (Resident #68). The findings included: Review of facility's policy titled, Insulin Pen Policy, with an implementation date of [DATE], revealed that insulin pens should be disposed of after 28 days or according to the manufacturer's recommendations. Record review for Resident #68 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Obstructive Sleep Apnea, Hypertension, Type 2 Diabetes Mellitus with Diabetic Neuropathy. Review of the Physician's Orders for Resident #68 revealed an order dated [DATE] for Novolog Flex Pen 100 Units (U) per ml (Milliliter) solution per sliding scale: If 0 - 149 = 0 U; ,d+[DATE]=2 U; ,d+[DATE]=4 U; ,d+[DATE]=6 U; ,d+[DATE]=8 U; ,d+[DATE]=10 U, subcutaneously before meals for Diabetes Mellitus (DM). During a medication administration observation on [DATE] at 4:43 PM with Staff P, LPN, she stated she obtained a blood sugar of 202 for Resident #68, and she will give 4 units of Novolog insulin based on the sliding scale. She took the flex pen out of the first drawer of Medication Cart 2 on the [NAME] Wing. When Staff P, LPN, showed the Novolog Flex pen to the surveyor, it revealed an opened date of ,d+[DATE] and an expiration date of ,d+[DATE]. When Staff P, LPN was asked regarding the expiration date, she stated the Novolog Flex pen had an expiration date of ,d+[DATE]. When asked if she will use the insulin to the resident, she stated, Yes, because in this facility, insulin expires in 35 to 45 days. When asked what kinds of insulin expire in 35 to 45 days, she responded, All insulin we use. She proceeded to get the medications ready . The surveyor stopped her and asked again about the expiration date. She looked at the Novolog Flex pen and reread the date written on it, ,d+[DATE]. When asked if she had given insulin doses to Resident #68 after ,d+[DATE], she responded, Yes. When asked if she had another Novolog Flex pen available for this resident, Staff P, LPN left the [NAME] Wing and returned after 10 minutes and told this surveyor that she found an Insulin Flex pen inside the emergency medication cart. She labeled the new Novolog flex pen with the open date and the expiration date before administering the required insulin units to Resident #68. In an interview with the Pharmacist Consultant on [DATE] at 10:08 AM, when asked about the effects of expired short acting insulin for a resident, he responded, There would be no harm, but the medications would be less effective or not as effective. When asked if the administration of expired insulin would contribute to hyperglycemia, he responded, It is possible. When asked about medication cart audits, he responded, I review and perform medication carts audits once a month, and Nurses are instructed to check their medication carts as often as possible. When he was asked about the expiration dates of commonly used insulin flex pens in the facility, he responded, The insulin when opened and kept in room temperature have the following expiration dates: Humulin R will expire in 31 days, Admelog will expire in 28 days, and Novolog will expire in 28 days. Review of the [DATE] Medication Administration Record (MAR) for Resident #68 revealed the resident received Novolog insulin on [DATE] three times; on [DATE] three times: on [DATE] two times; on [DATE] three times; and on [DATE] two times.

Based on observations, interviews and record review, the facility failed to monitor behaviors and side effects accurately for Residents on Psychotropic medications (Residents #29, #48, #63, and #10), and failed to monitor side effects for a resident on anticoagulant (Resident #29) for 5 of 5 residents sampled for Unnecessary Medications. The findings included: A review of the facility's policy titled Use of Psychotropic Drugs, dated 12/17/2017, showed the following: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The attending Physician will assume leadership in medication management by developing, monitoring, and modifying the medication regime in collaboration with residents, their families and/or representatives, other professionals, and the interdisciplinary team. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice and the resident's Comprehensive Plan of Care. 1. Record review revealed Resident #10 was readmitted to the facility on [DATE] with diagnoses of Psychotic disturbances, Dementia, and Major Depressive Disorder. The Quarterly Minimum Data Set, dated dated dated [DATE] revealed that Resident #10 was cognitively severely impaired. A review of the Physician's order showed an order for Remeron Oral Tablet (Mirtazapine), 15 milligrams, at bedtime for depression, which was dated 12/3/24. The Care plan dated 2/5/25 showed to monitor for the following: itching, picking at skin, hypotension, gait disturbance, cognitive impairment, behavioral impairment, decline in appetite, and abnormal involuntary movements. Monitor for the effectiveness of psychotropic drugs such as targeted symptoms/behaviors are controlled and observed for any adverse drug-related symptoms. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not show that any of the behaviors or side effects were monitored or recorded by the nursing team regarding Resident #10. A review of the Psychiatrist's note dated 4/25/25 showed that staff to monitor, document, and report worsening symptoms of depressive symptoms: feelings of sadness/depressed mood hopelessness poor concentration loss of interest/lack of pleasure sleep disturbances tiredness and decreased energy change in weight and appetite feelings of worthlessness/guilt In an interview conducted on 5/6/25 at 3:25 PM with Staff E, a Licensed Practical Nurse (LPN), she stated that Resident #10 is monitored for side effects such as seizures, falls, sleepiness, withdrawal, and dizziness. They monitor behaviors and document in the MAR and TAR in the electronic system. In an interview with the Pharmacist on 5/7/25 at 10:45 AM, he stated that the facility staff should monitor behaviors and side effects for residents on psychotropic medication. He could not show this Surveyor that the behaviors or side effects were completed for Resident #10. 41837 2. Record review for Resident #29 revealed the resident was originally admitted on [DATE] with most recent readmission on 08/06/24 with diagnoses that included in part the following: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Atrial Fibrillation, Anxiety Disorder, and Vascular Dementia. The Minimum Data Set, dated dated dated [DATE] documented in Section C a Brief Interview of Mental Status score of 13 indicating a cognitive response. Review of the Physician's orders for Resident #29 revealed in part the following: An order dated 08/06/24 for Mirtazapine (antidepressant) Oral Tablet 30 MG give 1 tablet orally at bedtime for Depression. An order dated 08/06/24 for Eliquis (anticoagulant) 5 MG Tablet give 1 tablet orally two times a day for AFib. An order dated 04/16/25 Bupropion HCl (antidepressant) Tablet 75 MG give 1 tablet by mouth two times a day related to Depression Record review for Resident #29 including the MAR/TAR for month of May 2025 revealed no monitoring of side effect or behaviors for psychotropic medications and no monitoring of side effects for anticoagulant. Review of the Care Plan for Resident #29 dated 08/13/24 with a focus on the resident is ordered to receive psychotropic medications which increase risk for: hypotension, gait disturbance, cognitive impairment, behavioral impairment, ADL decline, decline in appetite, abnormal involuntary movements. Drug Class: Antidepressant (Bupropion, Mirtazapine). The goal was for the resident to receive the lowest dose possible of the prescribed medication to ensure maximum functional ability both mentally and physically through next review date. The interventions included to monitor the resident for effectiveness of psychotropic drug(s) (i.e. targeted symptoms/behaviors are controlled). Review of the Care Plan for Resident #29 dated 08/13/24 with a focus on the resident is at risk for abnormal bleeding or hemorrhage because of anticoagulant usage (Xarelto). The goal was for the resident to have a reduction of complications associated with anti-platelet/anticoagulant therapy through the next review date. The interventions included to: monitor for and report to nurse any of the following signs of bleeding: bleeding gums, nose bleeds, usual bruising, tarry, black stool or pink/discolored urine. Interview conducted on 05/07/25 at 9:59 AM with the Consultant Pharmacist who was asked if a resident is receiving a psychotropic medication does he check to see if the facility is monitoring for behaviors and side effects, he said yes and he verifies this by running an audit report. The report does not show him the monitoring it will only show the resident and the drugs they are monitoring the behaviors/side effects for. When asked if he checks if the facility monitors for side effects if a resident is receiving anticoagulant, he said he does not and that is up to nursing to monitor. 49060 3. Record review revealed Resident #48 was admitted to the facility on [DATE], a re-admission on 04/14/25 with diagnoses of Dementia, Type 2 Diabetes Mellitus, Psychosis, Depression, and Anxiety Disorder. Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #48 had a Brief Interview for Mental Status (BIMS) of 05, which indicated that she was severely cognitively impaired. Review of the Physician's Orders showed that Resident #48 had orders dated 04/14/25 for Aripiprazole (an antipsychotic medication) Oral 2 milligrams (mg), to give 1 mg daily for Mood Disorder; and Mirtazapine (a psychotropic medication) 7.5 mg to be given at bedtime for Depression. Review of the Care plan dated 03/28/25 documented a focus that Resident #48 had orders to receive psychotropic medications which increased risk for: hypotension, gait disturbance, cognitive impairment, behavioral impairment, ADL decline, decline in appetite, abnormal involuntary movements. The interventions included administer medications as prescribed by the physician, monitor for effectiveness of psychotropic drug(s) (Targeted symptoms/behaviors are controlled), and observe for any adverse drug-related symptoms. Continued review of the Care Plan documented a focus that Resident #48 had behavior problems on 03/29/25 (combative and getting out of bed without assistance), on 04/02/25 combative and refused medications, 04/04/25 combative during care, threaten staff, 04/07/25 and 04/08/25 combative, 04/09/25 calling out for husband, 04/15/25 combative with periods of confusion, 04/16/25 remains combative. Record review of Resident #48's psychiatry consultations dated 04/02/25 and 04/22/25 recommended for staff to monitor, document, and report worsening symptoms of psychosis, depression and anxiety. Review of the April Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed Resident #48 was not monitored for behavior and no interventions in place. In addition, there was no documentation for monitoring side effects for psychotropic medications. 4. Record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Generalized Anxiety Disorder, Major Depressive Disorder, and Psychotic Disorder with Hallucinations. Section C of the MDS revealed Resident #48 had a BIMS of 12, which indicated that she was moderately cognitively impaired. Review of the Physician's Orders showed that Resident #63 had orders dated from 10/18/24 to 02/19/25 for the following psychotropic medications: Memantine 5 mg tablet to be given two times daily for Dementia, Zonisamide 25 mg capsule given at bedtime related to Psychotic Disorder, Donepezil 5 mg tablet given at bedtime for Dementia, and Buspirone 10 mg tablet give three times daily for anxiety. Continued review of the order summary report revealed an order for behaviors - monitor the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care; and to document: 'Y' if monitored and none of the above observed; 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and document findings and interventions. Review of the Care plan dated 03/18/25 documented a focus that Resident #63 had orders to receive psychotropic medications which increased risk for: hypotension, gait disturbance, cognitive impairment, behavioral impairment, ADL decline, decline in appetite, abnormal involuntary movements. The interventions included administer medications as prescribed by the physician, monitor for effectiveness of psychotropic drug(s) (Targeted symptoms/behaviors are controlled), and observe for any adverse drug-related symptoms. Review of the May MAR and TAR revealed Resident #63 was monitored for behaviors, however, there are only check marks which indicated administered. As per the order to monitor behavior a Y or N were to be documented and progress notes to follow with interventions. In addition, there's no monitoring of the side effects of the psychotropic medications. During an interview conducted on 05/06/25 at 3:44 PM with Staff D, Licensed Practical Nurse (LPN), who stated she has worked at the facility for [AGE] years. She stated they monitor behaviors and side effects for residents that are taking psychotropic medications. She also stated the documentation is recorded on the computer under the MAR and TAR because they no longer document in the paper charts. Staff D was accompanied by Staff P, LPN, who stated she has worked at the facility for [AGE] years and she agreed that the documentation is recorded on the computer. An interview was conducted on 05/07/25 at 10:10 AM with the consultant Pharmacist. He stated that if a resident is on a psychotropic medication the resident is to be monitored for behaviors and side effects. A side-by-side review of the monthly behavior report that he runs from the facility revealed that residents are monitored for behaviors of psychotropic medications. He then stated the report lets him know that behavior monitoring is in place; however, he does not know how the facility is doing the monitoring. He also stated that he does not need to see whether the resident is having behaviors because he does his recommendations according to the CMS regulations. 50370 5. Resident #76 was admitted on [DATE] with diagnoses that included Post Traumatic Stress Disorder (PTSD), Wedge Compression Fracture of Second Lumbar Vertebra , Type 2 Diabetes Mellitus, Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms, and Major Depressive Disorder. A review of the most current Minimum Data Set (MDS) assessment, dated 04/21/25, under Section C, revealed a Brief Interview of Mental Status( BIMS) score of 4 indicating Resident #76 had severely impaired cognition. Section I did not include the diagnosis of PTSD. Review of the Physician's Orders for Resident #76 revealed an order dated 09/30/24 for Escitalopram Oxalate Tablet 10 MG, 1 tablet by mouth one time a day for Depression. A review of recent Medication Administration Record (MAR) did not include monitoring for side effects of Escitalopram which might include insomnia and frequent falls. There was no documentation in MAR regarding observation of behaviors related to PTSD triggers. During an interview conducted on 05/06/25 at 11:11 AM with Staff C, Certified Nursing Assistant (CNA), who when asked if she knew Resident #76's triggers, responded, Resident does not have PTSD triggers. When asked about falls, she responded, she does not remember when. In an interview with Staff S, CNA on )05/06/25 4:16 PM who has been working in the facility for 4 months, who when asked about Resident #76's triggers, she stated, I think he is afraid to fall. We asked how many times resident fell , she responded, I do not know. In an interview with Staff T, Registered Nurse (RN) on 05/06/25 4:22 PM , who when asked about Resident #76s triggers, responded, I know resident forgets things, and has to be reminded by Staff. He does not want to remember a certain time in his life every year. When asked if Staff document behaviors and side effects related to antidepressant and other psychotropic medications, she responded' Yes, we do. When asked where Staff document behavior monitoring , she responded, In resident's MAR. During an interview conducted with the Director of Nursing (DON) on 05/08/25 at 1:21 PM, who when asked if Staff monitor behavior of residents on antidepressant, responded, We document them in Medication Administration Record (MAR). When asked if there are correlations with frequent falls and insomnia episodes of Resident #76 with the antidepressive medications, she responded, We have drug evaluations done by the Pharmacy Consultants. We also read Physician progress notes for additional information regarding monitoring for the side effects of medications. If there are falls , we write incident reports. She added that Resident #76 is getting support from the facility Staff and his family. When asked how many times the resident had a fall , she responded, I do not know but Resident #76 had a fall on 1/18/24, 3/19/24, 4/23/24, 5/26/24, 6/9/24, 7/6/24, 11/11/24, 1/24/25, 3/15/25. When asked if they could be related to his medications and the medications' side effects, she responded, Maybe, but physician is aware of what is happening to the resident, and so is the resident's family.

