Every finding on record at Holiday Heights Healthcare

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure the environment was free of accident hazards for 5 (Residents #6, #12, #19, #30, and #38) of 16 residents reviewed for smoking. Specifically, on 04/08/2025, Resident #12 reported receiving a cigarette burn while smoking, and the facility determined the resident had a full thickness burn (all layers of the skin were destroyed) to the left thigh. After the burn, the facility implemented a care plan intervention for a smoking apron; however, Resident #12 was noncompliant with the intervention. The facility failed to reassess the intervention when the resident demonstrated noncompliance, permitting Resident #12 to continue to smoke unsupervised and without safety interventions. Additionally, Resident #19's smoking checklist/assessment failed to reflect cigarette burn holes in the resident's clothes despite staffs' knowledge that burn holes existed and the resident's care plan was not revised with interventions for smoking safety until after the survey was initiated. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, serious harm, serious impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, F689, Free of Accident Hazards, at a scope and severity of J. The IJ began on 04/08/2025 when Resident #12 had a full-thickness cigarette burn to the left thigh.The survey team notified the General Manager, Administrator, and Director of Nursing (DON) of the IJ and provided the IJ template on 06/16/2026 at 5:18 PM. A removal plan was requested. The facility's removal plan was accepted by the state survey agency on 06/18/2026 at 9:42 AM. The IJ was removed on 06/16/2026, after the survey team performed onsite verification that the removal plan had been implemented. Noncompliance for F689 remained at a lower scope and severity of E. The facility also failed to ensure Resident #30, Resident #38, and Resident #6 were free of accident hazards while smoking.Findings included: A facility policy titled, Administrative Policies and Procedures Smoking/Vaping Policy and Procedures, revised 02/24/2020, revealed the purpose of the policy was To offer the resident the ability to smoke/vape free of danger to self or others. The terms smoking/vaping referenced herein includes the use of any type of cigarette, pipe, electronic device, battery powered device or any other object/device that produces smoke or vape. The policy revealed, 1. Failure to follow smoking/vaping policy and procedures or smoking/vaping contract agreement will result in immediate loss of privileges. 2. Upon admission, a smoking/vaping supervision checklist (NRSG-719) will be implemented to determine if the resident is able to smoke with no restrictions. 3. If it is determined by the interdisciplinary team that the resident is unable to smoke/vape without supervision, such team will develop a plan that will allow the resident to smoke/vape with supervision that is agreeable to facility team and/or responsible party. 4. If it is determined that the resident may smoke/vape without supervision, resident and/or responsible party will be required to sign a smoking/vaping contract (NRSG-720) which outlines the facility's guidelines. 5. The smoking/vaping supervision checklist will be updated if there is a change in resident condition and the facility team determines that the resident may be unsafe without supervision. 6. Smoking and/or vaping in the facility can only occur in designated areas provided for that purpose. 7. Residents requiring supervision to smoke/vape must surrender their cigarettes, vaping supplies, and lighters or matches to facility staff for safe keeping. 8. Residents who require supervision to smoke/vape must agree to smoke/vape during times when the facility can provide staff to supervise the resident. 9. Residents who may smoke/vape (supervised or unsupervised) must agree that tobacco and/or vaping products are solely for the residents' own personal use and will not be shared or disseminated to others. Nor will the resident accept tobacco/vaping products from anyone other than facility staff. 10. The facility reserves the right to enforce the smoking/vaping contract for any failure to follow the guidelines stated. 11. Physician's orders are not required for residents to utilize vaping products; however, physicians should be notified to appropriately update care plans and set goals for residents regarding smoking/vaping habits. 1. An admission Record revealed the facility admitted Resident #12 on 07/30/2019. According to the admission Record, the resident had a medical history that included diagnoses of cerebral infarction (stroke) due to unspecified occlusion or stenosis of unspecified cerebral artery, hemiplegia (paralysis) and hemiparesis (weakness) following unspecified cerebrovascular disease affecting left non-dominant side, scotoma of a blind spot area to the left eye, syncope and collapse, bipolar type schizoaffective disorder, and tobacco use. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/09/2026, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. According to the MDS, Resident #12 used tobacco during the assessment look-back period. A quarterly MDS, with an ARD of 04/10/2026, revealed Resident #12 had a BIMS score of 15, which indicated the resident had intact cognition. Resident #12's Care Plan Report revealed a focus area initiated 01/28/2021, that indicated Resident #12 was a smoker. Per the Care Plan Report, Resident #12 could smoke independently (06/15/2023) and would provide their own smoking supplies (initiated 01/28/2021). Interventions directed staff to complete a smoking assessment quarterly and as needed and educate the resident on the smoking policy and smoking safely (initiated 01/28/2021).Resident #12's Smoking/Vaping and Behavior Agreement, dated 03/24/2023, indicated, 6. Resident agrees and acknowledges that a failure to follow the facility's smoking/vaping policy constitutes a threat to the safety of [the] Resident and other residents and shall be grounds for the immediate discharge of [the] Resident. An Unobserved Event, report dated 04/08/2025, indicated Resident #12 reported dropping a cigarette a few days prior. According to the report, the resident had a small, circular, reddened area to the left thigh. A nursing Progress Note, authored by Assistant Director of Nursing (ADON) #13 and dated 04/08/2025 at 12:16 PM, revealed Resident #12 reported that they dropped a cigarette on themselves a few days ago. Per the Progress Note, the resident had a small, circular, reddened area to the left thigh. The note also revealed that the wound provider was in the facility and gave new orders for wound care for the area. A nursing Progress Note, dated 04/08/2025 at 12:29 PM, revealed, Family notified at time of incident. DON [Director of Nursing] notified. Resident was educated on the use of smoking apron and will monitor the affected area for s/s [signs and symptoms] of infection and report abnormal changes to MD [Medical Doctor]. A physician's Progress Note Details for Resident #12, dated 04/08/2025, revealed the wound to the left thigh was a full thickness burn that measured 1 centimeter (cm) in length by (x) 0.5 cm in width with no measurable depth. The Progress Note Details revealed a skin/subcutaneous tissue level excisional/surgical debridement was performed and devitalized (dead) tissue was removed. Resident #12's Smoking/Vaping Supervision Checklist, dated 04/08/2025 at 12:18 PM, revealed the resident used smoking tobacco, was alert, fell asleep easily while sitting in a chair, had limited range of motion (ROM) in the shoulders, was able to safely raise and lower a cigarette from their mouth to an ashtray, and there was evidence of cigarette burns to the resident's body or clothing. The facility determined that the resident's decision-making was moderately impaired and indicated that the resident needed a smoking apron while smoking. Resident #12's nursing Progress Note, authored by the DON and dated 04/08/2025 at 12:30 PM, revealed a head-to-toe assessment was completed after the report of the resident having a cigarette burn to their left thigh and no other injuries were noted. Per the note, the resident required staff assistance with transfers but was independent