Every finding on record at Glenwood Health Center by Harborview

Based on record review, staff interviews, and policy review, the facility failed to ensure one of five residents (R) (R8) reviewed for medication administration was free of significant medication errors out of a total sample of 60 residents. Specifically, the facility failed to ensure that physician-ordered medications were administered and documented for R8. This deficient practice had the potential to result in ineffective treatment of the residents' medical conditions and adverse clinical outcomes.Findings include:Review of R8's admission Record located under the Profile tab in the electronic medical record (EMR) revealed R8 was admitted on [DATE] with a diagnosis of type II diabetes. Review of R8's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/20/2026 located under the MDS tab in the EMR revealed R8 had a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated moderate cognitive impairment. Review of R8's Medication Order Summary with active orders dated 01/01/2026 located under the Orders tab in the EMR revealed an order dated 07/09/2025 for Insulin Glargine Solostar 300 units/milliliter (mL) (long-acting basal insulin), 14 units administered subcutaneously (SQ) at bedtime for diabetes mellitus (DM).Review of R8's MARs dated 02/2026 through 04/2026 located under the Orders tab in the EMR revealed no documentation that the Insulin Glargine Solostar 300 units/ml 14 units SQ at bedtime was administered as ordered on 02/02/26, 02/04/26, 02/25/26, 03/02/26, 03/04/26, 03/11/26, 03/20/26, and 03/27/26 at 9:00 PM. Review of R8's Progress Notes dated 02/2026 through 04/2026 located under the Progress Notes tab in the EMR revealed no documentation that the resident refused the medications, was out of the facility, or received the medications on the identified dates and times for which the corresponding MAR entries were blank. Further review revealed no documented explanation for the missing MAR documentation.During an interview on 07/21/26 at 3:50 PM, Regional Nurse Consultant (RNC) stated that if medication administration was not documented, the nurse probably administered the medication but failed to document it. The RNC stated nurses were expected to follow the medication administration process, including resident identification, medication, dose, route, time, and documentation. During an interview on 07/23/26 at 8:25 AM, Licensed Practical Nurse (LPN)11 stated nurses are responsible for documenting medication administration on the MAR. LPN11 stated that if the MAR was blank, the nurse either did not administer the medication or failed to document administration. LPN11 further stated the MAR was the expected location for documentation of medication administration.During an interview on 07/23/26 at 9:05 AM, the Staff Development Coordinator (SDC) stated medications should be documented when administered. The SDC stated that if administration was not documented on the MAR, the activity either was not performed or was not documented. The SDC confirmed that the expectation was that nurses document the administration of medication on the MAR. During an interview on 07/23/2026 at 4:35 PM, the Administrator stated nurses are responsible for administering medications and documenting administration on the MAR. The Administrator stated she was unaware of concerns regarding missed medication administration or incomplete medication documentation for R8. Review of the facility's policy titled Medication Orders revised 03/01/25, provided by the Administrator, revealed medications were to be administered only upon the order of an authorized prescriber. The policy further required medication orders to be documented on the physician order sheet and the MAR or electronic medication record.

Based on observations, interviews, record review, and policy review, the facility failed to ensure that one respiratory cart, one medication/treatment supply closet, and one housekeeping closet were locked when unattended on two of four survey days. This deficient practice created the potential for two vulnerable residents (R) (R58 and R60) to have access to medications, treatment supplies, and housekeeping chemicals, increasing the risk of medication errors, resident injury, and medication diversion.Findings include:1. During an observation on 07/20/2026 at 10:35 AM, an unattended medication storage supply office, on the Magnolia Wing (memory unit) was observed with the door open. Inside this room were seven large shelves filled with multiple containers of micro-kill bleach wipes, micro-kill One germicidal alcohol wipes, super absorbent wound dressings, gauze bandage rolls, dressing retention tape, Xeroform petrolatum dressing, abdominal pads, disinfectant wipes, zinc oxide paste, Plurogel, wound alginate wound dressing, and Dakin's Solution.R58 was observed on 07/20/2026 from 10:30 AM through 11:03 AM walking unsupervised independently up and down both sides of the Magnolia Wing (memory unit), passing the open door multiple times.Review of R58's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses of vascular dementia, and paranoid schizophrenia.Review of R58's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/25/2026 with a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated severe cognitive impairment. The MDS indicated that R58 was able to walk up to 10 feet with partial to moderate assistance.During an interview on 07/20/2026 at 10:36 AM, Regional Nurse Consultant (RNC) came down the Magnolia wing hallway and observed the medication storage supply office door open and unattended. The RNC confirmed the door should be shut and secure.2. During an additional observation on 07/20/2026 at 10:37 AM, the housekeeping closet near the nurse station on the Magnolia Wing had a large hair comb jammed against the bottom of the door, keeping the door from locking. The door opened readily. Inside the housekeeping closet was a 2.5-gallon container of {Brand} disinfectant cleaner attached to the wall, containers of dual action floor cleaner, and bio-enzymatic odor-eliminator chemicals.During an interview on 07/20/2026 at 10:39 AM, the RNC approached the housekeeping closet and stated that the door should have been secured and removed the comb from under the door.3. Observation on 07/20/2026 at 11:03 AM, was an unattended respiratory cart near resident room [ROOM NUMBER] on the Dogwood Wing with the cart's drawer fully opened. Inside the respiratory cart drawer were approximately ten 30 milliliter (ml) vials of Sodium Chloride 0.9%, and numerous ventilator and tracheostomy treatment equipment.4. Observation on 07/21/2026 from 10:59 to 11:16 AM revealed the respiratory therapist equipment cart was unlocked in the Dogwood unit solarium. The cart contained endotracheal tubes, face masks, nasal cannula, flow meters, suction catheters, bottles of normal saline, and syringes. R60's room was located in the solarium.Observation on 07/21/2026 at 3:00 PM revealed the respiratory therapist (RT) cart remained unlocked and R60 was propelling himself down the hallway.Review of R60's quarterly MDS with an ARD of 07/17/2026 located in the EMR under the Care Plan tab revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.Review of R60's Care Plan, with a revision date of 07/07/2026, located in the EMR in the Care Plan tab revealed the resident had a history of substance abuse and a history of storing medications within his room.During an additional interview on 07/20/2026 at 11:05 AM, the RNC stated that the RT's cart should always be secured and locked.During an interview with the Unit Manager (UM)1 on 07/21/2026 at 11:10 AM, UM1 stated that the RT was not on duty, and the cart had been unlocked since the UM1 arrived that morning. UM1 stated that staff were afraid to lock the cart in the event of an emergency. The UM1 further stated the cart was placed in the solarium so that residents would not have access to the cart but failed to realize that the solarium also contained R60's room. UM1 stated it was an expectation that the RT's cart would be kept locked when not in use.During an interview on 07/23/2026 at 8:58 AM, the Staff Development Coordinator (SDC) stated that she was not aware that a supply office and housekeeping closet were observed unlocked and unattended on the Magnolia Wing and that the RT's cart was unlocked and unsupervised on the Dogwood Wing. The SDC confirmed that all these locations and carts should have been locked and secured.During an interview with Licensed Practical Nurse (LPN) 15 on 07/21/2026 at 11:30 AM, LPN15 stated that staff could not locate the key to lock the RT's cart. Since the RT was not scheduled for that shift, they would have to call the RT at home to find out the location of the key.During an interview on 07/23/2026 at 9:25 AM, the Director of Nursing (DON) stated that she expected all supplies and medications to be secured. She confirmed that doors and carts should be locked for residents' safety. Review of the facility's policy titled Medication Storage, revised 03/01/2026, indicated, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.Only authorized personnel will have access to the keys to locked compartments.

Based on observations, record reviews, interviews, and policy review, the facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) for one resident (R) (R25) of seven residents reviewed for infection control who were on enhanced barrier precautions (EBP). This failure has the potential to promote the spread of infectious diseases to residents who are already compromised.1. Review of R25's admission Record in the EMR under the Profile tab revealed the resident was readmitted to the facility on [DATE] with diagnoses that included traumatic brain injury, sacral pressure ulcer, gastrostomy, tracheostomy, and sepsis.Review of R25's Physician's Orders dated 07/23/2026, located in the EMR under the Orders tab, revealed the resident was on EBP per facility protocol for tracheostomy, gastrostomy tube, and urinary catheter.Observation on 07/20/2026 at 11:30 AM revealed EBP precaution signage and PPE outside the resident's room. At this time, the Respiratory Therapist (RT) entered the resident's room without donning a gown. The RT donned only a pair of gloves.During an interview on 07/20/2026 at 11:40 AM, the RT confirmed the resident was on EBP due to the tracheostomy and gastrostomy tube, and he forgot to wear the gown while suctioning the resident.During an interview on 07/23/2026 at 3:00 PM, the Infection Preventionist (IP) stated that any resident with a tracheostomy, catheter of any type, intravenous fluids, or pressure ulcer/wounds are placed on EBP. Staff are expected to wear the appropriate PPE when providing resident care.Review of the facility's policy titled Enhanced Barrier Precautions dated 03/01/2026 directs staff to obtain physicians orders for residents with any of the of the following wounds such pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and chronic venous stasis ulcer; indwelling medical devices such as central lines, midline catheters, feeding tubes, tracheostomy ventilator tubes, hemodialysis.

Based on record review, interviews, and a review of the facility policy titled Fall Prevention Program, the facility failed to implement fall interventions to prevent falls for one of two sampled residents (R) (R18) reviewed for falls. Harm was identified to have occurred on 10/28/2025, when R18 sustained a fall, causing a laceration to R18's head, a nontraumatic intracranial (within the skull) hemorrhage (bleeding), and a nontraumatic subarachnoid (fluid-filled space around the brain through which major blood vessels pass) hemorrhage, which required hospitalization.Findings included:A review of the facility policy titled Fall Prevention Program, revised 1/1/2025, revealed that each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The policy revealed:9. When any resident experiences a fall, the facility will: a. Assess the resident; b. Complete a post-fall assessment; c. Complete an incident report; d. Notify physician and family; e. Review the resident's care plan and update as indicated; and f. Document all assessments and actions.A review of the admission Record revealed the facility readmitted R18 on 8/1/2024. According to the admission Record, the resident had a medical history that included a diagnosis of Alzheimer's disease (onset 11/22/2022), fracture of nasal bones (onset 9/20/2025), and nontraumatic intracranial hemorrhage (onset 10/31/2025).A review of R18's Fall incident report, dated 9/19/2025 at 1:01 pm, revealed Licensed Practical Nurse (LPN)3 was taking the resident to the dining room, and the resident leaned forward, fell, and hit their head. The document revealed, Immediate Action Taken indicated R18 sustained a bruise to their forehead, vital signs (measurements including body temperature, heart rate, respiratory rate, and blood pressure that indicate the status of the body's vital functions) were documented, and the resident's family member was notified. The report indicated that interventions included that staff were to ensure R18 was fully back in their wheelchair with their feet on the footrest and clothing/shoes adjusted before transport began.A review of the annual Minimum Data Set (MDS) assessment, with an Assessment reference Date (ARD) of 9/20/2025, revealed that R18 had moderate impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS). A review of the MDS revealed that R18 used a wheelchair. The MDS also indicated R18 had one fall with major injury since the prior assessment.A review of R18's Post Fall record, dated 10/28/2025 at 3:52 pm, indicated R18 slid out of their wheelchair to the floor and hit their head as a staff member was taking the resident to their room after lunch. The record indicated R18 experienced pain, had a small size laceration (a cut) to their upper right eye, and had swelling and bruising to the right eye. The record indicated the resident's nurse practitioner was notified, and a new order was received to send the resident to the emergency room for evaluation.A review of R18's Exception Report, dated 10/28/2025 at 4:25 pm, revealed that a fall occurred on 10/28/2025. The record indicated R18 slid out of their wheelchair to the floor when a staff member transported the resident from the cafeteria to their room, resulting in a small hematoma (a collection of blood outside of blood vessels) above the resident's right eye. The record indicated R18 was eating lunch before the event. The record indicated that R18 was sent to the hospital for evaluation and treatment of the hematoma and medication review.A review of R18's hospital Demographics record revealed the hospital admitted R18 on 10/28/2025 with diagnoses that included laceration without foreign body of other part of head, initial encounter; Nontraumatic intracranial hemorrhage, unspecified; and Nontraumatic subarachnoid hemorrhage, unspecified.A review of R18's hospital H&P [History and Physical], dated 10/28/2025 at 10:38 pm, indicated R18 was brought to the emergency department (ED) on 10/28/2025 following a fall after attempting to stand from their wheelchair. The record indicated R18 had right periorbital ecchymosis and edema (bruising and swelling) around the right eye and a laceration near the right eyebrow, which was repaired in the ED. The record indicated that a computerized tomography (CT) scan of R18's head revealed a trace subarachnoid hemorrhage over the left temporal convexity (left side of the brain). The record indicated neurosurgeons were consulted, who recommended Intensive Care Unit (ICU) admission for close neurological monitoring and a six-hour follow-up head CT. The record indicated that the resident recently fell on 9/19/2025 and fractured their nose. The record indicated R18 was critically ill and required continued critical care treatment.A review of R18's Hospital Medicine Discharge Summary indicated that the hospital discharged the resident back to the facility on [DATE].During an interview on 1/2/2026 at 9:57 am, Certified Nurse Assistant (CNA)1 stated that on the day R18 fell, CNA1 was in the dining room assisting with lunch and assisting residents back to their rooms. CNA1 stated that when she pushed R18 in their wheelchair around the corner and out of the dining room, the resident went face forward to the floor and hit their head (pointing to the right temporal area). CNA1 stated R18 had bruising, swelling, and bleeding in the area. CNA1 stated that when she was pushing R18, the resident had their legs straight out approximately five inches off the floor, and on that day, there were no footrests on the wheelchair. CNA1 stated she did not know who brought R18 to the dining room, but they would have been responsible for putting the footrests on the wheelchair before bringing the resident to the dining room for lunch. CNA1 stated she noticed there were no footrests on the chair when R18 fell out of the chair, but there should have been. CNA1 stated that before the fall, R18 had no swelling or bruising to that area.During an interview on 1/2/2026 at 10:51 am, CNA2 stated she took R18 to the dining room the day the resident fell out of their wheelchair. CNA2 stated R18 was in bed, and she got the resident up with the assistance of another staff member. CNA2 stated she made sure R18 was positioned correctly, and she thought the footrests were on the wheelchair before transporting the resident to the dining room. CNA2 stated that sometimes there were footrests on the wheelchair, but sometimes there were not. CNA2 stated that the footrests should have been on the wheelchair, and they always tried to make sure the footrests were on before transporting the resident in their wheelchair.During an interview on 1/2/2026 at 11:02 am, LPN3 stated she was at the nurses' station when R18 fell out of their wheelchair. LPN3 stated she heard a thud and looked up, and the resident was on the floor in front of their wheelchair with CNA1 at their side. LPN3 stated she ran to assess R18, and the resident had a hematoma and bleeding from a cut on the right side of their head above their eyebrow. LPN3 stated she cleaned the wound and stopped the bleeding by putting pressure on it. LPN3 stated she took R18 to their room and called the ambulance to take the resident to the hospital. LPN3 stated she remembered telling CNA2 to make sure the footrests were on before taking the resident to the dining room. She stated that someone could have taken the footrests off after getting to the dining room so that R18's legs could fit under the table to eat. LPN3 stated the footrests should have been put back on the wheelchair prior to transporting R18 back to their room.During an interview on 1/3/2026 at 1:36 pm, the Director of Nursing (DON) stated that all interventions should be in place before transporting R18 in their wheelchair. The DON stated that if the footrests were removed from the wheelchair after arriving in the dining room, then they should have been put back on before transporting the resident.During an interview on 1/3/2026 at 1:43 pm, the Administrator stated that she expected all interventions to be put in place to prevent future falls with major injuries.