Based on observations, interviews and record review the facility failed to provide pharmaceutical services that assure the accurate acquiring, receiving and dispensing and administering of all medications as well as drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled to include removing discontinued medications timely for 4 of 9 residents reviewed for controlled medications (Residents #56, #13, #68, and #308). The findings included: Review of the facility's policy titled, Medication Reconciliation with an implemented date of 11/28/17 included in part the following: Obtain and transcribe any new orders in accordance with facility procedures. Obtain clarification as needed. Verify medications received match the medications orders. Provide pharmacy consultant access to all medication areas and records for completion of pharmacy services activities. Review of the facility's policy titled, Controlled Substance Storage, dated May 2022, included the following: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Procedures: The director of nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR). 1. Record review for Resident #56 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Encephalopathy, Other Abnormalities of Gait and Mobility, and Unspecified Dementia. The Minimum Data Set, dated dated dated [DATE] documented in Section C a Brief Interview of Mental Status score of 7 indicating severe cognitive impairment. Review of the Physician's orders for Resident #56 revealed an order dated 03/31/25 for Clonazepam 0.5mg give 1 tablet by mouth every 24 hours as needed for Panic Attack for 7 days and was discontinued on 04/07/25. On 05/07/25 at 2:00 PM a review of the controlled medication Clonazepam 0.5mg for Resident #56 was conducted with Staff A Registered Nurse (RN). The controlled medication form listed Clonazepam 0.5mg 1 tablet orally once a day for 7 days. The medication was still in the med cart. During an interview conducted on 05/07/25 at 2:05 PM with Staff A RN who acknowledged the order for the Clonazepam on the bingo card did not match the order in Resident #56's medical record and the medication was discontinued on 04/07/25. When asked about the process when receiving a controlled medication from the pharmacy. Staff A RN stated he checks the medication label on the bingo card and on the control sheet both match the order in the resident's chart. Staff A RN stated the medication should have been removed from the medication cart. During an interview conducted on 05/07/25 at 2:23 PM with the Director of Nursing who was asked about the medication order of Clonazepam for Resident #56, and she acknowledged the order in the resident's record was for PRN and the label on the medication bingo card and the label on the Medication Monitoring/Control Record both listed the medication at routine. The DON stated the receiving nurse is supposed to verify the label on the medication bingo card and the label on the Medication Monitoring/Control Record should both match the order in the resident's record. The DON also acknowledged the order in the resident's record was discontinued on 04/07/25 and should have been removed from the med cart at that time. 49060 2. Record review for Resident #13 revealed that the resident was admitted to the facility on [DATE] with a re-admission on 06/14/24 with diagnoses of Generalized Anxiety Disorder; Mood Disorder Due To Known Physiological Condition; Major Depressive Disorder; Adjustment Disorder with Anxiety and Dementia. Review of the Physician's order dated 08/08/24 showed that Resident #13 had an order for Clonazepam (a psychotropic medication) 0.5 milligrams (mg) tablet to be given every 8 hours for anxiety (at 0000 (12:00 AM), 0800, 1600 (4:00 PM).) On 05/07/25 at 5:30 PM, a side-by-side review of Resident #13's Medication Monitoring/Control Record sheet for Clonazepam 0.5 mg tablet was conducted with Staff P, Licensed Practical Nurse (LPN). The review revealed that Clonazepam 0.5 mg medication packet was received by a nurse on 04/25/25 containing a total of 42 tablets. From 04/26/25 to 05/07/25, one (1) tablet of Clonazepam 0.5 mg was removed from the controlled substance box 3 times daily and at the time of the observation, 6 tablets remained in the packet, which matched the amount remaining on the Medication Monitoring/Control Record sheet. According to the Medication Monitoring/Control Record sheet: on 04/27/25 at 12:13 AM, the amount on hand of Clonazepam 0.5 mg was 38 tablets, given 1 tablet, remaining 37 tablets. on 04/27/25 at 0800 AM, the amount on hand was 37 tablets, given 1 tablet, remaining 36 tablets on 04/27/25 at unable to read the time, the amount on hand was 36, given 1 tablet, remaining 35 tablets. on 04/28/25 at 0008 (12:08 AM), the amount on hand of Clonazepam 0.5 mg was 34, given 1 tablet, remaining 33 tablets. No additional documentation was recorded for the discrepancy (the amount on hand should have been 35). on 04/28/25 at 0900, the amount on hand was 33, given 1 tablet, remaining 32 tablets on 04/28/25 at 1625 (4:25 PM), the amount on hand of Clonazepam 0.5 mg was 32 given 1 tablet, remaining 31 tablets. 3. Record review for Resident #68 revealed that the resident was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus with Diabetic Nephropathy, Major Depressive Disorder, Metabolic Encephalopathy and Ventricular Tachycardia. Review of the Physician's order dated 08/08/24 showed that Resident #68 had an order for Tramadol (a controlled substance for pain) 50 milligrams (mg) tablet to be given daily for nonacute pain. On 05/07/25 at 5:30 PM, a side-by-side review of Resident #68's Medication Monitoring/Control Record sheet for Tramadol 50 mg tablet was conducted with Staff P, Licensed Practical Nurse (LPN). The review revealed that the medication packet was received by a nurse on 04/10/25 containing a total of 29 tablets and at the time of the observation (05/07/25), 6 tablets remained in the packet, which matched the amount remaining on the Medication Monitoring/Control Record sheet. According to the Medication Monitoring/Control Record sheet Resident #68 was administered Tramadol 50 mg from 04/10/25 to 05/07/25. Continued review of the Medication Monitoring/Control Record sheet revealed the following: on 04/15/25 one (1) tablet of Tramadol 50 mg was removed from the controlled substance box and not recorded as wasted on 04/26/25 the amount on hand of Tramadol 50 mg was 15 tablets, given 1 tablet, remaining 14 tablets on 04/27/25 the amount on hand of Tramadol 50 mg was 14 tablets, given 1 tablet, remaining 13 tablets on 04/28/25 the amount on hand of Tramadol 50 mg was 13 tablets, given 1 tablet, remaining 13 tablets on 04/29/25 the amount on hand of Tramadol 50 mg was 13 tablets, given 1 tablet, remaining 12 tablets on 04/29/25 the amount on hand of Tramadol 50 mg was 12 tablets, given 1 tablet, remaining 11 tablets on 05/06/25 the amount on hand of Tramadol 50 mg was 6 tablets, given 1 tablet, remaining 5 tablets on 05/06/25 the amount on hand of Tramadol 50 mg was 5 tablets, given 1 tablet, remaining 4 tablets. Review of Resident #68's April and May Medication Administration Record (MAR) revealed that the Tramadol 50 mg removed from the controlled substance box on 04/15/25 was not documented on the resident's MAR as being administered. Continued review of the April and May MAR revealed that on 04/29/25 and on 05/06/25 Tramadol 50 mg was documented as administered once, while two Tramadol 50 mg tablets were removed from the controlled substance box on those days. Furthermore, no other documentation was found as to why Resident #68 was administered Tramadol 50 mg twice on those days instead of daily as per physician's order. During an interview conducted on 05/08/25 at 9:20 AM with Staff I, Registered Nurse (RN), who stated she has worked at the facility for 2 years. She stated she first reviews the physician's order, removes the medication from the controlled substance box, administers the medication to the resident and then documents in the MAR and in the Medication Monitoring/Control Record sheet. A side-by-side review of both residents' (Resident #13 and Resident #68) Medication Monitoring/Control Record sheets and MARs was conducted with Staff I, who was unable to explain the discrepancies. During an interview conducted on 05/08/25 at 2:44 PM with the Director of Nursing (DON), who stated pharmacy comes in monthly and conducts audits for all medications including controlled substance drugs. In addition, the DON stated that routine, random audits of the medications, monthly or quarterly, are conducted by the unit managers or herself; however, if a resident or family member has a concern with a medication not being administered, then the audits are conducted daily. The DON was then asked if reconciliation of the controlled substance medications is conducted and she stated the nurses reconcile the controlled drugs every change of shift. The DON also stated the nurses are to sign the Medication Monitoring/Control Record sheet when the medication is removed from the controlled substance box, administer the medication to the resident and then document in the MAR as administered. At this time, a side-by-side review of both residents' (Resident #13 and Resident #68) Medication Monitoring/Control Record sheets and MARs was conducted with the DON. She acknowledged that there are discrepancies with the reconciliation of the controlled substance medications. 50370 4. A record review revealed Resident #308 was admitted to the facility on [DATE] with diagnoses that included Displaced Obliqued Fracture of Base of the Neck of Left Femur, Muscle Weakness, and Other Abnormalities of Gait and Mobility. A review of the most current Minimum Data Set (MDS) assessment, dated 05/02/25, under Section C, revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating Resident #308 had good mental cognition. A review of Physician orders for Resident # 308 revealed an order dated 04/18/25 for Tramadol Hydrochloride 50 mg oral tablet every 6 hours as needed for non-acute pain. A review of the Control Drug Record for Resident #308 for Tramadol 50 mg every 6 hours as needed documented the drug was signed out and given on 04/25/25 at 5:30 AM. A review of Medication Administration Record for Resident #308 for 04/25/25 did not have any documentation for Tramadol 50 mg one tablet being administered on 04/25/25 at 5:30 AM. During an interview conducted on 05/08/25 at 11:16 AM with Staff L, Registered Nurse (RN) who was asked how she verifies that a controlled medication was administered in the MAR, responded, I will see a check mark, the Nurse's initials and the time the medication was given parallel to the medication's name. When asked what marks indicate that the medication was not administered, she stated, I will see a blank box or an x in a designated box parallel to the medication name and the date. When Staff L, RN was shown Resident #308's MAR for Tramadol 50 MG ( milligram), with a start date 0f 04/18/25 revealed an x on 04/25/25 box. When Staff L, RN was asked what it means, she responded, Tramadol was not administered to Resident #308 on that date. During an interview conducted with the DON on 05/08/25 at 11:55 AM who was asked when a controlled drug is being administered, how do Nurses document, responded, The Nurses document on the Controlled Drug Record and in the resident's Medication Administration Record.

Based on observations, record reviews and interviews, the facility failed to follow the Physician orders regarding oxygen therapy for 8 of 8 sampled residents (Residents #25, #49, #50, #99, #20, #29, #22, and #44). The facility also failed to correctly document oxygen therapy on Minimum Data Set (MDS) assessment for 3 of 8 sampled residents (Residents #49, #50, and #99). The Findings included: 1) Resident # 25 was admitted to the facility on [DATE] with diagnoses that included Heart Failure, Presence of Cardiac Pacemaker, Acute Kidney Failure, Type 2 Diabetes Mellitus and Chronic Obstructive Pulmonary Disease. A review of the annual Minimum Data Set (MDS) assessment, dated 03/06/25, under Section C, revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating Resident #25 had good mental cognition. Section O revealed no oxygen therapy . An additional review of records revealed Resident #25 recently received oxygen via nasal cannula on these dates and times: on 04/30/25; on 05/02/25; on 05/05/25 and 05/06/25. A review of Pulmonary progress notes dated 3/19/25 revealed Resident #25's problems included shortness of breath and unspecified cough. Additional notes revealed Resident #25's dependence on supplemental oxygen. During an observation on 05/05/25 at 9:48 AM, Resident #25 was observed sitting opposite an oxygen concentrator with an inspection date of 10/2023. The oxygen tubing connected to the concentrator was not dated, and the concentrator was off. When he was asked if he is currently receiving an oxygen therapy, he responded, I use it while I am in bed. A review of the Physician Orders revealed an order dated 4/22/24 for oxygen at 1 to 4 Liters via nasal cannula as needed to keep oxygen saturation above 93 %. A record review of the nursing care plan did not include goals, plans and interventions for oxygen therapy. 2) Resident #49 was admitted to the facility on [DATE] with diagnoses that included Thyroid Disorder, Cardiomegaly, Dementia, Pneumonia and Heart Failure. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], under Section C, revealed an empty space on a Brief Interview of Mental Status (BIMS), indicating no score for mental cognition. Section O revealed Resident #49 does not receive oxygen therapy. A review of Physician order dated 10/25/24 revealed oxygen at 1 to 4 Liters via nasal cannula as needed for oxygen saturation less than 90 %. An additional review of records revealed Resident #49 received oxygen via nasal cannula on these dates: 05/01/25, 4/23/25, 3/26/25, 3/5/25, 2/23/25. During an observation on 05/05/25 at 09:56 AM, Resident #49 was observed with a nasal cannula infusing at 2 Liters per minute, connected to a concentrator with an inspection date of 10/2023. Closer observation revealed the oxygen tubing was not dated. Additional observation revealed a suction machine on top of the bedside table. The nebulizing tubing and mask connected to another small machine were both undated and not contained. In an Interview with Staff J, RN on 05/07/25 at 3:21 PM who has been working in the facility for less than 3 months, who when asked regarding oxygen therapy care for residents, stated, We provide oxygen therapy with physician's orders. When asked regarding dating oxygen tubing, she responded that it is changed every Sunday during the night shift and as needed. She stated that Staff put the date on the oxygen tubing when it was changed. In an interview with MDS Coordinator on 05/08/25 at 11:57 AM, who when asked if Resident #49 was receiving oxygen therapy per MDS assessment done on 4/20/25, responded, No, Resident #49 was not on oxygen therapy. When asked how she verifies that residents receive oxygen, she responded, I check the doctors' orders. 3) Resident # 50 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Degenerative Disease of Basal Ganglia, Cerebral Infarction, Hypertension, Type 2 Diabetes Mellitus, Multiple Fractures of Ribs, Right Side, and Dysphagia. A review of the most recent Minimum Data Set (MDS) assessment, dated 03/12/25, under Section C, revealed no score for Brief Interview of Mental Status (BIMS) indicating unknown mental cognition. Section O revealed a no response to oxygen therapy, indicating Resident #50 does not receive oxygen therapy. A further review of nursing care plan initiated on 7/25/24 and quarterly reviewed on 10/31/24 revealed a focus on oxygen therapy at 2 Liters per minute as needed to maintain oxygen saturation of 92 %. The interventions included changing oxygen tubing every week on Sundays, during night shift. During an observation on 05/05/25 at 9:56 AM, Resident #50 was wearing a nasal cannula on both nares while being fed by a CNA. Further observation revealed the oxygen tubing was not dated. 4) Resident #99 was admitted to the facility on [DATE] with diagnoses that included Traumatic Subdural Hemorrhage with Loss of Consciousness, Spinal Stenosis of the Lumbar Region with Neurogenic Claudication, and Obstructive Sleep Apnea. A review of the recent Minimum Data Set (MDS) assessment dated [DATE], Section O for oxygen therapy revealed a no response, indicating Resident #99 was not receiving oxygen therapy. A record review of Physician order dated 3/23/25 revealed to change oxygen tubing weekly when in use, and label tubing with a date every Sunday. A review of Nursing care plan revealed no focus, goals and interventions for oxygen therapy. A review of May 2025 MAR revealed a check mark, and Nurses initials on 05/04/25, indicating the oxygen tubing was changed, and labeled with a date. During an observation conducted on 05/05/25 at 10:05 AM, it revealed a mask connected to a machine by an undated tube. Further observation revealed the mask was not securely contained but placed on top of the bedside table. An oxygen concentrator with an undated tubing was also observed. During an observation on 05/06/25 at 10:06 AM, there was no oxygen sign at Resident #99's door. In an interview with the MDS Coordinator on 05/08/25 at 12:02 PM, who when asked why some Residents have inaccurate MDS assessment for oxygen therapy, responded, Each MDS Coordinator has different set of residents to assess, so she cannot answer for the assessments performed by other MDS Coordinators. When asked if they conduct MDS review for accuracy of assessments, she responded, I will update all MDS assessments of all residents with oxygen therapy today. 41837 5) Record review for Resident #20 revealed the resident was originally admitted to facility on 02/01/19 with most recent readmission on 08/18/24 with diagnoses that included in part the following: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Morbid (Severe) Obesity Dependence on Supplemental Oxygen, Sleep Apnea, and Respiratory Failure Unspecified. The Minimum Data Set, dated dated dated [DATE] documented in Section C a Brief Interview of Mental Status score of 10 indicating a moderate cognitive response. Review of the Physicians orders for Resident #20 revealed in part the following: An order dated 08/18/24 Oxygen at 2 liters per minute via nasal canula continuously maintain oxygen saturation at 92%. An order dated 08/18/24 Oxygen: Change O2 tubing every 72 hours when in use. An order dated 08/28/24 Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 6 hours as needed for Shortness of Breath or Wheezing via nebulizer. In summary there was no order to change nebulizer tubing. Review of the Treatment Administration Record for Resident #20 for the month of April 2025 and May 2025 documented the oxygen tubing was changed only on Sundays, not every 72 hours. Review of the Medication Administration Record for Resident #20 documented for the month of April 2025 and May 2025 the resident was wearing oxygen continuously. Review of the Care Plan for Resident #20 with a focus on the resident on Oxygen Therapy via nasal cannula at 2L/M continuously with humidifier due to COPD. Resident #20 is also using a C-PAP machine. The goal was for the resident to have decreased episode of respiratory distress by next review date. The interventions included in part the following: Change O2 tubing every week when in use every night shift every Sunday. Change neb tubing every week every night shift every Sunday. On 05/05/25 at 09:48 AM an observation was made of Resident # 20 sitting up in bed wearing oxygen connected to an oxygen concentrator that had a service label on the concentrator of 09/26/23, the nebulizer tubing was in a plastic bag on nightstand with no date on the nebulizer tubing or on the plastic bag. 6) Record reviewrevealed Resident #22 was admitted [DATE] with diagnoses that included in part the following: Dementia, Chronic Obstructive Pulmonary Disease, Generalized Anxiety Disorder, and Major Depressive Disorder Recurrent Moderate. The Minimum Data Set, dated dated dated [DATE] documented in Section C that the Brief Interview of Mental Status was not attempted due to the resident is rarely/never understood. Review of the Physician's Orders for Resident #22 revealed in part the following: An order dated 03/13/25 for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally two times a day for Shortness of Breath and 1 vial inhale orally every 6 hours as needed for Shortness of breath. There was no order to change nebulizer tubing. On 05/05/25 at 9:30 AM an observation was made of Resident #22 sitting up in bed with 2 nebulizer masks in 2 separate plastic bags one dated 04/03/25, the other was dated 04/21/25. 7) Record review for Resident #29 revealed the resident was originally admitted on [DATE] with most recent readmission on 08/06/24 with diagnoses that included in part the following: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Paroxysmal Atrial Fibrillation, Anxiety Disorder, and Vascular Dementia. The Minimum Data Set, dated dated dated [DATE] documented in Section C a Brief Interview of Mental Status score of 13 indicating a cognitive response. Review of the physician's orders for Resident #29 revealed in part the following: An order dated 08/23/24 O2@ 2L/min PRN to maintain Saturating greater than 92% An order dated 01/14/25 Ipratropium-Albuterol Solution 0.5-2.5 (3) MG\/3ML 1 vial inhale orally every 6 hours for COPD In summary there were no orders to change nebulizer tubing. Record review for Resident #29 revealed no documentation of nebulizer tubing being changed. Review of the Care Plan for Resident #29 dated 08/13/24 with a focus on the resident is at risk for respiratory distress due to history of shortness of breath (SOB)/COPD / Dyspnea/ Hypoxia and the resident uses oxygen therapy as needed. The interventions included in part the following: Change neb tubing every 72 hours when in use on night shift Sunday. Change oxygen tubing weekly or as indicated. On 05/05/25 at 09:20 AM an observation was made of Resident #29 in bed not wearing oxygen, nebulizer mask was in a plastic bag on the nightstand with no date on the nebulizer tubing or the plastic bag it was in. During an interview conducted on 05/06/25 at 2:14 PM with Staff A, Registered Nurse, who stated he has worked at the facility for just over 1 year. When asked about oxygen tubing and nebulizer mask tubing being changed, he said the night shift does that on Sundays. On 05/06/25 at 2:30 PM a side-by-side observation was made with Staff A RN who acknowledged the nebulizer masks for Residents # 29, #22 and #20 were dated over a week ago. 49060 8) During the facility initial tour on 05/05/25 at 9:49 AM, Resident #44 was observed in her room in her Geri chair and not wearing a nasal cannula for oxygen therapy. Further observation revealed that there was no oxygen concentrator and no oxygen tubing in the resident's room. On 05/06/25 at 11:15 AM observed Resident #44 in bed and not wearing a nasal cannula for oxygen therapy as ordered. On 05/07/25 at 2:07 PM observed Resident #44 in bed and not wearing a nasal cannula for oxygen therapy as ordered. Resident #44 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included: Dementia, Type 2 Diabetes Mellitus, Dysphagia, Hypertension and Encephalopathy. Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #44 had a Brief Interview for Mental Status of 00, which indicated that she was rarely understood. The order summary report showed an order for Oxygen at 2 Liters (L) continuous via nasal canula dated 10/17/23. Review of the Care Plan dated 04/20/25 documented a focus that Resident #44 is on Oxygen Therapy via nasal cannula at 2 L via nasal cannula continuously for shortness of breath, with interventions that included change oxygen tubing every week on a Sunday during night shift, check for proper fit of cannula or mask as needed, check rate of Oxygen flow every shift, notify doctor as needed for changes or complications and provide oxygen as ordered. During an interview conducted on 05/08/25 at 2:44 PM with Staff I, Registered Nurse (RN), who stated she has worked at the facility for 2 years. She stated she is not sure if Resident #44 is on Oxygen therapy. Then, a side-by-side review of Resident #44's physician's orders with Staff I revealed that Resident #44 has an order for continuous oxygen 2 L via nasal canula. Then Staff I and this surveyor went to Resident #44's room, and she was asked if the resident was currently receiving oxygen therapy and she replied no. Further observation by Staff I revealed that there was no oxygen concentrator and no oxygen tubing in the room. She then acknowledged that the resident should have the oxygen by the bedside.