with mobility when in a wheelchair. Per the Progress Note, the resident was a non-supervised smoker. The note revealed Resident #12 was educated regarding a smoking apron, a new intervention. According to the Progress Note, the resident stated that they would be compliant with wearing a smoking apron. Resident #12's Care Plan Report focus area initiated 01/28/2021, that indicated Resident #12 was a smoker revealed the facility revised the care plan to include the Smoking Incident with a burn to the thigh on 04/08/2025. Interventions directed staff to encourage the resident to wear a smoking apron. Per the care plan, Resident #12 was known to be non-compliant with wearing a smoking apron at times and safety education should be provided frequently (initiated 04/10/2025 and revised 07/29/2025). Resident #12's Smoking/Vaping Supervision Checklist, dated 04/17/2025 at 3:07 PM, revealed the resident used smoking tobacco, was alert, was able to safely raise and lower a cigarette from their mouth to an ashtray, and there was evidence of cigarette burns to the resident's body or clothing. The checklist revealed the facility determined the resident was independent with decision-making and indicated the resident needed to wear a smoking apron but was known to be non-compliant. Resident #12's Physician Note Details, dated 04/29/2025 revealed the resident was seen getting ready to go outside and smoke. According to the note, the resident's left thigh burn was resolved. The note revealed that discussion and coordination of care with the facility nurse included smoking cessation. Resident #12's quarterly Smoking/Vaping Supervision Checklist, dated 04/10/2026 at 10:24 PM (locked 04/13/2026), revealed the resident used smoking tobacco and vaping products, was alert, and was able to safely raise and lower a cigarette from their mouth to an ashtray. The checklist also revealed that the resident was able to demonstrate safe charging capabilities of vaping products and was able to store vaping products in a secure location. The facility assessed the resident's decision-making as independent. Per the checklist, there was no plan for the resident's smoking/vaping privileges or noncompliance with a smoking apron. During an interview on 06/15/2026 at 9:46 AM, Resident #12 stated they had been out smoking. The resident stated that they were allowed to go to the smoking terrace, and they did not wear a smoking apron. During an interview on 06/15/2026 at 10:58 AM, Resident #12 stated staff did not supervise the resident while smoking. The resident stated that they had not had any accidents/burns while smoking. During an observation on 06/15/2026 at 7:24 PM, Resident #12 exited the rear of the facility and went to a table. Resident #12 used a vaping device before storing it in their shirt pocket. Resident #12 was not wearing a smoking apron. The observation revealed that there were no smoking aprons in the smoking area or visible in the dining room or nurses' station that were adjacent to the exit to the smoking area. During an observation on 06/15/2026 at 8:07 PM, Resident #12 and another resident passed a cigarette back and forth, taking puffs when they held the cigarette. Resident #12 was not wearing a smoking apron at this time. During an interview and observation on 06/16/2026 at 9:35 AM, Resident #12 was wearing a smoking apron. Resident #12 stated that in April of the previous year, they knocked the cherry (the burning tip) off their cigarette, and it fell through the slats of the table and onto the resident's lap. The resident stated that it burned through their clothing, and the resident had a burn on their thigh. Resident #12 stated, It hurt like a [expletive], and I got the scar to prove it. The resident stated that after the incident, the resident was supposed to wear a smoking apron, and it was hanging on their door. According to the resident, Most of the time, I don't wear it. Resident #12 stated there was one nurse on night shift that thought she could make the resident wear the smoking apron, and the resident told her, I'm not going to wear it, and you can't make me. Just go 'head and try. During an interview on 06/15/2026 at 3:24 PM, Certified Nurse Aide (CNA) #8 stated Resident #12 was able to smoke unsupervised and kept their smoking materials. The CNA stated that Resident #12 did not like to wear a smoking apron. CNA #8 stated, None of us, really were responsible for ensuring Resident #12 had a smoking apron. During a follow-up interview on 06/16/2026 at 8:25 AM, CNA #6 stated that Resident #12 was supposed to wear a smoking apron, but she had never seen the resident wearing one. According to CNA #6, Resident #12's smoking apron, was on the resident's closet door. During an interview on 06/16/2026 at 8:16 AM, Licensed Practical Nurse (LPN) #9 stated that Resident #12 did not require supervision when outside, and no resident used a smoking apron when smoking. Per LPN #9, they were not aware that the resident had a history of a smoking accident, or that a smoking apron was part of Resident #12's care plan. LPN #9 also stated that they did not know where smoking aprons were kept. During an interview on 06/16/2026 at 10:01 AM, ADON #13 stated that on 04/08/2025 (when the ADON was a floor nurse), Resident #12 came to her and told her about the injury. She stated the wound care provider saw the resident, and the area was monitored and treated. ADON #13 also stated that the facility completed another smoking evaluation. Per ADON #13, Resident #12 refused to wear a smoking apron, which was on the resident's care plan. She stated that if a resident refused to follow the smoking rules, the facility talked with the family and resident and created a safe smoking plan. ADON #13 stated she knew staff educated the resident; however, the ADON did not know whether other steps were taken. ADON #13 stated ADON #12 would know how the facility determined whether someone was safe when smoking. She stated that anyone could do a smoking evaluation and if they felt someone was unsafe, they could change a resident's assessment. According to ADON #13, Resident #12 was not safe to smoke and stated that the resident has a tendency to be [NAME] nilly with [their] cigarette. ADON #13 stated that Resident #12 frequently dropped their cigarettes. Per ADON #13, she did not recall Resident #12 burning themself since the incident on 04/08/2025. During an interview on 06/16/2026 at 11:30 AM, ADON #12, who was also the MDS nurse, stated that she conducted smoking assessments, which included assessing the resident's tobacco use, alertness, ROM, ability to safely raise and lower a cigarette from their mouth to an ashtray, and safe storage of smoking materials. Per ADON #12, safe storage, in that case, was residents keeping smoking items safely in their room or on their person. ADON #12 stated she was also in charge of completing and updating resident care plans regarding smoking. According to ADON #12, she revised Resident #12's care plan when the resident had a burn on 04/08/2025, and the intervention was for the resident to wear a smoking apron. ADON #12 stated that the resident was noncompliant with the intervention, and staff continued to encourage the resident to wear a smoking apron. During a follow-up interview on 06/16/2026 at 12:15 PM, ADON #12 clarified that the admitting nurse completed a resident's initial smoking assessment and she completed quarterly smoking assessments. ADON #12 stated that when a resident refused to wear their smoking apron, the facility only encouraged the resident to wear it. She stated it was the resident's choice whether to wear it and since Resident #12 had a BIMS of 15, the resident was able to make their own decisions. According to ADON #12, since Resident #12 had no other incidents, that part of the care plan should be resolved. The ADON also stated that residents were not permitted to share smoking materials. During an interview on 06/16/2026 at 3:59 PM, the DON stated that the admitting nurse on the floor conducted the admission smoking assessment and ADON #12 conducted the quarterly assessments. The DON stated that smoking independence was based on the resident's cognition, alertness and orientation, ability to safely raise a cigarette to the mouth, and ability to keep