Based on record review, facility document review, interviews, and a review of the facility policy titled Abuse, Neglect and Exploitation, the facility failed to thoroughly investigate and failed to maintain accurate documentation of investigations of abuse for four of the five (incident involving R97 and R176; incident involving R34 and Certified Medication Assistant(CMA)12; incident involving R59 and R194; and incident involving R171 and Certified Nursing Assistant(CNA)13) abuse allegations reviewed.Findings included:A review of the facility policy titled Abuse, Neglect and Exploitation, last reviewed 7/15/2025, indicated, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The policy revealed, V. Investigation of alleged Abuse, Neglect and Exploitation included, A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. The policy continued, B. Written procedures for investigations included, which included 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation.1. A review of the admission Record indicated the facility admitted R176 on 3/29/2025. According to the admission Record, the resident had a medical history that included a diagnosis of unspecified injury at an unspecified level of cervical spinal cord, subsequent encounter.A quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/26/2025, revealed R176 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident did not exhibit behavioral symptoms directed toward others during the assessment timeframe.A review of the admission Record included the facility admitting R97 on 5/28/2025. According to the admission Record, the resident had a medical history that included a diagnosis of nontraumatic intracerebral hemorrhage, intraventricular.A review of the annual MDS, with an ARD of 11/11/2025, revealed R97 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident did not exhibit behavioral symptoms directed toward others during the assessment timeframe.A review of the Facility Incident Report Form, dated 11/13/2025 and completed by the Administrator (ADM), indicated that the facility reported a Resident to Resident incident that occurred that day between R97 and R176. The document indicated that it was reported that R176 spat on R97, then R97 struck R176. The Facility Incident Report Form indicated that the residents were separated and that an investigation was initiated. The report revealed that the Date and Time of Incident revealed the date (12/22/2025) but did not list the time.A review of a typed statement, dated 11/13/2025 and signed by the Director of Nursing (DON), indicated that on 11/13/2025 at 11:00 am, the DON heard commotion and when he went to the hallway to check, R97 was alleging that R176 had spit on them (R97). The statement indicated that R176 stated that R97 had hit them (R176). The statement indicated that the DON witnessed spit on R97's shirt. Per the statement, the residents were separated. The statement did not indicate when the ADM, who was the Abuse Coordinator, was notified of the incident.A review of R97's Exception Report, dated 11/13/2025, indicated that the incident between R97 and R176 occurred on 11/13/2025 at 1:05 pm (in contrast with the DON's typed statement and the time the initial report was made).A review of R176's Exception Report, dated 11/13/2025, indicated that the incident between them and R97 occurred on 11/13/2025 at 1:21 pm (in contrast with the DON's typed statement and the time the initial report was made).A review of the facility's investigation documents included a typed investigative summary that was addressed to the state survey agency, dated 11/20/2025. The document revealed that it did not list the time the incident occurred, nor when the ADM was notified of the incident.2. A review of the admission Record indicated the facility admitted R34 on 5/1/2024. According to the admission Record, the resident had a medical history that included diagnoses of stroke, traumatic brain injury (TBI), major depressive disorder, and anxiety disorder.A review of the quarterly MDS assessment, with an ARD of 11/11/2025, revealed R34 had modified independence in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS).A review of the Facility Incident Report Form, dated 12/22/2025 and completed by the ADM, indicated that the facility reported an incident to the state survey agency involving R34 that occurred on 12/22/2025. The report revealed Other was selected under Type of Incident. The report indicated that R34, who was non-verbal, pointed at their genitalia, then pointed at CMA12. Per the report, the CMA was immediately suspended, and an investigation was initiated. The report revealed that the Date and Time of Incident revealed the date (12/22/2025) but did not list the time of the incident.A review of the facility's investigation documents revealed that they did not indicate when the ADM, who was the Abuse Administrator, was notified of the incident.3. A review of the admission Record indicated the facility admitted R59 on 8/14/2023. According to the admission Record, the resident had a medical history that included diagnoses of major depressive disorder, anxiety disorder, dementia, and other schizoaffective disorders.A review of the quarterly MDS assessment, with an ARD of 9/19/2025, revealed R59 had severe impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a SAMS.A review of the quarterly MDS assessment, with an ARD of 12/23/2025, revealed the facility added R194 on 6/16/2017. Per the MDS, the resident had a BIMS score of 4, which indicated the resident had severe cognitive impairment.A review of the Facility Incident Report Form, dated 11/11/2025 and completed by the ADM, indicated that the facility reported a Resident-to-Resident incident to the state survey agency. The report indicated that it was reported that R59 was slapped by R194. The report revealed that the Date and Time of Incident revealed the date (11/11/2025) but did not list the time of the incident.The facility's investigation documents revealed that they did not include when the ADM, who was the Abuse Coordinator, was informed of the incident.4. A review of the admission Record indicated the facility admitted R171 on 8/9/2023. According to the admission Record, the resident had a medical history that included diagnoses of chronic congestive heart failure, depression, and chronic respiratory failure.A review of the quarterly MDS assessment, with an ARD of 11/11/2025, revealed that R171 had a BIMS score of 15, which indicated the resident had intact cognition.A review of the Facility Incident Report Form, dated 11/24/2025 and completed by the ADM, indicated that the facility reported a Staff-to-Resident incident to the state survey agency. The report indicated that R171 reported that CNA13 was rough with them. The report revealed that the Date and Time of Incident revealed the date (11/24/2025) but did not list the time of the incident.A review of the Exception Report, dated 11/24/2025, related to the incident that occurred involving R171, indicated that the ADM, who was the Abuse Coordinator, reviewed the incident on 11/17/2025 (in contrast with when the incident allegedly occurred).A review of the facility's investigation documents revealed that they did not include when the ADM was notified of the incident.During an interview on 1/3/2026 at 9:01 am, the DON stated that he expected the facility's abuse investigations to be complete and thorough. He stated that he expected the exact date and time the incident occurred to be in the investigation. He stated that he expected the time the Abuse Coordinator was notified to be in the investigation.During an interview on 1/1/2026 at 2:02 pm, the ADM stated she was the Abuse Coordinator. The ADM stated that she expected investigations to include the date and time the incident occurred, and when she was notified.

Based on record review, facility document review, interviews, and a review of the facility policy titled Abuse, Neglect and Exploitation, the facility failed to report allegations of abuse to the state survey agency within two hours for two of five incidents (the incident involving R34 and the incident involving R208) of abuse reviewed.Findings included:A review of the facility policy titled Abuse, Neglect and Exploitation, last reviewed 7/15/2025, indicated, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The policy revealed, IV. Identification of Abuse, Neglect and Exploitation, included, B. Possible indicators of abuse include, but are not limited to, which included, 1. Resident, staff or family report of abuse; 2. Physical marks such as bruises or patterned appearances such as handprint, belt or ring mark on a resident's body; and 3. Physical injury of a resident, of unknown source. The policy revealed, VII. Reporting/Response included, A. The facility will have written procedures that included, which included, 1. Reporting of all alleged violations, regardless of residents [sic] cognitive status, to the Administrator, state agency, adult protective services, physician, responsible parties, law enforcement (when applicable, regardless of cognitive status) and to all other required agencies within specified timeframes, which included, a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.1. A review of the admission Record indicated the facility admitted R34 on 5/1/2024. According to the admission Record, the resident had a medical history that included diagnoses of stroke, traumatic brain injury (TBI), major depressive disorder, and anxiety disorder.A review of the quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/11/2025, revealed R34 had modified independence in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS).A review of the Facility Incident Report Form, dated 12/22/2025 and completed by the Administrator (ADM), indicated that the facility reported an incident involving R34 that occurred on 12/22/2025 to the state survey agency. The report revealed Other was selected under Type of Incident. The report indicated that R34, who was non-verbal, pointed at their genitalia, then pointed at Certified Medication Aide (CMA)12. Per the report, the CMA was immediately suspended, and an investigation was initiated. The report revealed that the Date and Time of Incident revealed the date (12/22/2025) but did not list the time of the incident.A review of the facility's Exception Report, dated 12/22/2025 at 10:35 pm, revealed the incident involving R34 occurred on 12/22/2025 at 7:00 pm.A review of the facility's investigation documents included an email response from the state agency to the ADM, dated 12/22/2025 at 10:18 pm, that indicated the state agency had received the facility's initial report, over three hours after the incident occurred.During an interview on 12/31/2025 at 3:31 pm, Licensed Practical Nurse (LPN)9 stated they were made aware of the allegation involving R34 by Receptionist28. LPN9 stated they were told that R34 motioned as though they had been sexually assaulted. LPN9 stated that they got Unit Manager (UM)22 to help with the investigation. LPN9 stated that the ADM was on the phone with them and UM22 while R34 was interviewed. LPN9 stated that allegations of abuse should be reported to the state survey agency within two hours.During an interview on 1/2/2026 at 12:07 pm, LPN9 stated they were not sure what time the allegation was made by Receptionist28.During an interview on 1/2/2026 at 12:18 pm, UM22 stated that LPN9 came to them at around 6:00 pm, reported an allegation of abuse, and asked for help with it being their first one to initiate. UM22 stated she and LPN9 went to R34's room to interview them and collect more information. UM22 stated that was unsure of the time it was reported to the ADM, who was the Abuse Coordinator, but knew it was shortly after they went to interview the resident because the ADM was on speaker phone with them and R34. UM22 stated that all allegations should be reported to the state survey agency within two hours of notification.During an interview on 1/2/2026 at 4:45 pm, Receptionist28 stated that R34 approached them in the hallway by the dining room entrance around 4:30 pm to 5:00 pm. Receptionist28 stated R34 gestured at their private area, grunted, and pointed at the [NAME] Hall nurse station. Receptionist28 stated that the resident's face was red, and they tried to get a point across. Receptionist28 stated that at 6:40 pm, she reported it to a nurse. Receptionist28 stated that she did not report it right away because she was unsure of what to do and did not know what the resident said.During an interview on 1/3/2026 at 9:01 am, the Director of Nursing (DON) stated that allegations of abuse were to be reported by staff immediately. He stated that they had two hours to report it to the state survey agency if it was physical, verbal, mental, or sexual abuse. He stated that he expected any allegation of sexual abuse to be reported within two hours of the facility staff becoming aware of the allegation.During an interview on 1/2/2026, the ADM stated that when a report was submitted to the state survey agency, they automatically received an email indicating that it was received.During an interview on 1/3/2026 at 9:14 am, ADM stated that any allegation or incident of abuse, such as physical, verbal, mental, or sexual, should be reported immediately and then reported to the state survey agency within two hours. She stated that she expected any allegations or incidents of abuse to be reported to the state survey agency within two hours. 2. A review of the admission Record revealed the facility admitted R208 on 4/17/2020. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus and chronic kidney disease.A review of the quarterly MDS assessment, with an ARD of 6/23/2025, revealed R208 had a BIMS score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated R208 did not have psychosis, physical or verbal behavioral symptoms, or rejection of care.A review of R208's Care Plan Report included a focus area, initiated 4/29/2020, that indicated the resident had an Activities of Daily Living (ADL) self-care performance deficit related to dementia, limited mobility, and cellulitis. The focus area also indicated R208 was blind and was new to the facility. Interventions directed staff to provide assistance with transfers, bed mobility, dressing, personal hygiene, bathing, incontinence care/toileting, eating, and locomotion on and off the unit as needed (revised 3/6/2022).A review of the Facility Incident Report Form, dated 8/12/2025, indicated R208's Family Member (FM30) reported that per the MD [medical doctor] at the hospital, [R208] has a subdural hematoma [bleeding on the brain] which could have been caused by a fall or a strike to the head.A review of an untitled facility investigation document, dated 8/17/2025, revealed in the section Incident that On Monday, (8/11/2025), [FM30] came to the facility and stated that the doctor in the hospital stated that [R208] has a subdural hematoma and it might be from a fall or a strike to the head. The section Conclusion revealed that the allegation was unsubstantiated. The investigation was signed by the ADM.During an interview on 1/2/2026 at 3:43 pm, the DON stated his expectation was that when a resident exhibited an injury of unknown origin was to report it to the state within two hours.During an interview on 1/3/2026 at 8:50 am, the ADM stated her expectation was that when a resident exhibited an injury of unknown origin, it was to be reported to the state within two hours.During an interview on 1/3/2026 at 10:36 am, the ADM reviewed R208's investigation that she submitted to the state and stated it was accurate. The ADM stated that the DON reported to her that the family reported to the facility on 8/11/2025, and she did not report to the state until 8/12/2025. The ADM stated the allegation should have been reported to the state within two hours of the facility being made aware of the allegation.

Based on interviews, record review, and a review of the facility policy titled Comprehensive Care Plans, the facility failed to include discharge goals in the comprehensive care plan for one of four sampled residents (R) (R104) reviewed for care planning.Findings included:A review of the facility policy titled Comprehensive Care Plans, revised 3/1/2025, indicated that it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The policy continued, 3. The comprehensive care plan will describe, at a minimum, the following: d. The resident's goals for admission, desired outcomes, and preferences for future discharge. e. Discharge plans, as appropriate.A review of the admission Record revealed the facility admitted R104 on 5/26/2023. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, problems related to unspecified psychosocial circumstances, and functional quadriplegia.A review of the quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/20/2025, revealed R104 had a Brief Interview of Mental Status (BIMS) of 15, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff assistance for toileting, showering/bathing, dressing, and personal hygiene.A review of R104's Care Plan Report, for admission date 5/26/2023, lacked evidence of a focus area for the resident's discharge goals.During an interview on 12/29/2025 at 11:50 am, R104 stated they wanted to be in a hospital where they could get surgeries because they wanted to walk again and then have a caseworker to help the resident get to a new place. R104 stated that Social Services Assistant (SSA)6, the resident, and the resident's family member had met and identified three facilities to send referrals, but the resident stated that nobody had accepted the resident. The resident stated they had been accepted by a sister facility, but they did not want to go to that facility. During a follow-up interview on 12/31/2025 at 2:24 pm, R104 stated they wanted to go back to Tennessee.During a phone interview on 1/2/2026 at 10:16 am, the Nurse Practitioner stated she had cared for R104 for over two years, and the resident had been trying to get out of the facility but really had nowhere to go.During an interview on 1/1/2026 at 9:14 am, Social Worker (SW)11 stated she had been employed with the facility since August 2025. She stated R104 felt the facility was trying to keep the resident, and the resident wished to go to Tennessee. SW11 stated that before her employment, the facility had sent multiple referrals to other facilities seeking alternative placement for R104. She stated that as of December 2025, they had begun sending three referrals a month. She stated most of the facilities had declined to admit R104. Per SW11, they were still attempting to get R104 placement in Tennessee.During an interview on 1/1/2026 at 4:07 pm, SSA6 reviewed R104's care plan and stated that the discharge focus area was not on the care plan. She stated that they should have revised R104's care plan once they knew the resident wished to be discharged to another facility closer to family.During an interview on 1/2/2026 at 12:27 pm, the Director of Nursing (DON) stated his expectation regarding discharge was for social services to work with the resident, make sure everything was in place, and update the care plan.During an interview on 1/2/2026 at 12:22 pm, the Administrator stated her expectation was for resident care plans to be accurate.

Based on observation, interview, and a review of the facility policies titled Nail Care and Activities of Daily Living (ADLs), the facility failed to ensure staff provided nail care for one of seven sampled residents (R) (R35) reviewed for ADL care.Findings included:A review of the facility policy titled Nail Care, revised 3/1/2024, revealed that the purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. The policy revealed: 3. Routine cleaning and inspection of nails will be provided during ADL [activities of daily living] care on an ongoing basis. 4. Principles of nail care: a. Nails should be kept smooth to avoid skin injury. b. Only licensed nurses shall trim or file the fingernails of residents with diabetes. Toenails of residents with diabetes or circulation problems shall be filed only.A review of the facility policy titled Activities of Daily Living (ADLs), revised 7/15/2025, revealed that the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure that a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care. The policy continued, 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, including assistance and cueing as necessary, while also following the physician's orders and Care Plan with regard to assistive devices, grooming, and personal and oral hygiene. A review of the admission Record revealed the facility readmitted R35 on 10/20/2023. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the dominant right side, cerebellar stroke syndrome, type two diabetes mellitus, and major depressive disorder.A review of the annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/19/2025, revealed R35 had a Brief Interview of Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required partial to moderate assistance from staff with personal hygiene.A review of R35's Care Plan Report included a focus area, revised on 1/18/2024, that indicated the resident required assistance with activities of daily living. Interventions directed staff to provide nail care as needed (revised 3/6/2022).During a concurrent observation and interview on 12/29/2025 at 12:53 pm, R35 was outside of the resident's room in a wheelchair. R35's fingernails on the left hand were observed to extend approximately one-half inch past the end of the fingertip, with a yellow tint and brown matter under the fingernails. R35's fingernails on the right hand were observed to extend approximately one-half inch past the end of the fingertip. The resident's fingernail on the middle finger of the right hand was noted to be black, and the fifth fingernail had white discoloration present. R35 stated the staff never asked to cut the resident's nails. R35 stated they wanted the staff to cut their fingernails.During an interview on 12/31/2025 at 10:33 am, Unit Manager (UM)22 entered R35's room and observed R35's fingernails. She stated R35's fingernails were thick and overgrown on the right hand, and the middle fingernail was discolored. She stated R35's fingernails on their left hand needed to be trimmed, but none of the nurses or aides had let her know. UM22 stated that typically, R35 would tell her, and the resident had not. She stated that the staff should have taken care of R35's fingernails.A review of R35's Progress Notes for the timeframe from 12/20/2025 through 12/30/2025 revealed no documented evidence to indicate the resident had refused nail care.During a phone interview on 1/1/2026 at 6:29 pm, Certified Nurse Assistant (CNA)19 said he gave R35 a bed bath on 12/25/2025. He confirmed that he did not clean or trim the resident's nails.During a phone interview on 1/1/2026 at 8:50 pm, CNA17 stated he remembered giving R35 a shower, and when he checked off nail care on the shower sheet, it meant he just cleaned the nails. He stated he did not notice if R35's fingernails needed to be cut. He stated he did not recall R35 saying anything about wanting their fingernails cut.During a phone interview on 1/1/2026 at 8:02 pm, Licensed Practical Nurse (LPN)23, stated that neither R35 nor a CNA told her the resident's fingernails needed to be trimmed. She stated that if R35's nails needed to be trimmed, she expected the aides to tell the nurses. She stated she did not notice R35's nails needed to be trimmed.During a phone interview on 1/2/2026 at 11:33 am, Charge Nurse (CN)24 stated she trimmed R35's nails after it was brought to her attention by UM22. She stated R35's fingernails on the right hand were thick, hard, and black in color. She stated that R35's fingernails on the left hand were overgrown.During an interview on 1/2/2026 at 12:31 pm, the Director of Nursing (DON) stated his expectation was that if a resident were diabetic, podiatry services would trim the resident's fingernails for the resident. The DON stated that if R35 refused nail care, the refusal should be documented in the resident's chart. He stated that when staff completed room observations and gave medications, they were doing an overall observation of the resident, and it should be identified at that time. He clarified and stated that a nurse could trim a diabetic's nails, and if uncomfortable, they could call podiatry services. He stated his expectation for a CNA was to clean the resident's nails when bathing a resident; they were to provide ADL care, and if the fingernails needed to be trimmed, they could do so if the resident was not a diabetic.During an interview on 1/2/2026 at 12:14 pm, the Administrator stated her expectation was that staff should provide nail care for residents who needed it. She stated that staff should provide nail care when providing a shower, if the resident requested it, or as needed.