Based on observation, interview, and record review, the facility failed to follow their policy for urinary catheter care and failed to follow care plan interventions for catheter care, for 1 of 3 sampled residents (Resident #26). The findings included: Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Aphasia, Contracture of the Right Hand, Chronic Kidney Disease, and Neurogenic Bladder. A review of quarterly Minimum Data Set (MDS) assessment, dated 03/17/25, under Section C, revealed a Brief Interview of Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. A review of the Nurse Practitioner progress notes dated 04/22/25, revealed Resident #26 had an indwelling urinary catheter draining clear light-yellow urine under genitourinary examination; right hemiplegia, non-ambulatory, and decreased upper and lower extremity strength under neurologic examination; alert, oriented x 2, with poor eye contact, judgement, insight impaired, and flat affect under psychological examination. Review of the quarterly care plan, dated 12/17/24, revealed a focus on an indwelling urinary catheter related to Obstructive Uropathy. The goal included Resident #26 will remain free from catheter -related trauma through review date. The interventions included: catheter urinary drainage; catheter care every shift; secure catheter to leg to prevent migration and abrupt dislodgement every shift. During an observation on 05/06/25 at 10:00 AM, Resident #26's urinary catheter tube was not secured or clipped to resident's leg to prevent tube migration to prevent migration or accidental dislodgement of the urinary catheter. During another observation on 05/07/25 at 9:10 AM, Resident #26's urinary catheter tube was not secured or clipped to resident's leg to prevent tube migration. During an observation on 05/07/25 at 12:13 PM, Staff W, Certified Nursing Assistant (CNA), and Staff X, CNA stated they will perform urinary catheter care for Resident #26. They both performed hand washing, donned on gloves and assembled supplies needed for the urinary catheter care. They did not don on gowns. Staff W, CNA told Resident #26 what she was planning to do and loosened Resident #26's brief and exposed the urinary catheter tube. It was observed that the urinary catheter tube was not secured using a visible blue clip to prevent migration and accidental dislodgement. Both Staff stated that the urinary catheter tube was not secured to Resident #26's leg to prevent moving and accidental dislodgement. After the catheter care and brief changing were completed, they did not secure the catheter tube onto Resident #26's leg. In another observation on 05/08/25 at 9:09 AM, Resident #26's catheter tubing was not secured to the resident's leg. In an interview with the Director of Nursing (DON) on 05/08/25 at 2:00 PM, when asked if Nurses follow the urinary care plan, she responded, Nurses are educated to follow the interventions on the care plan.

Based on observations, interviews, and record review, the facility failed to follow their Fall policy including implementation of fall interventions for 1 of 3 residents reviewed for accidents (Resident #70), and failed to prevent and have an effective response for a resident who eloped for 1 of 1 resident reviewed for elopement (Resident #259). The findings included: Review of the facility's policy titled, Elopements and Wandering Residents, date implemented 11/28/17, included in part the following: Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. The facility is equipped with door locks/alarms to help avoid elopements. Unannounced drills at least twice yearly to be done across all shifts and as needed depending on the ongoing identified wandering/exit seeking behaviors. The facility may complete an after action review process to help us develop an actionable after action report (AAR). The process will include a roundtable discussion that includes leadership, department leads and critical staff who can identify and document lessons learned and necessary improvements in an official AAR. The AAR, at a minimum, should determine a) what was supposed to happen; b) what occurred; c) what went well; d) what the facility can do differently or improve upon; and e) a plan with timelines for incorporating necessary improvement. Review of the facility's policy titled, Fall Prevention Program with an implemented date of 11/28/17 included in part the following: Fall refers to unintentional change in position coming to rest on the ground, floor, or other lower level. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. When any resident experiences a fall, the facility will: c. Complete an incident report and notify MD and responsible parties. e. Implement immediate intervention within the first 24 hours. H. Monitor staff compliance and resident response. 1. On 05/07/25 around 12:00 PM, the surveyor team was made aware by the Administrator that Resident #259 had left the facility early this morning unauthorized, unaccompanied and an investigation was started. Review of the facility's investigation revealed that on 05/06/25 at 11:00 PM Resident #259 was in bed sleeping. On 05/07/25 at 1:00 AM and 2:00 AM Resident #259 was observed sleeping in bed. At approximately 3:15 AM, the nurse heard an alarm going off and immediately went to see what was happening. The nurse went and checked all residents and found that Resident #259 was not in his bed. The nurse notified all the staff on duty, and everyone began to search inside the facility and then outside of the facility. The search was extended to the back and west side of the facility, and to the neighboring areas. At 3:48 am, the DON/Risk manager was called for notification, and she advised the nurse to call police to assist with the search. At approximately 3:57 am, the police officers were at the facility receiving report and description of the resident. Three minutes later (4:00 am) officers in facility received notification that police officers had located the resident walking down the road on [NAME] Boulevard based on the description provided. At approximately 04:15 am Resident #259 was escorted back to the facility with the police officer unharmed. Full body assessment done with no findings. He was moved to a room closer to the nurse's station and began a safety check every 30 minutes. Resident #259 was asked why he left without notifying staff and he responded, he was taking a walk. The facility also put the following corrective actions in place: Room changed closer to nursing station. [NAME] 30 minutes safety check in process until further notice. Elopement assessment completed as he is now at risk. Wander guard bracelet in place on his person. Elopement information in circulation to raise awareness. Elopement care plan initiated. Will initiate one to one sitter at night until discharge from the facility. An in-service was conducted to all staff regarding responding to alarms. Another BIMS score was done today 5/7/25 at 11:00 AM which showed a score of 14, which indicated he was cognitively intact. Record review for Resident #259 revealed that the resident was admitted to the facility on [DATE] with diagnoses that included: Hydrocephalus, Dementia, Hypertension and presence of Cerebrospinal Fluid Drainage Device. On 05/02/25 a Brief Interview for Mental Status (BIMS) conducted with a score of 14 of 15, which indicated that he had an intact cognitive response. On 05/05/25 an Elopement Risk Assessment/Evaluation was conducted for Resident #259 which revealed he was not at risk for elopement. Review of the Physician's Orders showed that Resident #259 had orders dated 05/02/25 for Levetiracetam 1000 milligrams (mg) tablet give two times daily for Seizures and Nicotine Patch 24 Hour 7 mg/24 hour apply 1 patch transdermal daily for Smoking Cessation for 3 Weeks and remove per schedule, 05/03/25, end date: 05/24/25. During an interview conducted on 5/7/25 at 12:00 PM with Resident #259, who was asked if he had left the facility and he responded that he had gone for a walk and was not told that he could not leave the facility or the property. When he was asked if he returned to the facility with a staff member or own his own, Resident #259 was reluctant to answer and said he did not recall that anyone accompanied him. During an interview conducted on 05/07/25 at 3:30 PM with Staff J, Registered Nurse (RN), who stated she has been working at the facility for less than 3 months, usually works the 11-7 shift, and volunteered today to work the 3-11 shift. She stated she worked last night at the [NAME] wing, assigned to Resident #259. She stated depending on what she is doing, if she is finished with the medication pass, she does her rounds every 2 hours and starts on her documentation. She stated Resident #259 did not have any medications scheduled for administration during the night and the last time she saw him was around 2:00 AM. Staff J also noted she did not see Resident #259 walking in the hallway or passing by the nurses' station during the night. She was at the nurses' station when she heard a beep, beep noise and at first, she thought it was a call light going off; however, no lights appeared to be on. Then, she thought that it might be a resident with a wander-guard who got too close to the emergency exit door. The alarm did not appear to get louder and it was not continuous. She then stated that she went into the hallway and noticed the noise was louder from the back end of the facility (near Resident #259's room) and immediately started to check in the rooms for residents. She called the other nurse that was at the nurses' station for assistance, she looked in Resident #259's room and noticed that the resident was not in the room, or the bathroom. Staff J acknowledged not knowing the code for the emergency exit door to stop the alarm noise. By that time, all the staff were assisting her to look for the resident inside the building and then a few of the staff went outside and searched in the back and front of the facility, basically all around the facility towards the hotel. At this time, Staff J stated that they did not see Resident #259 and the Director of Nursing (DON) was called and she advised to contact the police for assistance in locating the resident. She stated she spoke with the resident when he returned to the facility and he stated, I was just taking a walk. Staff J was asked if she received elopement education and participated in drills to which she replied that she has received training; however, does not recall doing any drills for elopement. Then Staff J was asked if there's a different alarm noise for when there's a wander-guard near the door or when the door is pushed open and she stated did not know. An interview was conducted on 05/07/25 at 3:30 PM with the Administrator near the [NAME] emergency exit door closest to Resident #259's room on the night of the elopement. He stated that if you press lightly on the door it will beep, beep, etc. for 15 seconds, then the light on the top of the door will turn from red to green; if the door is opened, it will then make a continuous beeping sound until the code is entered on the keypad. Only certain staff personnel have the code, usually one of the nurses. During an interview conducted on 05/08/25 at 7:17 AM with Staff K, Certified Nursing Assistant (CNA), who stated she has worked at the facility for over [AGE] years. She has been working the 11-7 shift for the last [AGE] years, usually assigned at the [NAME] wing and on that night (05/06-05/07/25) she was assigned to Resident #259. She stated that at the beginning of her shift she makes her rounds and checks on the residents. Staff K confirmed that Resident #259 is able to make his needs known, can walk around independently and does not require any walking device. When she saw Resident #259 at around 11:15 PM, he was trying to get out of bed to go to the bathroom, and she assisted with changing his brief and went back to bed and covered him with the blanket. She returned at 1:00 AM and saw him in bed with the covers on him. Between 2:00 and 2:15 AM, she again saw Resident #259 was in bed half covered and thought maybe he went to the bathroom, she left him half covered because he appeared to be sleeping. Around 3:00 AM, she was assisting another resident when she heard the nurse talking outside of the room by the nurses' station that Resident #259 was not in his room, she went out of the room to see what was going on, and that's when she heard the continuous beeping of the alarm. At this time, she assisted in the search for Resident #259 inside the facility and then outside (front and back of the facility). Staff K stated all staff have the emergency codes printed on their ID badge, code green is for elopement and at night they do not use the overhead speaker. She stated she has participated in the Mock drills in the past; the beep, beep sound means that someone touched the door, if continue to touch the door for 15 seconds the beep, beep will continue, and it will change sound when the door is opened to a continuous loud beeping. Staff K was asked what she would do if she heard the change of sound from beep, beep to continuous beeping, she replied, she would look outside first because it would mean someone opened the door. An interview was conducted on 05/08/25 at 8:54 AM with the DON. She stated she received a few phone calls that night from the nurses including Staff J, RN. The DON stated Staff J was calling to let her know that they were looking for Resident #259 and then the DON advised Staff J to call the police for assistance in locating the resident and then notify the family. Then the DON stated while she was on her way to the facility, the staff called her that the police had found Resident #259. She stated she went to see the resident around 4:25 AM but was sound asleep. She then spoke with the staff who stated they heard the alarm towards the back of the facility on the [NAME] wing and Staff J provided a statement in which she believed that the resident went out using the emergency exit door located in the back of the [NAME] wing. The DON also stated that Staff J stated she immediately responded and searched the rooms and did not see him in his room so she got all other staff members to go on search, started the search in the facility and then went outside. The DON was asked how often and who runs elopement drills, in which she responded that drills are done by maintenance, managers, herself and the social worker; and the drills are done quarterly, and as needed. The DON confirmed that Beep, beep for 15 minutes is a warning that someone is by the door and continuously beeping suggest that the door was pushed open, the alarm continues to beep until the code is entered to stop it. At this point, the DON acknowledged that the nurses should have responded accordingly and more education and drills will be conducted. 41837 2. Record review for Resident #70 revealed the resident was originally admitted to the facility on [DATE] with a most recent readmission on 12/13/24 with diagnoses that included in part the following: Cerebral Infarction, Glaucoma, Muscle Weakness (Generalized), Seizures, Other Lack of Coordination, Anxiety Disorder, Contracture Left Elbow, Contracture Left Wrist, and Contracture Left Ankle. The Minimum Data Set, dated dated dated [DATE] documented in Section C a Brief Interview of Mental Status score of 7 indicating severe cognitive impairment. Review of facility incident log revealed Resident #70 had an unwitnessed fall on 04/13/25. The Fall Risk Evaluation for Resident #70 completed 09/29/24 documented a score of 12 indicating at risk. The Fall Evaluation Morse for Resident #70 completed 04/14/25 documented a score of 75 indicating a high risk for falling. The Health Status Note for Resident #70 dated 04/13/25 at 2:00 AM documented, during midnight round at 12:53 AM, writer observed resident laying down on the floor. Writer questioned resident regarding the incident and how she found herself lay down by her bedside. Resident stated I am trying to go back to the dining room for the party. Writer oriented resident mentioned that it passed midnight it is bedtime, the dining room is close at this time, she can go back when it open at 0800 AM. Resident insisted that she must go right now, despite multiple tries to orient resident back to reality she is constantly ignoring me and started using profanity. Writer transferred resident back to bed assisted by two nursing assistants. Physical, and neuro assessment performed, no physical injury, no abrasion, no bruises noted, she was able to squeeze my hands when asked to, pupil reacted to light, she was able to move her upper/lower extremities w/o difficulty. Vitals are within normal range. Resident was changed she remains clean and dry and made comfortable in bed. All safety precautions maintained, by keeping the bed low to the ground, wheels are locked, head of bed placed at 45 degrees to facilitate a comfortable breathing pattern. Staff will continue with frequent rounds and continue to educate resident on fall prevention and encouraged resident to continue using the call light for assistance. The Health Status Note for Resident #70 dated 04/13/25 at 11:03 AM documented post fall follow up, resident observed in bed no s/s of pain noted, denies pain or any discomfort, appeared to be stable, consumed up to 80 % of her breakfast. Safety measures maintained and reinforced. Assigned nurse will continue with care. The Health Status Note for Resident #70 dated 04/13/25 at 2:50 PM documented, received resident in bed alert and verbally responsive. S/P fall in progress no C/O pain or discomfort. Resident is able to move all extremities. Routine meds administered as prescribed and well tolerated. Kept clean and dry. Bed is in lowest position. Call light within reach. The incident report for Resident #70 dated 04/13/25 for un-witnessed fall/observed on floor documented the Physician was notified on 04/14/24 at 10:14 AM (more than 24 hours post incident). Review of the Care Plan for Resident #70 dated 05/24/24 with a focus on I am at risk for a fall related to injury. The goal was for the resident to have a reduction in falls and related injuries through next review date. The interventions included in part the following: Floor mats at bedside dated 04/13/25. Review of the Physician's Orders for Resident #70 revealed no orders for floor mats at the bedside. On 05/05/25 at 10:19 AM an observation was made of Resident # 70 lying in bed with 2 floor mats, one behind the bed and the other on the resident's left side of bed. On 05/05/25 at 1:25 PM a second observation was made of Resident #70 lying in bed with only one floor mat next to the bed. During an interview conducted on 05/05/25 at 10:19 AM Resident #70's daughter said her mother had a fall a couple of weeks ago and she is afraid her mother will fall again, this is one of her biggest fears. She came in yesterday (Sunday 05/04/25) and there were no floor mats on side of bed, so she pulled one out from behind the resident's bed and put it on the floor next to the bed by herself. During an interview conducted on 05/06/25 at 2:14 PM with Staff A, Registered Nurse, who stated he has worked at the facility for just over 1 year. When asked if a resident has a care plan intervention for floor mats at bedside when would the resident have the floor mats at the bedside, Staff A RN stated they would just leave the floor mats on the floor next to each side of the bed all the time. During an interview conducted on 05/07/25 at 10:35 AM with the Infection Preventionist (IP) who stated she has worked at the facility since 2020. When asked if a resident has an unwitnessed fall what do they do, who do they notify and where do they document the information. The IP stated they would do neuro checks and notify the physician and the family and the notification of physician and family would be documented in the notes. When asked about floor mats at the bedside, the IP stated they would be placed on each side of the bed while the resident was in bed.