cigarettes and lighters in a safe place. According to the DON, during a smoking assessment, staff also monitored how the resident disposed of cigarettes and ashes. The DON stated that if there was an accident while smoking, the facility implemented interventions to keep the resident safe and reevaluated the resident. According to the DON, if a resident was noncompliant with the interventions, the facility documented the resident's noncompliance and reviewed the care plan. The DON stated that if there was another incident, the facility would supervise the resident while smoking. According to the DON, residents who required smoking aprons kept them in their room and staff offered them to residents if they saw a resident smoking without an apron. The DON stated that if the facility discovered residents were sharing smoking materials, they separated the residents, reeducated them, monitored them, and called the family if necessary. During an interview on 06/16/2026 at 4:31 PM, the Administrator stated he had been with the facility since February/March 2026. He stated that when the facility admitted a resident who smoked, staff assessed the resident, reviewed the smoking contract and rules with the resident, and continued to assess the resident's ongoing safety. According to the Administrator, if the resident did not follow the facility's smoking rules, the facility supervised the resident while smoking. The Administrator stated that accidents happened, and the facility wanted to give residents the right to smoke. Per the Administrator, if a resident self-reported an injury, it showed they were trying to be safe. The Administrator also stated that the facility monitored the resident to make sure there were no further incidents. If a resident was noncompliant with facility interventions, such as a smoking apron, the facility monitored them and if the resident was safe, the intervention did not have to be in place forever. The Administrator stated he was unaware that residents were sharing smoking materials. 2. An admission Record revealed the facility initially admitted Resident #19 on 06/12/2013 and readmitted the resident on 05/24/2025. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia, psychotic disorder with hallucinations, and chronic obstructive pulmonary disease. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/27/2026, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #19 had no impairment in range of motion to bilateral upper extremities and was a tobacco user. Resident #19's Care Plan Report, revised 11/24/2021, included a focus area that indicated the resident had behaviors of repetitively begging and asking for cigarettes. Interventions directed staff to:- administer medications as ordered and monitor/document for side effects and effectiveness (11/15/2020);- intervene as necessary to protect the right of others, approach/speak in a calm manner, divert attention (11/15/2020);- assist the resident to develop more appropriate methods of coping and interacting (11/24/2021);- provide opportunities for positive interaction, attention, and stop and talk with the resident when passing by (11/24/2021);- monitor behavior episodes and attempt to determine underlying cause (11/24/2021); and- provide a program of activities that was of interest to the resident and accommodated their status (11/24/2023). Resident #19's Care Plan Report revised 06/16/2026, included a focus area that indicated the resident was a smoker and was at risk of smoking related injuries. Interventions included:- staff were directed to periodically assess the resident for burns on their clothing and/or skin (06/25/2025);- staff were directed to complete quarterly smoking assessments per facility policy (06/25/2025);- the resident signed the smoking/vaping and behavior agreement (06/25/2025);- staff would assess and monitor the resident to ensure smoking/vaping or using lighters/matches did not occur in the vicinity of oxygen (06/25/2025);- staff would ensure the resident did not share their tobacco/vaping products and lighters/matches with others, and the items were stored in a secure location (06/25/2025);- the resident was made verbally aware of the risks associated with not following the smoking/vaping policy and the interventions provided to ensure the resident's safety, and the resident verbalized understanding (06/16/2026);- the resident was a supervised smoker, and staff would keep the resident's cigarettes/vaping supplies and lighters/and or matches and distribute the smoking/vaping supplies during assigned and supervised smoking times (06/16/2026);- staff would assess the resident frequently for safety while smoking/vaping (06/16/2026);- staff would ensure the resident used a smoking apron as directed (06/16/2026); and- the resident was made aware of the designated smoking area and the designated smoking times, and the resident verbalized understanding and agreement (06/16/2026). Resident #19's Smoking/Vaping and Behavior Agreement, dated 03/24/2023, revealed, 1. Resident agrees that Resident will not smoke tobacco products or use vaping products or use lighters or matches while Resident is in possession of any type of oxygen equipment or while Resident is in the presence or vicinity of such equipment.2. Resident further agrees to surrender oxygen equipment when requesting tobacco or vaping products from the facility, including the staff nurse or the staff nurse's designee.3. Resident agrees to report any violations of the smoking/vaping policy immediately to staff.4. Resident agrees that all tobacco or vaping products may be retained and maintained by the facility for the safety of all residents and in compliance with facility smoking/vaping policy and procedure.5. Resident therefore agrees that any tobacco or vaping products provided to resident by the facility will be used by [the] resident solely for [the] resident's personal use and will not be shared or disseminated to others. Nor will [the] resident request or accept tobacco or vaping products from anyone other than facility staff.6. Resident agrees and acknowledges that a failure to follow the facility's smoking/vaping policy constitutes a threat to the safety of [the] Resident and other residents and shall be grounds for the immediate discharge of [the] Resident.7. Resident agrees that the facility, in its sole discretion, may establish hours and locations for smoking or vaping, all in accordance with and pursuant to the facility smoking/vaping policy and procedures. Resident #19's quarterly Smoking/Vaping Supervision Checklist, dated 01/02/2026, revealed Resident #19 utilized smoking tobacco, was alert, was able to safely raise and lower a cigarette from their mouth to an ashtray, and was moderately impaired for decision making. Resident #19's annual Smoking/Vaping Supervision Checklist, dated 03/27/2026, revealed Resident #19 utilized smoking tobacco, was alert, was able to safely raise and lower a cigarette from their mouth to an ashtray, and was independent for decision making. An observation on 06/15/2026 at 7:24 PM revealed no smoking aprons on the smoking patio, in the dining room, or at the nurses' station located adjacent to the smoking patio. An observation on 06/15/2026 at 7:28 PM revealed Resident #19 sitting outside in the smoking patio smoking a lit cigarette without a smoking apron or supervision. The observation revealed Resident #19 was wearing a sweatshirt jacket that had a circular burn hole located on the upper chest area. Resident #19 confirmed that the hole was a burn hole. Resident #19 stated they smoked cigarettes all day long, and they were not required to be supervised or wear a smoking apron. Resident #19 stated they were allowed to maintain possession of their smoking materials. During a concurrent observation and interview on 06/16/2026 at 9:48 AM, Resident #19 stated they smoked cigarettes, and they kept their lighter and cigarettes in their possession. Resident #19 stated that they had not been asked to demonstrate their ability to light a cigarette, and staff had not spoken to the resident about how to safely store smoking materials when not in use. Resident #19 stated they were an independent smoker. Resident #19 stated they did not use a smoking apron, had not been told they needed to, and