Based on observation, interview, and a review of the facility policy titled Enhanced Barrier Precautions, the facility failed to maintain infection prevention and control practices to prevent the transmission and/or development of infection for one of three sampled residents (R) (R15) reviewed for Enhanced Barrier Precautions (EBP). Specifically, staff failed to wear appropriate personal protective equipment (PPE) while providing wound care to R15.Findings included:A review of the facility policy titled Enhanced Barrier Precautions, dated 3/1/2025, revealed that it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities. The policy also indicated that high-contact resident care activities include wound care: any skin opening requiring a dressing.A review of the admission Record revealed the facility initially admitted R15 on 7/24/2023. According to the admission Record, the resident had a medical history that included diagnoses of pressure ulcer of the sacral region, tracheostomy status, and gastrostomy status.A review of the quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/27/2025, revealed R15 had severe impairment in cognitive skills for daily decision-making and had a short-term or long-term memory problem per a staff assessment of mental status (SAMS). The MDS indicated R15 required total assistance with all activities of daily living (ADLs). The MDS indicated R15 had one unhealed Stage 3 pressure ulcer/injury. The MDS indicated R15 had a tracheostomy.A review of R15's Care Plan Report included a focus area, initiated 9/29/2024, that indicated the resident was on EBP related to a percutaneous endoscopic gastrostomy tube (PEG tube), tracheostomy, and wounds. Interventions directed staff to utilize PPE per the facility protocol, 9/29/2024.An observation on 12/31/2025 at 2:05 pm revealed that a sign for EBP was posted on R15's room door.An observation on 12/31/2025 at 2:05 pm of wound care provided by LPN7 and LPN8 to R15's left upper buttocks revealed that neither LPN donned a gown before or during wound care. During concurrent interviews immediately after the completion of the wound care, both LPN7 and LPN8 stated they did not don gowns, they should have worn gowns, and it was an oversight.During an interview on 1/1/2026 at 9:21 am, LPN8 stated that gloves, gowns, masks, and goggles, if required, should be worn if a resident is on EBP. LPN8 stated she knew if a resident was on precautions because there would be a sign on the resident's door. LPN8 stated R15 was on EBP because they had a wound and a tracheostomy. LPN8 stated she knew she should have worn a gown during care, but she did not because of nerves.During an interview on 1/1/2026 at 9:33 am, LPN7 stated that gowns and gloves were required for residents on EBP. LPN7 stated she knew if a resident was on EBP because there would be a sign on the resident's door. LPN7 stated R15 was on EBP because they had a wound, tracheostomy, and a PEG tube. LPN7 stated she did not wear a gown during the observed wound care, and she should have worn a gown, but she was nervous.During an interview on 1/1/2026 at 10:39 am, the Director of Nursing (DON) stated that a resident who was on EBP would have a sign on their door to alert staff that the resident was on precautions. The DON stated that hand hygiene, gloves, and gowns were required when providing care to a resident on EBP. The DON stated he expected staff to don the appropriate PPE when caring for a resident on EBP.During an interview on 1/1/2026 at 12:51 pm, the Administrator stated her expectation regarding EBP was that the staff would have followed the proper protocol, and if PPE was required for resident care, the staff should have utilized the proper PPE.

Based on observations and staff interviews, the facility failed to ensure the vents directly over the food preparation areas were free from dirt and debris and failed to prevent flies from contaminating the prepared food. This failure has the potential to affect 194 residents that consume the food prepared in the kitchen.Findings include:During an observation on 7/22/2025 at 11:25 am, a fly was observed on a carton that was sitting on the food preparation station/area.Further observation of the kitchen on 7/22/2025 at 11:30 am revealed a mold-like substance in one of the drop-in ceiling tiles. The Dietary Manager (DM) stated the dampness and condensation were from the air conditioning.Observation on 7/22/2025 at 11:39 am, there were three dirty vents directly over the food preparation areas that had build-up of dirt and debris. During an observation on 7/22/2025 at 11:37 am, another fly was observed in the kitchen preparation area. This fly was on a box of potato pearls. At 11:42 am, an additional fly was observed flying over the dinner rolls. At 11:47 am, two flies were observed hovering over the cooked meatloaf, one next to the container of salt.During an interview on 7/22/2025 at 11:58 am, [NAME] AA said, It's the summertime and it's hard to keep the flies out, especially when the doors are open and closed. There was a fly zapper close to the back door. The fly zapper was unplugged. It was plugged back in and the fly catcher was now illuminated.Observation on 7/22/2025 at 11:59 am, the back door was propped open with a rock.Interview on 7/24/2025 at 9:11 am with the Maintenance Director (MD) revealed they had been working on patient safety and hadn't really been in the kitchen yet. The MD continued to say he was not sure who was supposed to be taking care of the vents. When asked what the vents looked like, he thought they looked like wear and tear rather than dirt and debris. Additionally, when asked about the substance on the tile, the MD stated it looked like mold, but it wasn't. It would have been tested to confirm mold.Interview on 7/29/2025 at 9:27 am with the Administrator, they provided a sheet named Monthly Kitchen Vent Cleaning Schedule. There was no date to indicate the day or year of the cleaning.

Based on record review, observations, staff interviews, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to protect the residents' right to be free from sexual abuse by another resident for two of seven sampled residents (R) (R2 and R3). Specifically, R2 was seen touching the breast of R3.Findings include:Review of the facility policy titled Abuse, Neglect and Exploitation with an implementation date of 3/1/2022 and a revision date of 7/1/2024 revealed under the section Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: . (C) increased supervision of the alleged victim and residents.1. Review of the Facility Reported Incident (FRI) dated 11/3/2024 revealed while in the dining room, R2 was seen touching the breast of R3. Review of the admission record for R2 revealed admission to the facility with diagnoses of but not limited to essential (primary) hypertension, type 2 diabetes mellitus with diabetic amyotrophy, unspecified sequelae of unspecified cerebrovascular disease, iron deficiency anemia, unspecified, hyperlipidemia, unspecified, constipation, atherosclerotic heart disease of native coronary artery without angina pectoris (, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, other psychoactive substance dependence, uncomplicated, major depressive disorder, recurrent, moderate, muscle weakness (generalized) other symbolic dysfunctions, cognitive communication deficit, other lack of coordination, other fatigue, other abnormalities of gait and mobility, hypokalemia, unspecified glaucoma, unspecified lack of coordination, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.Review of the Minimum Data Set (MDS) dated [DATE] showed that R2 has a Brief Interview for Mental Status (BIMS) score of 99, indicating that resident's cognitive impairment could not be scored. A review of the MDS dated [DATE] showed a BIMS score of 3, indicating severe cognitive impairment.Resident is also care planned for having a psychological well-being problem (actual or potential) related to unwanted physical contact with another resident. Interventions included allow resident to answer questions and to verbalize feelings perceptions, and fears. Intervention was initiated on 8/30/2024.Further review of the care plan for R2 showed that resident has displayed behaviors that include inappropriate sexual contact with female residents (squeezing female breasts). Interventions included assess resident's coping skills and support system. Assess resident understanding of situation and allow time for the resident to express self and feelings towards the situation. Do not seat resident around others who could disturb them. Let physician know if any of resident's behaviors are interfering with daily living. Offer resident something they like as a diversion. When negative behaviors begin, remove resident from current activity; return/resume when behavior subsides.A review of the progress notes for R2 dated 11/10/2025 showed a progress note stated that R2 was still inappropriately touching staff during medication pass.A review of the progress notes for R2 dated 12/6/2024 revealed, This note is to provide accurate details to the observations with the residents this am. Resident was seen from afar reaching toward another resident while sitting next to them in his wheelchair. Upon, approaching the residents, the resident was only observed touching the other residents coat. The resident was redirected and moved to another resident. Both residents continued about their normal activity.During the initial tour of the facility on 7/16/2025 at 3:15 pm, R2 and R3 were both observed in activities in the main dining room. R2 was sitting at the table and R3 was observed in the doorway to the dining room sitting in a wheelchair. An attempt was made to interview R2, but resident was confused and could not be interviewed.During an observation on 7/28/2025 at 12:22 pm R2 was observed sitting at dining room table and R3 was sitting right beside R2. Staff was not near, but were passing trays to other residents.Information was requested in reference to the monitoring of R2 after the incident occurred until he was seen by psych (psychiatric) services. As of 7/29/2025, no information was received. Also, information was requested in relation to what measures had been taken to ensure that other residents were kept safe. No information was received as of 7/29/2025, prior to survey exit.2. A review of the admission record for R3 showed that resident was admitted to the facility with diagnoses of but not limited to injury, unspecified, initial encounter, displaced intertrochanteric fracture of unspecified femur, initial encounter for closed fracture, fracture of lateral orbital wall, right side, initial encounter for closed fracture, fracture of orbital floor, right side, initial encounter for closed fracture, displaced intertrochanteric fracture of right femur, initial encounter for closed fracture, unspecified speech disturbances, maxillary fracture, right side, initial encounter for closed fracture, dehydration, mild protein-calorie malnutrition, hypokalemia, hyperosmolality and hypernatremia, scoliosis, thrombocytopenia, major depressive disorder, single episode, mild, primary insomnia.Review of the MDS for R3 dated 6/28/2025 revealed a BIMS score was not obtained, section C0100 revealed that resident is rarely/never understood.An attempt was made to interview R3, but resident was confused and could not be interviewed.During an interview on 7/28/2025 at 2:40 pm with the Assistant Administrator (AA) who stated that in the absence of the Administrator (Abuse Coordinator), she stepped in as the Abuse Coordinator. Administrator AA also stated that when there was an allegation of abuse, the investigation depended on what the allegation was, but we investigate, interview all of the residents, interview all of the parties, take statements and put it all together. If a resident was inappropriate with another resident (male and female), we would report it, and we would interview the residents separately and privately. We would interview all of the patients and staff and try to figure out what's going on. If a male resident was touching a female resident's breast, we would need documentation of monitoring of the resident and whether a care plan or interventions were put in place, and any interviews of cognitively intact residents or skin assessments on cognitively-impaired residents. Administrator AA also stated that she expected the staff to have all of the information available to her at the completion of the report. Everybody was supposed to do what they were supposed to do so we could have a positive outcome.Review of an Attendance Form provided to document an in-service for 11/3/2024 through 11/4/2024 revealed that information provided during this in-service included monitoring residents frequently for those residents who displayed inappropriate behaviors.

Based on staff interviews, record review, and review of the facility policy titled, Transfer and Discharge (including AMA (against medical advice), the facility failed to have an effective discharge planning process in place for one (R13) of three residents reviewed for discharge. Specifically, the facility failed to ensure that R13, who required wound care services, was referred and accepted for services prior to discharge. Findings include:Review of the facility policy last revised 7/1/2024, titled Transfer and Discharge (including AMA) documented under Policy Explanation and Compliance Guidelines:.14. Anticipated Transfer or Discharges.c. Orientation for transfer or discharge must be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand. d. Assist with transportation arrangements to the new facility and any other arrangements as needed.Review of the electronic medical record (EMR) for R13 revealed admission to the facility with diagnoses that included but was not limited to heart failure, acute respiratory failure, type 2 diabetes and acute hematogenous osteomyelitis (infection and inflammation of bone and bone marrow).Review of R13's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/24/2024 indicated the facility assessed R13 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R13 was cognitively intact. Review of R13's Order Audit Report dated 11/27/2024 documented R13 to be discharged home with home health agency (HHA), Social Worker (SW), Skilled Nursing (SN) Wound Care, Physical Therapy (PT) and Occupational Therapy (OT) on 11/29/2024.Review of R13's Order Audit Report dated 12/5/2024 documented R13 may be discharged on 12/6/2024 to a homeless shelter with discharge instructions and medications. The facility will provide R13 with a wheelchair, seat cushion, leg rest and bedside commode. An outside medical provider will provide wound care services to R13's left toe.Review of a Social Services progress note dated 12/5/2024 documented the Social Worker (SW) spoke with the durable medical equipment (DME) company and was told that R13's insurance had not been active since 7/1/2024. Another insurance was obtained and the DME company was unable to verify. It was attempted to utilize R13's Medicaid insurance, however he did not have any benefits. The SW spoke with the Rehab Director and permission was granted for R13 to keep the wheelchair he had been utilizing while at the facility.Review of R13's Discharge Planning Assessments signed by R13 on 12/5/2024 documented R13 was discharged with their medications and orders. It was documented that R13 was instructed to follow up with their primary care provider (PCP), however there was no information listed for PCP contact information. Discharge assessment also did not document if R13 was educated on how to care to their left foot wound or who to reach out to if in need of care.Interview on 7/24/2025 at 10:36 am with the SW, the SW stated they were responsible for setting up discharges to the community. The SW stated she would bring up the discharge in the morning meeting and ensure outside referrals were set up prior to residents being discharged . The SW stated upon the day of discharge nursing staff were responsible for performing the discharge and providing the paperwork and medications to the resident or resident representative. The SW stated on the day of discharge the nurses were responsible for ensuring the paperwork was complete. The SW stated the nurses would complete the paperwork, and they were also providing the residents with their medication at that time. The SW stated resident families were followed up with about a day or two prior to discharge date to ensure that they were aware and well informed. The SW stated they entered their discharge orders prior to the actual discharge date .Interview on 7/28/2025 at 3:00 pm with the Administrator revealed their expectations for their discharge orders and discharge assessments to reflect the residents' actual discharge information and referrals with the correct information at the time of discharge.Follow up interview on 7/28/2025 at 3:15 pm with the SW, they revealed they did not update R13's discharge order or discharge assessment to indicate that the resident did not have skilled nursing services set up for wound care following discharge due to an insurance concern. The SW stated the discharge order/assessment should have been updated to reflect that R13 was educated on how to do his wound care, provided supplies to do such, and was instructed to go to the emergency department for further treatment if needed.

Based on staff interviews, record review, and review of the facility's policy titled, Documentation in Medical Record, the facility failed to keep accurate medical record for one of 27 sampled residents (R) (R7).Findings include:Review of the facility's policy titled Documentation in Medical Record dated 3/1/2025 revealed under 4. a. False information shall not be documented. 4. b. Documentation shall be accurate, relevant and complete, containing sufficient details about the resident's care and/or responses to care. A review of the Electronic Medical Record (EMR) for R7 revealed an original admission diagnoses of but not limited to type II diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma, acute kidney failure, cellulitis of left lower limb, hypertension, chronic diastolic (congestive) heart failure, hypothyroidism, bipolar disorder, stage III chronic kidney disease, gout, hyperlipidemia, acute osteomyelitis (left ankle and foot), morbid obesity and sarcopenia (the gradual loss of muscle mass, strength and function).Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed R7 had a Brief Interview for Mental Status (BIMS) score of 12, indicating R7 was moderately cognitively impaired.Review of R7's Resident/Family Education dated 4/18/2025 revealed resident educated on the importance of complying with oxygen orders when experiencing shortness of breath.Further review of R7's Summary of Skilled Services dated 4/18/2025 revealed Resident received up in wheelchair. Resident experiencing shortness of breath. Resident has current orders for oxygen via nasal canula at 2 liters per minute. Resident non-compliant, and received education on importance of remaining compliant with oxygen orders while experiencing SOB (shortness of breath), and is currently on O2 (oxygen) as ordered. Resident displays no s/s (signs/symptoms) of shock or distress. Received all medications PO (orally) as ordered with no adverse effects. Currently in room, call light in reach.Review of R7's Physician's orders revealed R7 did not have a physicians' order for oxygen.In an interview on 7/23/2025 at 3:01 pm, the Director of Nursing (DON) revealed R7 never had a physician's order for oxygen.In an interview on 7/23/2025 at 3:39 pm, the DON stated that R7 had congestive heart failure (CHF) so if he had SOB, R7 would have to be sent out to the hospital for evaluation. The DON reviewed the writer of the note and the staff that wrote the note was written up for false documentation. The staff was suspended on 4/25/2025 and subsequently demoted after she came back. She went from Unit Manager to medication cart nurse. She was terminated 5/19/2025.