Based on observations, interviews and record reviews, the facility failed to accurately document the Comprehensive Assessments for 4 of 30 sampled residents (Residents #13, #49, #76, and #26), related to diagnoses, vision, and oxygen use. The Findings included: 1) Record review for Resident #13 revealed that the resident was admitted to the facility on [DATE] with a re-admission on 06/14/24 with diagnoses of Generalized Anxiety Disorder; Mood Disorder Due To Known Physiological Condition; Major Depressive Disorder; Adjustment Disorder with Anxiety and Dementia. The order summary report showed orders for 3 psychotropic medications, Buspirone HCl 15 milligrams (mg) tablet two times daily for Anxiety, Clonazepam 0.5 mg tablet every 8 hours for anxiety, and Depakote Delayed Release 125 mg, give 3 tablets three times daily for Mood Disorder. Review of Section I of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #13 had diagnoses of Coronary Artery Disease, Hypertension, Non-Alzheimer's Dementia, Anxiety Disorder, and Schizophrenia. Review of Resident #13's psychiatry assessments dating back to re-admitted (06/14/24) revealed diagnoses of Depression, Anxiety Disorder, Schizoaffective Disorder, however, no documentation of Resident #13 being diagnosed with Schizophrenia. During an interview conducted on 05/08/25 at 3:09 PM with Staff O, MDS Registered Nurse (RN), who stated she has worked at the facility for 5 years. She stated the nurses are responsible for entering the physician orders and she is responsible for entering the diagnoses for the residents. Staff O stated that during morning clinical meetings she receives new information for the residents including any new diagnoses and then inputs them into the resident's medical record. Staff O noted that the MDS is then updated with the new diagnosis on the next quarterly or annual MDS for that resident. At this time, a side-by-side record review of Resident #13's MDS and medical diagnoses was conducted with Staff O, who acknowledged that Resident #13 was coded for Schizophrenia in the MDS while there was no medical report (psychiatry notes) or record indicating Resident #13 had such a diagnosis. 2) Resident #49 was admitted on [DATE] with the diagnoses that included Non-Pressure Chronic Ulcer of the Left Lower Leg, Psychotic and Mood Disturbance, Congestive Heart Failure, and Heart Failure. A review of the most current Minimum Data Set (MDS) assessment, dated 04/21/25, under Section C, revealed no Brief Interview of Mental Status( BIMS) score for Resident #49. Section B for vision revealed Resident #49 had adequate vision. Section O for oxygen revealed a no response. A review of Physician orders dated 10/25/24 revealed Oxygen at 1 to 4 Liters via nasal cannula as needed for oxygen saturation of less than 90 %. Oral and pharyngeal suction every day and evening shifts for Advanced Dementia (unable to clear oral secretions). A review of care plan dated 01/20/25 revealed Resident #49 had impaired vision as evidenced by the following: diagnosis of legal blindness, blurry/hazy/cloudy vision, double vision, side vision deficit, visual loss . An additional review of care plan dated 2/6/25 , originally initiated on 10/20/24 revealed Resident #49 was on respiratory therapy related to shortness of breath. Record review of Resident #49's oxygen saturation results in Point Click Care (PCC) revealed oxygen was delivered via nasal cannula on the following dates: 01/27/25, 02/23/25, 03/05/25, 03/26/25, 4/23/25 and on 05/ 01/25. During the continuing interview with the MDS Coordinator, she was informed that resident #49 had a care plan focus for impaired vision which was contradictory to the MDS assessment of adequate vision, she did not respond. The MDS Coordinator was also informed that Resident #49 has oxygen concentrator, oxygen suction machine, mask and oxygen nasal cannula tubing which was observed being used by resident during the past few days of the survey. Staff MDS Coordinator stated she will update the oxygen assessment in MDS. 3) Resident #76 was admitted on [DATE] with diagnoses that included Post Traumatic Stress Disorder (PTSD), Wedge Compression Fracture of Second Lumbar Vertebra , Type 2 Diabetes Mellitus, Benign Prostatic Hyperplasia, and Major Depressive Disorder. A review of the most current Minimum Data Set (MDS) assessment, dated 04/21/25, under Section C, revealed a Brief Interview of Mental Status( BIMS) score of 4 indicating Resident #76 had severely impaired cognition. Section I did not include the diagnosis of PTSD. During an interview conducted on 05/06/25 at 11:11 AM with Staff C, Certified Nursing Assistant (CNA), who when asked if she knew Resident #76's triggers, responded, Resident does not have PTSD triggers. In an interview with Staff S, CNA on 05/06/25 at 4:16 PM who has been working in the facility for 4 months, when asked about Resident #76's triggers, she stated, I think he is afraid to fall. In an interview with Staff D, Licensed Practical Nurse (LPN), on 05/06/25 at 4:18 PM , when asked about triggers for the resident, she responded, I know he does not like cold, and likes to stay in bed. In an interview with Staff T, registered Nurse ( RN), on 05/06/25 at 4:22 PM , who when asked about Resident #76s triggers, responded, I know resident forgets things, and has to be reminded by Staff. He does not want to remember a certain time in his life every year. During an interview conducted with the MDS Coordinator on 5/8/25 at 11:45 AM, when asked where in MDS assessment , Post Traumatic Stress Disorder (PTSD) is documented, she added ,In Section I. She added that in Section D, MDS Staff will also document the mood triggers for any depressive mood or any mental illness. When she was asked about PTSD triggers, she responded, I do not think we have any PTSD triggers. She was informed that Resident #76 did not have a documentation of a PTSD diagnosis under Section I. The MDS Coordinator added that she is not the only MDS Coordinator in the facility. When asked where are the other MDS Coordinators she responded, 'They are not here today. 4) Resident #26 was admitted on [DATE] with diagnoses that included Chronic Cough, Dysphagia, Essential Primary Hypertension and Type 2 Diabetes Mellitus. A review of the most current Minimum Data Set (MDS) assessment, dated 04/21/25, under Section C, revealed a Brief Interview of Mental Status( BIMS) score of 12 indicating Resident #26 had moderate cognitive impairment. Section B revealed adequate vison, and clear speech. A review of initial care plan dated 10/10/24 and quarterly updated on 01/09/25 revealed that Resident # 26 had impaired communications . The interventions included to anticipate and meet needs per physical and nonverbal indicators of discomfort and distress. During a continuing review of nursing care plan with an initial date of 07/14/24 and reevaluation date of 12/10/24, it revealed a focus on impaired vision as evidenced by visual loss due to Glaucoma, Cataract and Open Angle with Borderline Findings. During an interview conducted with the MDS Coordinator on 5/8/25 at 11:45 AM, she stated she has been working in the facility for 5 years, and when asked about identifying vison, hearing, and speech impairment of residents, responded, when residents have hearing problems, you provide them with reading materials. When residents have visual problems or blind people, you get visual consultations. When the MDS Coordinator was asked where the above impairments are documented, she responded, Under Section B of the MDS assessment. She added that Social Services Staff also document and complete some areas of the MDS assessments, clarifying that both Social Services and MDS Departments have to complete their assigned tasks for the completion of resident's MDS assessment. When asked how often the MDS staff assess and verify the impairments and treatments receive by residents for accuracy of MDS assessments, she responded I do frequent rounds, and I check the Physician orders as often as possible. In an interview conducted on 05/08/25 at 3:22 PM with the Social Services Director, when asked regarding Resident #26's vison, she stated, This resident has adequate vision. She was informed that Resident #26's care plan had a focus for impaired vision. 49060

Based on observations, interviews and record review the facility failed to secure medications at the bedside for 2 of 30 sampled residents (Residents #19 and #68). The findings included: Review of the facility's policy titled, Medication Storage with an implemented date of 11/28/17 included in part the following: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy offsite and/or medications rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation , moisture control, seclusion, and safekeeping. All drugs and biologicals will be stored in locked compartments under proper temperature controls. During medication pass, medication must be under the direct observation of the person administering medications or locked in the medication storage cart. 1 Record review for Resident #19 revealed the resident was admitted to the facility on [DATE] with most recent readmission on 04/20/25 with diagnoses that included Type 2 Diabetes Mellitus. The Minimum Data Set, dated dated dated [DATE] documented in Section C a Brief Interview of Mental Status (BIMS)score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #19 revealed no order for Mupirocin ointment 2% or an order to self-administer medication. On 05/05/25 10:20 AM an observation of Resident #19 in wheelchair in doorway to room, on dresser across from bed was a tube of Mupirocin ointment 2%. On 05/06/25 10:20 AM a second observation was made in Resident #19's room on dresser across from bed was a tube of Mupirocin ointment 2%. During an interview conducted on 05/06/25 at 2:14 PM with Staff A Registered Nurse (RN) who stated he has worked at the facility for just over 1 year. When asked about medications at the bedside, he said no, the residents cannot have medications at the bedside unless they have been assessed to have the meds at the bedside. On 05/06/25 at 2:30 PM a side-by-side observation was made with Staff A RN who acknowledged d the prescription medication Mupirocin ointment 2%. was on Resident #19's dresser in plain sight. Staff A RN immediately removed the medication. 49060 2. During observational room rounds conducted on 05/05/25 at 9:25 AM of Resident #68's room, observed 4 over the counter (OTC) large bottles of Calcimate Plus with Magnesium and Vitamin D-3 800 milligrams (mg) caplets, Magnesium Citrate 200 mg gummies, Probiotic gummies, and High-Metabolite Immunogens 500 mg capsules. The OTC medication bottles were unsecured, in plain sight and accessible to residents, staff members and visitors. Photographic evidence obtained. During a brief interview with Resident #68 on 05/05/25 at 9:25 AM, this surveyor asked Resident #68 about the OTC supplement bottles on her bedside table, the resident replied that her daughter brought them in since she was taking them when she was home. She stated she has not been able to take the supplements yet because she cannot reach them. She was asked if she knew if the doctor had ordered the supplements for her to take daily and she stated no. On 05/05/25 at 1:51 PM, Resident #68 was observed to have the 4 (OTC) large bottles sitting on her bedside table unsecured, in plain sight and accessible to other residents, staff members and visitors. Record review for Resident #68 revealed that the resident was admitted to the facility on [DATE] with diagnoses Type 2 Diabetes Mellitus. Section C of the Minimum Data Set (MDS) revealed that Resident #68 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that she had an intact cognitive response. The order summary report showed an order for Meropenem (antibiotic medication) Solution Reconstituted 1 gram intravenously every 8 hours for Urinary Tract Infection (UTI) for 7 days starting on 05/01/25. Continued review of the order summary report revealed Resident #68 had no orders for the supplements: Calcimate Plus with Magnesium and Vitamin D-3 800 mg, Magnesium Citrate 200 mg, or High-Metabolite Immunogens 500 mg. In addition, there was no order for self-administration of medications. Review of the Care Plan dated 04/01/25 revealed no focus on Resident #68 to be able to self-administer medications. An interview was conducted on 05/08/25 at 2:44 PM with Staff I, Registered Nurse (RN), who has worked at the facility for 2 years and was the assigned nurse for Resident #68 for the 7-3 shift. She stated that if a resident has medications at the bedside, she is to confiscate them and hold them for the family to pick up. Staff I was not often assigned to the [NAME] wing; however, she was not aware Resident #68 can self-administer her medications and that she had supplements at the bedside table. During an interview conducted on 05/08/25 at 2:56 PM with Resident #68, who stated the nurse came into her room and took all the supplement bottles she had on the table, and she was not sure why. Resident #68 stated she is not getting those supplements at the facility, like Vitamin D-3 and the probiotic, and she needs them since she is currently on an antibiotic.

Based on observation, interviews, record and policy review, the facility failed to maintain Peripherally Inserted Central Catheter (PICC) lines in a sanitary manner for 3 of 3 sampled residents reviewed for PICC lines, Residents' #67, #89, and #557. The findings included: The facility's policy, titled, PICC/Midline/CVAD Dressing Change implemented 11/28/17, revealed It is the policy of this facility to change peripherally inserted central catheter (PICC), midline or central venous access device (CVAD) dressing, weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. 1. Resident #89 was admitted to the facility on [DATE], and readmitted on [DATE] with a Peripherally Inserted Central Catheter (PICC) line to the right upper arm for Osteomyelitis. Other documented diagnoses included Chronic Obstructive Pulmonary Disease and Pressure Ulcer of sacral region. Review of the Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. On 02/05/24 at 8:55 AM, an observation of the resident's PICC line dressing was conducted during the initial screening process. The dressing was labeled with a date of 01/28/24. On 02/06/24, another observation was made of Resident #89's PICC line dressing. It was still labeled 01/28/24 and was bloody. Photographic Evidence Obtained. Review of the resident's Medication Administration Record (MAR) for February 2024 revealed no antibiotic or flushes to the PICC line were scheduled for February 2024. Review of the nursing progress note dated 02/06/24 revealed Picc line removed to right upper arm foul odor and pus noted informed .(Physician's Assistant) PA wound care consult in placed. Interview with the Director of Nurses (DON) on 02/07/24 at 1:19 PM revealed she was unaware there was a problem with Resident #89's PICC line and she would look into it. On 02/07/24, a Health Status note revealed, Resident observed with PICC line still in place. IV [intravenous] antibiotic completed 01/30/2024, flush orders completed on 01/31/2024. PICC site assessed, no pain or swelling, no redness or discoloration and no drainage observed at the site. MD [Medical Doctor] notified order received to discontinue PICC line, CBC [complete blood count], blood culture of site. On 02/07/24 at 4:00 PM, the PICC line concern was discussed with the Director of Nursing (DON). She stated the CBC was completed and the white blood cell count was improved from the last blood test dated 01/29/24. The blood culture will not be ready until 02/12/24. The DON revealed the PICC line should have been discontinued within 2 days after the antibiotic was finished which was 01/30/24. On 02/08/24 at 5:00 PM, the DON revealed that batch orders are put in the computer for PICC lines but for some reason the order for the dressing change was not put in for Resident #89 so her dressing was not changed weekly. 41837 2. Record review for Resident #557 revealed the resident was originally admitted to the facility on [DATE], with a most recent readmission of 01/29/24 with diagnoses that included: Sepsis, Urinary Tract Infection (UTI), Guillain-Barre Syndrome, Paraplegia, and Obesity. Review of the MDS assessment, dated 02/05/24, for Resident #557 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 15, indicating cognition was intact. Review of the Physician's orders for Resident #557 revealed an order dated 01/29/24 to change PICC (Peripherally Inserted Central Catheter) dressing every 72 hours on Thursdays for hygiene. Review of the Care Plan for Resident #557 revealed there was no PICC care plan implemented. On 02/05/24 11:44 AM, observation of Resident #557 revealed the left arm PICC line was in place with a dressing that was clean, dry, intact and dated 01/29/24. An interview was conducted on 02/05/24 at 11:44 AM with Resident #557 who stated he is receiving Vancomycin and Rocephin for UTI. He said he has a PICC line, and the dressing should be changed today. An interview was conducted on 02/08/24 at 3:00 PM with Staff I, MDS Coordinator (MDSC) who acknowledged there was no care plan implemented for a PICC for Resident #557. 36057 3. Record review of Resident #67's clinical record documented an admission on 10/26/22 and no readmissions. The resident's diagnoses included Adult Failure To Thrive, Alzheimer's Disease, Hemiplegia and Hemiparesis following Cerebral Infarction, Vascular Dementia, Severe with other Behavioral Disturbance and Urinary Tract Infection. Review of Resident #67's MDS annual assessment dated [DATE] showed a BIMS score was not conducted due to the resident is rarely/never understood. The resident had severe cognition impairment. The assessment documented under Functional Abilities & Goals that the resident was dependent on the staff to complete the activities of daily living (ADLs). Review of Resident #67's MDS annual assessment dated [DATE] showed a BIMS score was not conducted due to the resident is rarely/never understood. The resident had severe cognition impairment and was totally dependent on the staff to complete the ADLs. Review of Resident #67's care plan, for I am on antibiotic therapy .related to Urinary Tract Infection, initiated on 01/26/24, had an intervention to change (Midline) dressing .every 72 hours .monitor (Midline) insertion site every shift for any changes in appearance . Resident #67's physician order dated 01/25/24 documented, Insert Midline .for leukocytosis (infection) for 10 days. Resident #67's physician order dated 01/26/24 documented Change (Midline) dressing 24 hours after initial insertion; then every 72 hour every evening shift every 3 day(s) for hygiene change every 72 hours. Resident #67's physician order dated 01/25/24 documented, Ceftriaxone 1 gram intravenously every 24 hours for Urinary Tract Infection for 7 days. Resident #67's physician order dated 01/29/24 documented, Meropenem 500 milligrams intravenously every 8 hours for Urinary Tract Infection for 7 days. Review of Resident #67's February 2024 Treatment Administration Record (TAR) documented the resident's Midline dressing was changed on 02/04/24 evening. On 02/07/24 at 10:02 AM, a side-by-side review of Resident #67's Midline dressing was conducted with Staff O, Licensed Practical Nurse (LPN). Staff O stated the resident's Midline dressing on the upper right arm was not dated and it was supposed to be changed. Staff O added it was changed but was not dated. On 02/07/24 at 2:45 PM, an interview was conducted with Staff O who stated she worked on 02/04/24 evening shift and did not change Resident #67's Midline dressing that was scheduled for 02/04/24 evening. Subsequently, a side-by-side review of the resident February 2024 TAR was conducted with Staff O. Staff O was apprised that she documented that she did change the resident's dressing when she did not do it. Staff O was asked why she did not do the change as scheduled and did not answer.