did not know where to locate a smoking apron. Resident #19 was observed with burn holes in their jacket. Resident #19 stated the jacket burns happened when they were smoking at the facility about six months ago when the wind blew the ashes, and the ashes landed on their jacket and burned it. Resident #19 stated they knocked the ashes off, it was fine, and they had had no burns since. Resident #19 stated they did not report the incident, and they did not know if staff knew about the incident. Resident #19 stated staff did not go out with the residents when they smoked. An observation outside on the smoking patio on 06/16/2026 at 10:15 AM revealed Resident #19 lit a cigarette and handed the cigarette to Resident #12. The observation revealed Resident #12 then handed Resident #19 a green electronic cigarette, and Resident #19 took a couple of puffs from the electronic cigarette and returned the electronic cigarette to Resident #12 who then passed it to Resident #30. During an interview on 06/15/2026 at 7:15 PM, Licensed Practical Nurse (LPN) #10 stated that all the smokers in the facility were assessed to be independent smokers. LPN 10 stated all residents were allowed to keep their smoking materials on their person, and it did not have to be secured by staff. LPN 10 stated smokers were allowed to smoke until 9:00 PM and were not required to wear aprons. During an interview on 06/16/2026 at 8:14 AM, Certified Nursing Aide (CNA) #6 stated many residents knew the code to the back door of the facility, and if residents could open the back door of the facility, they were allowed to smoke independently. CNA #6 stated staff walked by and checked to ensure there were no accidents and that the residents were not getting into fights. During an interview on 06/16/2026 at 12:13 PM, the Assistant Director of Nursing (ADON) #12, who was also the MDS Nurse, stated the admitting nurses on the unit completed the resident's initial smoking assessment on admission. ADON #12 stated the smoking assessment included observations of the resident in the smoking area to determine if the resident was able to raise and lower their arms to reach their mouth with a cigarette. ADON #12 stated she completed the quarterly smoking assessments. ADON #12 stated she also reviewed the resident's BIMS score, and assessed the resident's range of motion (ROM) and the resident's ability to safely use a lighter. ADON #12 stated that during random staff observations, the facility determined if the resident was in violation of the smoking contract. ADON #12 stated that she could not recall any resident having their smoking privileges modified or revoked for violations of the smoking contract. ADON #12 stated residents were not allowed to take a puff of a cigarette and then share it with others. ADON #12 stated it was not appropriate for residents to light other residents' cigarettes. ADON #12 stated Resident #19 could go out alone and had no recommendations for smoking such as a smoking apron. ADON #12 stated she was not aware of any burns to Resident 19's clothes. ADON #12 stated the smoking assessment included a history of burns and should be documented for any resident that was known to have a history of burning themselves from a cigarette or ashes. During an interview on 06/16/2026 at 3:59 PM, the Director of Nursing (DON) stated that residents were assessed for smoking on admission by the admitting nurse then reassessed on a quarterly basis by ADON #12. The DON stated smoking contracts were obtained by her, the social services staff, or the admitting nurse on admission for each resident who smoked. The DON indicated a resident's ability to smoke independently was based on the resident's cognition, the resident's ability to raise the cigarette safely to their mouth, and if the resident could safely store their smoking materials. The DON stated if a resident stopped following the facility's smoking rules, the resident would be reassessed, reeducated, and the resident would become supervised if they breached the contract. The DON stated no residents had their smoking privileges restricted or rescinded since she had been at the facility. The DON stated staff were to report any observations of burn holes in resident clothing to a member of management. The DON stated if a resident were observed to take a puff on a cigarette and pass the cigarette to another resident, the facility would educate the resident, separate the residents, monitor the residents smoking, and contact families if necessary. During an interview on 06/16/2026 at 4:16 PM, the General Manager (GM) stated that the facility completed a smoking assessment and obtained a smoking contract for residents who wished to smoke in the facility. The GM stated that if staff observed any holes in clothing, they were to report the observations to a nurse. The GM stated because of the facility's communication staff knew which residents smoked, what level of supervision each resident required, and each resident's recommendations for smoking. The GM stated the facility did not have any residents who required supervised smoking. The GM stated if a resident did not follow the rules for smoking, staff provided education on safety to the resident, the resident did not have their rights to smoke taken away, but the facility would attempt to accommodate the resident to keep them safe while smoking. The GM stated staff received education on safe smoking practices on hire and when an incident occurred in the facility. During an interview on 06/16/2026 at 4:31 PM, the Administrator (ADM) stated that when a resident was admitted to the facility, a smoking assessment was completed, and a smoking contract was obtained. The ADM stated smoking residents continued to have ongoing assessments for safety. The ADM stated the smoking assessments were subjective in nature and included monitoring the residents for a few days to determine if it was safe for the resident to smoke. The ADM stated that a resident's BIMS score was not used as part of the determination of whether a resident would require supervision. The ADM there were not too many safe smokers in the world. The ADM stated if a resident reported an accident occurred, it showed the resident was trying to be safe, and the facility would monitor the resident for a period of time to ensure no further incident. The ADM stated they were unaware of residents sharing smoking materials or lighting each other's cigarettes, but that would not be appropriate. The ADM stated if non-nursing staff observed burn holes in a resident's clothing, he expected them to report the observation to a member of the nursing staff. The ADM stated resident safety always outweighed resident rights to smoke, and the facility educated and worked out ways to work around residents who had unsafe smoking practices. During an interview on 06/16/2026 at 5:04 PM, Laundry Worker (LW) #1 stated they were unsure who to report burn holes to, and she stated she could not recall seeing any resident clothing with burn holes recently. During an interview on 06/18/2026 at 9:16 AM, Certified Nurse Aide (CNA) #2 stated Resident #19 was independent with their activiti