Based on observations, record review, resident and staff interviews, and review of the policy titled Comprehensive Care Plans, the facility failed to develop and/or implement the person-centered care plan for six residents (R) (R71, R266, R19, R25, R111, R118) reviewed for smoking. In addition, the facility failed to develop a care plan for one resident (R172) related to Post Traumatic Stress Disorder (PTSD). The facility's failures created potential risks for the safety and well-being of the residents. The sample size was 102 residents. On 10/9/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Corporate Regional Director of Operations, Corporate Regional Nurse Consultant (RNC), and Director of Nursing (DON) was informed of an Immediate Jeopardy (IJ) on 10/9/2024 at 3:11 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/22/2024. Upon survey entrance to the facility, residents were observed sitting out front of the facility, smoking unsupervised. Throughout the duration of the survey, the facility failed to monitor the smoking practices by not maintaining accurate smoking assessments, allowing residents to keep smoking materials in their possession, not supervising residents while smoking, and allowing a resident in the dementia care unit to smoke inside the facility. A Credible Allegation of Compliance was received on 10/11/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 10/11/2024. The facility remains out of compliance while the facility continues management level oversight as well as continues to develop and implement a Plan of Correction. (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding facility smoking practices, to include smoking assessments, and following care plans related to smoking. Resident records were reviewed to ensure that resident care and treatment was current and accurate. Findings include: 1. A review of the facility policy titled Comprehensive Care Plans reviewed 10/1/2024 indicated the Policy Statement: Facility will develop and implement a comprehensive-person centered care plan for each resident. Consistent with resident rights, that includes measurable objectives and timeframes to meet a residents medical, nursing, mental and psychosocial needs. Person-centered care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. Policy Explanation and Compliance Guidelines: Number 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. Number 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. d. The resident's goals for admission, desired outcomes, and preferences for future discharge. e. Discharge plans, as appropriate. f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate. g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. Number 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. A. Review of the electronic medical record (EMR) for R71 revealed an admitted [DATE] with diagnosis that include conversion disorder with seizures or convulsions, traumatic brain injury (TBI), muscle weakness, unspecified intellectual disabilities, dysphagia, lack of coordination, other specified forms of tremor, and lattice degeneration of retina. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 12, which indicated moderate cognitive impairment. Section J on the 3/26/2024 annual MDS revealed resident was coded as a current tobacco user. A review of the smoking assessments dated 3/22/2024, 3/28/2024, 7/4/2024, and 10/5/2024 for R71 documented that resident should only smoke during morning, afternoon, and evening smoke breaks, should wear an apron, requires supervision- including retrieval of supplies, and needs someone to light/extinguish cigarette. Review of R71's smoking assessments revealed yes to the question, does resident smoke? A review of R71's care plan initiated 6/11/2021 and revised 10/5/2024 revealed that resident was an unsafe smoker, she is non-compliant with smoking policy - resident was observed smoking in her bathroom (10/10/2017), she solicits smoking materials from other residents, staff, and visitors (2/17/2016), she refused to wear smoking apron (3/7/2024). Interventions to care include educate and provide safety awareness for smoking, instruct resident about the facility policy on smoking: locations, times, safety concerns, resident requires a smoking apron, and notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Observation on 10/4/2024 at 12:09 pm, R71 was outside smoking and not wearing a smoking apron. She is observed to have burn holes in her shirt as she is seen wiping the ashes off of her clothes. B. Review of the EMR for R266 revealed he was admitted to the facility on [DATE] with diagnoses including pneumonia, protein calorie malnutrition, sacral pressure ulcer, deep vein thrombosis, and sepsis due to escherichia coli (e-coli). A review of the admission MDS dated [DATE] revealed a BIMS was coded as 14, which indicated no cognitive impairment. Section J revealed resident was not coded as a current tobacco user. A review of the smoking assessments dated 10/6/2024 revealed the question does resident use smoking/tobacco/nicotine products? Response was documented no-stop here. A review of R266's care plan revised on 9/20/2024 revealed resident did not have a care plan for smoking. He has a behavior care plan which documented R266 was observed smoking in his room on 9/19/2024, without an intervention to address his smoking. Observation on 10/10/2024 at 2:18 pm, R266 was outside smoking in his wheelchair. There were no staff members supervising the resident during the smoke break. 49673 C. Review of the EMR for R19 revealed he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, malignant neoplasm of lower gastrointestinal tract, diabetes, end stage renal disease (ESRD), hypertension, and depression. A review of the quarterly MDS dated [DATE] revealed a BIMS score of six which indicated that the resident had severe cognitive impairment. Section J on the 12/23/2023 annual MDS revealed resident was not coded as a current tobacco user. A review of the smoking assessment dated [DATE] revealed R19 requires supervision with retrieval of smoking supplies. A review of R19's care plan revised 10/6/2024 revealed resident is a smoker and requires supervision and will not have injury related to smoking. Interventions to care include smoking assessment per facility protocol, staff supervision during smoking, and staff to maintain/store all smoking materials. Observation and Interview on 10/7/2024 at 12:03 pm, R19 observed smoking outside in the front smoking area unsupervised. Resident was noted to be wearing a pair of pants with one visible burn hole on them. Interview with resident at this time confirmed that he had a burn hole in his pants. He stated that he keeps his cigarettes and lighter with him. 50374 D. Review of the EMR for R25 revealed he was admitted to the facility on [DATE] with diagnoses including dementia, cognitive communication deficit, lack of coordination, mood and psychotic disorders, hypertension (HTN), and anxiety. Review of the quarterly MDS dated [DATE] documented a BIMS score of five, indicating severe cognitive impairments. Section J revealed resident was not coded as a current tobacco user; however, the 3/24/2024 annual MDS revealed resident was coded as a current tobacco user. A review of the smoking assessment dated [DATE] revealed due to R25's behavior and score with smoking assessment, resident will need supervision with smoking and he requires someone to light/extinguish the cigarette. A review of R25's care plan initiated on 11/5/2021 revealed R25 is an unsafe smoker and will not smoke without supervision. Resident was found smoking in his room and was documented that he will only smoke in appropriate area under direct supervision. Further review documented removal of all smoking devices from resident room and store in locked container. Observation on 9/24/2024 at 10:06 am, R25 was outside in the dementia care smoking area smoking unsupervised. There were no staff members outside at this time. Interview on 10/7/2024 at 10:08 am, R25 stated he smokes two to three times a day and revealed that he keeps his own cigarettes and lighter in his room. During further interview, he stated nobody helps him with his cigarettes and lighter, and states that he can do it on his own. 49140 E. Review of the EMR for R111 revealed he was admitted to the facility on [DATE] with diagnoses including dementia, cognitive communication deficit, major depressive disorder, and anxiety disorder. A review of the annual MDS dated [DATE] revealed a BIMS score of two, indicating the resident is severely cognitively impaired. Section J revealed resident was not coded as a current tobacco user. A review of the smoking assessment dated [DATE] revealed that residents safety awareness was good and no supervision required, which is conflicting with his current plan of care. A review of R111's care plan revised 7/9/2025 revealed resident is a smoker and he will not suffer injury from unsafe smoking practices and will not smoke without supervision. Interventions to care include resident requires supervision while smoking. Observation on 10/6/2024 at 3:58 pm, R111 on the memory care unit, pulled a cigarette out of his right pocket and a lighter out of his left pocket. He lit the cigarette and began smoking, inside the building. Surveyor informed Medical Records Clerk (MRC) MM that R111 had lit a cigarette and began to smoke it while inside the building, and she went down the hall and took the cigarette and lighter from him. 49138 F. Review of the EMR for R118 revealed he was admitted to the facility on [DATE] with diagnoses including acute kidney failure, metabolic encephalopathy, paraplegia, right/left hand contractures, hypertension and major depressive disorder. A review of the quarterly MDS assessment dated [DATE] revealed a BIMS was coded as 15, which indicated no cognitive impairment. Section J revealed resident was not coded as a current tobacco user. A review of the smoking assessment dated [DATE] revealed the question does resident use smoking/tobacco/nicotine products? Response was documented no-stop here. A review of R118's care plan revised on 3/29/2022 revealed he did not have a care plan to address resident's smoking preference. He did have a care plan addressing a focus that R118 chooses to leave the facility for social interactions with friends, including alcohol consumption and drugs. Interview on 10/7/2024 at 9:10 am, R118 stated he was an occasional smoker and he smokes once or twice every two to three months. Interview on 10/7/2024 at 2:20 pm, with MDS Regional Coordinator indicated that residents that use any type of tobacco/nicotine products are required to have a smoking assessment and a care plan addressing their smoking status. She confirmed R118's smoking assessment documented that he was not a smoker. Observation on 10/7/2024 at 2:49 pm, R118 was observed outside front of the facility smoking, without wearing a smoking apron. 46579 2. Review of the EMR for R172 revealed he was admitted to the facility on [DATE] with diagnoses that included seizures, encephalopathy, post-traumatic stress disorder (PTSD), and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 00, which indicates the residents cognitive status cannot be determined. No moods or behaviors exhibited. Resident has medically complex conditions, including PTSD. A review of R172's care plan initiated on 10/2/2024 revealed focus areas documenting resident receives antidepressant medication and has impaired cognitive function/dementia or impaired thought processes related to impaired decision making and long and short-term memory loss. Further review of the care plan did not address a focus area or interventions addressing residents diagnosis of PTSD. Interview on 10/5/2024 at 4:10 pm, the Regional Director of Clinical Reimbursement (RDCR) revealed that information for the completion of the MDS is gathered from resident hospital records, EMR, staff, resident, and family interviews. The RDCR stated that the interdisciplinary team (IDT) team is responsible for the developing resident comprehensive person-centered care plans. During further interview, she stated the MDS is updated quarterly, annually, or for a significant change in condition. The RDCR confirmed that R172 did not have a care plan addressing how to care for a resident with PTSD. Review of the psychotherapist notes for resident R172 revealed that resident had periods of agitation during visits and experienced episodes of depression and being withdrawn. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility failed to develop a comprehensive person-centered care plan for residents R25, R145, R111, R19, R71, R118, R266 and R365. On 10/9/2024 the Regional Nurse Consultant and Director of Nursing reviewed and revised each of their smoking care plans to ensure that they are person centered and comprehensive. 2. The Regional Director of Operations on 10/9/2024 in-serviced the Director of Nursing, Assistant Director of Nursing, Minimum Data Set nurses and Regional Nurse Consultant on the smoking policy, ensuring that smoking care plans are followed and completed timely, and importance of accurate smoking assessments. The Administrator will be in-serviced prior to returning to work by the Regional Director of Operations. 3. Regional Director of Operations on 10/9/2024 in-serviced the MDS nurses on reviewing for complete and accurate comprehensive person-centered smoking care plans for all residents who smoke. 4. On 10/9/2024 the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Regional operations, and/or Regional Nurse began in-servicing all staff on the smoking policy, all residents on Dementia Unit will be required to wear smoking aprons, smoking times, and on the smoking monitors will be present at all smoke breaks (Registered Nurse 10 of 10, Licensed Practical Nurse 33 of 34, Certified Nurse assistant 62 of 67, Certified Medication Aides 7 of 8, Respiratory Therapist 1 of 2, Dietary 14 of 25, Therapy 8 of 13, Administrative 18 of 1 8, Maintenance 4 of 4, Housekeeping 30 of 37, Activities 3 of 4 staff). The current percentage of staff educated is 86% at this time. In addition, clinical staff are being in serviced on importance of following smoking care plans and completing timely and accurate smoking assessments. 5. Currently 10 of 10 Registered Nurses, 33 of 34 Licensed Practical Nurses, 62 of 67 Certified Nurse assistants, and 7 of 8 Certified Medication Aides have been in serviced on importance of following care plans. There is currently 94% in serviced completion. 6. On 10/9/2024 the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Regional operations, and/or Regional Nurse began in-servicing all staff on the smoking monitors will be present at all smoke breaks. 7. All new licensed staff will be in-serviced on these items above during the orientation process by the Assistant Director of Nursing and/or Director of Clinical Education. 8. We have no agency staff currently. 9. AD Hoc Quality Assurance Performance Improvement (QAPI) meeting was completed on 10/10/2024 for policy review and root cause analysis was determined staffing education was needed. Attendance to the meeting was Regional Director of Operations, Director of Nursing, Regional Nurse, [NAME] President of Quality, business office manager, dietary manager, dietary assistant manager, medical supply clerk, transportation coordinator, Director of Rehab, Social Worker, and Unit Managers. The Medical Director was notified by phone. 10. Corrective actions will be completed by 10/10/2024. Alleged date of IJ removal: l0/11/2024 The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Care Plan and Smoking Assessment Review : R25 - Unsafe smoker, Care plan revised on 10/9/2024, Smoking assessment was completed on 10/9/2024- requires supervision. R145 - is a safe smoker however was observed lighting cigarettes for other residents. R145 is a safe smoker 10/9/2024- R111- is an unsafe smoker. 10/9/2024-requires supervision and an apron. R19 - is an unsafe smoker 10/11/2024- needs supervision and an apron. R71- is an unsafe smoker. Resident solicits to residents, staff, and/or visitors when cigarettes are not available. Resident has a history of being non-compliant with smoking policy - 10/9/2024-requires supervision and an apron. R118 - is unsafe smoker, 10/9/2024 - requires apron, cigarette holder, someone to light and extinguish and supervision. R266- Resident is a safe smoker. 10/9/2024- no supervision, R365- is a safe smoker; however, sometimes non-compliant with the smoking policy. History of lighting other resident's cigarettes 10/9/2024-independent smoker. 2. In an interview on 10/11/2024 at 4:09 pm, with Regional Director of Operations (RDO) revealed in-service education was conducted by her and Training and Development Coordinator, Licensed Practical Nurse (LPN) Unit Manager (UM) GGGG. She stated her in-service included ensuring the residents have their smoking aprons, smoking times, and direct supervision over all smokers safe and unsafe. In an interview on 10/11/2024 at 4:29 pm, with Regional Nurse Consultant (RNC) revealed her most recent in-service education was on 10/9/2024 by the RDO and LPN UM GGGG. She stated the in-service education she received was relating to the smoking policy, abiding by smoking times and ensuring all smokers are care planned. She stated she learned once a person who wants to smoke is identified a smoking assessment is completed. In an interview on 10/11/2024 at 4:49 pm, the Director of Nursing (DON) revealed she received in-service from her Regional Director of Operations on 10/9/2024. She stated she was educated on the new smoking times, smoking policy and creating safe smoking habits for residents. She stated she was taught smoking assessments must be done quarterly and as needed (PRN) and all care plans must be updated to ensure they are in alignment with the assessment. She revealed she was taught to ensure unsafe smokers will not have their equipment on them, instead they will be locked in a lock box. In an interview on 10/11/2024 at 5:14 pm, the Assistant Director of Nursing (DON) revealed she received in-service education on 10/9/2024 and 10/11/2024 relating to all the smokers in the building. She stated she learned the smokers cannot smoke anytime they like and that they are not allowed to hold their own smoking material. She stated her in-service education consisted of smoker's policy, timely assessments and care plans. She stated each resident must be supervised every 2 hours, and a smoking list kept at each nursing section. 3. Interview on 10/11/2024 at 4:49 pm, the Minimum Data Set nurse JJJJJ revealed she received in-service education on 10/9/2024 and 10/11/2024 from the Regional Director of Operations. She stated the RDO covered topics such as updating care plans, the smoking policy and smoking assessments for all residents that smoke. 4. Interview on 10/11/2024 with LPN KKKK at 4:20 pm, stated she received in-service on smoking last week and this week. She signed the in-service sign in sheet. The training pertained to the residents, fire extinguisher, aprons, and smoking hours. In addition to care plan for safe smokers and unsafe smokers. She continued to state the Unit Manager KKKK gave the staff the updated list of smokers with safe and unsafe identified residents. The smoker list is posted in the CNA book and the Nurse book behind the nurse's station. Interview on 10/11/2024 at 4:37 pm, the Scheduling Manager revealed she received smoking in-service training. She stated everyone on Magnolia Hall is consider unsafe. She continued to state apron should be on, they are not to have cigarettes or lighters on person. Smoking box is kept at the nursing station. Further, the nursing keeps the list of the smokers, also list in the smoke box upstairs. The fire blankets are kept in the boxes in both locations up and down stairs. Additionally, the smoking assessment must be done by the nurses, clinical manager or MDS personnel. Once the assessment is completed it is put in the care plan. Interview on 10/11/2024 at 4:29 pm, with Certified Nursing Assistant (CNA) MMMM, stated she received smoking in-service recently. The in-service training pertained to the safety of the residents, the nurses conducting the smoking assessments. She continued to state the nurses are the monitors and the CNA are making sure they keep their smoking aprons on and providing supervision. 5. Review of the in-service training for the removal plan determined all numbers are accurate. 6. Interview on 10/11/2024 at 4:20 pm, with LPN KKKK stated she received in-service on smoking last week and this week. She signed the in-service sign in sheet. The training pertained to the residents, fire extinguisher, aprons, and smoking hours. In addition to care plan for safe smokers and unsafe smokers. She continued to state the Unit Manager gave the staff the updated list of smokers with safe and unsafe identified residents. The smoker list is posted in the CNA book and the Nurse book behind the nurse's station. Interview on 10/11/2024 at 4:25 pm, with CNA NNNN stated she did receive in-service pertaining to smoking. In-service referred to the up-to-date policy, safe smokers, and unsafe smokers. She stated the safe smoker do not have to have an apron on versus the unsafe smokers don't have to have an apron. Nurses are the ones who do the smoking assessment. The updated list is found at the nurse station. Unit upstairs smokes every two hours and downstairs on Magnolia start at 10:00 am - 6:00 pm. Interview on 10/11/2024 at 4:29 pm, with CNA MMMM stated she received smoking in-service recently. The in-service training pertained to the safety of the residents, the nurses conducting the smoking assessments. She continued to stated nurses are the monitors and the CNA are making sure they keep their smoking aprons on and providing supervision. Interview on 10/11/2024 at 4:32 pm, with LPN OOOO revealed she has received the in-service training for smoking. She stated the training pertained to safe and unsafe smoker, the smoking aprons, light the cigarettes and monito them. If the resident is deemed safe still monitor. She continued to state nurses can do the assessment for smoking. All Magnolia residents are monitored at all times during smoking times. In addition, to keep the cigarettes locked in the smoke box which is located in the Activities office. If any new staff, the staff can show them the list that is posted at the nurse's station. 7. Interview with Regional Director of Operations and Regional Nurse Consultant on 10/11/2024 at 3:35 pm, both stated new onboarding employees will review the smoking policy as part of their orientation process. During this onboarding process the smoking components are: There is a new Smoking Schedule, and all staff should direct residents to the times. Smoking Assessment will be conducted as soon as the resident is identified as a smoker with care plan. All unsafe smokers should have a care plan, assessment, supervised residents will have on a smoking apron at all times. All residents on Magnolia are required to wear a smoking apron. Smoking Monitors should be present at all schedule smoking break times. Importance of following smoking care plans and accurately completing smoking assessment in a timely manner. Ensure smoking aprons are on correctly, residents are not allowed to light other resident cigarettes. Residents not on the smoking list are not allowed to smoke until the Charge Nurse, Administrator, or Director of Nursing have been notified and Smoking Assessment is completed. 8. We have no agency staff currently. 9. Record Review of the AD HOC QAPI Meeting confirmed the root cause was determined and that education to staff and residents on the smoking policy and expectations was needed, and a set smoking schedule established. Record Review revealed the removal plan binder with printed sheets in large bold print of the smoking schedule for the designated smoking area in courtyard and downstairs courtyard outside of Magnolia. Smoking schedule starts at 6:00 am - 6:30 am and repeating availability every 2 hours for 24 hours a day for a total of twelve (12) smoke breaks. The Downstairs Courtyard outside of Dementia Unit smoking schedule is 10:00 am - 10:30 am, 12:00 pm - 12:30 pm, 2:00 pm - 2:30 pm, 4:00 pm - 4:30 pm, and final break for the night at 6:00 pm - 6:30 pm for a total of five (5) smoking breaks. Interview on 10/11/2024 at 3:58 pm, with Regional Director of Operations assisted in verifying and identifying the staff that was present at the AD HOC QAPI Meeting: - Regional Nurse Consultant was present - [NAME] President of Quality was present - Business Office Manager was present - Dietary Manager was present - Dietary Assistant Manager was present - Medical Supply Clerk was present - Transportation Coordinator was present - Director of Rehabilitation was present - Social Worker was present - Unit Managers IIII, GGGG, CC, ZZ were present - Medical Director was present Record review of the AD HOC QAPI Meeting Log revealed Medical Director was notified over the phone. Phone Interview on 10/11/2024 at 4:11 pm, with Medical Director confirmed he attended the AD HOC QAPI meeting over the phone. Record review of the AD HOC QAPI Meeting Log for F835 confirmed all stated staff was present at the AD HOC QAPI Meeting. No other concerns identified.