Based on observations, interviews, and record review, the facility failed to provide nutritional interventions and assessments in a timely manner for 2 of 5 sampled residents reviewed for nutrition, Resident #15 and Resident #70. The findings included: Review of the facility's policy, titled, Weight Height Monitoring Policy, with a reviewed date of 11/28/23, included: In accordance with the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition suggests otherwise or not aligned with the resident preferences. The facility will obtain heights and measure/monitor weights upon admission, on Day 3 post admission by Restorative, weekly and monthly to assure communication and timely interventions to support or reverse weight gained or lost. Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. 1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors. b. Evaluating/analyzing the assessment information. c. Developing and consistently implementing pertinent approaches. d. Monitoring the effectiveness of interventions and revising them as necessary. 1. Record review revealed Resident #15 was admitted to the facility on [DATE] with the most recent readmission on 08/16/23. The diagnoses included: Dementia, Anxiety Disorder, Gastroparesis, Myasthenia Gravis, Sjogren syndrome, Systemic Lupus Erythematosus, and Schizoaffective Disorder Review of the Minimum Data Set (MDS) for Resident #15 dated 11/11/23 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15, indicating cognition is intact. In Section K, it was documented the resident's height as 61 inches (5'1) and the weight in pounds as 100, weight loss of 5% or more in the last month or loss of 10% or more in last 6 months was answered yes, not on a physician-prescribed weight-loss regimen. Review of the weights for Resident #15 revealed the following: On 08/16/23, the resident weighed 115.8 pounds. For the month of September 2023, there were no weights. On 10/10/23, the resident weighed 100.0 pounds. This indicated from 08/16/23 to 10/10/23, the resident had a 13.64 % weight loss. On 08/16/23, the resident weighed 115.8 pounds and on 10/10/23, the resident weighed 100.0 pounds which is a -13.64 % weight loss. Review of the Physician's orders for Resident #15 revealed an order dated 11/13/23 for NAS (No Added Salt) diet, Regular texture, Regular / Thin consistency. Review of the Care Plan for Resident #15 dated 04/29/21 with a focus on the resident is at nutritional risk: As evidenced by: Therapeutic diet, mechanically altered texture, h/o [history of] poor appetite PTA, c/o [complaint of] nausea Related to: Disease process / condition, Constipation. The goals were resident desires her laboratory values to be within desired limits (per physician) by the next review date, and she desires her weight to remain +/- 5% current weight through next review date. The interventions included: Weights monthly and as needed. No sig. wt. [significant weight] change seen One inconsistence in wt. seen, reweigh the patient. 25-100% Poor to fair intake. Review of the Nutrition / Dietary Note for Resident #15 dated 05/31/23 revealed: Resident readmit to the facility s/p [status post] hospitalization Diagnoses; Dementia, Gastroparesis, Hypokalemia, HTN [Hypertension], HLD [Hyperlipidemia] Resident refuses for weight checkup. Diet; Reg [Regular] diet, Reg. Text. Reg. thin consistency, PO [oral] Intake : poor Various intake noted in chart 25-76% she refuses to eat meal sometimes, Meds; Ondansetron, Amlodipine, Statin, Colace, Pantoprazole, Losartan, Megace, Tramadol, No recent labs; Recommendation; Boost x 2 daily, She likes ginger ale; snack in between. Request to reweight. Will monitor any change in weight, po intake skin. Will follow as needed. Review of the Weight Change Note for Resident #15 dated 06/02/23, Refused; on 05/08/23, Refused weight. Review of the Standard of Care (SOC) Noted dated 08/09/23 included: Resident with adequate po intake consuming 75% or more of all meals. No significant wt (weight) loss noted at this time. Current wt within desirable range. Review of the Plan of Care Note for Resident #15 dated 08/31/23 included: Dietitian met with care plan team for resident's quarterly review. Contacted POA [power of attorney] regarding resident's current nutritional status. Resident continues to be weighed. POA stated Last known weight at hospital in 123lbs (pounds). Review of the Nutrition Risk Assessments for Resident #15 revealed the last Nutrition Risk / Assessment was completed on 03/06/23. Review of the Notes for Resident #15 revealed no notes related to diet/nutrition or weight loss were documented after 08/31/23. An interview was conducted on 02/05/24 at 1:00 PM with Resident #15 who was asked if she had been trying to lose weight, she said no. When asked about being weighed, she stated she does not like to be weighed. An interview was conducted on 02/06/24 at 11:00 AM with Staff I, MDS Coordinator (MDSC), who acknowledged there were no dietary / nutrition notes or assessments since August of 2023. The MDSC stated she is responsible for the care plan meetings and to make sure the assessments are in the residents' chart. She stated there was a period of time when they were 'with no RD' but did not remember the dates. She acknowledged the RD did not attend the care plan meeting for the resident on 08/31/23. An interview was conducted on 02/07/24 at 2:45 PM with the Registered Dietician (RD) who stated she has worked at the facility for 3 months and 2 weeks full time and is leaving on 02/16/24. She stated she was a covering as the Registered Dietician when the RD would go on vacation or if the dietician had left. The last time the dietician left was maybe 5 months ago around August or September. She mainly would fill in the MDS sections. The RD stated a significant weight loss is 5% in 30 days, 7.5% in 90 days, or 10% in 180 days. The RD stated the restorative aides give her the weights for the resident on a weight sheet, monthly weights are given monthly and weekly weights are given to her weekly. She puts the weights in the chart, and she will print out the last 6 months to see if a resident has any significant weight loss. The RD stated there is no issue with residents being weighed. If a resident has weight loss, she would put interventions in place, such as appetite stimulant, supplements, or weekly weights. Nutritional assessments are done on admission and quarterly, and then annually. When asked about Resident #15, the RD stated if the resident refused her weights, she would simply put a zero in for the weight. The RD acknowledged the resident was not weighed on 10/23/23, 11/14/23, and 12/15/23. She said she would talk to the resident to encourage her to get weighed and she would ask restorative aides to try to reweigh the resident. The RD acknowledged she did not put in any notes for this. She stated the other RD would have identified significant weight loss on 08/16/23 as 16% weight loss in 30 days. The last nutrition assessment completed for Resident #15 was completed on 03/10/23. The RD stated she missed an assessment in November 2023 and the resident had missed an additional nutrition assessment before she started working at the facility. The weight for the resident on 10/10/23 was 100 pounds which was a 13.6# weight loss in 60 days. She stated that for a lot of these weights, she did not have time to address them because she had just started and was trying to get caught up and she missed the significant weight loss in October, and also missed her nutritional assessment as well. She was trying to catch up on the assessments that were not done prior to her starting at the facility and putting a system in place for the weights to be put into the resident's records. The RD acknowledged she did not address the significant weight loss for the resident in October and therefore did not put any interventions in place to address the weight loss. When asked about care plans, she said she would attend the care plan meetings. For the care plan meeting on 12/04/23, she was on vacation for a week and did not attend the 2 care plan meetings scheduled for that week. The RD stated there was no RD covering her for when she was on vacation for the week in December 2023. An interview was conducted on 02/08/24 at 3:30 PM with Resident #15 who was asked if she had been trying to lose weight, she said no, but knows she lost some weight and had put it back on recently. When asked if she refused to be weighed at times, she said she hates to get on the scale so yes, she sometimes refuses. 40153 2. Record review showed Resident #70 was admitted to the facility on [DATE] with diagnoses of protein-calorie malnutrition, colon cancer, and lung cancer. Review of the Physicians' orders, dated 11/03/23, revealed the following: Boost (nutritional supplement) three times a day for weight management, Chocolate flavor Boost 237 milliliters (one bottle). The Significant Change Minimum Data Set (MDS) assessment, dated 12/07/23, revealed Resident #70 has a Brief Interview of Mental Status (BIMS) score of 15, indicating cognition was intact. An interview was conducted on 02/05/24 at 9:40 AM with Resident #70 who was noted in bed with the breakfast tray at the bedside out of reach. When asked why he was not eating, he stated that he was waiting for staff to assist him with his breakfast tray. Resident #70 stated that he had lost about 50 pounds and that he has cancer. He then asked the surveyor if any staff was noted at the nurse's station to help him with his breakfast meal. Continued observation at 10:32 AM, an hour and a half later, revealed the meal tray was still at the bedside untouched. At 10:35 AM, Staff A, Licensed Practical Nurse (LPN), went into Resident #70's room and pushed the side table with the breakfast tray closer to Resident #70, so he could reach his meal. In an observation conducted on 02/05/24 at 11:00 AM, Resident #70 had eaten 10% of his oatmeal but did not touch anything else. When asked why he was not eating, he said he was in pain, was tired and that he asked Staff A for Boost when she gave him the pain medication around 10:30 AM. An interview was conducted on 02/05/24 at 11:30 AM with Resident #70, who stated Staff A still needed to bring his Boost supplement and asked the surveyor if they could speak to the nurse regarding his supplement. In an observation conducted on 02/05/24 at 12:35 PM, Resident #70 was noted in the room eating his lunch meal. At 12:55 PM, Resident #70 had eaten 10% of his meal and asked the surveyor if they could bring him another bottle of Boost. Review of the Medication Administration Record (MAR) revealed that on 02/05/24, the Boost was given at 9:00 AM, 1:00 PM, and another one at 5:00 PM. Review of the weight log showed the following weights for Resident #70: 140 pounds dated 11/07/23, 140 pounds dated 11/14/23, no weight recorded on 12/15/23, and no weight recorded on 01/10/24. The nutrition risk assessment dated [DATE] revealed the following: Resident #70 is consuming between 25% to 100% of his meals. He has diagnoses that could cause unavoidable weight and loss of appetite. It further showed that Resident #70 was in hospice and was receiving Boost supplements three times a day. Resident #70 will be followed and monitored with adjustments as needed. In an interview conducted on 02/06/24 at 1:30 PM with Resident #70, he stated that it is easier for him to drink the Boost supplements than to eat the food. When asked by the surveyor if he would drink more than 3 Boost supplements a day if offered, he said yes. Review of the care plans for Resident #70 did not show that any care plan was initiated for nutrition. An interview was conducted on 02/07/24 at 3:07 PM with the facility's Dietitian who stated she did not notice that Resident #70 did not have a care plan for nutrition and that she is in charge of the nutrition care plan for all residents. The facility's Dietitian reported that she should have followed up on Resident #70's nutritional status sooner and acknowledged that the last follow-up note was completed on 12/07/23.

Based on record review and interviews, the facility failure to administer antibiotic therapy in a timely manner for 1 of 1 sampled resident, Resident #505, as evidenced by not administering the antibiotic on 09/16/23 for two consecutive doses as ordered; and failed to ensure physician orders were followed for residents with a Left Ventricular Assistive Device (LVAD), as evidenced by lack of accurate monitoring, calulating and documentation of mean arterial pressure (MAP) for 1 of 1 sampled residents, Resident #87. The findings included: 1. Review of Resident #505's clinical record documented an admission on 09/15/23 with a discharge on 10/09/23. The resident's diagnoses included Cellulitis of Left Lower Limb, Fracture of Left Patella with subsequent encounter for Closed Fracture with Routine Healing, and Acute Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity. Review of Resident #505's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident had intact cognition. The assessment documented the resident received an antibiotic 7 days prior to the assessment. Review of Resident #505's care plan, titled, I am on antibiotic therapy (Linezolid) related to (skin and soft tissue) infection initiated on 09/18/23, had an intervention to include administer antibiotic medications as ordered by physician . Review of Resident #505's hospital discharge medication list dated 09/15/23 documented, Linezolid 600 milligram (mg) every 12 hours for 15 doses - last time this was given on 09/15/23 at 10:17 AM . Review of Resident #505's physician orders dated 09/15/23 documented, Linezolid (antibiotic) Oral tablet 600 mg (Linezolid) give 1 tablet by mouth two times a day for skin and soft tissue infection. This physician order was reordered on 09/18/23 as, Linezolid Oral Tablet 600 MG (Linezolid) Give 1 tablet by mouth two times a day for Cellulitis Left Lower extremity for 12 Administrations until finished. Review of Resident #505's September 2023 Medication Administration Record (MAR) documented Linezolid Oral tablet 600 mg (Linezolid) give 1 tablet by mouth two times a day for skin and soft tissue infection start date 09/15/23 at 9:00 PM. Further review of the resident's September MAR documented that Linezolid was administered on 09/15/23 at 9:00 PM and was not administered on 09/16/23 for the 9:00 AM and 9:00 PM doses as scheduled and as per physician order. Review of Resident #505's Staff M, Registered Nurse (RN), note dated 09/16/23 at 3:52 PM documented, Linezolid Oral Tablet 600 MG Give 1 tablet by mouth two times a day for skin and soft tissue infection. Not Given, Pharmacy made aware. The note documented, Show on Shift Report Show on 24 Hour Report. Review of Resident #505's nursing note dated 09/16/23 at 11:51 PM documented, Linezolid Oral Tablet 600 MG Give 1 tablet by mouth two times a day for skin and soft tissue infection. Awaiting on delivery, pharmacy called, NP (Nurse Practitioner) notified. The note documented Show on Shift Report Show on 24 Hour Report. Review of Resident #505's nursing note dated 09/17/23 at 4:29 AM documented, in part, .resident had numerous questions in regard to the antibiotic treatment .resident was informed that an approval from insurance was needed .resident feels her condition is too critical for a delay in sending the medication .pharmacy calls facility stating the antibiotic has a contraindication to one of the resident's current medication. Physician was contacted and stated no changes .pharmacy was recontacted with the doctor's decision, awaiting medication from the pharmacy . On 02/08/24 at 11:38 AM, an interview was conducted with Staff M, RN, who stated medications for new admission are taken from the Pyxis system (an automated medication dispensing system). Staff M stated she recalled Resident #505 and that on 09/16/23, a Saturday, the resident's ordered antibiotic was not in the Pyxis system in either wing. Staff M added she then called the weekend supervisor to make him aware of that, who instructed her to call the pharmacy to get the antibiotic. Staff M stated she did not have the antibiotic to administer to the resident on 09/16/23 for the 9:00 AM dose. Staff M added the medication was not delivered on her shift. On 02/08/24 at 9:17 AM, an interview was conducted with the Director of Nursing (DON) who stated the facility changed the pharmacy provider in 01/2024. The DON was asked if she had heard of any residents not getting their antibiotic therapy as ordered in the last 5 months. The DON stated she had not. The DON was apprised that Resident #505 did not receive the Linezolid antibiotic twice on 09/16/23 after receiving the initial dose upon admission. The DON stated new admissions can come at any time of the day or night. The DON stated if a new resident comes in and needs antibiotic therapy, the nurse can start the initial dose provided it is in house (Emergency kit/ Pyxis system). The DON stated nursing staff had been trained on how to use the Pyxis/Emergency kit. The DON stated that if the antibiotic tablets were not in the Pyxis system, they needed to order before the cut off time and that they could get them at 6:00 PM or on the midnight pharmacy run. The DON added that if they needed the medication right the way, she would contact the Director of Pharmacy and ask for a special run. On 02/08/24 at 1:51 PM, an interview was conducted with the DON who stated she remembered Resident #505 because they bonded. The DON stated she did not know why there was a break on the resident's antibiotic therapy administration on 09/16/23. The DON read nursing note for 09/17/23 at 4:29 AM and stated she did not know why the pharmacy did not communicate the information regarding antibiotic contraindication or insurance approval with her. The DON stated it was not mentioned in the quality meeting about issues with Resident #505 not receiving her antibiotic as ordered. The DON was apprised that the nursing notes for 09/16/23 day and evening shift were checked off to show on the 'shift and 24 report'. The DON stated she was not aware of the payment issue for Resident #505's Linezolid antibiotic and added it was a fluke. 41837 2. Review of the facility's protocol, titled, Nursing Protocols for Resident with Left Ventricle Assistive Devices (LVAD), with a date of 01/16/24, included: Monitor MAP (Mean Arterial Pressure) every shift with the cuff left in the room (Manual brachial cuff device) Do NOT USE the vital sign auto machine to obtain his MAP. Adequate blood pressure (typically, a MAP between 60mmhg and 90 mmhg) helps maintain sufficient pump flow. Commonly prescribed antihypertensive drugs include vasodilators, beta blockers, angiotensin-converting enzyme (ACE) inhibitors. Always monitor heart rate and blood pressure when giving these medications. Record review revealed Resident #87 was admitted to the facility on [DATE] with diagnoses that included: Encounter for Orthopedic Aftercare Following Surgical Amputation, Atrial Fibrillation, Presence of Heart Assist Device, Dependence on Renal Dialysis, and Type 2 Diabetes Mellitus. The MDS for Resident #87 dated 01/22/24 revealed in Section C, a Brief Interview of Mental Status score of 15, indicating an intact cognitive response. Review of the Physician's orders for Resident #87 revealed an order dated 01/16/24 for full set of vital signs every shift. Review of the Physician's orders for Resident #87 revealed an order dated 02/06/24 to monitor mean arterial pressure (MAP) every shift using manual cuff only (kept at bedside) and record first sound parameters between 100-110 mmhg without doppler 40 mmhg must be subtracted from the reading. Normal flow 60-90 mmhg every shift for monitor and notify MD if lower than 60 mmhg use record LVAD only. Review of the blood pressures for Resident #87 from 02/01/24 to 02/05/24 were documented as: 02/01/24 at 1:15 AM, 127/71 mmhg 02/01/24 at 4:34 PM, 1/1 mmhg (as documented by Staff M, RN) 02/02/24 at 3:04PM, 108/66 mmhg 02/02/24 at 10:37 PM, 115/64 mmhg 02/03/24 at 4:01 AM, 110/62 mmhg 02/03/24 at 3:04 PM, 123/76 mmhg 02/03/24 at 5:30 PM, 120/66 mmhg 02/04/24 at 12:40 AM, 115/75 mmhg 02/04/24 at 2:04 PM, 1/1 mmhg (as documented by Staff M, RN) 02/04/24 at 5:05 PM, 118/70 mmhg 02/05/24 at 12:06 AM, 122/80 mmhg 02/05/24 at 12:40 PM, 1/1 mmhg (as documented by Staff M, RN) 02/05/24 at 6:52 PM, 130/776 mmhg This revealed nursing staff were not accurately documenting the MAP correctly. On 02/06/24 at 9:00 AM, an observation was made of Resident #87 who was sitting on the edge of his bed. There was a black bag next to the bed with a cord that went under the resident's shirt. On the nightstand, there was a charging device with 6 battery-type of boxes in the charging device. An interview was conducted on 02/06/24 at 9:00 AM with Resident #87 who was asked about the black bag with the cord that went under his shirt. He stated he has a LVAD (Left Ventricular Assistive Device). He further stated the device runs on 2 battery packs. He has a total of 8 battery packs, and they are kept on the charger at all times. The resident then lifted his shirt to show where the device was connected to his abdomen that had a border dressing with no date. When asked if the dressing was changed, he said yes, every day. He said he checks it every day at least once a day. An interview was conducted on 02/06/24 at 9:19 AM with Staff M, RN, who was asked if she is familiar with the LVAD. She said yes one of our residents has one. When asked if she does any sort of checks for the device, she said the resident is alert and he checks it. She said she looks at the batteries to make sure they are on the charger and the device gets a green light. When asked if she received any in-service on the LVAD she said yes and she was familiar with the LVAD (prior to the resident being admitted to the facility). When asked about the blood pressure, she stated it has to be done manually with the blood pressure cuff in the resident's room. Staff M stated you don't use a stethoscope, you just look at the needle on the dial and when the needle jumps that is the MAP (Mean Arterial Pressure). When asked where this is documented in the resident's chart, she said it is under the blood pressures, but you cannot just document 1 number (the MAP is only 1 number, not 2 numbers). An interview was conducted on 02/06/24 at 9:40 AM with the Director Of Nursing (DON) who was asked about residents with a LVAD. She stated she made a protocol and in-serviced the nurses. When asked if the staff monitor the LVAD, she said they check the green light and make sure the batteries are being charged. When asked about the blood pressure, she stated they cannot do a regular blood pressure for the resident, and they cannot use an automatic blood pressure machine. She said the resident has a manual blood pressure cuff at the bedside and the nurse will check the blood pressure with the manual cuff and when the needle on the dial first jumps that is the MAP. The nurse will then document this MAP on the resident's chart under blood pressures. She stated the normal MAP is between 60-90. The nurses were not calculating or documenting the MAP as specified by the physician order.