Based on observation, interview, record review, facility policy review, and manufacturer instructions review, the facility failed to ensure the medication error rate was less than 5 percent (%). The facility had 8 medication errors out of 25 opportunities, resulting in a medication error rate of 32%, which affected 3 (Residents #20, #2, and #4) of 12 residents reviewed during the medication administration task.Findings included: 1. An admission Record revealed the facility admitted Resident #20 on 11/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of drug- or chemical-induced diabetes mellitus (when the body cannot produce or use insulin correctly resulting in high blood sugar levels) without complications. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2026, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident received insulin injections daily during the assessment's seven-day lookback period. Resident #20's Care Plan Report revealed a focus area initiated11/26/2024, that indicated the resident had diabetes mellitus and was at risk for complications. Interventions directed staff to administer Novolog (insulin apart; a fast-acting insulin) as directed (revised 05/18/2026). Resident #20's Order Summary Report, with active orders as of 06/16/2026, contained an order, dated 06/18/2025, to inject 100 units per milliliter Novolog injection solution according to a sliding scale before meals and at bedtime. Novolog injection pen's Instructions for Use, revised 02/2023, indicated, Preparing your Novolog FlexPen included A. Pull off the pen cap; B. Attaching the needle, which specified, Remove the protective tab from a disposable needle. Screw the needle tightly onto your FlexPen; C. Pull off the big outer needle cap; and D. Pull off the inner needle cap and throw it away. The instructions revealed, Giving the airshot before each injection included Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing, the instructions specified to E. Turn the dose selector to select 2 units; F. Hold your NovoLog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge; and G. Keep the needle pointing upwards, press the push-button all the way in [reference to a diagram]. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. The instructions revealed, Selecting your dose included Check and make sure that the dose selector is set at 0; and H. Turn the dose selector to the number of units you need to inject. An observation of medication administration on 06/15/2026 at 7:45 PM revealed Licensed Practical Nurse (LPN) #10 administered nine units of Novolog insulin to Resident #20 using a FlexPen. LPN #10 did not prime the insulin pen prior to administration. During an interview on 06/18/2026 at 5:30 PM, LPN #10 stated he did not prime the insulin pen prior to administration of insulin to Resident #20. LPN #10 stated he was not familiar with the process of priming an insulin pen or the purpose of priming an insulin needle. During an interview on 06/19/2026 at 8:52 AM, Assistant Director of Nursing (ADON) #13 stated that LPN #10 should have primed the insulin pen with two units of insulin prior to administering the ordered dose of insulin to Resident #20. 2. An admission Record revealed the facility admitted Resident #2 on 06/10/2013. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus (when the body cannot produce or use insulin correctly resulting in high blood sugar levels) without complications. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/19/2026, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident received insulin injections daily during the assessment's seven-day lookback period. Resident #2's Care Plan Report revealed a focus area revised 11/14/2021, that indicated the resident had diabetes mellitus and was at risk for complications. Interventions directed staff to administer Lantus (a long-acting insulin) as directed (revised 04/01/2025). Resident #2's Order Summary Report, with active orders as of 06/16/2026, contained an order, dated 10/03/2025, for Lantus SoloStar Subcutaneous Solution Pen-Injector, with instructions to inject 12 minutes two times a day. Lantus' manufacturer's instructions titled, Lantus How to use your Lantus Solostar pen, dated 2022, indicated, Step 1. Get Ready, included Remove the pen cap with clean hands; and Check the reservoir to make sure the insulin is clear and colorless and has no particles- if not, use another pen. The instructions revealed, Step 2. Attach The Needle included Wipe the pen tip (rubber seal) with an alcohol swab; Remove the protective seal from the new needle, line the needle up straight with the pen, and screw the needle on; After you have attached the needle, take off the outer needle cap and save it; and Remove the inner needle cap and throw it away. The instructions revealed, Step 3: Perform A Safety Test, which included 1. Dial a test dose of two Units; Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle; Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test; and If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again. The instructions specified, Always perform the safety test before each injection. An observation of medication administration on 06/15/2026 at 7:50 PM revealed Licensed Practical Nurse (LPN) #10 administered 12 units of Lantus insulin via insulin injection pen to Resident #2. LPN #10 did not prime the insulin pen prior to the administration. During an interview on 06/18/2026 at 5:30 PM, LPN #10 stated he did not prime the insulin pen prior to administration of insulin to Resident #2. LPN #10 stated he was not familiar with the process of priming an insulin pen or the purpose of priming an insulin needle. During an interview on 06/19/2026 at 8:52 AM, Assistant Director of Nursing (ADON) #13 stated that LPN #10 should have primed the insulin pen with two units of insulin prior to administering the ordered dose of insulin to Resident #2. 3. A facility policy titled, Enteral Medication Administration Guideline, effective 06/2025, indicated the Procedure included 11. Administer one medication at a time with a flush of 5-10 ml [milliliters] of water between each medication. An admission Record revealed the facility admitted Resident #4 on 07/07/2006 and readmitted the resident on 05/25/2024. According to the admission Record, the resident had a medical history that included a diagnosis of encounter for attention to gastrostomy (a tube surgically inserted into the stomach to provide nutrition, fluids, and medications). An annual Minimum Data (MDS), with Assessment Reference Date (ARD) of 04/21/2026, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #4's Care Plan Report revealed a focus area revised 01/06/2022, that indicated the resident had a nutritional problem and was at risk for weight fluctuations related to a percutaneous endoscopic gastrostomy (PEG) tube. Interventions directed staff to, Crush or open medications and dilute in 30 cc [cubic centimeters] H2O [water] and Bolus [a single large administration of a substance] (revised 01/06/2022). Resident #4's Order Summary Report, with active orders as of 06/16/2026, contained the following orders:- Valproate sodium solution (a fatty acid derivative anticonvulsant) 250 milligrams (mg) per 5 ml, 5 ml enterally at bedtime, dated 12/03/2021.- Lactobacillus (a probiotic), one tablet via PEG-tube two times a day, dated 12/03/2021.- Esomeprazole magnesium, (a proton pump inhibitor) 40 mg, one capsule via PEG-tube two times a day, dated 01/10/2025.- Multivitamin with minerals, one table via PEG-tube in the evening, dated 01/30/2026.- Gabapentin (a gabapentinoid) 300 mg, on capsule via PEG-tube one time a day, dated 06/28/2024.- Diazepam (a benzodiazepine) 5 mg, one table via PEG-tube two times a day, dated 12/03/2021.- Crush or open medications and dilute in 30 cc of water and bolus, dated 12/03/2021. An observation on 06/15/2026 at 9:05 PM revealed Licensed Practical Nurse (LPN) #10 mixed valproic acid, lactobacillus acidophilus, esomeprazole, multivitamin with minerals, gabapentin, and diazepam with water in a single cup and administered the medications all together via feeding tube to Resident #4. During an interview on 06/19/2026 at 5:30 PM, LPN #10 stated that he mixed all of Resident #4's medications together in a cup of water for administration via the feeding tube on 06/15/2026. LPN #10 stated he did not know he was not allowed to mix the medications together for administration. During an interview on 06/19/2026 at 9:06 AM, the Pharmacy Consultant stated that insulin pens should be primed with two units of insulin prior to administering each dose of insulin via an insulin pen. She stated priming an insulin pen was important to get the air out of the needle and ensure correct dosing. The Pharmacy Consultant stated medications should be administered through a feeding tube one medication at a time. During an interview on 06/19/2026 at 3:37 PM, the Director of Nursing (DON) stated that insulin pens should be primed with two units of insulin prior to administering the ordered dose of insulin. The DON stated she expected LPN #10 to administer each medication through a feeding tube one medication at a time. During an interview on 06/19/2026 at 4:07 PM, the Administrator revealed he deferred his expectations of medication error rates, priming insulin pens prior to administration, and administering medication through a feeding tube to the DON.