Based on observations, record review, resident and staff interviews, and review of the facility's policy titled Smoking Policy - Residents, and Resident Smoking and Banned Item List and Safe Water Temperatures and Oxygen Storage, the facility failed to ensure that the environment and facility were free from potential accident hazards for residents and staff. Specifically: 1. Immediate Jeopardy was identified for facility's failure to enforce the smoking policy and Banned Item List for eight of 44 sampled residents reviewed for smoking (R) (R71, R266, R145, R365, R25, R111, R118, R19); 2. Failed to ensure three residents (R83, R60, and R91) were not allowed to keep hazardous materials in their rooms; 3. Failed to maintain safe and comfortable water temperatures below 120 degrees Fahrenheit in 18 rooms on five of five units (E111, E112, E108, E107, E102, E101, W134, W129, W124, G217, G224, G229, D215, D206, D203, M109, M101, M118); and 4. Failed to properly secure a portable oxygen cylinder in one resident room (W132). The facility's failures created potential risks for the safety and well-being of the residents, staff, and any visitors in the building. On 10/9/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Corporate Regional Director of Operations, Corporate Regional Nurse Consultant (RNC), and Director of Nursing (DON) was informed of an Immediate Jeopardy (IJ) on 10/9/2024 at 3:11 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/22/2024. Upon survey entrance to the facility, residents were observed sitting out front of the facility, smoking unsupervised. Throughout the duration of the survey, the facility failed to monitor the smoking practices by not maintaining accurate smoking assessments, allowing residents to keep smoking materials in their possession, not supervising residents while smoking, and allowing a resident in the dementia care unit to smoke inside the facility. A Credible Allegation of Compliance was received on 10/11/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 10/11/2024. The facility remains out of compliance while the facility continues management level oversight as well as continues to develop and implement a Plan of Correction. (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding facility smoking practices, to include smoking assessments, and following care plans related to smoking. Resident records were reviewed to ensure that resident care and treatment was current and accurate. Findings include: 1. A review of the facility policy titled Smoking Policy - Residents revised August 2022 revealed Policy Statement: This facility has established and maintains safe resident smoking practices. Policy Interpretation and Implementation: Number 1. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. Number 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Smoking is not allowed inside the facility under any circumstances. Number 6. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes a. current level of tobacco consumption; b. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. desire to quit smoking; d. ability to smoke safely with or without supervision (per completed Safe Smoking Evaluation). Number 8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff. Number 9. Any smoking-related privileges, restrictions, and concerns (need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Number 11. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. Number 12. Residents who have independent smoking privileges are permitted to keep cigarettes, electronic-cigarettes, pipes, tobacco, and other smoking items in their possession. Only disposable safety lighters are permitted. Number 13. Residents are not permitted to give smoking items to other residents. Number 14. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision. A review of the facility policy titled Resident Smoking Policy revised 3/21/2024 revealed Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, as related to smoking. Policy Explanation and Compliance Guidelines: Number 5. Residents who smoke will be assessed using the Resident Safe Smoking Assessment to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. Number 7. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas, at designated times, and in accordance with his/her care plan. Number 9. All safe smoking measures will be documented on each residents care plan Supervision will be provided as indicated on each residents care plan. Number 11. If a resident or family does not abide by the smoking policy or care plan (e.g. smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional safety measures. Number 12. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. A review of the undated facility document titled Banned Item List revealed the following items: Cigarettes and cigarette lighters, smokeless tobacco, and vapes. Observation on 9/22/2204 at 1:15 pm, upon survey entrance revealed approximately 12 residents crowded in the front of the building smoking. No staff members were present in the area and no residents had on aprons. Observation on 9/24/2024 at 10:06 am to 10:17 am, revealed there were five residents smoking unsupervised outside the dementia care/behavior unit smoking area. There was no evidence of facility staff members outside monitoring the residents smoking during this time frame. A. Review of the clinical record revealed R71 was admitted to the facility on [DATE] with diagnoses including seizure disorder, traumatic brain injury (TBI), schizoaffective disorder, depression and age-related bilateral cataracts. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 12, which indicated moderate cognitive impairment. Section J on the 3/26/2024 annual MDS revealed resident was coded as a current tobacco user. Review of facilities Smoking List dated 9/23-with no year indicated, revealed R71's name was on the list of residents identified as a tobacco user. Review of the facilities Smoking List dated 9/23-with no year indicated, revealed R71's name was on the list of residents identified as a tobacco user. Review of R71's documentation related to the smoking assessments revealed that the most recent assessment was completed on 10/5/2024. The smoking assessment revealed she prefers to smoke morning, afternoon, and evening. Further review revealed she requires an apron, someone to light/extinguish the cigarette, and supervision. Review of R71's care plan initiated 6/11/2021 and revised 10/5/2024 revealed that she was an unsafe smoker, she is non-compliant with smoking policy - resident was observed smoking in her bathroom, she solicits smoking materials from other residents, staff, and visitors. Interventions to care include educate and provide safety awareness for smoking, instruct resident about the facility policy on smoking: locations, times, safety concerns, resident requires a smoking apron. Observation on 10/4/2024 at 11:09 am, R71 was observed during smoke break to be wearing a smoke apron, but she does not have the apron on correctly. The apron is hanging around her neck off the shoulders and between her legs. She smokes with the assistance of both hands using one hand to hold the cigarette and the other hand to move her hand up and down from her mouth. Further observation revealed there are visible burn holes (approximately two centimeters) in her green shirt from the cigarettes. Observation on 10/4/2024 at 12:09 pm, R71 is back outside smoking and does not have on a smoking apron on this time. She is observed to have burn holes in her shirt as she is seen wiping the ashes off of her clothes. B. Review of the clinical record revealed R266 was admitted to the facility on [DATE] with diagnoses including pneumonia, protein calorie malnutrition, sacral pressure ulcer, deep vein thrombosis, and sepsis due to escherichia coli. Review of the admission MDS dated [DATE] revealed a BIMS was coded as 14, which indicated no cognitive impairment. Section J revealed resident was not coded as a current tobacco user. Review of facilities Smoking List dated 9/23-with no year indicated, revealed R266's name was not on the list of residents identified as a tobacco user. Review of R266's documentation related to the smoking assessments revealed that the most recent assessment was completed on 10/6/2024. The smoking assessment revealed the resident does not use smoking/tobacco/nicotine products. Review of R266's care plan revised 9/21/2024 revealed no evidence addressing residents desire to keep a cigar in his possession to dry puff (a puff taken before lighting a cigar to taste the cigar's flavors). Observation on 10/7/2024 at 11:00 am, revealed resident with an un-lit cigar in his mouth. Interview with resident at this time stated he does not smoke it; he just dryly puffs on it because he is trying to quit smoking. C. Review of the clinical record revealed R145 was admitted to the facility on [DATE] with diagnoses including depression. Review of the annual MDS assessment dated [DATE] revealed a BIMS was coded as 13, which indicated no cognitive impairment. Section J revealed resident was coded as a current tobacco user. Review of facilities Smoking List dated 9/23-with no year indicated, revealed R145's name was on the list of residents identified as a tobacco user. Review of R145's documentation related to the smoking assessments revealed that the most recent assessment was completed on 7/12/2024. The smoking assessment revealed the resident was assessed as an independent smoker at any time morning, afternoon and evening. Review of R145's care plan revised 7/21/2024 documented that resident was a safe smoker and will not have any injury related to smoking. Interventions to care include smoking assessment per facility protocol. Further review revealed resident would adhere to all smoking policies. Observation on 10/4/2024 at 11:09 am, revealed R145 outside in smoking area, retrieved a lighter from his pants pocket and lit the cigarette for another resident. He then walked towards a bush, took a pack of cigarettes out of his pants pocket, removed a cigarette from the pack, lit it, and walked to his rollator sat down and began smoking. R145 has another new pack of cigarettes in his shirt pocket and gives one cigarette from the pack to another resident. D. Review of the clinical record revealed R365 was admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis with joint contractures, depression, and gastroesophageal reflux disease (GERD). There is no MDS data available for this resident. Review of facilities Smoking List dated 9/23-with no year indicated, revealed R365's name was on the list of residents identified as a tobacco user. Review of R365's documentation related to the smoking assessments revealed that the most recent assessment was completed on 9/18/2024. The smoking assessment revealed she prefers to smoke morning, afternoon, and evening. Further review documented her ability to hold and handle smoking/tobacco/nicotine products was poor with weakness and contractures. Review of R365's care plan initiated 6/20/2024 revealed that she was a smoker and that she will not suffer injury from unsafe smoking practices. Interventions to care include instruct resident about smoking risks and hazards and facility policy, including locations, times, and safety concerns. Observation on 9/25/2024 at 11:09 am, revealed R365 goes out to the smoking area to smoke. She has her cigarette in her hand and pulls her lighter from the seat of her rollator. Observation on 9/25/2024 at 3:30 pm, revealed R365 smoking outside under the small, covered portion in front of the building with no staff in sight. The resident had her cigarettes and a lighter in her possession. She was observed to be lighting other residents cigarettes. Interview on 10/5/2024 at 11:33 am, Activity Assistant (AA) LL, revealed that each smoking area has a smoke box that has the residents' smoking materials. Activity Assistant LL stated some residents are allowed to keep their own cigarettes with them, but they are not allowed to keep any lighters. When asked how she identifies which residents are allowed to keep their cigarettes, she revealed the Director of Nursing (DON) does an assessment to determine if they are safe or not safe. She stated if they are assessed to be safe smokers, then they can keep their own cigarettes. During further interview, she stated if there was an issue with the residents during smoking breaks, she would report the concern to the DON or the Social Services Director. She stated if the staff see the residents with lighters, they will ask the resident for the lighters. 50374 E. Review of the clinical record revealed R25 was admitted to the facility on [DATE]with diagnoses including dementia, cognitive communication deficit, lack of coordination, atherosclerotic heart disease, mood and psychotic disorders, and generalized muscle weakness. Review of the quarterly MDS dated [DATE] documented a BIMS score of five, indicating severe cognitive impairments. Section J on the 3/24/2024 annual MDS revealed resident was coded as a current tobacco user. Review of facilities Smoking List dated 9/23-with no year indicated, revealed R25's name was on the list of residents identified as a tobacco user. Review of R25's documentation related to the smoking assessments revealed that the most recent assessment was completed on 9/12/2024. The smoking assessment revealed he prefers to smoke morning, afternoon, and evening. Further review revealed due to resident's behavior and score with smoking assessment, resident will need supervision with smoking and he requires someone to light/extinguish the cigarette. Record review of R25's care plan initiated on 11/5/2021 revealed R25 is an unsafe smoker and will not suffer injury from unsafe smoking practices and will not smoke without supervision. Resident was found smoking in his room and was documented that he will only smoke in appropriate area under direct supervision. Interventions to care include provide direct supervision while smoking, staff to light/extinguish cigarette and supervision including retrieval of cigarettes and lighter, educate resident about smoking risks and hazards, instruct on facility policy on smoking including locations, times, and safety concerns, remove all smoking devices from resident room and store in locked container, and notify Charge Nurse if it is suspected resident has violated facility smoking policy. Observation on 9/24/2024 at 10:06 am, R25 was outside in the dementia care smoking area smoking unsupervised. There were no staff members outside at this time. Observation on 10/7/2024 at 10:04 am, Activity Assistant (AA) WWW was supervising the smoke break with no safety smoking tools outside with the residents. Interview on 10/7/2024 at 10:08 am, R25 stated he typically smokes two to three times a day and revealed that he keeps his own cigarettes and lighter in his room. During further interview, he stated nobody helps him with his cigarettes and lighter, and states that he can do it on his own. the facility failed to ensure that the environment and facility were free from potential accident hazards for residents and staff. Specifically: 1. Immediate Jeopardy was identified for facility's failure to enforce the smoking policy and Banned Item List for eight of 44 sampled residents reviewed for smoking (R) (R71, R266, R145, R365, R25, R111, R118, R19); 2. Failed to ensure three residents (R83, R60, and R91) were not allowed to keep hazardous materials in their rooms; 3. Failed to maintain safe and comfortable water temperatures below 120 degrees Fahrenheit in 18 rooms on five of five units (E111, E112, E108, E107, E102, E101, W134, W129, W124, G217, G224, G229, D215, D206, D203, M109, M101, M118); and 4. Failed to properly secure a portable oxygen cylinder in one resident room (W132). The facility's failures created potential risks for the safety and well-being of the residents, staff, and any visitors in the building. On 10/9/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Corporate Regional Director of Operations, Corporate Regional Nurse Consultant (RNC), and Director of Nursing (DON) was informed of an Immediate Jeopardy (IJ) on 10/9/2024 at 3:11 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/22/2024. Upon survey entrance to the facility, residents were observed sitting out front of the facility, smoking unsupervised. Throughout the duration of the survey, the facility failed to monitor the smoking practices by not maintaining accurate smoking assessments, allowing residents to keep smoking materials in their possession, not supervising residents while smoking, and allowing a resident in the dementia care unit to smoke inside the facility. A Credible Allegation of Compliance was received on 10/11/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 10/11/2024. The facility remains out of compliance while the facility continues management level oversight as well as continues to develop and implement a Plan of Correction. (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding facility smoking practices, to include smoking assessments, and following care plans related to smoking. Resident records were reviewed to ensure that resident care and treatment was current and accurate. Findings include: 1. A review of the facility policy titled Smoking Policy - Residents revised August 2022 revealed Policy Statement: This facility has established and maintains safe resident smoking practices. Policy Interpretation and Implementation: Number 1. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. Number 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Smoking is not allowed inside the facility under any circumstances. Number 6. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes a. current level of tobacco consumption; b. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. desire to quit smoking; d. ability to smoke safely with or without supervision (per completed Safe Smoking Evaluation). Number 8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff. Number 9. Any smoking-related privileges, restrictions, and concerns (need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Number 11. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. Number 12. Residents who have independent smoking privileges are permitted to keep cigarettes, electronic-cigarettes, pipes, tobacco, and other smoking items in their possession. Only disposable safety lighters are permitted. Number 13. Residents are not permitted to give smoking items to other residents. Number 14. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision. A review of the facility policy titled Resident Smoking Policy revised 3/21/2024 revealed Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, as related to smoking. Policy Explanation and Compliance Guidelines: Number 5. Residents who smoke will be assessed using the Resident Safe Smoking Assessment to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. Number 7. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas, at designated times, and in accordance with his/her care plan. Number 9. All safe smoking measures will be documented on each residents care plan Supervision will be provided as indicated on each residents care plan. Number 11. If a resident or family does not abide by the smoking policy or care plan (e.g. smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional safety measures. Number 12. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. A review of the undated facility document titled Banned Item List revealed the following items: Cigarettes and cigarette lighters, smokeless tobacco, and vapes. Observation on 9/22/2204 at 1:15 pm, upon survey entrance revealed approximately 12 residents crowded in the front of the building smoking. No staff members were present in the area and no residents had on aprons. Observation on 9/24/2024 at 10:06 am to 10:17 am, revealed there were five residents smoking unsupervised outside the dementia care/behavior unit smoking area. There was no evidence of facility staff members outside monitoring the residents smoking during this time frame. A. Review of the clinical record revealed R71 was admitted to the facility on [DATE] with diagnoses including seizure disorder, traumatic brain injury (TBI), schizoaffective disorder, depression and age-related bilateral cataracts. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 12, which indicated moderate cognitive impairment. Section J on the 3/26/2024 annual MDS revealed resident was coded as a current tobacco user. Review of facilities Smoking List dated 9/23-with no year indicated, revealed R71's name was on the list of residents identified as a tobacco user. Review of the facilities Smoking List dated 9/23-with no year indicated, revealed R71's name was on the list of residents identified as a tobacco user. Review of R71's documentation related to the smoking assessments revealed that the most recent assessment was completed on 10/5/2024. The smoking assessment revealed she prefers to smoke morning, afternoon, and evening. Further review revealed she requires an apron, someone to light/extinguish the cigarette, and supervision. Review of R71's care plan initiated 6/11/2021 and revised 10/5/2024 revealed that she was an unsafe smoker, she is non-compliant with smoking policy - resident was observed smoking in her bathroom, she solicits smoking materials from other residents, staff, and visitors. Interventions to care include educate and provide safety awareness for smoking, instruct resident about the facility policy on smoking: locations, times, safety concerns, resident requires a smoking apron. Observation on 10/4/2024 at 11:09 am, R71 was observed during smoke break to be wearing a smoke apron, but she does not have the apron on correctly. The apron is hanging around her neck off the shoulders and between her legs. She smokes with the assistance of both hands using one hand to hold the cigarette and the other hand to move her hand up and down from her mouth. Further observation revealed there are visible burn holes (approximately two centimeters) in her green shirt from the cigarettes. Observation on 10/4/2024 at 12:09 pm, R71 is back outside smoking and does not have on a smoking apron on this time. She is observed to have burn holes in her shirt as she is seen wiping the ashes off of her clothes. B. Review of the clinical record revealed R266 was admitted to the facility on [DATE] with diagnoses including pneumonia, protein calorie malnutrition, sacral pressure ulcer, deep vein thrombosis, and sepsis due to escherichia coli. Review of the admission MDS dated [DATE] revealed a BIMS was coded as 14, which indicated no cognitive impairment. Section J revealed resident was not coded as a current tobacco user. Review of facilities Smoking List dated 9/23-with no year indicated, revealed R266's name was not on the list of residents identified as a tobacco user. Review of R266's documentation related to the smoking assessments revealed that the most recent assessment was completed on 10/6/2024. The smoking assessment revealed the resident does not use smoking/tobacco/nicotine products. Review of R266's care plan revised 9/21/2024 revealed no evidence addressing residents desire to keep a cigar in his possession to dry puff (a puff taken before lighting a cigar to taste the cigar's flavors). Observation on 10/7/2024 at 11:00 am, revealed resident with an un-lit cigar in his mouth. Interview with resident at this time stated he does not smoke it; he just dryly puffs on it because he is trying to quit smoking. C. Review of the clinical record revealed R145 was admitted to the facility on [DATE] with diagnoses including depression. Review of the annual MDS assessment dated [DATE] revealed a BIMS was coded as 13, which indicated no cognitive impairment. Section J revealed resident was coded as a current tobacco user. Review of facilities Smoking List dated 9/23-with no year indicated, revealed R145's name was on the list of residents identified as a tobacco user. Review of R145's documentation related to the smoking assessments revealed that the most recent assessment was completed on 7/12/2024. The smoking assessment revealed the resident was assessed as an independent smoker at any time morning, afternoon and evening. Review of R145's care plan revised 7/21/2024 documented that resident was a safe smoker and will not have any injury related to smoking. Interventions to care include smoking assessment per facility protocol. Further review revealed resident would adhere to all smoking policies. Observation on 10/4/2024 at 11:09 am, revealed R145 outside in smoking area, retrieved a lighter from his pants pocket and lit the cigarette for another resident. He then walked towards a bush, took a pack of cigarettes out of his pants pocket, removed a cigarette from the pack, lit it, and walked to his rollator sat down and began smoking. R145 has another new pack of cigarettes in his shirt pocket and gives one cigarette from the pack to another resident. D. Review of the clinical record revealed R365 was admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis with joint contractures, depression, and gastroesophageal reflux disease (GERD). There is no MDS data available for this resident. Review of facilities Smoking List dated 9/23-with no year indicated, revealed R365's name was on the list of residents identified as a tobacco user. Review of R365's documentation related to the smoking assessments revealed that the most recent assessment was completed on 9/18/2024. The smoking assessment revealed she prefers to smoke morning, afternoon, and evening. Further review documented her ability to hold and handle smoking/tobacco/nicotine products was poor with weakness and contractures. Review of R365's care plan initiated 6/20/2024 revealed that she was a smoker and that she will not suffer injury from unsafe smoking practices. Interventions to care include instruct resident about smoking risks and hazards and facility policy, including locations, times, and safety concerns. Observation on 9/25/2024 at 11:09 am, revealed R365 goes out to the smoking area to smoke. She has her cigarette in her hand and pulls her lighter from the seat of her rollator. Observation on 9/25/2024 at 3:30 pm, revealed R365 smoking outside under the small, covered portion in front of the building with no staff in sight. The resident had her cigarettes and a lighter in her possession. She was observed to be lighting other residents cigarettes. Interview on 10/5/2024 at 11:33 am, Activity Assistant (AA) LL, revealed that each smoking area has a smoke box that has the residents' smoking materials. Activity Assistant LL stated some residents are allowed to keep their own cigarettes with them, but they are not allowed to keep any lighters. When asked how she identifies which residents are allowed to keep their cigarettes, she revealed the Director of Nursing (DON) does an assessment to determine if they are safe or not safe. She stated if they are assessed to be safe smokers, then they can keep their own cigarettes. During further interview, she stated if there was an issue with the residents during smoking breaks, she would report the concern to the DON or the Social Services Director. She stated if the staff see the residents with lighters, they will ask the resident for the lighters. 49140 F. Review of the clinical record revealed R111 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, alcohol abuse, history of falls, cognitive communication deficit, major depressive disorder, and anxiety disorder. Review of the annual MDS dated [DATE] documented a BIMS score of two, indicating the resident is severely cognitively impaired. Section J revealed resident was not coded as a current tobacco user. Review of facilities Smoking List dated 9/23-with no year indicated, revealed R111's name was on the list of residents identified as a tobacco user. Review of R111's documentation related to the smoking assessments revealed that the most recent assessment was completed on 7/25/2024. The smoking assessment revealed that residents safety awareness was good and no supervision required, which is conflicting with his current care plan. Review of R111's care plan revised 7/9/2025 revealed resident is a smoker, and he will n [TRUNCATED]