Based on observation, interviews, record and policy review, the facility failed to develop care plans for 2 of 3 sampled residents reviewed for Peripherally Inserted Central Catheter (PICC) lines, Resident #89 and Resident #557; and failed to develop care plans for residents with a Left Ventricular Assist Device (LVAD) for 1 of 1 sampled resident reviewed for a LVAD, Resident #87. The findings included: The facility's policy, titled, Comprehensive Care Plans, implemented 11/28/17, revealed, in part, The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Record review revealed Resident #89 was admitted to the facility on [DATE]. The resident was readmitted on [DATE] with a Peripherally Inserted Central Catheter (PICC) line to the right upper arm for Osteomyelitis, with other diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) and Pressure Ulcer of sacral region. Review of the Medicare 5- day Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Review of the resident's care plan revealed no care plan for the PICC line or the antibiotic. On 02/08/24 at 3:03 PM, it was discussed with Staff I, MDS Coordinator, regarding the lack of a care plan for the PICC line and antibiotic. She acknowledged there should have been a care plan for the PICC line and the antibiotic. 41837 2. Record review for Resident #87 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Encounter for Orthopedic Aftercare following Surgical Amputation, Atrial Fibrillation, Presence of Heart Assist Device. Dependence on Renal Dialysis, and Type 2 Diabetes Mellitus. Review of the MDS for Resident #87 dated 01/22/24 revealed in Section C a BIMS score of 15, indicating cognition was intact. Review of the Physician's orders for Resident #87 revealed an order dated 01/25/24 to cleanse the left lower quadrant Ventricular Assist Device (LVAD) site with normal saline, pat dry, and cover with border dressing every night. Review of the record for Resident #87 revealed no care plan for the LVAD (Left Ventricular Assistive Device). On 02/06/24 at 9:00 AM, an observation was made of Resident #87, who was sitting on the edge of his bed. There was a black bag next to the bed with a cord that went under the resident's shirt. An interview was conducted on 02/06/24 at 9:00 AM with Resident #87, who was asked about the black bag with the cord that went under his shirt. He stated he has a LVAD, it runs on 2 battery packs, he has a total of 8 battery packs, and the batteries not being used were kept on the charger at all times. The resident then lifted his shirt to show where the device was connected to his abdomen that had a border dressing with no date. He said he checks it at least once a day every day, proceeded to show the surveyor what he checks, and that he gets a green light. An interview was conducted on 02/06/24 at 9:19 AM with Staff M, Registered Nurse (RN), who was asked if she is familiar with the LVAD, who stated 'yes one of our residents has one'. When asked about a care plan for the LVAD, she said she there should be one. 3. Record review for Resident #557 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on 01/29/24 with diagnoses that included: Sepsis, Urinary Tract Infection, Guillain-Barre Syndrome, Paraplegia, and Obesity. Review of the MDS for Resident #557 dated 02/05/24 revealed in Section C a BIMS score of 15, indicating a cognition was intact. Review of the Physician's orders for Resident #557 revealed an order dated 01/29/24 to change the PICC dressing every 72 hours on Thursdays for hygiene. Review of the Care Plans for Resident #557 revealed no care plan for the PICC line. On 02/05/24 11:44 AM, observation of Resident #557's left arm PICC line that was in place revealed a clean dry intact dressing dated 01/29/24. An interview was conducted on 02/05/24 at 11:44 AM with Resident #557 who stated he is receiving Vancomycin and Rocephin for a Urinary Tract Infection (UTI), and he has a PICC line. An interview was conducted on 02/07/24 at 1:30 PM with Staff N, RN, who was asked how often a PICC line dressing is changed. She said she would have to look in the resident's chart, and was unable to answer the question in general. When asked about Resident #557's PICC line, she said she noticed the dressing needed to be changed based on the date and said it would be changed today. When asked how often the PICC line dressing is changed, she looked in Resident #557's chart and said it is supposed to be changed every 72 hours (3 days) on Thursdays. When asked to clarify if it is every 72 hours or every Thursday, she acknowledged the order was confusing. When asked if there was a care plan for the PICC line, she said there should be one.

Based on record review, observations and interviews, the facility failed to ensure residents Do Not Resuscitate (DNR) directives were signed by the resident's Power of Attorney (POA) agent for 1 of 27 sampled residents reviewed for Advances Directives, Resident #67. The findings included: Review of the facility's policy, titled, Resident Rights Regarding Treatment and Advance Directives implemented on 11/28/17, provided by the administrator, did not address the DNR (Do Not Resuscitate) for procedure. Review of Resident #67's clinical record documented an admission on 10/26/22 with no readmissions. The resident's diagnoses included Adult Failure to Thrive Alzheimer's Disease and Vascular Dementia. Review of Resident #67's Minimum Data Set (MDS) annual assessment dated [DATE] documented a Brief Interview of the Mental Status was not conducted due to the resident is rarely / never understood. The resident had severe cognition impairment and was totally dependent on the staff to complete the activities of daily living (ADLs). Review of Resident #67's care plan, titled, I have advanced directives .My code is DNR initiated on 11/18/22, had an intervention that read facility to discuss and review Advanced Directives with the Resident and/or Responsible Party Review of Resident #67's record profile listed a Power of Attorney (POA) Agent/Responsible Party. Further review of the resident's record documented a physician's DNR order dated 06/29/23. The record included the State of Florida Do Not Resuscitate Order form signed on 10/18/22 by Resident #67's emergency contact who was not listed as the POA. On 02/05/24 at 10:46 AM, observation revealed Resident #67 sitting up at the edge of the bed and fidgeting with the bed linen. An interview with the resident was attempted, who stated she was moving up north and stated she did not have any family. On 02/06/24 at 3:18 PM, an interview was conducted with the facility's Social Services Assistant who stated if the resident was not able to sign a DNR form, the resident's POA or a responsible party would be the one signing the DNR form. The Social Services Assistant stated Resident #67 was severely cognitively impaired. The Social Services Assistant stated that the resident had a POA who was to take care of the DNR form. The Social Services Assistant was apprised that the resident's DNR was not signed by the POA who referred the surveyor to the Director of Social Services. On 02/06/24 at 3:32 PM, an interview was conducted with the Director of Social Services (DSS) who stated that Resident # 67's POA was the person who had to sign the DNR form. The DSS stated she would call the resident's POA today to discuss the DNR and obtain a new form signed by POA. During an interview on 02/07/24 at 9:17 AM, the DSS stated Resident #67's POA was coming on 02/07/24 to sign the DNR form. On 02/07/24 at 9:19 AM during an interview, the administrator was apprised that Resident # 67's DNR was not signed by the POA.

Based on observations, interviews, and record review, the facility failed to address residents' pain in a timely manner for 1 of 1 sampled resident reviewed for Pain, Resident #70. The findings included: Review of the facility's policy, titled, Pain Management, implemented on 11/28/2017, showed the following: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. To help a resident attain or maintain their highest practicable level of well-being and to prevent or manage pain, the facility should recognize when the resident is experiencing pain. Record review showed that Resident #70 was admitted to the facility on [DATE] with diagnoses to include Protein-Calorie Malnutrition, Colon Cancer, and Lung Cancer. Review of the Physicians' orders revealed the following: -On 12/01/23, an order for Morphine Sulfate (pain medication), 15 milligrams, one tablet by mouth every 12 hours for severe pain. - On 11/05/23, an order for Oxycodone (pain medication), 10 milligrams, every 4 hours as needed for pain. Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed Resident #70 has a Brief Interview of Mental Status (BIMS) score of 15, indicating cognition is intact. Section J of this MDS showed that Resident #70 is in constant pain. In an interview conducted on 02/05/24 at 9:40 AM, Resident #70 stated that he was in pain and was waiting on his pain medication. He further said that the pain medication was not given to him at the scheduled times, which was twice a day at 9:00 AM and 9:00 PM. In an interview conducted on 02/05/24 at 10:39 AM, Resident #70 stated Staff A, Licensed Practical Nurse (LPN), had just given him his pain medication (Morphine), which was scheduled for 9:00 AM. Review of the Medication Administration Audit Report revealed the following: -On 02/05/24, the Morphine medication that should have been given at 9:00 AM was given at 10:28 AM. -On 02/05/24, the Morphine medication that should have been given at 9:00 PM was given at 11:03 PM. -On 02/01/24, the Morphine medication that should have been given at 9:00 PM was given at 10:23 PM. -On 02/01/24, the Morphine medication that should have been given at 9:00 AM was given at 2:12 PM. -The Morphine medication that should have been given at 9:00 PM was given at 12:12 AM (next day). The care plan initiated on 12/21/23 revealed Resident #70 was at risk for pain and the pain would be reduced by the interventions put in place. Continued reviewing of the care plan showed the nurse would administer and monitor the effectiveness of the routine pain medication. In an observation conducted on 02/06/24 at 8:31 AM, Resident #70 was in bed waiting on his breakfast tray. In this observation, Resident #70 said that he has pain everywhere and that he is waiting on his pain medication (Morphine) that was supposed to be given at 9:00 AM. An interview was conducted on 02/06/24 at 1:21 PM with Staff H, Registered Nurse / RN, who stated Resident #70's pain level is around 6 to 8 levels out of 10. Before giving Resident #70's his pain medication, she would always ask him about his pain level. When asked when the Morphine medication is given for Pain, Staff H said it is given twice daily at 9:00 AM and at 9:00 PM. Interview was conducted with Director of Nursing (DON) regarding the pain on 02/06/24 at 3:20 PM, who stated that regarding pain management, she expects the nursing staff to administer pain medication and assess the pain level as well. When asked about the medications' timing, she said it is usually one hour before and one hour after the scheduled medication time.

Based on review of the facility's Policies and Procedures, record review, interview, and observation, the facility failed to timely revise the care plan with appropriate safety precautions for 2 of the 3 smokers in the facility at the time of the incident (Residents #1 and #3). Resident #1's care plan for smoking did not address that he was on continuous oxygen, which is flammable and he was permitted to keep smoking materials at the bedside. Resident #1 smoked in bed on 11/01/18 and started a fire which burned himself and endangered all other residents in the facility. Resident #3 was not reassessed for smoking until 11/07/18, when he was determined an unsafe smoker, but his care plan did not address the newly identified risk [MEDICAL CONDITION] 11/09/18. This was Immediate Jeopardy and the Immediate Jeopardy was removed based on the allegation of compliance provided by the Administrator that was approved on 11/09/18. The Immediate Jeopardy was removed on 11/09/18 and the Scope and Severity was reduced to a (D). The findings included: 1. The facility Policy and Procedure titled Smoking Policy - Residents, dated (MONTH) (YEAR), that was in effect at the time of the incident, 11/01/18, documented: 4. Oxygen use is prohibited in smoking areas. and 8. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation . and 10. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 2. A Fire Incident Report dated 11/02/18 documented a fire incident in the facility on 11/01/18 at 11:05 PM that involved Resident #1, who sustained [MEDICAL CONDITION] was airlifted to a burn trauma unit. The Fire Incident Report dated 11/02/18 documented Resident #2 reported that Resident #1 had been smoking in bed, that Resident #1's mattress caught on fire, resulting [MEDICAL CONDITION] Resident #1. 3. Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. Medication Administration Records document Resident #1 was on continuous oxygen since admission, including his last full day in the facility, 11/01/18. A Certificate of Incapacity to Give Informed Consent/Make Health Care Decisions dated 05/21/18 and signed by a physician documents Resident #1 lacked the capacity to give informed consent and make health care decisions. Resident #1's Quarterly MDS (Minimum Data Assessment) with Assessment Reference Date 08/16/18 documents Resident #1's BIMS score was 8 out of 15, indicating moderate cognitive impairment; that Resident #1 was on oxygen; could not walk, needed extensive assist to get out of bed, and limited assistance for personal hygiene. Resident #1's Resident Smoking Assessment, dated 11/01/18 and signed by the Social Services Assistant, documents Resident #1's smoking status as Unsupervised. Resident #1's Social Service Note dated/timed 11/01/18 at 4:27 PM documented .Smoking assessment concluded that resident is a safe smoker and he was provided with a lock box to store his smoking materials. Care plan to reflect . Resident #1's Social Service Note dated/timed 11/01/18 at 4:28 PM documented Resident's mentation reassessed. Resident scored a 14 on BIMS assessment concluding to be alert with independence in decision making. Resident #1's Care Plan entry for the Focus area I am a smoker created 11/01/18 by the Social Services Assistant documents under Goals I will not suffer injury from unsafe smoking practices through the next review date and includes under Interventions I am able to keep my own cigarette, keep lighter in provided locked box. The care plan for smoking does not address that Resident #1 uses oxygen which is flammable and should not be used around cigarettes or lighting materials. Further review of Resident #1's entire Care Plan revealed no evidence of any interventions to address smoking safely although he was oxygen dependent, such as he should not of smoke with oxygen, whether he could of safely be off of oxygen to smoke, and how staff should of ensure his safety while he smoked. Resident #1's Health Status Note dated/timed 11/02/18 at 02:00 AM documents Resident's roommate reported resident lit up a cigarette and apparently fell asleep. Resident awake, alert oriented to person, place and time. Air lifted to (hospital name) due to self [MEDICAL CONDITION]. During interview on 11/02/18 at 10:40 AM, the Director of Nursing (DON) stated Resident #1 had previously denied being a smoker and staff first observed him smoking on 11/01/18 at approximately 3:30 PM in the designated outdoor smoking area. During interview 11/02/18 at 10:40 AM, the DON stated that on 11/01/18 Social Services staff did a smoking assessment, determined Resident #1 was a safe smoker, and gave him a lockbox in which to keep smoking materials at the bedside. During interview on 11/02/18 at 1:34 PM, the Administrator stated residents with oxygen are not allowed to have lighters or matches in their rooms, that Resident #1 knew and signed the policy acknowledging they weren't allowed to have them, but that he must have snuck a lighter in. During interview with the Social Services Assistant on 11/05/18 at 12:10 PM, she admitted to observing Resident #1 smoking outside on 11/01/18 at around 3:30 PM, completed his smoking assessment, and having him sign a smoking contract. The Social Services Assistant admitted on [DATE] at 12:10 PM that she did not recall informing a nurse or anyone on the evening shift of the care plan revisions or that Resident #1 started smoking and had smoking materials at the bedside. During telephone interview on 11/05/18 at 2:33 PM with Nurse Supervisor, Staff A, Staff A reported they worked the 3:00 PM to 11:00 PM shift on 11/01/18 during which she removed Resident #1 from the fire and had shut off the oxygen in that room. Staff A reported on 11/05/18 at 2:33 PM that she had not been informed Resident #1 was a smoker and, if she had known, she would have kept any smoking materials at the nursing station. During a telephone interview with the Physician Assistant on 11/08/18 at 11:40 AM, the Physician Assistant reported that Resident #1 did not recall prior discussions from visit to visit, that she was not consulted when he started smoking again on 11/01/18, and that she didn't believe he could make medical or financial decisions. 2) Resident #3's medical record review revealed Resident #3 was first admitted to the facility on [DATE], readmitted on [DATE], and had [DIAGNOSES REDACTED]. Resident #3's Resident Smoking Assessment, dated 07/05/18 and signed by the Social Services Assistant, documents Resident #3's smoking status as Unsupervised. Review of the record revealed no evidence of documentation of a new smoking assessment for Resident #3 until on 11/07/18, during the survey. A Standards of Care with all sections dated 01/12/18 documents under Smoking The IDT (interdisciplinary team) recommends: Supervision with smoking and a handwritten Progress Note Resident understands that lighter must be kept by staff - IDT to emphasize the importance of facility's safety policy. Resident #3's care plan with print date of 11/05/18 and Review Start Date of 10/01/18 documents for the Focus area I am a smoker under Goals I will not suffer injury from unsafe smoking practices through the next review date and includes under Interventions I am able to: keep own cigarette, keep lighter in provided locked box. During an interview with Resident #3 on 11/08/18 at 4:50 PM, he admitted that on 11/02/18 they had to turn in their lockbox with their lighter and cigarettes and since then must sign their smoking materials in and out each time they go outside to smoke. Resident #3's Resident Safe Smoking Assessment, dated 11/07/18 and signed by Resident #3 but not a staff member, documented that Resident #3 did not demonstrate the ability to light and smoke a cigarette or other smoking devices, did not demonstrate a safe technique for putting out matches or lighter or disposing of ash, did not demonstrate the ability to physically hold the smoking device while smoking, and that Resident #3 has physical limitations which have implications on the resident's ability to smoke. The Resident Safe Smoking assessment dated [DATE] documents that based on the assessment, Resident #3 was deemed a supervised smoker. Resident #3's care plan with revision date 11/07/18 documents for the Focus area I am at risk for injuries related to smoking; the unmeasurable Goal My risk for injuries related to smoking will be minimized through the review date. and includes no interventions other than staff supervision to prevent fire [MEDICAL CONDITION] dropped ashes or cigarettes, for which Resident #3 was assessed to be at risk on 11/07/18. During further interview on 11/09/18 at 10:05 AM, the Director of Nursing admitted Resident #3's assessment had changed and they were now unsafe to smoke a without supervision, that Resident #3 had good and bad days, that sometimes Resident #3 could light and hold their cigarette safely but sometimes they needed help. During observation of the outdoor smoking area on 11/09/18 at 10:35 AM, Resident #3 was observed to be wearing street clothes and smoking a cigarette with no protective barrier over his clothing to prevent fire [MEDICAL CONDITION] dropped ashes or cigarettes. During interview on 11/09/18 at 11:15 AM, the Administrator and Director of Nursing reported a smoking apron was ordered on [DATE] but had not arrived and the Director of Nursing stated they could not add this to Resident #3's care plan until the smoking apron was available. The summary of the allegation of compliance submitted by the facility that was approved on 11/09/18 includes the following: The Smoking Policy was revised to address residents on oxygen. Residents may not smoke with oxygen present. Residents on oxygen must have a physician order [REDACTED]. Nursing staff to hold lighting and smoking materials. New smokers would be evaluated by the interdisciplinary team to ensure appropriate safety measures are put in place before being permitted to smoke. Care plans are to include safety measures for smoking as decided by the interdisciplinary team. Findings are to be discussed in weekly and quarterly meetings. Cross reference to F689.