Based on observation, interview, record review, and facility policy review, the facility failed to develop/implement a comprehensive infection control program when staff failed to do the following:- Ensure a multi-resident use glucometer was disinfected between residents observed during 2 (Resident #20 and Resident #2) of 3 glucometer use observations.- Follow enhanced barrier precautions (EBP) as ordered for 1 (Resident #4) of 12 residents reviewed for the medication administration task.Findings included: 1. A facility policy titled, Blood Glucose Monitoring Guideline, revised 01/2026, revealed, Glucometer machines should be disinfected before and after use on a resident with a disposable disinfectant wipe. An admission Record revealed the facility admitted Resident #20 on 11/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of drug- or chemical-induced diabetes mellitus (when the body cannot produce or use insulin correctly resulting in high blood sugar levels) without complications. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2026, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident received insulin injections daily during the assessment's seven-day lookback period. Resident #20's Care Plan Report revealed a focus area initiated11/26/2024, that indicated the resident had diabetes mellitus and was at risk for complications. Interventions directed staff to check the resident's blood sugar as directed (revised 05/14/2025). Resident #20's Order Summary Report, with active orders as of 06/16/2026, contained an order, dated 06/18/2025 to inject insulin aspart (a fast-acting insulin) according to a sliding scale. The Order Summary Report also included an order, dated 11/12/2024, to complete a finger stick blood sugar (FSBS) test as needed. An admission Record revealed the facility admitted Resident #2 on 06/10/2013. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus without complications. An annual MDS, with an ARD of 03/19/2026, revealed Resident #2 had a BIMS score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident received insulin injections daily during the assessment's seven-day lookback period. Resident #2's Care Plan Report revised 11/14/2021 revealed a focus area that indicated the resident had diabetes mellitus and was at risk for complications. Interventions directed staff to check the resident's blood sugar via finger stick as directed (initiated 07/06/2025). Resident #2's Order Summary Report, with active orders as of 06/16/2026, contained an order, dated 10/03/2025, to complete a FSBS test as needed. An observation of a medication administration on 06/15/2026 at 7:45 PM revealed Licensed Practical Nurse (LPN) #10 used a multi-resident use glucometer to complete a FSBS test to obtain Resident #20's blood sugar level. LPN #10 did not clean or disinfect the glucometer after obtaining Resident #20's blood sugar. LPN #10 then used the same glucometer to check Resident #2's blood sugar level. During an interview on 06/15/2026 at 8:02 PM, LPN #10 stated he completed an FSBS test on Resident #20. LPN #10 stated he had been trained to disinfect the glucometer between each resident to prevent bloodborne illness, but he did not do so. LPN #10 stated he was not thinking about disinfecting the glucometer when he obtained Resident #2's blood sugar. During an interview on 06/19/2026 at 3:37 PM, the Director of Nursing (DON) stated she expected staff to disinfect the multi-resident use glucometers between each resident. During an interview on 06/19/2026 at 4:07 PM, the Administrator (ADM) deferred his expectation of disinfecting glucometers to the DON. 2. A facility policy titled, Infection Control and Isolation Guideline, effective 07/2025, revealed, 1. Standard Precautions included Apply to all residents regardless of diagnosis or infection status, including Gloves: When anticipating contact with blood, body fluids, mucous membranes, or contaminated surfaces; and Gowns: When clothing or skin may come into contact with infectious material. The policy further indicated, 3. Enhanced Barrier Precautions (EBP), which specified Apply to residents with, which included Wounds and/or indwelling medication devises; and Gloves and gown during high-contact care. The policy revealed, High-contact care activities include, which included Device care or use (e.g. [exempli gratia, for example], central line, urinary catheter, feeding tube, tracheostomy/ventilator). The policy specified, Indwelling Medical Devices that DO require EBP, which included Feeding tube (e.g., PEG [percutaneous endoscopic gastrostomy] tube). An admission Record revealed the facility admitted Resident #4 on 07/07/2006 and readmitted the resident on 05/25/2024. According to the admission Record, the resident had a medical history that included a diagnosis of encounter for attention to gastrostomy (a tube surgically inserted into the stomach to provide nutrition, fluids, and medications). An annual Minimum Data (MDS), with Assessment Reference Date (ARD) of 04/21/2026, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #4's Care Plan Report, revealed a focus area initiated 04/04/2024, that indicated the resident was at risk for infection related to an indwelling device (PEG tube) and a wound and indicated the resident was on EBP. Interventions directed staff to maintain EBP. (04/24/24). Resident #4's Order Summary Report, with active orders as of 06/16/2026, contained an order, dated 01/13/2026, that revealed that the resident was on EBP related to a PEG tube. An observation on 06/15/2026 at 9:05 PM revealed Licensed Practical Nurse (LPN) #10 medications to Resident #4 via feeding tube. During the observation, signage that indicated the resident was on EBP was on the resident's door. LPN #10 wore a pair of clean gloves but did not wear a gown during the observation. During an interview on 06/15/2026 at 9:41 PM, LPN #10 stated he administered Resident #4's medication via feeding tube on 06/15/2026. LPN #10 stated he could not recall what EBP was but thought it was for residents with bloodborne illnesses. He stated staff were trained to wear a mask, gloves, and a gown when caring for the residents. LPN #10 stated he was not sure why Resident #4 was on EBP. LPN #10 stated he did not see that EBP was indicated on the medication administration record (MAR) before he entered the room and stated he never wore a gown when administering medication to Resident #4 via feeding tube. During an interview on 06/19/2026 at 3:37 PM, the Director of Nursing (DON) stated she expected LPN #10 to wear a gown and gloves when providing care to Resident #4, who was on EBP for the feeding tube. During an interview on 06/19/2026 at 4:07 PM, the Administrator (ADM) stated he deferred his expectation of personal protective equipment use for EBP to the DON.