Based on observations, record review, interviews, review of the Administrator Job Description and Director of Nursing Job Description, and review of the policy titled Smoking Policy - Residents, the facility administration failed to provide oversight and monitoring of the facility operations related to enforcement of its smoking policy and failed to ensure that licensed nursing staff were knowledgeable and competent to assess residents and implement care plans for smoking. The facility's failures created potential risks for the safety and well-being of the residents. The census was 210 residents. Specifically 1. Facility Administrator and Director of Nursing (DON) failed to perform duties of their job descriptions that facilitated providing a safe environment to the residents of the facility. 2. Administration failed to enforce the facility smoking policy by allowing residents to keep smoking materials on their person, allowed residents to smoke unsupervised, and failed to maintain accurate smoking assessments that correlated to person-centered care plans. Cross Refer F689 3. Facility Administration failed to develop and/or implement the smoking care plans for six identified residents (R) R71, R266, R19, R25, R111, R118. Cross Refer F656 On 10/9/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Corporate Regional Director of Operations, Corporate Regional Nurse Consultant (RNC), and Director of Nursing (DON) was informed of an Immediate Jeopardy (IJ) on 10/9/2024 at 3:11 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/22/2024. Upon survey entrance to the facility, residents were observed sitting out front of the facility, smoking unsupervised. Throughout the duration of the survey, the facility failed to monitor the smoking practices by not maintaining accurate smoking assessments, allowing residents to keep smoking materials in their possession, not supervising residents while smoking, and allowing a resident in the dementia care unit to smoke inside the facility. A Credible Allegation of Compliance was received on 10/11/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 10/11/2024. The facility remains out of compliance while the facility continues management level oversight as well as continues to develop and implement a Plan of Correction. (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding facility smoking practices, to include smoking assessments, and following care plans related to smoking. Resident records were reviewed to ensure that resident care and treatment was current and accurate. Findings include: Review of the undated and un-signed document titled Administrator Job Description, indicated the position purpose is to lead, guide, and direct the operations of the healthcare facility in accordance with local, state, and federal regulations, standards, and established facility policies and procedures to provide appropriate care and services to residents. Major duties and Major Duties and Responsibilities: *Plans, develops, organizes, implements, evaluates, and directs the overall operations of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations. *Identifies, in conjunction with the Director of Nursing and selected department heads, the facility's key performance indicators. *Evaluates key performance indicators with department heads to determine the need for action from leadership and/or management such as re-education or revisions relayed to the facility's outcomes, regulatory compliance and/or customer satisfaction. *Leads and coordinates daily, weekly, monthly management team meetings to discuss priorities and develop solutions with facility leaders. *Evaluates work performance of department heads and maintains accountability across all departments. *Knows and understands general nursing practices and procedures, ONRA regulations, Code of Federal Regulations, Appendix PP State Operations Manual, reimbursement processes, Life Safety Code regulations, applicable labor relations law, and all other regulatory entities. *Communicates directly with residents, medical and nursing staff, family members, department heads and members of the interdisciplinary team to coordinate care and services. Responds and resolves complaints and concerns when necessary. *Reads and stays informed regarding regulatory, business practices and other changes influencing facility outcomes; thereby, facilitating continued success for all. *Reports any allegations of abuse, neglect, misappropriation of property, exploitation, or mistreatment of residents to appropriate regulatory entities. Protects resident from abuse and cooperates with all investigations. Review of the undated and un-signed document titled Director of Nursing Job Description, indicated the position purpose is to plan, organize, develop, and direct the overall operations of the Nursing Services Department in accordance with local, state, and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical director, to provide appropriate care and services to the residents. Major duties and Major Duties and Responsibilities: *Plans, develops, organizes, implements, evaluates and directs the overall operations of the Nursing Services department, as well as its programs and activities, in accordance with current state and federal laws and regulations. *Interprets and communicates policies and procedures to nursing staff, and maintains staff practices and implementations. *Participates in daily or weekly management team meeting to discuss census changes, resident changes in status, complaints ot concerns. *Participate in Quality Assurance Performance Improvement (QAPI) or facility assessment activities as needed, such as carrying out duties assigned as part of a performance improvement committee. *Ensures delivery of compassionate quality care and nursing supervision as evidenced by adequate staff coverage on the units, general cleanliness, and maintaining optimal resident functions. *Collaborates with members of the interdisciplinary team, physicians, consultants, and community agencies to identify and resolve issues and improve the quality of services. *Performs rounds to observe resident and ensure nursing needs are being met. *Monitors, assists and implements the infection control program in accordance with current infection control guidelines to prevent the development and transmission of disease and infection. *Communicates directly with residents, medical and nursing staff, family members, department heads and members of the interdisciplinary team to coordinate care and services and respond to and resolve complaints and concerns. *Oversees resident incidents and concerns daily to identify and unusual occurrences and reports them promptly to the Administrator and/or state agency for appropriate ations. *Monitors for allegations of potential abuse or neglect, misappropriations of resident property and participates in the investigative process. A review of the facility policy titled Smoking Policy - Residents revised August 2022 revealed Policy Statement: This facility has established and maintains safe resident smoking practices. Policy Interpretation and Implementation: Number 2. Smoking is permitted in designated resident smoking areas, which are located outside of the building. Smoking is not allowed inside the facility under any circumstances. Number 9. Any smoking-related privileges, restrictions, and concerns (need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Number 11. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. Number 13. Residents are not permitted to give smoking items to other residents. Number 14. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision. Observation on 9/22/2024 at 1:15 pm, upon survey entrance revealed approximately 12 residents crowded in the front of the building smoking. No staff members were present in the area and no residents were wearing smoking aprons. Observation on 9/24/2024 at 10:06 am to 10:17 am, revealed there were five residents smoking unsupervised outside the dementia care/behavior unit smoking area. There was no evidence of facility staff members outside monitoring the residents smoking during this time frame. Observation on 10/4/2024 at 11:09 am, resident outside in smoking area, observed to have possession of lighter and cigarettes. Resident gave another resident a cigarette and lit it for him. Observation on 10/5/2024 at 3:58 pm, resident on the memory care unit, lit a cigarette and began smoking, inside the building. Observation on 10/7/2024 at 10:04 am, the Activity Assistant (AA) WWW was supervising the smoke break with no safety smoking aprons outside with the residents. Interview on 10/6/2024 at 5:53 pm, with the Corporate Representative stated everyone will be re-assessed in the building, its according to the assessment and the policy whether or not they can be automatically deemed as a responsible smoker. It largely depends on where they are. Interview on 10/6/2024 at 5:53 pm with the Corporate Representative stated everyone will be re-assessed in the building, its according to the assessment and the policy whether or not they can be automatically deemed as a responsible smoker. It largely depends on where they are. Interview on 10/7/2024 at 10:08 am, the Activities Director (AD) LLL revealed there are three Activity Assistants who rotate monitoring during the smoke breaks. She described the training as a walk through in order to train the Activity Assistants, then she will observe them do what she has shown them. During further interview, she revealed staff would know which residents smoke and whether they need any special supervision, the more they work with the residents. She stated rhe nursing department gives the activity department the smoking list and then she will give it to her assistants. Interview on 10/7/2024 at 5:33 pm, the DON and Regional Nurse Consultant (RNC) indicated residents who are unsafe smokers must abide by the scheduled smoking times. They revealed that it is the responsibility of the nursing staff to complete resident smoking assessments, on admission and quarterly thereafter. During further interview, both the DON and the RNC stated residents are not allowed to smoke inside the building, and that will automatically make a resident be put on the unsafe smoking list. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility failed to address: A. Resident #25 and #365 smoking unsupervised. On 10/9/2024 the Regional Operations and Director of Nursing instituted smoking times for all residents who smoke. The smoke breaks will be supervised by smoking monitors who will be staff assigned daily. The smoke breaks times are as follows: Courtyard smoking schedule starts at 6:00 am - 6:30 am and repeating availability every 2 hours for 24 hours a day for a total of twelve (12) smoke breaks. The Downstairs Courtyard outside of Dementia Unit smoking schedule is 10:00 am - 10:30 am, 12:00 pm - 12:30 pm, 2:00 pm - 2:30 pm, 4:00 pm - 4:30 pm, and final break for the night at 6:00 pm - 6:30 pm for a total. of five (5) smoking breaks. B. Resident #145 and #365 observed lighting other residents' cigarettes. A smoking assessment was completed on two hundred and twelve (212) residents and identified sixty-one (61) residents that chose to smoke. Residents #145 and #365 outcome was a safe smoker. Education on only lighting their own cigarettes was provided to both residents. List of residents who choose to smoke was compiled by the Director of Nursing and Regional Nurse on 10/9/2024. The list contains sixty-one (61) residents with twenty-seven (27) residents who are identified on the list as needing smoking aprons. C. Resident #111 observed lighting a cigarette in the building. The Director of Nursing completed a new smoking assessment on 10/9/2024 and confiscated the residents lighter and cigarettes making him an unsafe smoker. D. Resident #19 observed what appeared to be cigarette burns on clothes. List of residents who need smoking aprons was compiled by Director of Nursing and Regional Nurse on 10/9/2024. Residents that require a smoking apron are identified by the resident's name on the list available at each nursing station and updated accordingly by the Director of Nursing. E. Resident #71 observed with smoking apron on incorrectly on one instance and one time without a smoking apron on: Smoking monitoring assigned will be responsible for ensuring smoking aprons are used correctly. F. Resident #118 observed with no smoking apron, no smoking assessment, and no smoking care plan. The residents' smoking assessment was completed by the Director of Nursing and the smoking care plan was completed by Minimal Data Specialist on 10/9/24. G. Resident #266 observed with no smoking apron and staff were unaware he is a smoker. Director of Nursing completed a smoking assessment for the resident on 10/9/2024. List of residents that are identified beside their name as unsafe require smoking aprons. H. The facility failed to develop a comprehensive person-centered care plan for residents #25, #145, #111, #19, #71, #118, #266 and #365. On 10/9/2024 the Regional Nurse and Director of Nursing reviewed and revised eight (8) of eight (8) residents smoking care plans to ensure that they are person centered and comprehensive. 2. On 10/9/2024 the Director of Nursing, Minimal Data Specialist, and/or Regional Nurse began reviewing and revising all sixty-one (61) smoking care plans to ensure that they are person centered and comprehensive. 3. On 10/9/24 the Director of Nursing, Assistant Director of Nursing, Unit Manager, Minimal Data Specialist, and/or Regional Nurse completed a smoking assessment on two hundred and twelve (212) residents and identified sixty-one (61) residents that choose to smoke. Smoking assessments were conducted to identify residents who choose to smoke, reassess for unsafe smoking residents, identify residents who need smoking aprons and any other safety measures. 4. On 10/9/24 the Director of Nursing and Regional Nurse compiled a list of unsafe smokers, safe smokers and those residents who require a smoking apron. The list of sixty-one (61) residents will be available at each nursing station for the smoking monitors to reference. The list will be updated accordingly by the Director of Nursing. 5. The Regional Operations on 10/9/2024 in-serviced the Director of Nursing, Assistant Director of Nursing, Minimal Data Specialist and Regional Nurse on the smoking policy, ensuring that smoking care plans are followed and completing timely and accurate smoking assessments. The Administrator will be in service prior to returning to work by the Regional Operations. 6. Regional Operations on 10/9/2024 in-serviced the Minimal Data Specialists on reviewing and completing accurate comprehensive person-centered smoking care plans for all residents who smoke. 7. On 10/9/2024 the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Regional Operations, and/or Regional Nurse began in-servicing all staff (Registered Nurse 10 of 10, Licensed Practical Nurse 33 of 34, Certified Nurse assistant 62 of 67, Certified Medication Aides 7 of 8, Respiratory Therapist 1 of 2, Dietary 14 of 25, Therapy 8 of 13, Administrative 18 of 18, Maintenance 4 of 4, Housekeeping 30 of 37, Activities 3 of 4 staff) on the smoking policy. The current percentage of staff educated is 86% at this time. 8. All residents on the Dementia Unit will be required to wear a smoking apron, all residents will adhere to the set smoking times for designated areas, designated staff will be assigned daily as smoking monitors and will be present at all smoke breaks, ensuring that smoking care plans are followed and completing timely and accurate smoking assessments. 9. The Director of Nursing, Assistant Director of Nursing and/or Regional Nurse began in person educating on 10/9/2024 with all staff on education for daily assigning of smoking monitors, and expectations on ensuring that smoking aprons are donned correctly, residents are not allowed to help other residents light their cigarettes and to ensure that all residents who require smoking aprons have one on. They also instructed the smoking monitors that any residents that are not listed on the smokers list should not be allowed to smoke. If any residents not on the list are attempting to smoke, they must notify the Charge Nurse, Director of Nursing, Administrator or Assistant Director of Nursing so that they can complete a smoking assessment. They were also in-serviced that all residents downstairs on the Downstairs Dementia unit will be required to wear a smoking apron during their monitored smoke breaks. The Downstairs Courtyard outside of Dementia Unit smoking schedule is 10:00 am - 10:30 am, 12:00 pm - 12:30 pm, 2:00 pm - 2:30 pm, 4:00 pm - 4:30 pm, and final break for the night at 6:00 pm - 6:30 pm for a total of five (5) smoking breaks. 10. The Regional Operations on 10/9/2024 decided that all resident's downstairs on the Downstairs Dementia Unit will be required to wear a smoking apron during their monitored smoke breaks. She instructed the Director of Nursing and Regional Nurse on this directive. 11. On 10/9/2024 the Regional Operations and Director of Nursing instituted smoking times for all residents who smoke. The smoke breaks will be supervised, and times as follows: Courtyard smoking schedule starts at 6:00 am - 6:30 am and repeating availability every 2 hours for 24 hours a day for a total of twelve (12) smoke breaks. The Downstairs Courtyard outside of Dementia Unit smoking schedule is 10:00 am - 10:30 am, 12:00 pm - 12:30 pm, 2:00 pm - 2:30 pm, 4:00 pm - 4:30 pm, and final break for the night at 6:00 pm - 6:30 pm for a total of five (5) smoking breaks. 12. All new Staff will be in serviced on these items during the orientation process by the Assistant Director of Nursing and/or Director of Clinical Education. 13. We have no agency staff currently. 14. Job descriptions of Director of Nursing and Administrator were reviewed by the Regional Operations, Regional Nurse, [NAME] President of Quality. Director of Nursing and Administrator (contacted via phone) were educated and voiced understanding of responsibilities and job duties. 15. AD Hoc QAPI meeting was completed on 10/10/2024 for policy review and root cause analysis. The root cause was determined that education to staff and residents on the smoking policy and expectations was needed, and a set smoking schedule established. Attendance to the meeting was Regional Director of Operations, Director of Nursing, Regional Nurse, [NAME] President of Quality, business office manager, dietary manager, dietary assistant manager, medical supply clerk, transportation coordinator, Director of Rehab, Social Worker, and Unit Managers. The Medical Director was notified by phone. 16. Corrective actions will be completed by 10/10/2024. Alleged date of IJ removal: 10/11/2024 The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: A. Record Review on 10/11/2024 at 3:50 pm revealed the removal plan binder with printed sheets in large bold print of the smoking schedule for the designated smoking area in courtyard and downstairs courtyard outside of Magnolia. Smoking schedule starts at 6:00 am - 6:30 am and repeating availability every 2 hours for 24 hours a day for a total of twelve (12) smoke breaks. The Downstairs Courtyard outside of Dementia Unit smoking schedule is 10:00 am - 10:30 am, 12:00 pm - 12:30 pm, 2:00 pm - 2:30 pm, 4:00 pm - 4:30 pm, and final break for the night at 6:00 pm -6:30 pm for a total. of five (5) smoking breaks. Observation on 10/11/2024 at 4:45 pm revealed smoking schedules posted with large bold letters of the smoking schedule for the designated smoking areas and hanging on a wall board outside of elevator and near front entrance receptionist desk. B. Interview on 10/11/2024 at 6:07 pm with R365 confirmed she received education to only light her own cigarette by Social Worker RRR. Furthermore, R365 revealed she feels like she is a safe smoker. Interview on 10/11/2024 at 6:10 pm with R145 confirmed he received education to only light his own cigarette but does not remember who provided the education. Furthermore, R145 revealed he feels like he is a safe smoker. C. Interview on 10/11/2024 at 6:00 pm with R111 revealed he never had any cigarettes on him. He stated he does not have any cigarettes or cigars currently on him. He stated the Unit Manager educated him on the safety of smoking and especially not smoking inside of the building. He stated that he wears an apron when he is on his smoking break. D. Record Review on 10/11/2024 at 5:30 pm revealed the residents that are required to have a smoking apron and are identified by the resident's name on the list available at each nursing station and updated by the Director of Nursing. E. Interview on 10/11/2024 at 6:05 pm with R71 confirmed she wears an apron when she goes on her smoking break, and she further confirmed a smoking apron is provided. F. Record Review on 10/11/2024 at 5:30 pm revealed the residents' smoking assessment was completed by the Director of Nursing and the smoking care plan was completed by Minimal Data Specialist on 10/9/2024. G. Interview on 10/11/2024 at 6:10 pm with R266 revealed he is a smoker but just started smoking not too long ago. He stated he is offered an apron; however, he is considered a safe smoker. He stated he smokes during the designated smoking break. Interview on 10/11/2024 at 6:20 pm with Licensed Practical Nurse (LPN) Unit Manager (UM) CC revealed R266 was assessed as a safe smoker because he can light his own cigarette, hold it steady and dispose of his ashes. H. Record Review on 10/11/2024 at 5:30 pm revealed the following: Care Plan and Smoking Assessment Review: R25- Unsafe smoker, Care plan revised on 10/9/2024. Smoking assessment was completed on 10/9/2024- requires supervision. R145- is a safe smoker; however, was observed lighting cigarettes for other residents. R145 is a safe smoker 10/9/2024- R111- is an unsafe smoker. 10/9/2024-requires supervision and an apron. R19- is an unsafe smoker 10/11/2024- needs supervision and an apron. R71- an unsafe smoker. Resident solicits to residents, staff, and/or visitors when cigarettes are not available. Resident has a history of being non-compliant with smoking policy-10/9/2024-requires supervision and an apron. R118- is unsafe smoker, 10/9/2024-requires apron, cigarette holder, someone to light and extinguish and supervision. R266- Resident is a safe smoker. 10/9/2024- no supervision, R365 - is a safe smoker; however, sometimes non-compliant with the smoking policy. History of lighting other resident's cigarettes 10/9/2024-independent smoker. 2. Interview on 10/11/2024 at 6:55 pm with, the Director of Nursing confirmed she reviewed and revised all sixty-one (61) smoking care plans to ensure that they are person centered and comprehensive Interview on 10/11/2024 at 6:58 pm with, Minimum Data Specialist (MDS) BBB confirmed she reviewed and revised all sixty-one (61) smoking care plans to ensure that they are person centered and comprehensive. Record review on 10/11/2024 of all sixty-one (61) smoking residents confirmed smoking care plans to ensure that they are person centered and comprehensive. 3. Interview on 10/11/2024 at 6:55 pm, with DON, confirmed she completed a smoking assessment on two hundred and twelve (212) residents and identified sixty-one (61) residents that choose to smoke. Furthermore, DON confirmed a smoking assessment was conducted to identify residents who choose to smoke, reassess for unsafe smoking residents, identify residents who need smoking aprons and any other safety measures. Interview on 10/11/2024 at 7:02 pm, with Assistant Director of Nursing (ADON), confirmed she completed a smoking assessment on two hundred and twelve (212) residents and identified sixty-one (61) residents that choose to smoke. Furthermore, ADON confirmed a smoking assessment was conducted to identify residents who choose to smoke, reassess for unsafe smoking residents, identify residents who need smoking aprons and any other safety measures Interview on 10/11/2024 at 7:00 pm with. LPN UM IIII confirmed he completed a smoking assessment on two hundred and twelve (212) residents and identified sixty-one (61) residents that choose to smoke. Furthermore, UM confirmed a smoking assessment were conducted to identify residents who choose to smoke, reassess for unsafe smoking residents, identify residents who need smoking aprons and any other safety measures Interview on 10/11/2024 at 6:55 pm, with Regional Nurse Consultant (RNC), confirmed she completed a smoking assessment on two hundred and twelve (212) residents and identified sixty-one (61) residents that choose to smoke. Furthermore, RNC confirmed a smoking assessment was conducted to identify residents who choose to smoke, reassess for unsafe smoking residents, identify residents who need smoking aprons and any other safety measures Interview on 10/11/2024 at 6:58 pm with MDS Data Specialist BBB confirmed she completed a smoking assessment on two hundred and twelve (212) residents and identified sixty-one (61) residents that choose to smoke. Furthermore, MDS confirmed a smoking assessment was conducted to identify residents who choose to smoke, reassess for unsafe smoking residents, identify residents who need smoking aprons and any other safety measures Record review on 10/11/2024 confirmed smoking assessments on two hundred and twelve (212) residents and identified sixty-one (61) residents that choose to smoke. Furthermore, record review confirmed smoking assessment were conducted to identify residents who choose to smoke, reassess for unsafe smoking residents, identify residents who need smoking aprons and any other safety measures. 4. Record Review on 10/11/2024 of Plan of Correction Binder confirmed a master list of unsafe smokers, safe smokers and those residents who require a smoking apron. Confirmation on 10/11/2024 at 4:39 pm confirmed a list of sixty-one (61) residents who smoke on [NAME] Wing nurses' station. Confirmation on 10/11/2024 at 4:45 pm confirmed a list of sixty-one (61) residents who smoke on East Wing nurses' station. Confirmation on 10/11/2024 at 4:51 pm confirmed a list of sixty-one (61) residents who smoke on Dogwood and Georgia Hall's nurse's station. Confirmation on 10/11/2024 at 4:55 pm confirmed a list of sixty-one (61) residents who smoke on Magnolia Hall's nurses' station. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: 5. Interview on 10/11/2024 at 7:00 pm with VP of Quality has in-serviced all staff making sure the staff are all aware of the smoking list and aware of the smoking carts. All staff have been randomly quizzed on the in-service. They are by hall and unit it is in the care plan since all staff have access to it. Have made staff aware of who is an unsafe smoker vs who is. Educated staff on assisting the residents on wearing the aprons appropriately and that they should be over the resident clothes. There is a designated area of smoking area for staff. Staff had a quiz they took about the smoking times and areas. Made sure all the administrative positions who are not currently in the building will be educated before they come back on shift. Lighters and cigarettes are secured, and residents know they cannot be in their rooms. If there is a resident who wants to smoke after hours, then that would be a 1:1 for the residents. Is unaware of a disposable safety lighter but will find out to see if it is beneficial for them. 6. Regional Operations on 10/9/2024 in-serviced the Minimal Data Specialists on reviewing and completing accurate comprehensive person-centered smoking care plans for all residents who smoke. 7. A review of the Ad Hoc Quality Assurance Performance Improvement (QAPI) Smoking Policy dated 10/9/2024 detailed four areas that were reviewed. Area one identified issues or concerns. Area two identified steps to immediate correct issue. Area three how are you going to prevent it from happening in future. Area four how will facility monitor compliance with smoking policy. There is an attached sign in form where names are printed, signature, date attended, department, and shift. There are a total of 26 names on the list including those from Administration, Nursing department, Dietary, Social Work, Medical Records, and housekeeping. 8. Observation on 10/11/2024 from 4:00 pm to 4:25 pm at designated smoking area for Dementia Unit. eight residents went outside, they were assisted by three staff members (2 nurses and 1 Activities assistant). At 4:10 pm all residents received smoking aprons and staff members helped each to put apron on to ensure that residents' clothing is protected. Cigarettes were distributed from plastic container labeled cigarettes for each resident. Staff lighted cigarettes for each resident. At the end of smoking break all cigarettes buds were collected by the staff and disposed. Observed blue binder at nursing station on the Dementia Unit and verified that binder has a list of all smoking residents from that unit. All smoking resident from Dementia Unit were marked unsafe smokers, requiring supervision and smoking aprons. Interview on 10/11/2024 at 4:40 pm with Regional Director of Operations for Georgia revealed that staff received education on how to supervise residents during smoking times. Facility created a Quiz about safety during smoking times and keep quizzing all staff. Observation on 10/11/2024 at 4:00 pm revealed five staff member assisting residents with putting on a smoke apron and lighting resident's cigarettes. There are six residents with aprons. The aprons were on the residents fully covering their clothes while they smoked. There were three smokers with no aprons. Residents with aprons are being assisted by staff with lighting their cigarettes. When the residents were finished smoking, the aprons were observed being disinfected, aired out, folded, then put in a bag. Observation on 10/11/2024 at 4:34 pm revealed staff collecting lighters from the residents without aprons who were given lighters to light their cigarettes. The remaining residents were unsafe smokers and did not have lighters in their possession and went back into the building after the smoke break was complete. 9. Interview on 10/11/2024 at 7:00 pm, with VP of Quality has in serviced all staff making sure the staff are all aware of the smoking list and aware of the smoking carts. All staff have been randomly quizzed on the in-service. They are by hall and unit it is in the care plan since all staff have access it. Have made staff aware of who is an unsafe smoker vs who is. Educated staff on assisting