Based on review of the facility's Policies and Procedures, record review, interview, and observation, the facility failed to implement appropriate safety precautions for 2 of the 3 smokers in the facility at the time of the incident (Residents #1 and #3), and 1 non-smoker (Resident #2). This harmed Resident #1, who was on continuous oxygen and was permitted to keep smoking materials at the bedside. Resident #1 smoked in bed on 11/01/18 and started a fire which burned himself and endangered all residents in the facility. This harmed Resident #2 a nonsmoker and roommate of Resident #2, who was hospitalized for [REDACTED]. This also affected Resident #3 who still did not have interventions to prevent identified risk [MEDICAL CONDITION] unsafe smoking on 11/09/18. This was Immediate Jeopardy and the Immediate Jeopardy is now removed based on the allegation of compliance provided by the Administrator that was approved on 11/09/18. The Immediate Jeopardy was removed on 11/09/18 and the Scope and Severity was reduced to a (D). The findings included: 1.) The facility Policy and Procedure titled Smoking Policy - Residents, dated (MONTH) (YEAR) that was in effect at the time of the incident, 11/01/18, documents: 4. Oxygen use is prohibited in smoking areas. 7. The resident will be evaluated on admission to determine if he or she is a smoker or nonsmoker. If a smoker, the evaluation will include: a. Current level of tobacco consumption; b. Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe; etc); c. Desire to quit smoking, if a current smoker; and d. Ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 8. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 9. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff. 10. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. and 13. Residents who have independent smoking privileges are permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted . 2.) A Fire Incident Report dated 11/02/18 documented a fire incident in the facility on 11/01/18 at 11:05 PM that involved Resident #1, who sustained [MEDICAL CONDITION] was airlifted to a burn trauma unit. The Fire Incident Report dated 11/02/18 documented Resident #2 reported that Resident #1 had been smoking in bed, and that Resident #1's mattress and a privacy curtain had caught on fire; that the fire was extinguished by staff with minimal damage to the facility, residents were temporarily removed from nearby rooms, and the area was ventilated. 3.) Resident #1's History and Physical with service date/time of 11/01/18 at 00:00 AM from the first hospital he was taken to documents he was admitted on [DATE] at 11:40 PM with 20% total body surface area partial-[MEDICAL CONDITION] his left and upper extremities, including the left axilla, left flank, and also left thigh and considering the extent of the patient's injuries and the involvement of flexor surfaces, as well as his difficulty breathing, we find it advisable to transfer him to a dedicated burn center at this time. History and Physical Notes with service date/time of 11/02/18 at 3:37 AM from the second hospital Resident #1 was taken to document he had 2nd and 3rd degreee 9.5%[MEDICAL CONDITION] the left abdomen, flank, and upper arm and that he stated he didn't remember what happened and that he woke up in bed on fire. Progress Notes with service date/time of 11/04/18 at 4:23 AM document that upon arrival Resident #1 was oriented, requested to change his status to full code, and was admitted to intensive care for close monitoring of his heart, breathing, and fluid status. The Progress Notes for service 11/04/18 at 4:23 AM document at approximately 2:11 AM Resident #1's breathing became increasingly fast with difficulty breathing despite scheduled breathing treatments, his mental status declined, and a breathing tube was urgently inserted to help him breath artificially. The Progress Notes for service 11/04/18 at 4:23 AM document Resident #1's heart rhythm and oxygen levels were then normal,, but 2 minutes later his heart rate and oxygen levels dropped, he went into a fatal heart rhythm, and despite 28 minutes of aggressive resuscitative efforts, they could not keep him alive. Review of Resident #1's nursing home medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Current Physician order [REDACTED]. Resident #1's Admission MDS (Minimum Data Assessment) with Assessment Reference Date 05/16/18 documented Resident #1 had a BIMS (Brief Interview for Mental Status) score of 8 out of 15, indicating he was moderately cognitively impaired; that he was on hospice and had a history of [REDACTED]. A Certificate of Incapacity to Give Informed Consent/Make Health Care Decisions dated 05/21/18 and signed by a physician documents I, (physician name) have evaluated (Resident #1) and have determined that the resident lacks the capacity to give informed consent and make health care decisions. In my opinion this condition is permanent and there is little chance that he / she will be competent to make his / her health care decisions in the future. An undated sticky note over the Certificate of Incapacity to Give Informed Consent/Make Health Care Decisions included the handwritten note no longer incap. as resident score a 14 on BIMS. An Advance Directives Acknowledgement documents under Check which forms are in place: a checkmark for Certificate of Incapacity dated 05/21/18 with a handwritten note resolve 11/1/18 with the Social Services Assistant's initials. Review of Resident #1's Medication Administration Records reveal he was on continuous oxygen since admission and including his last full day in the facility, 11/01/18. Resident #1's Side Rail Use Assessment Form signed by a nurse on 07/31/18 documents the answer Yes for the question Does the resident's level of consciousness fluctuate? Resident #1's Quarterly MDS (Minimum Data Assessment) with Assessment Reference Date 08/16/18 documented Resident #1's BIMS score was again 8 out of 15, indicating moderately impaired cognition; that he was on hospice and used oxygen; that he was nonambulatory and used a wheelchair, and that he needed extensive assistance of 1 person for bed mobility, transfers, locomotion on and off the unit, and toileting; and limited assistance for personal hygiene. Resident #1's Resident Smoking Assessment, dated 11/01/18 and signed by the Social Services Assistant, documents his smoking status as Unsupervised. Further review of Resident #1's Resident Smoking assessment dated [DATE] reveals it is incomplete in that there are 4 unanswered questions below which it documents If yes to any of above: resident is at risk and not safe to smoke independently. The four unanswered questions on this Resident Smoking Assessment are: 1. Does resident have a history of poor judgment regarding safety of himself or others? 2. Are there any physical limitations, which have implications on the resident's ability to smoke (i.e. arthritis, hand injury, paralysis)? 3. Does the resident have a history of falling asleep while seated? 4. Does resident take any medication which could affect his/her ability to smoke safely (e.g. cause drowsiness)? If yes, please specify: __ Resident #1's Independent Smoker Contract, dated 11/01/18 and signed by Resident #1 and the Social Services Assistant, documents in part: I, (resident name), accept the responsibility and privilege of smoking and keeping my own smoking materials. I understand that if I do not follow these guidelines, my privilege to handle my own tobacco products and/or electronic cigarettes may be taken away. 1. I understand that smoking will take place in the designated smoking area outside the facility ONLY. NO SMOKING is allowed inside the facility at any time. 2. I understand that I can not keep a lighter or matches if there is oxygen in my room (either being used by myself or my roommate). 3. I will store my smoking materials per facility policy and the IDT's decision: (Circle a. or b.) a. In a locked box in my room b. At the nurses's station 4. I will store my lighting materials per the facility policy and the IDT's decision: (Circle a. or b.) a. In a locked box in my room b. At the nurses's station 5. I understand I need to maintain the locked box in a secure area. (i.e. in a drawer or closet) The key to the lockbox needs to be kept in a secure place or in my possession at all times. On this document options a. were circled for both items 3 and 4. Resident #1's Social Service Note dated/timed 11/01/18 at 4:27 PM documented Writer met with the resident as staff communicated the resident may be a smoker. Smoking assessment concluded that resident is a safe smoker and he was provided with a lock box to store his smoking materials. Care plan to reflect. Writer reviewed the smoking policy including the area to smoke on the patio/educated on risk of smoking etc. Resident verbalized understanding. No issues or concerns communicated at this time. Writer to remain supportive as needed. Resident #1's Social Service Note dated/timed 11/01/18 at 4:28 PM documented Resident's mentation reassessed. Resident scored a 14 on BIMS assessment concluding to be alert with independence in decision making. Resident #1's Care Plan entry for the Focus area I am a smoker created 11/01/18 by the Social Services Assistant documents under Goals I will not suffer injury from unsafe smoking practices through the next review date and includes under Interventions I am able to keep my own cigarette, keep lighter in provided locked box. The care plan for smoking did not address that Resident #1 uses oxygen which is flammable and should not be used around cigarettes or lighting materials. Further review of Resident #1's entire Care Plan reveals no evidence of any interventions to address how Resident #1 could smoke safely although they were oxygen dependent, such as that Resident #1 should not smoke while on oxygen or in the presence of oxygen, whether Resident #1 could safely be off of oxygen to smoke, and how or whether Resident #1 would be monitored for compliance with not using oxygen while smoking or for shortness of breath while off of oxygen to smoke. Resident #1's Health Status Note dated/timed 11/02/18 at 02:00 AM documents Resident's roommate reported resident lit up a cigarette and apparently fell asleep. Resident awake, alert oriented to person, place and time. Air lifted to (hospital name) due to self [MEDICAL CONDITION]. During interview on 11/02/18 at 10:40 AM, the Director of Nursing (DON) stated Resident #1 was admitted to the facility in (MONTH) (YEAR), had previously denied being a smoker, and was first observed by staff smoking on 11/01/18 at approximately 3:30 PM in the designated outdoor smoking area. During interview 11/02/18 at 10:40 AM, the DON stated that on 11/01/18 Social Services staff did a smoking assessment, determined Resident #1 was a safe smoker, and gave him a lockbox in which to keep smoking materials at the bedside. During interview on 11/02/18 at 10:40 AM, the DON stated Resident #1 knew he wasn't allowed to smoke in his room but that night Resident #1 smoked in bed and caught himself on fire, that facility staff got him and Resident #2 out of the room, extinguished the fire, and acted quickly to get other residents out of the nearby area. During interview on 11/02/18 at 10:40 AM the Administrator stated residents from nearby rooms were temporarily relocated to other rooms in the facility, where they remained at the time of interview, while the affected area was being aired out. During interview on 11/02/18 at 1:34 PM, the Administrator stated residents with oxygen are not allowed to have lighters or matches in their rooms, that Resident #1 knew and signed the policy acknowledging he wasn't allowed to have them, but that he must have snuck a lighter in. During interview on 11/02/18 at 1:41 PM, the Social Service Director stated a staff member had approached her on 11/01/18 and said Resident #1 might be a smoker, so she talked to Resident #1 admitted they were starting smoking as of that same day. During interview on 11/02/18 at 1:41 PM, the Social Service Director stated she did a smoking assessment and determined Resident #1 was a safe smoker, that she gave him a lockbox for cigarettes and explained he cannot keep a lighter or matches since he had oxygen in the room. During interview on 11/02/18 at 1:41 PM, the Social Service Director stated Resident #1 didn't admit, and she didn't know, that he had a lighter. During an interview on 11/02/18 at 4:30 PM with nurse, Staff B, Staff B reported she had cared for and knew Resident #1, that he had periods of confusion and needed oxygen and Staff B denied that she would trust Resident #1 with matches or a lighter in their room. During further interview on 11/02/18 at 5:06 PM, the Social Service Director stated on 11/01/18 around 3:30 PM she walked through the courtyard where she saw Resident #1 smoking and, upon questioning, he admitted they started smoking that day, so she watched him for the smoking assessment to ensure he was holding the cigarette properly. When asked during interview on 11/02/18 at 5:06 PM if Resident #1 had oxygen when she saw him outside smoking, the Social Services Director paused for several seconds before asking that would be a problem, right? then quickly answered no, she didn't see it and didn't think he had it (oxygen). When asked during interview on 11/02/18 at 5:06 PM if she educated Resident #1 about not smoking with oxygen on, the Social Services Director stated she told him he can't smoke in the building and can't smoke in their room because he and his roommate (Resident #2) were both on oxygen. During interview on 11/02/18 at 5:06 PM, the Social Services Director stated she went over the smoking contract with Resident #1 in his room and was with him for at least 20 minutes, that she saw him put cigarettes in the lockbox she provided to be kept at the bedside, but Resident #1 denied having a lighter and she didn't see one. Upon questioning on 11/02/18 at 5:06 PM that Resident #1's smoking contract had a circled option a to indicate he could keep lighting materials in their room, the Social Services Director replied he circled that himself and denied agreeing he could keep lighting materials in the lockbox in his room. During interview with the Social Services Assistant on 11/05/18 at 12:10 PM, she identified herself as the one who was informed by a staff member that Resident #1 was smoking, had talked to and observed him while he smoked on the patio on 11/01/18 at around 3:30 PM, had completed his smoking assessment, and had reviewed and had him sign the smoking contract in the presence of the Social Services Director. On 11/05/18 at 12:10 PM, upon review of Resident #1's Resident Smoking assessment dated [DATE] the Social Services Assistant admitted she had completed that form and explained she does not use the last 4 questions unless there is a no to at least one of the first set of questions and that this was how she was taught by her previous boss. The Social Services Assistant did not admit that a positive answer to any of those 4 unanswered questions should disqualify a resident from smoking without supervision. The Social Services Assistant admitted on [DATE] at 12:10 PM that she did not recall informing a nurse or anyone on the evening shift that Resident #1 was a smoker or had smoking materials. On 11/05/18 at 12:10 PM the Social Services Assistant admitted that some time ago the Social Services Director had initiated guardianship proceedings, which she believed were still pending, for Resident #1 because family had not want to be involved and that there was a Certification of Incapacity in place for him but, since she herself reassessed his BIMS score to be improved with a 14 out of 15 on 11/01/18, that incapacity was resolved and he could make his own decisions. On 11/05/18 at 12:10 PM the Social Services Assistant admitted she wrote resolve 11/1/18 next to Certificate of Incapacity on the Advance Directives Acknowledgement and that she was told to do this by the Social Services Director. The Social Services Assistant explained on 11/05/18 at 12:10 PM that she uses the BIMS score to assess both memory and judgment, that a high BIMS score indicates the person is responsible to make decisions for themselves. On 11/05/18 at 12:10 PM the Social Services Assistant denied awareness that Social Services cannot reverse a physician's judgment for Certification of Incapacity and admitted she did not discuss doing so with a physician. During telephone interview on 11/05/18 at 2:33 PM with Nurse Supervisor, Staff A, Staff A reported they worked the 3:00 PM to 11:00 PM shift on 11/01/18 and had participated in removing Resident #1 from the fire and had shut off the oxygen in that room. Staff A reported on 11/05/18 at 2:33 PM she hadn't heard that Resident #1 was a smoker and, had she known, she would have realized he needed supervision, would have kept any smoking materials at the nursing station, and that she would never leave Resident #1 with a lighter. During interview on 11/05/18 at 2:58 PM, the resident's assigned Hospice Nurse, she reported Resident #1 seemed oriented to her but was oxygen dependent, that he sometimes took the oxygen off and she would remind him to put it back on, that he needed help to get out of bed, and that she never saw him out of his room. During interview with Certified Nursing Assistant, Staff D on 11/05/18 at 4:36 PM, Staff D reported she worked with Resident #1 regularly and he always used oxygen in bed but she wasn't sure if he used, or should use, oxygen when out of bed. During interview with the Activities Director on 11/06/18 at 6:16 PM, she reported Resident #1 wore oxygen in his room and always had it on when they came to activities. During a telephonic interview with the Physician Assistant on 11/08/18 at 11:40 AM, the Physician Assistant reported that Resident #1 did not recall prior discussions from visit to visit, that he was oriented to himself and place but she wasn't sure about time, that she knew he had smoked in the past but was not consulted when he started smoking again on 11/01/18, and that she didn't believe he was capable to make medical or financial decisions. During interview with the Rehab Director on 11/08/18 at 2:35 PM, she admitted she had seen Resident #1 smoking on the patio on 11/01/18 between 3:00 PM and 3:15 PM, that she knew he was not asessed as a smoker, so had asked another staff member to notify the Social Services Assistant so Resident #1 could be assessed for smoking safety. On 11/08/18 at 2:35 PM the Rehab Director denied Resident #1 being on oxygen while she observed him smoking or seeing him with any smoking materials other than a cigarette. 4.) Resident #2 was the roommate of Resident #1 on 11/01/18. Review of the record revealed Resident #2 had a medical history of [REDACTED]. The fire that started with Resident #1 in bed A was between Resident #2 and the only doorway. Review of the hospital record documented Resident #2 was fully oriented, had suffered smoke inhalation and was hospitalized for [REDACTED]. During interview on 11/05/18 at 5:23 PM, Resident #2 reported that Resident #1 had yelled out that he was on fire on 11/01/18 around 11:00 PM, that he looked over to see Resident #1's clothing and bed on fire, a cigarette lighter on the floor next to the bed, and yelled for help. During interview on 11/05/18 at 5:23 PM, Resident #2 admitted that he and Resident #1 used oxygen and stated Resident #1 had a tank on their wheelchair that he used whenever he got out of bed. 5.) Review of the record revealed Resident #3 was first admitted to the facility on [DATE], readmitted on [DATE], and had [DIAGNOSES REDACTED]. Resident #3's Resident Smoking Assessment, dated 07/05/18 and signed by the Social Services Assistant, documents his smoking status as Unsupervised. Further review of Resident #1's Resident Smoking assessment dated [DATE] reveals it is incomplete in that the following 4 questions were unanswered: 1. Does resident have a past history of poor judgment regarding safety of himself or others? 2. Are there any physical limitations, which have implications on the resident's ability to smoke (i.e. arthritis, hand injury, paralysis)? 3. Does the resident have a history of falling asleep while seated? 4. Does resident take any medication which could affect his/her ability to smoke safely (e.g. cause drowsiness)? If yes, please specify: __ Below these 4 questions the form documents If yes to any of the above: resident is at risk and not safe to smoke independently. Review of the record revealed no evidence of documentation of a new smoking assessment for Resident #3 until 11/07/18, during the survey. Resident #3's Independent Smoker Contract, dated 09/20/14 and signed by Resident #3 and a facility representative, documents in part: I, (resident name), accept the responsibility and privilege of smoking and keeping my own smoking materials. I understand that I may only smoke tobacco products and only in the designated smoking area outside the building. I understand that if I do not follow these guidelines, my privilege to handle my own tobacco products may be taken away: 1. I understand that smoking will take place in the designated smoking area outside the facility ONLY. NO SMOKING is allowed inside the facility at any time. 2. I will store my smoking materials per facility policy and the IDT's decision: (Circle a. or b.) a. In a locked box in my room b. At the nurses's station 3. I will store my lighting materials per the facility policy and the IDT's decision: (Circle a. or b.) a. In a locked box in my room b. At the nurses's station 4. I will use the ashtrays provided to extinguish my cigarettes. Neither options were circled or indicated as selected for items #2 and #3. Review of the record revealed no evidence of documentation of a new Smoker Contract until during the survey, on 11/07/18. A Standards of Care with all sections dated 01/12/18 documents under Smoking The IDT (interdisciplinary team) recommends: Supervision with smoking and a handwritten Progress Note Resident understands that lighter must be kept by staff - IDT to emphasize the importance of facility's safety policy. Resident #3's care plan with print date of 11/05/18 and Review Start Date 10/01/18 documented for the Focus area I am a smoker under Goals I will not suffer injury from unsafe smoking practices through the next review date and includes under Interventions I am able to: keep own cigarette, keep lighter in provided locked box. During an interview with Resident #3 on 11/08/18 at 4:50 PM, he admitted that on 11/02/18 he had to turn in his lockbox with lighter and cigarettes and since then must sign his smoking materials in and out each time he goes outside to smoke. Resident #3's Resident Safe Smoking Assessment, dated 11/07/18 and signed by Resident #3 but not a staff member, documented the following: -The answer No to question 4. Does resident demonstrate the ability to light and smoke a cigarette or other smoking devices? - The answer No to question 5. Does resident demonstrate a safe technique for putting out matches or lighter or disposing of ash? - The answer No to question 6. Does resident demonstrate ability to physically hold the smoking device while smoking? - no answer to the question 8. Is the resident on Oxygen? - The answer Yes to question 10. Are there any physical limitations, which have implications on the resident's ability to smoke (i.e. arthritis, hand injury, paralysis)? - The answer Yes to question 12. Does resident take any medication which could affect his/her ability to smoke safely (e.g. cause drowsiness)? If yes, please specify: handwritten names of medications and their description as hypertensive and diabetic medications. Below the questions the form documents that based on the assessment, the resident is deemed a supervised smoker. Resident #3's care plan with revision date 11/07/18 documents for the Focus area I am at risk for injuries related to smoking; the unmeasurable Goal My risk for injuries related to smoking will be minimized through the review date. and includes no interventions other than staff supervision to prevent fire [MEDICAL CONDITION] dropped ashes or cigarettes, for which he was assessed to be at risk on 11/07/18. During interview on 11/08/18 at 11:49 AM, the Director of Nursing reported the Smoking Assessment form had been revised to address whether the smoker was on oxygen. During further interview on 11/09/18 at 10:05 AM, the Director of Nursing admitted Resident #3's assessment had changed and he was now unsafe to smoke without supervision, reported he had good and bad days, that sometimes he could light and hold his cigarette safely but sometimes he needed help. During observation of the outdoor smoking area on 11/09/18 at 10:35 AM, Resident #3 was observed to be wearing street clothes and smoking a cigarette with no protective barrier over their clothing to prevent fire [MEDICAL CONDITION] dropped ashes or cigarettes. During interview on 11/09/18 at 11:15 AM, the Administrator and Director of Nursing reported a smoking apron was ordered on [DATE] but had not arrived and the Director of Nursing stated they could not add this to Resident #3's care plan until the smoking apron was available. The summary of the allegation of compliance submitted by the facility that was approved on 11/09/18 includes the following: A facility wide audit was conducted to inquire about residents smoking status or plans to start smoking and all rooms were checked, with residents' permission, for lighting and smoking materials. The Smoking Policy was revised to address residents on oxygen and that new smokers would be evaluated by the interdisciplinary team before permitted to smoke. The Smoking Contract was revised to reflect no smoking materials would be permitted at residents' bedside. Rooms of known smokers would be checked daily for lighting and smoking materials. The Smoking Assessment was revised to address oxygen use and Social Services staff were inserviced to complete the new form in its entirety. Cross Reference to F657 and F926