Based on observation, record review, and interview, the facility failed to ensure MDS assessments were accurately entered for three (#3, #14 and #30) of four sampled residents reviewed for MDS accuracy. ADON #1 identified 41 residents resided in the facility. Findings: 1. Res #3's annual MDS, dated [DATE], documented the resident had a restraint. On 07/21/24 at 10:03 a.m., Res #3 was observed in their bed. A circular half rail was observed on the right side of the bed. The resident stated they had the rail for positioning, and it was their preference to have the rail. A record review documented the required consents and assessments were completed for the rail. On 07/23/24 11:39 a.m., the MDS coordinator stated there were no residents in the facility with restraints. They stated they coded the MDS incorrectly. 2. Res #14's annual MDS, dated [DATE], documented the resident had a wound infection. On 07/21/24 at 8:58 a.m., Res #14 stated they had not had any infections in months and did not have any wound infections they could remember. A record review documented Res #14 did not have a wound infection during the review period for the annual MDS. On 07/23/24 11:39 a.m., the MDS coordinator stated the infection was coded incorrectly. 3. Res #30's quarterly MDS, dated [DATE], documented the resident had a restraint. On 07/21/24 at 10:38 a.m., the resident was observed in their room in their wheelchair. Half side rails were observed at the head of the bed on both sides of the resident's bed. The resident stated they liked the rails and used them to pull themselves up in bed. A record review documented the required consents and assessments were completed for the rail. On 07/23/24 11:39 a.m., the MDS coordinator stated there were no residents in the facility with restraints. They stated they coded the MDS incorrectly.

Based on record review and interview, the facility failed to ensure laboratory tests were obtained per physician's order for one (#15) of five residents reviewed for unnecessary medications. ADON #1 identified 41 residents who resided in the facility. Findings: Res #15 had diagnoses which included cerebral infarction, polyneuropathy, and diabetes mellitus. A physician's order, dated 12/04/21, documented to obtain a lipid profile yearly in June. There were no results of the lipid profile for June 2024 found in Res #15's medical record. On 07/23/24 at 8:35 a.m., the corporate nurse consultant was asked to provide the results of the June 2024 lipid profile. On 07/23/24 at 8:45 a.m., the corporate nurse consultant stated the lipid profile lab had not been obtained per order.

Based on observation and interview, the facility failed to properly store food and keep the kitchen and equipment clean and in good repair. The DM identified 45 residents received services from the kitchen. Findings: On 06/27/23 at 11:27 a.m., an initial tour of the kitchen was conducted. The following observations were made: a. there was a very dirty saturated blanket on the floor beside the ice machine with puddles of water surrounding it in the dry storage room. b. there were particles of food on the shelves inside both freezers in the kitchen area. c. there were white dish towels that were observed to be wet and had orange juice spills on them under the shelving in both refrigerators in the kitchen. d. there was a dirty saturated blanket with shoe prints on it in front of the two refrigerators in the kitchen. On 06/28/23 at 8:43 a.m., a follow up tour of the kitchen was conducted. The following observations were made: a. there was an accumulation of dust and hair on all of the shelves underneath the kitchen counters. There were trays with plastic drinking cups and pans stored on the shelves. b. there was an accumulation of lint on the outside of the window A/C unit in the kitchen area. On 06/27/23 at 11:30 a.m., the DM was asked why there were wet blankets on the floor in front of the ice machine in the dry storage area and in front of the refrigerators in the kitchen. The DM stated it was because of the condensation from the refrigerators and ice machine. The DM stated the towels were changed out every Thursday and needed to be changed out today. On 06/28/23 at 9:14 a.m., the shelves underneath the counters in the kitchen area were wiped with a clean white paper towel. The paper towels were covered with dust, debris, and hair. The paper towels were shown to the DM manager and the director of nutritional services. The director of nutritional services stated but it is not by the food. On 06/28/23 at 9:16 a.m., the DM and the director of nutritional services was asked how often they cleaned the refrigerators, freezers, and shelving below the kitchen counters. The DM stated every two weeks.

Based on record review and interview, the facility failed to ensure resident assessments accurately reflected the residents' status for two (#8 and #48) of thirteen sampled residents whose assessments were reviewed. The facility failed to accurately code antipsychotic medications for resident #8 and discharge status for resident #48. The Resident Census and Conditions of Residents form documented 45 residents resided in the facility. Findings: 1. Res #8 had diagnoses which included anxiety, depressive disorder, and schizoaffective disorder. An annual assessment, dated 04/01/23, documented the resident received an antipsychotic medication seven of seven days of the look back period. A review of the resident's medication documented the resident had not received an antipsychotic medication during the assessment period. On 06/29/23 at 1:27 p.m., the MDS coordinator #1 reported the MDS was filled out incorrectly. 2. Res #48 had diagnoses which included acute kidney failure, diabetes, and hypertension. A discharge assessment, dated 05/05/23, documented the resident was discharged to an acute hospital. A review of the resident's discharge summary documented the resident was discharged home with the services of home health. On 06/29/23 at 1:30 p.m., the MDS coordinator #1 reported the MDS was inaccurately filled out and that the resident had discharged home.