Based on observations, interviews, and review of facility's policies titled Date Marking for Food Safety and Record of Food Temperatures, the facility failed to ensure proper food labeling and storage, failed to discard food items by the expiration dates, failed to ensure foods were maintained at proper temperatures, and failed to maintain sanitary conditions of the ice machine. The census was 210. Findings Include: Review of the undated policy titled Food Receiving and Storage, revealed Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Compliance: Number 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in - first out system. Number 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Review of the policy titled Date Marking for Food Safety, dated [DATE] revealed Policy Statement: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. Policy Explanation and Compliance Guidelines for Staffing: Number 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. Number 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. Number 5. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday.) Number 6. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. Number 7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed. Review of policy titled Record of Food Temperatures, reviewed [DATE] revealed it is the policy of the facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled. Policy Explanation and Compliance Guidelines: Number 10. Ready-to-eat foods that require heating before consumption should be taken directly from a sealed container or an intact package from an approved food processing source and heated to at least 135 degrees F for holding for hot service. Number 11. No food will be served that does not meet the food code standard temperatures. Number 12. Food will not be cooked or reheated using the steam table because it does not bring food to the proper temperature within acceptable timeframes. Observation on [DATE] at 12:23 pm during initial kitchen tour with cook EEE, revealed the following: *uncovered ice scoop laying on top of the ice machine *unwrapped yellow slices of block cheese in cooler *one gallon pitcher of brown liquid not labeled nor dated in cooler *31 individual single serve foam cups of liquids without a label or date in cooler *one 1.8 pound (lb) expired box of biscuit mix in dry storage *one 11.3 ounce (oz) expired package of gravy mix in dry storage *one 1.8 lb package of opened mashed potatoes without open date or use by date in dry storage *one opened box of scallop potatoes without open date or use by date in dry storage *two eight-quart containers of red food substance resembling Jello, unlabeled and no use by date in refrigerator *one eight-quart container of yellow food substance resembling pudding, unlabeled and no use by date in refrigerator *large pan of cut apples, unlabeled and no use by date, in milk refrigerator *Two 100 count box expired single serve sour cream cups on top of milk storage refrigerator *four one-gallon bags of food items (two with a white unidentified food substances, one with cut cucumbers, and one with block cheese) unlabeled and no use by date in walk in cooler During continued tour, observation of a double sink used for washing and prepping vegetables/produce and thawing meat was observed with dirty dish container inside the sink; under [NAME] the three-compartment sink was rust, dirt, and debris; can opener revealed red/brown build up substance, sugar container observed with scoop inserted inside the sugar bin. Observation on [DATE] at 1:06 pm, [NAME] XXX opened a stock can of chicken noodle soup, poured it into a Stainless Steele pan on the steam table line, and prepared to serve residents during the lunch tray serving. Interview on [DATE] at 1:08 pm, [NAME] EEE revealed the proper serving procedure for hot foods was to bring goods to 135 degrees before placing on serving line. [NAME] EEE removed soup from steam table and instructed cook XXX to bring soup to temperature by placing in oven. Observation on [DATE] at 10:14 am, revealed 41 individual one lb seasoning containers without an open or discard date, 25 of the 1 lb containers were left open and unattended; lighter fluid was found near plastic and paper; 61 four fluid oz containers of prune juice with expiration date ,d+[DATE]; ice machine ventilation openings were covered in layers of dust like particles. Inside ice machine revealed a black flake material inside the machine on the ice. Observation on [DATE] at 9:57 am, revealed the hood vent was not cleaned by 'next service date' of ,d+[DATE]. Interview on [DATE] at 9:36 am, with Lead Dietary Aide (LDA) DDD stated dietary department is short staffed, and wrong items are placed on trays because they are still learning. The LDA DDD stated they are trying to ensure all dietary staff know how to perform each duty in the kitchen, but some staff that are nonchalant about it. During further interview, LDA DDD stated the cooks and supervisors are responsible for labeling food. Interview on [DATE] at 10:00 am, with [NAME] EEE revealed everyone is responsible for labeling and dating foods items, but whatever they use they are supposed to put open date and used by date. [NAME] EEE revealed the facility is in the middle of hiring new staff and getting new management, and states that is why people are not doing their jobs and being nonchalant. [NAME] EEE confirmed if management is not here, cooks are in charge. [NAME] EEE shared the items found outdated or no label is from people not doing their jobs and being nonchalant. Interview on [DATE] at 12:18 pm, with Assistant Dietary Manager (ADM) revealed he makes sure the kitchen runs properly, residents get what they need, food ordering, performs preference likes and dislikes, and attends resident council meetings. ADM shared labeling/dating is everyone responsibility and he check in the morning with assistance sometimes from prep dietary staff. ADM confirmed the expired, unlabeled and undated items were overlooked. ADM mentioned the last in-service was on [DATE] on food storage, labeling, and dating, but stated obviously still has work to be done.

Based on observations, record review, and resident and staff interviews, the facility failed to ensure that it was maintained in a safe, clean, and comfortable home-like environment for 12 rooms (G224, G226, G227, G228, G229, G230, D201, W143, M101, M106, M107, M108) on four of five wings (Georgia Wing, [NAME] Wing, Dogwood Wing, and Magnolia Wing) including dirty bathrooms with noisy and dusty exhaust vents, broken light switches, dirty packaged terminal air conditioner (PTAC) units, a broken window, and dead insects in resident rooms. In addition, the laundry room had rancid odor, leaking pipes, dirty laundry overflowing from laundry chute onto floor, trash and lint atop the dryers, and a dusty fan in the clean laundry room. The census was 210. Findings: 1. Observation on 9/22/2024 at 2:21pm, Georgia Wing shared bathroom in room [ROOM NUMBER]/226, revealed the base/support for the toilet was noted to be covered in rust colored substance; the door frame had the same rust colored substance; the light switch was pushed up in the on position, but the light did not come on for resident use when using the bathroom. Observation on 9/22/2024 at 2:50 pm, Georgia Wing shared bathroom in room [ROOM NUMBER]/229, revealed the out take vent was covered with a fuzzy grey substance and was making a churning sound when in the on position; there were dead bugs in the bathroom light globe; and the hand sanitizer pump in room [ROOM NUMBER] was empty. Observation on 9/22/2024 at 3:32 pm, Georgia Wing, in room [ROOM NUMBER], the base board behind the door is missing. Observation on 9/22/2024 at 4:05 pm, Georgia Wing room [ROOM NUMBER], the filter on the packaged terminal air conditioner (PTAC) unit, both PTAC filters were covered with fuzzy grey colored substance, and there was black colored particles on the left side filter. Observation on 9/23/2024 at 2:37 pm, Georgia Wing in room [ROOM NUMBER], revealed the window has a crack in the glass, and a dead bug on the window sill. Observation on 9/23/2024 at 2:47 pm, Georgia Wing shared bathroom in room [ROOM NUMBER]/226 revealed a strong urine smell in the bathroom, bathroom light still does not work, the base boards were covered with rust colored substance; and the base of the toilet continued to be covered with a rust-colored substance. Observation on 9/23/2024 at 3:01 pm, Georgia Wing room [ROOM NUMBER], PTAC filter remains covered with fuzzy grey substance. Observation on 9/23/2024 at 3:15 pm, Georgia Wing in room [ROOM NUMBER], revealed the bathroom exhaust fan had grey dust build-up, and the fan squeals loudly. The bathroom light flickers in the on position. 50526 2. Observation and interview on 9/22/2204 at 1:30 pm, Dogwood Wing in room [ROOM NUMBER], revealed a large amount of trash on the floor around the bed and the trash can was out of reach of the resident. There was a strong odor noted in the room. The toilet bowl had brown fluid around back part of commode. R48 has a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitvely intact. He stated the housekeepers rarely come in to clean his room, maybe every three days. R48 also stated the water in the bathroom often runs a rusty in color. Water turned on and was not rusty color at this time. 50374 3. Observations on the Magnolia Wing revealed: *9/22/2024 room [ROOM NUMBER] revealed PTAC air filter were filled with debris. *9/22/2024 room [ROOM NUMBER] revealed PTAC air filter were filled with debris. *9/22/2024 room [ROOM NUMBER] revealed PTAC air filter were filled with debris. *9/22/2024 room [ROOM NUMBER] revealed PTAC air filter were filled with debris. Interview on 10/5/2024 at 10:34 am, with Regional Maintenance Director revealed the facility is currently cleaning air filters every three months. Upon verifying the manufacturers recommendations, he stated the air filters are supposed to be cleaned every month. Regional Maintenance Director provided an email indicating the change to be made for cleaning the PTAC air filters from every three months to once per month. Interview on 10/7/2024 at 12:18 pm, with Corporate Maintenance Director revealed the PTAC air filters need to be cleaned every three-months based on Tels (web-based ticketing system to track day-to-day building operations) they use for all of their facilities. The Maintenance Director was present and corrected him that based on manufacturers recommendations PTAC air filters are supposed to be cleaned every month. 49138 4. Observation on 9/23/2024 at 3:47 pm, 10/4/2024 at 2:32 pm, and 10/7/2024 at 9:10 am, [NAME] Wing room [ROOM NUMBER], revealed the PTAC unit to have debris on the inside of the unit throughout the length of the survey. Tour of laundry room on 10/9/2024 on 2:11 pm, with Laundry/Housekeeping Manager NNN revealed a rancid smell. A leaking pipe in the laundry room was observed attached to the wall above an active surge protector. This leaking pipe was slowly dripping a wet liquid substance on a wire connected to the surge protector. The laundry Chute had an overflow of dirty linens spilling on to the floor, most of which were not in bags. Observation of the dryer room revealed two broken dryer machines and two dryer machines that were not reaching the proper temperatures. One of the drying machines was observed missing a door. Observation on 10/9/2024 at 2:40 pm, revealed a total of four dryers, but only two are operational. There are exposed pipes at the top of the dryers with lint and debris substance on top. In the washing area there was a pipe coming down the wall that was leaking water. At the top of that same wall there was a big fan full of fuzzy dark gray and black like substance. Observation on 10/10/2024 at 11:08 am revealed the fan had been cleaned. The laundry Chute door is now being closed so that clothes are not falling onto the floor or overflowing into the bin. There was a team of individuals working on the leaking pipe in the laundry room. Observed on top one of the washing machines was a white and brownish grimy substance. Interview/Walk Around on 10/9/2024 at 11:30 am, the Administrator Assistant (AA), Maintenance Director (MD), and Housekeeping/Laundry tech PPPP revealed that all washers are in working order. The AA stated that if the washers are going in and out, that is a power issue and not an issue with the washers and dryers, themselves. During continued interview, the AA revealed dirty clothes are supposed to be dropped down the Chute and there is a staff member waiting at the bottom of the Chute to get the clothes as they come through. He reiterated that the clean clothes are taken out of the laundry room before they start working on the dirty clothes/linens. Interview on 10/10/2024 at 11:08 am, the MD stated they tried to swap out parts from one of the other dryers to see if that would fix the broken dryer. However, that didn't work, so the MD stated they were going to call out a service team. The MD confirmed that this is an issue that needs to be addressed.