Based on record review, and interview the facility failed to have adequate policies and procedures in place to address smoking safety and fire hazards, including the use of oxygen. This seriously harmed Resident #1, who was on continuous oxygen but was permitted to keep smoking materials at the bedside. Resident #1 smoked in bed on 11/01/18 and started a fire which burned himself and endangered all residents in the facility. This also harmed Resident #2 a nonsmoker who happened to be near the fire and was hospitalized for [REDACTED]. There were 3 residents who smoked in the facility at the time of the fire incident. This was Immediate Jeopardy and the Immediate Jeopardy is now removed based on the allegation of compliance provided by the Administrator that was approved on 11/09/18. The Immediate Jeopardy was removed and the Scope and Severity was reduced to a (D). The findings included: The facility Policy and Procedure titled Smoking Policy - Residents, dated (MONTH) (YEAR) that was in effect at the time of the incident, 11/01/18, documents: 4. Oxygen use is prohibited in smoking areas; 7. The resident will be evaluated on admission to determine if he or she is a smoker or nonsmoker. If a smoker, the evaluation will include: a. Current level of tobacco consumption; b. Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe; etc); c. Desire to quit smoking, if a current smoker; and d. Ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 8. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 9. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff. 10. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues; and 13. Residents who have independent smoking privileges are permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted . The Smoking Policy did not address safety for residents who want to smoke but use oxygen or that lighters should not be kept near oxygen. Review of the record reveals Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Current Physician order [REDACTED]. Review of Resident #1's Medication Administration Records reveal Resident #1 was on continuous oxygen since admission, and including their last full day in the facility, 11/01/18. A Fire Incident Report dated 11/02/18 documented a fire incident in the facility on 11/01/18 at 11:05 PM that involved Resident #1, who sustained [MEDICAL CONDITION] was airlifted to a burn trauma unit. The Fire Incident Report dated 11/02/18 documented Resident #2 reported that Resident #1 had been smoking in bed, and that Resident #1's mattress and privacy curtain had caught on fire. During telephone interview on 11/05/18 at 2:33 PM with Nurse Supervisor, Staff A, Staff A reported she worked the 3:00 PM to 11:00 PM shift on 11/01/18 and had participated in removing Resident #1 from the fire before shutting off the oxygen in that room. Resident #2 was the roommate of Resident #1 on 11/01/18. Review of the record revealed Resident #2 had a medical history of [REDACTED]. The fire that started at Resident #1 in bed A was between Resident #2 and the only doorway. Review of the hospital record documented Resident #2 was fully oriented, had suffered smoke inhalation, and was hospitalized for [REDACTED]. During interview on 11/05/18 at 5:23 PM, Resident #2 reported that Resident #1 had yelled out that he was on fire on 11/01/18 around 11:00 PM, that he looked over to see Resident #1's clothing and bed on fire and a lighter on the floor next to the bed. During interview on 11/05/18 at 5:23 PM, Resident #2 admitted that he and Resident #1 both used oxygen, and that Resident #1 had used oxygen continuously and had an oxygen tank on his wheelchair. The summary of the allegation of compliance submitted by the facility that was approved on 11/09/18 includes the following: the Smoking Policy was revised to address residents on oxygen and that new smokers would be evaluated by the interdisciplinary team before being permitted to smoke. The Smoking Contract was revised to reflect no smoking materials would be permitted at residents' bedside. The Smoking Assessment was also revised to address oxygen use. Cross Reference to F689 and F835.

Based on record review, interview, and observation, the facility Administrator failed to ensure the safety of all residents residing in the facility as evidenced by failing to ensure staff followed resident smoking policies and that those policies were adequate; failing to reassess and implement additional measures to ensure the safety of residents after a smoking fire incident burned Resident #1 who died 2 days later and resulted in hospitalization of Resident #2, a nearby nonsmoker, for smoke inhalation; and failed to reassess and implement appropriate safety measures in a timely manner for Resident #3 who was identified as an unsafe smoker but did not have interventions in place to prevent [MEDICAL CONDITION] observation on [DATE]. There were 3 residents who smoked in the facility at the time of the fire incident.This was Immediate Jeopardy and the Immediate Jeopardy is now removed based on the allegation of compliance provided by the Administrator that was approved on [DATE]. The Immediate Jeopardy was removed and the Scope and Severity was reduced to a (D). The findings included: 1. The facility's Job Description, dated [DATE], for Administrator includes the following under Duties and Responsibilities: Review the facility's policies and procedures periodically, at least annually, and make changes as necessary to assure continued compliance with current regulations . and Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services. and Ensure that all residents receive care in a manner and in an environment that maintains or enhances their quality of life without abridging the safety and rights of other residents. Ensure that each resident receives the necessary nursing, medical and psychosocial services to attain and maintain the highest possible mental and physical functional status, as defined by the comprehensive assessment and care plan. 2. The facility Policy and Procedure titled Smoking Policy - Residents, dated (MONTH) (YEAR) that was in effect at the time of the incident, [DATE], documents: 4. Oxygen use is prohibited in smoking areas, that smokers will be evaluated for their ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). and 8. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 9. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff. 10. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues; and 13. Residents who have independent smoking privileges are permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted . 3. A Fire Incident Report dated [DATE] documented a fire incident in the facility on [DATE] at 11:05 PM that involved Resident #1, who sustained [MEDICAL CONDITION] was airlifted to a burn trauma unit. The Fire Incident Report dated [DATE] documented Resident #2 reported that Resident #1 had been smoking in bed, and that Resident #1's mattress and a privacy curtain had caught on fire. 4. Review of the record reveals Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Medication Administration Records reveal Resident #1 was on continuous oxygen since admission, and including their last full day in the facility, [DATE]. Resident #1's Resident Smoking Assessment, dated [DATE] and signed by the Social Services Assistant, documents Resident #1's smoking status as Unsupervised. Further review of Resident #1's Resident Smoking assessment dated [DATE] reveals it is incomplete in that there are 4 unanswered questions below which it documents If yes to any of above: resident is at risk and not safe to smoke independently. The four unanswered questions on this Resident Smoking Assessment are: 1. Does resident have a history of poor judgment regarding safety of himself or others? 2. Are there any physical limitations, which have implications on the resident's ability to smoke (i.e. arthritis, hand injury, paralysis)? 3. Does the resident have a history of falling asleep while seated? 4. Does resident take any medication which could affect his/her ability to smoke safely (e.g. cause drowsiness)? If yes, please specify: __ The Smoking Assessment did not assess for use of oxygen, which is flammable and dangerous around smoking. Resident #1's Independent Smoker Contract, dated [DATE] and signed by Resident #1 and the Social Services Assistant, documents in part: 2. I understand that I can not keep a lighter or matches if there is oxygen in my room (either being used by myself or my roommate). but also 3. I will store my smoking materials per facility policy and the IDT's decision: .a. In a locked box in my room (a was circled) and 4. I will store my lighting materials per the facility policy and the IDT's decision: .a. In a locked box in my room (a was circled) and 5. I understand I need to maintain the locked box in a secure area. (i.e. in a drawer or closet) The key to the lockbox needs to be kept in a secure place or in my possession at all times. Resident #1's Social Service Note dated/timed [DATE] at 4:27 PM documented Writer met with the resident as staff communicated the resident may be a smoker. Smoking assessment concluded that resident is a safe smoker and he was provided with a lock box to store his smoking materials. Care plan to reflect. Writer reviewed the smoking policy including the area to smoke on the patio/educated on risk of smoking etc. Resident verbalized understanding. No issues or concerns communicated at this time. Writer to remain supportive as needed. Resident #1's Social Service Note dated/timed [DATE] at 4:28 PM documented Resident's mentation reassessed. Resident scored a 14 on BIMS assessment concluding to be alert with independence in decision making. Resident #1's Care Plan entry for the Focus area I am a smoker created [DATE] by the Social Services Assistant documents under Goals I will not suffer injury from unsafe smoking practices through the next review date and includes under Interventions I am able to keep my own cigarette, keep lighter in provided locked box. The care plan for smoking does not address that Resident #1 uses oxygen which is flammable and should not be used around cigarettes or lighting materials. Further review of Resident #1's entire Care Plan reveals no evidence of any interventions to address how Resident #1 could smoke safely although they were oxygen dependent, such as that Resident #1 should not smoke while on oxygen or in the presence of oxygen, whether Resident #1 could safely be off of oxygen to smoke, and how or whether Resident #1 would be monitored for compliance with not using oxygen while smoking or for shortness of breath while off of oxygen to smoke. Resident #1's Health Status Note dated/timed [DATE] at 02:00 AM documents Resident's roommate reported resident lit up a cigarette and apparently fell asleep. Resident awake, alert oriented to person, place and time. Air lifted to (hospital name) due to self [MEDICAL CONDITION]. During interview on [DATE] at 1:34 PM, the Administrator stated residents with oxygen are not allowed to have lighters or matches in their rooms, that Resident #1 knew and signed the policy acknowledging they weren't allowed to have them, but that Resident #1 must have snuck a lighter in. The Administrator did not acknowledge that if cigarettes had not been left with the resident, he could not have been tempted to smoke in bed. The Administrator also did not acknowledge that a resident who was oxygen-dependent should not have been identified as an independent and safe smoker but should have interventions care planned to address the risk of smoking while on oxygen for their own safety and safety of all residents in the facility. During interview on [DATE] at 5:06 PM, the Social Services Director stated she went over the smoking contract with Resident #1 in their room and was with them for at least 20 minutes, that she saw Resident #1 put cigarettes in the lockbox she provided to be kept at the bedside, but Resident #1 denied having a lighter and she didn't see one. Upon questioning on [DATE] at 5:06 PM that Resident #1's smoking contract had a circled option a to indicate Resident #1 could keep lighting materials in their room, the Social Services Director replied Resident #1 circled that themselves and denied indicating Resident #1 could keep lighting materials in the lockbox in his room. During telephone interview on [DATE] at 2:33 PM with Nurse Supervisor, Staff A, Staff A reported she worked the 3:00 PM to 11:00 PM shift on [DATE] and had participated in rescuing Resident #1 from the fire and had shut off the oxygen in that room. Staff A reported on [DATE] at 2:33 PM that she never heard that Resident #1 was a smoker and, had she known, she would have known he needed supervision and would have kept any smoking materials at the nursing station, that she would never leave Resident #1 with a lighter. During a telephonic interview with the Physician Assistant on [DATE] at 11:40 AM, the Physician Assistant reported she was not consulted or informed on [DATE] that Resident #1 wanted to start smoking again. 5. Review of the record revealed Resident #3 was first admitted to the facility on [DATE], readmitted on [DATE], and had [DIAGNOSES REDACTED]. Resident #3's Resident Smoking Assessment, dated [DATE] and signed by the Social Services Assistant, documents Resident #3's smoking status as Unsupervised. Further review of Resident #1's Resident Smoking assessment dated [DATE] reveals it is incomplete in that the following 4 questions were unanswered: 1. Does resident have a past history of poor judgment regarding safety of himself or others? 2. Are there any physical limitations, which have implications on the resident's ability to smoke (i.e. arthritis, hand injury, paralysis)? 3. Does the resident have a history of falling asleep while seated? 4. Does resident take any medication which could affect his/her ability to smoke safely (e.g. cause drowsiness)? If yes, please specify: __ Below these 4 questions the form documents If yes to any of the above: resident is at risk and not safe to smoke independently. Review of the record revealed no evidence of documentation of a quarterly smoking assessment after [DATE] or of a new smoking assessment for Resident #3 until on [DATE], during the survey. Resident #3's Independent Smoker Contract, dated [DATE] and signed by Resident #1 and a facility representative, did not indicate whether Resident #3's smoking and lighting materials would be stored in a locked box in his room or at the nurses's station. Review of the record revealed no evidence of documentation of a new Smoker Contract until during the survey, on [DATE]. A Standards of Care with all sections dated [DATE] documents under Smoking The IDT (interdisciplinary team) recommends: Supervision with smoking and a handwritten Progress Note Resident understands that lighter must be kept by staff - IDT to emphasize the importance of facility's safety policy. Resident #3's care plan with print date of [DATE] and Review Start Date [DATE] documented for the Focus area I am a smoker under Goals I will not suffer injury from unsafe smoking practices through the next review date and includes under Interventions I am able to: keep own cigarette, keep lighter in provided locked box. There was no evidence of documentation that the IDT had determined Resident #3 no longer needed staff to keep their lighter for safety. Review of the facility's Smoking QA (Quality Assurance) dated as completed on [DATE] and provided as evidence of their action to prevent future smoking accidents or fires documents Resident #3's smoking assessment was completed and last reviewed on [DATE], N/A (not applicable) to the question If not a safe smoker does supervision need to be provided? and that a smoking care plan was in place. Further review of the Smoking QA dated [DATE] reveals documentation that Resident #5's smoking assessment was completed and last reviewed on [DATE], N/A (not applicable) to the question If not a safe smoker does supervision need to be provided? and that a smoking care plan was in place. There was no evidence that Residents #3 and #5 were reassessed for smoking safety until after the facility was informed of Immediate Jeopardy. During an interview with Resident #3 on [DATE] at 4:50 PM, he admitted that on [DATE] he had to turn in his lockbox with his lighter and cigarettes and since then must sign smoking materials in and out each time he smokes. Resident #3's Resident Safe Smoking Assessment, dated [DATE] and signed by Resident #3 but not a staff member, documented the following: the answer No to the question 4. Does resident demonstrate the ability to light and smoke a cigarette or other smoking devices?, No to the question 5. Does resident demonstrate a safe technique for putting out matches or lighter or disposing of ash?, No to the question 6. Does resident demonstrate ability to physically hold the smoking device while smoking?, no answer to the question in bold print 8. Is the resident on Oxygen?, the answer yes to the question 10. Are there any physical limitations, which have implications on the resident's ability to smoke (i.e. arthritis, hand injury, paralysis)?, and the answer yes to the question 12. Does resident take any medication which could affect his/her ability to smoke safely (e.g. cause drowsiness)? If yes, please specify: __ with handwritten names of medications and their description as hypertensive and diabetic medications. Below the questions the form documents that based on the assessment, the resident is deemed a supervised smoker. Resident #3's care plan with revision date [DATE] documents for the Focus area I am at risk for injuries related to smoking; the immeasurable Goal My risk for injuries related to smoking will be minimized through the review date. and includes no interventions other than staff supervision to prevent fire [MEDICAL CONDITION] dropped ashes or cigarettes, for which Resident #3 was assessed to be at risk on [DATE]. During interview on [DATE] at 11:49 AM, the Director of Nursing reported the Smoking Assessment form had been revised to address whether the smoker was on oxygen. During further interview on [DATE] at 10:05 AM, the Director of Nursing admitted Resident #3's assessment had changed and he was now unsafe to smoke without supervision, that Resident #3 had good and bad days, that sometimes Resident #3 could light and hold his cigarette safely but sometimes he needed help. During observation of the outdoor smoking area on [DATE] at 10:35 AM, Resident #3 was observed to be wearing street clothes and smoking a cigarette with no protective barrier over their clothing to prevent fire [MEDICAL CONDITION] dropped ashes or cigarettes. During interview on [DATE] at 11:15 AM, the Administrator and Director of Nursing reported a smoking apron was ordered on [DATE] but had not arrived and the Director of Nursing stated they could not add this to Resident #3's care plan until the smoking apron was available. Cross Reference to F689 and F926.