Based on observations, staff interviews, and review of the facility's policy titled Sufficient and Competent Nursing, the facility failed to ensure nursing staff provided supervision and oversight for residents, as evidenced by nursing staff sleeping and watching videos during a third shift observation. The census was 210. Findings include: Review of the facility's undated policy titled Sufficient and Competent Nursing under the Policy Statement revealed, Our facility provides enough nursing staff with the appropriate skills and competency to provide nursing and related care and services for all residents in accordance with resident care plans and assessment. Under the Policy Interpretation and Implementation section revealed, 1. Licensed nurses and certified nursing assistants are available 24 hours a day, seven 7 days a week to provide competent resident care services including: (a) assuring resident safety, (b) attaining or maintaining the highest practical physical, mental, and psychosocial well-being of each resident and (d) responding to resident needs .2.(b) A charge nurse is a licensed nurse with designated responsibilities that may include staff supervision. Observation on 10/3/2024 at 3:50 am, revealed on the Magnolia Hall (dementia care unit) staff members were behind the nurse's station on their personal phone, sleeping, and watching movies on a laptop. Specifically, Certified Nurse Assistant (CNA) GGGG was sleeping at the nurse station with her head down; CNA HHH and CNA HHHH were both in the resident dining room with their back turned away from the resident's rooms watching a movie on a laptop computer; Licensed Practical Nurse (LPN) IIII was nodding at the nurse station and Infection Preventionist (IP) was scrolling on her phone at the nurse's station. Interview on 10/3/2024 at 10:21 am, with the Director of Nursing (DON) revealed they do not currently have a night supervisor. The DON revealed, the LPN's on each hall are the Charge Nurses for the overnight shifts. She continued to state the Magnolia Hall has four to five staff members for the overnight shift with an additional staff member as a sitter. The DON stated the observation related to the overnight staff who were observed sleeping was not brought to her attention. She further stated she expects the staff to be held accountable for their actions and to perform their professional duties and responsibilities. She revealed, the 11:00 pm - 7:00 am shift supervisor was to make sure things on their floor were going well. Interview on 10/3/2024 at 11:30 am, the DON, Regional Nurse Consultant (RNC), and Regional Director of Operations (RDO) confirmed staff should not be sleeping, should not be on their phones, and should not be watching movies on the unit and those actions were not acceptable. They stated that CNA GGGG was on her 30-minute break when the surveyor observed her sleep behind the nurse's station. During further interview, the Regional Director of Operations stated there were no residents harmed during that duration of time, and believes there should not be a federal regulation violation.

Based on observations, record review, staff interviews, and review of the facility policies titled Infection Surveillance, Infection Prevention and Control Program, Tracheostomy Care, Hand Hygiene, and Routine Cleaning and Disinfection, the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation and control of infections to prevent possible cross contamination. Specifically, facility staff failed to wash and/or sanitize hands during the provision of tracheostomy care, during medication administration, during the handling of clean linens, passing ice to residents; failed to maintain hand sanitizer dispensers; failed to store residents personal care items appropriately; failed to clean and disinfect reusable equipment (blood pressure machine); and failed to clean resident bathrooms appropriately. The census was 210. Findings: 1. Review of the facility policy titled Infection Surveillance reviewed 6/1/2024 revealed Policy: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order is to reduce infections and prevent the spread of infections. Policy Explanation and Compliance Guidelines: Number 7. Monthly time periods will be used for capturing and reporting data. Line charts will be used to show data comparisons over time and will be monitored for trends. Number 12. revealed that Data to be used in the surveillance activities may include, but are not limited to: a. 24-hour shift reports b. Lab reports c. Antibiograms d. Antibiotic use reports from pharmacy e. Medication regimen review reports f. Skills validations for hand hygiene, PPE, and/or high-risk procedures g. Rounding observation data h. Documentation of signs and symptoms in clinical record Interview on 10/5/2024 at 9:46 am, the Director of Nursing (DON) was asked for the facility's infection control line listings for the past year, the infection control education, hand hygiene observations, vaccine records for five selected residents, and antibiotic stewardship. Review of the provided documents occurred. Review of the facilities surveillance data for October 2023 through September 2024 revealed the infection control line listings did not have documentation reflecting facility's tracking and trending of infections. The infections listed on the line listing did not have symptoms, any testing and results listed, or antibiotic start and stop dates. There were also no infection rates included for the months. The only months with facility maps associated with the infections were August and September. Interview on 10/7/2024 at 1:20 pm, the DON revealed she had been doing the Infection Preventionist work until the Infection Preventionist returned full time. 2. Review of the facility policy titled Hand Hygiene revised 5/30/2024, revealed the Policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Observation on 9/22/2024 at 9:46 am, during the initial screening of the residents on the Georgia Wing revealed there were only two hand sanitizer dispensers on the hall for rooms 217 through 230. Observation on 9/22/2024 at 2:50 pm, Georgia Wing in room [ROOM NUMBER] revealed the hand sanitizer dispenser in room was not functioning. Observation on 9/22/2024 at 3:51 pm, Georgia Wing in room [ROOM NUMBER] revealed the hand sanitizer dispenser was not functioning. Observation on 9/22/2024 at 3:54 pm, Georgia Wing in room [ROOM NUMBER] revealed that the hand sanitizer dispenser was not functioning. Observation on 9/22/2024 at 3:54 pm, Georgia Wing in room [ROOM NUMBER] revealed that the hand sanitizer dispenser was not functioning. 3. Observation on 9/22/2024 at 2:50 pm, Georgia Wing shared bathroom in room [ROOM NUMBER]/229 revealed one unlabeled bath basin and one unlabeled bed pan on the bathroom floor. They did not have a room number or a resident name on them, nor were they in a bag. Observation on 9/22/2024 at 3:15 pm, Georgia Wing shared bathroom in room [ROOM NUMBER]/226 revealed one bath basin and one urinal in the bathroom, unbagged and unlabeled. Observation on 9/22/2024 at 3:51 pm, Georgia Wing shared bathroom of 228/230 revealed one urinal, and one bed pan in the bathroom and was not labeled and was not in a bag. Observation on 9/23/2024 at 2:37 pm, Georgia Wing shared bathroom in room [ROOM NUMBER]/226 revealed the bath basin and urinal were still present, unlabeled, and un-bagged. Observation on 9/23/2024 at 3:02 pm, Georgia Wing shared bathroom in room [ROOM NUMBER]/230 revealed that the urinal in the bathroom was not labeled and not in a bag. Interview on 9/24/2024 at 12:35 pm, CNA GGGG verified the personal care items (bath basin/bedpan/urinal) in the shared bathrooms on the Georgia Wing were not labeled with room number or resident name, and none of them were in a bag. Interview on 10/7/2024 at 1:20 pm, the DON stated that it is her expectation that all bath basins, bed pans, and urinals be labeled and bagged. She stated that it is not as important as the date but at least the name and that it is bagged. 4. Review of the facility policy titled Routine Cleaning and Disinfection revised on 4/20/2024 indicated Policy Statement: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Definitions: Cleaning refers to the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water and detergents or enzymatic products. Disinfection refers to thermal or chemical destruction of pathogenic and other types of microorganisms. Standard Precautions refer to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. Policy Explanation and Compliance Guidelines: Number 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge. Number 5. Standard precautions will be adhered to when cleaning any blood or body fluid spills, or soiled material that have the potential to contain these or other potentially contaminated substances. Number 11. Staff will ensure cleaning carts are checked and stocked with necessary supplies at the beginning of each shift. Observation on 10/3/2024, at 4:02 am, during an 11:00 pm - 7:00 am shift observation, Licensed Practical Nurse (LPN) TTT was observed entering a room on the Dogwood Wing with the rolling electronic blood pressure machine. After a few minutes in the room, she was observed leaving the room with the blood pressure machine, and without cleaning/disinfecting the machine, she entered another room across the hall. After a few minutes, she left that room without cleaning the machine. She left the machine in the hallway and returned to the medication cart. Observation on 10/3/2024 at 4:08 am, during an 11:00 pm - 7:00 am shift observation, CNA SSS was observed leaving a room and going to a computer in the hallway, presumably to be charting for resident care. A resident came out of his room and asked CNA SSS for a cup of ice. She walked away from the computer and walked down to the ice cooler, picked up the ice scoop, and filled a cup of ice for the resident. She walked back to the residents room and gave him the cup of ice and left the room. She went to a linen cart on the hallway and grabbed some clean linen from the cart, and then entered the room again with the linen. After she left the room, she returned to the computer. She never stopped to wash her hands or apply hand sanitizer before, during, or after the series of tasks. Interview on 10/3/2024 at 4:12 am, LPN TTT was questioned about the process for cleaning equipment that is shared between residents. She stated that it is to be cleaned after every three residents. She then stated that it is to be cleaned with a bleach wipe that has a 3-minute kill time. Interview on 10/3/2024 at 4:20 am, CNA SSS was interviewed about getting ice and clean linen without cleaning her hands, after exiting residents rooms, and after working on the computer. She revealed that she should have cleaned her hands before obtaining ice for the resident. She also stated that she should have cleaned her hands before obtaining clean linen because she is not supposed to be wearing gloves in the hallway. Interview on 10/7/2024 at 1:20 pm, the DON stated that hand hygiene should be completed before and after care and between residents. During further interview, she stated that if staff are charting the computer, and went to get ice, they should perform hand hygiene before getting the ice. She stated that hand hygiene education is something that occurs continuously. 50526 Review of the facility policy titled Hand Hygiene revised 5/30/2024, revealed the Policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Observation on 10/2/2024 at 9:23 am, during morning medication administration with LPN AA began to prepare resident medications and failed to perform hand hygiene prior to, or following medication administration for each resident. During the preparation, she placed a medication in a medicine cup, and two pills fell into the cup. Using her bare hands, LPN AA took the extra tablet out of the medicine cup and discarded it into the sharps container. In addition, she failed to clean and disinfect shared equipment (blood pressure cuff) between uses for other residents. Interview on 10/2/2024 at 9:50 am, with LPN AA confirmed that all shared equipment should be cleaned between resident use, and that she did not wash her hands or use hand sanitizer after every resident. Also states she cannot touch any of the medicine. Interview on 10/2/2024 at 10:41 am, the DON stated that all staff should be washing their hands between each resident they care for, and the medication nurses should definitely at least be using hand sanitizer during medication administration. During further interview, she stated that staff should be taking precautions with infection control and cleaned shared equipment with an appropriate disinfectant for the appropriate dwell time. 5. Review of the policy titled Tracheostomy Care dated 1/1/2023, section; Number 6. procedure with use of reusable cannula: items a through o revealed policy statement for staff to perform hand hygiene, put on exam gloves, mask and eye protection to perform tracheostomy care. Further states remove exam gloves are used to remove old dressing and discard of exam glove with dressing. Staff member will then prepare the equipment needed at bedside table, open the sterile tracheostomy care kit, and apply sterile gloves. Pour saline water into basin of kit with non-dominant gloved hand. Remove and clean inner cannula using sterile technique. Clean stoma with normal saline or sterile water, moistened gauze, and dry the area. Change tracheostomy ties, dispose of equipment and perform hand hygiene. Document procedure and report signs or symptoms of infections to the physician. Observation on 9/22/2024 at 2:15 pm revealed R154 with tracheostomy tube in place, noted with a copious amount of yellow thick secretions noted coming out around tubing and drainage on gauze. Oxygen at 2.5 liters per minute via tracheostomy collar. Observation on 9/22/2024 at 2:20 pm, Respiratory Therapist (RT) KK performed tracheostomy care/suctioning. RT KK brought the supply cart into residents room on side of bed near the door, donned non-sterile gloves, removed the gauze around trach, wiped with 4x4 gauze, reached into pack of non-sterile gauze with contaminated gloves for more gauze, continuing to wipe away secretions. He reached into gauze pack again with contaminated gloves, a total of four times. RT KK then opened suctioning cath kit, placed sterile gloves to side and picked up suction catheter with contaminated gloves, catheter brushed against bed curtain as he reached for suction cannister tubing out of the drawer. RT KK then suctioned trach three times holding finger over opening for continuous suction during insertion and removal of suction catheter. R154 coughed continually. Return of thick white secretions noted. RT KK removed suction catheter placed in trash and laid suction tubing over the suction machine uncovered. RT KK did not wash his hands or use hand sanitizer prior to or after the provision of tracheostomy care. Interview on 9/22/2024 at 2:26 pm, with RT KK stated suctioning tracheostomy is not a sterile procedure for R154, referring to resident as he gets suctioned so frequently. During further interview, RT KK stated he gets gauze out of the bag as needed throughout the procedure and uses package until it is gone for any resident needing respiratory care. He stated he always brings the supply cart into resident room for care. Interview on 9/25/2024 at 9:51 am, RT JJ revealed tracheostomy suctioning is always a sterile procedure, if new non-sterile gauze is needed during procedure. RT JJ revealed she will change gloves as that would ensure remaining gauze in bag would remain clean. Interview on 10/2/2024 at 10:45 am, the DON revealed the Respiratory Therapists report to her, and she stated they have completed the competency check off for tracheostomy care. She stated her expectation is for tracheostomy care to be done following policy and best practices to ensure sterile technique is maintained. Interview on 10/3/2024 at 1:27 pm, the Infection Preventionist confirmed that tracheostomy care and suctioning begins with removing current dressing with exam gloves, but then moves to a sterile procedure per policy. During further interview, she revealed at no point should staff go back into a package of clean gauze with contaminated gloves. She stated her expectations are to follow policies. Review of the Competency Assessment for Tracheostomy Care for Respiratory Therapists KK and JJ, with all areas marked as yes indicating demonstrated competency. The competency checkoff's are dated 3/24/2024 (RT JJ) and 5/29/2024 (RT KK). 50170 6. Review of the facility policy titled Infection Prevention and Control Program reviewed 3/12/2024 documented the Policy: The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections per national standards and guidelines. Policy Explanation and Compliance Guidelines: Number 12. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. b. Clean linen shall be separated from soiled linen at all times. c. Clean linen shall be delivered to resident care units on covered linen carts with covers down. d. Linen shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closets. e. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom. f. Environmental services staff shall not handle soiled linen unless it is properly bagged. Observation on 10/9/2024 at 2:11 pm, upon entry to the laundry room noted a rancid smell. The laundry chute had an overflow of dirty linens spilling on to the floor, most were not in bags. Interview on 10/9/2024 at 2:50 pm, with Assistant Administrator stated that dirty clothes are supposed to be dropped down the laundry chute, there is a staff member waiting at the bottom of the chute to get the clothes as they come down. He did not provide an explanation as to why the laundry chute was full and spilling onto the floor. Observation on 10/10/2024 at 11:08 am, the laundry chute is now being closed so that clothes aren't falling onto the floor or overflowing into the bin. 50272 7. Review of the facility policy titled Routine Cleaning and Disinfection revised on 4/20/2024 indicated Policy Statement: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Definitions: Cleaning refers to the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water and detergents or enzymatic products. Disinfection refers to thermal or chemical destruction of pathogenic and other types of microorganisms. Standard Precautions refer to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. Policy Explanation and Compliance Guidelines: Number 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge. Number 5. Standard precautions will be adhered to when cleaning any blood or body fluid spills, or soiled material that have the potential to contain these or other potentially contaminated substances. Number 11. Staff will ensure cleaning carts are checked and stocked with necessary supplies at the beginning of each shift. Observation and interview on 10/2/2024 at 10:39 am, with Housekeeping Aide AAA exited from room G229's bathroom carrying an exposed toilet brush, dripping with water, as she walked through the room out to the hallway. She then proceeded to go the room across from G229. Housekeeping Aide AAA was asked about the protocol regarding the handling of dirty cleaning items, such as the toilet brush after use, and she stated they're supposed to have a bucket to carry the toilet brush back to the cart. She stated she doesn't have a bucket at the moment, since there is only one bucket for the entire building. During continued interview, Housekeeping Aide AAA stated she normally mops the floors afterward and was waiting for the surveyors to leave the room before she could mop. Interview on 10/7/2024 at 12:47 pm, with the Housekeeping Director (HD) revealed once the housekeeping aides clean the toilet bowl, they have a bowl with the toilet brush that is connected together, and they have to put brush in the bowl and transport the brush back to the cart once they are done cleaning the bathroom. The HD stated his expectations are that once housekeeping aides are done cleaning the toilet, they transport the toilet brush in the brush bowl back in to the cart. He stated they don't use buckets. During further interview, he stated he has provided housekeeping aides with in-service training on infection control practices regarding housekeeping.