Based on record review and interview, the facility failed to refer a resident with a new serious mental illness diagnosis to OHCA for a level II evaluation for two (#3 and #5) of three residents sampled for PASRR level II evaluations. The Resident Census and Conditions of Residents form documented 45 residents resided in the facility. Findings: 1. Res #3 was admitted with diagnoses of osteoporosis, hypertension, and cauda equine syndrome. On 09/10/18 the resident was diagnosed with paranoid personality disorder. On 02/14/19 the resident was diagnosed with schizoaffective disorder, bipolar type. There was no documentation the OHCA had been notified of the resident's new diagnosis to see if a level II PASRR was required. 2. Res #5 was admitted to the facility on [DATE] with diagnoses of quadriplegia, abnormal involuntary movements, aphasia, and chronic kidney disease. A PASRR level I, dated 07/07/06, documented the resident had no serious mental illness. The medical record documented, on 01/25/18, the resident was diagnosed with unspecified psychosis and specified mental disorders. There was no documentation the OHCA had been notified of the resident's new diagnosis to see if a level II PASRR was required. On 06/30/23 at 9:45 a.m., the administrator was asked if OHCA had been notified to see if the resident required a level II PASARR. The administrator stated, I don't know. On 06/30/23 at 9:53 a.m., Corporate Nurse #1 reported OHCA should have been notified.

Based on observation, interview, and record review, the facility failed to ensure privacy and confidentiality for six (#4, 15, 34, 43, 147, and #247) of six sampled residents reviewed for abuse. The facility failed to ensure a staff member did not take photos of residents and send them electronically to the staff member's family. The Census and Conditions of Residents report documented 44 residents resided at the facility. Findings: Pictures of Residents (Res) #4, 15, 34, 43, and #147; and two videos of Res #247 had been submitted to OSDH by an anonymous person. CNA #1 was also observed to be included in the pictures and the videos. 1. Res #4 was pictured in her wheelchair, fully clothed, in the hallway. Half of CNA #1's face could be seen in the picture. Res#4 was unable to be interviewed due to cognitive impairment. 2. Res #15 was pictured in bed with her body covered by a blanket. Res #15 was unable to be interviewed due to cognitive impairment. 3. Res #34 was pictured sitting on the front porch of the facility with resident #147. CNA #1 was also included in the picture. On 01/04/22 at 4:10 p.m., the resident was observed sitting on his bed. The resident stated no staff had taken pictures of him. He stated he had not been abused or mistreated. 4. Res #43 was pictured from the hallway, seated on the side of her bed, fully clothed. On 01/04/22 at 8:58 a.m., the resident was observed seated on the side on her bed. She stated no one had taken any pictures of her. She stated she was not scared of anyone and had not been abused or mistreated. 5. Res #147 was pictured in his bed with body covered by a blanket and also on the facility porch with Res #34. CNA #1 was also included in the picture. The electronic record documented Res #147 had discharged from the facility on 08/10/21. 6. Res #247 was included in two videos fully clothed, lying on the lobby couch. CNA #1 was included in the videos. The electronic record documented Res #247 had discharged from the facility on 05/28/21. On 01/04/22 at 1:40 p.m. the DON and administrator viewed the pictures and identified the residents in the pictures. They verified the staff member in the pictures as CNA #1 who was hired on 05/05/21. They stated they were not aware the pictures had been taken. The DON stated consents have to be filled out and signed before resident pictures could be taken. The DON and administrator stated the pictures should not have been taken. The administrator stated the employee would be suspended pending an investigation. On 01/04/22 at 3:20 p.m., CNA #1 was shown the pictures of the residents. He stated he had taken the pictures and video. He stated he took the pictures right after being hired. He stated he took the pictures and had sent them to his wife to show her some of the residents he took care of. He stated he knew he should not have done that and had not taken any pictures since that time in May 2021.

Based on observation, interview and record review, the facility failed to provide timely incontinent care and bathing for two (#8 and #36) of three sampled residents reviewed for ADL care. The Census and Conditions of Residents report documented 39 residents required assistance with bathing and 28 residents required assistance with toileting. Findings: 1. Resident (Res) #8's annual assessment, dated 10/15/21, documented she was cognitively intact and required total assistance with toileting. On 01/04/22 at 4:14 p.m., the surveyor entered the hall and Res #8's call light was observed on. At 4:19 p.m., CMA #1 entered Res #8's room. The CMA asked the resident what she needed. The resident stated she needed to be changed. The CMA stated she would get help and be back. The CMA then turned the call light off and left the room. At that time hall meal trays were not being passed. At 4:35 p.m., CNA #3 was observed on the hallway and CNA #2 was observed to take Res #8's meal tray to her. At 4:37 p.m., Res #8 stated she usually doesn't have to wait longer longer than 30 minutes and the day shift was the worst at being timely. She stated the staff often turned the call light off and would leave the room without giving care. At 4:45 p.m., the surveyor left the hallway to charge her computer. At 5:13 p.m., CNA #3 was observed coming out of Res #8's room with a trash bag full of linens. The aide was asked how long she had been in the room. She stated less then 10 minutes. She was asked how she knew Res #8 needed care. She stated the resident's call light had just come on so she had went in to change her. She was asked if anyone had told her the call light had been on earlier before the hall trays went out and she said, No. She stated she did not know the light had been turned off earlier. At 05:17 p.m., CMA #1 was asked who she told about the resident needing incontinent care. She stated she told CNA #2. On 01/06/22 at 12:18 p.m., the DON stated the staff should not turn off the call light if leaving the room without care being given. 2. Res #36's quarterly assessment, dated 12/03/21, documented the resident was cognitively intact, required extensive to total assistance with ADLs, and the bathing activity had not occurred. The ADL bathing report, dated December 2021, documented the resident was scheduled for a bath every Tuesday, Thursday, and Saturday. The report documented the resident did not receive a bath eight times out of 13 opportunities. On 01/11/22 at 11:49 a.m., Res #36 stated her shower days were Tuesday, Thursday, and Saturday. She stated she did not always get her shower as scheduled. On 01/11/22 at 2:15 p.m., the DON was interview related to the resident not getting her baths as scheduled. She stated it was probably because the aides were not documenting every time they had given a bath.

Based on record review and interview, the facility failed to guarantee the person designated to serve as the DM was certified no later than on year after hire and/or maintained certification. The DON identified 42 residents received services from the kitchen. Findings: An employee list, dated 01/04/22, documented the DM was hired 06/03/16. There was no documentation the DM was certified as a dietary manager. On 01/04/22 at 8:25 a.m., the DM was asked if he was certified as a DM. He stated the RD had been trying to set up classes to renew his certification.

Based on observation and interview, the facility failed to maintain the kitchen clean and in good repair. The DON identified 42 residents received services from the kitchen. Findings: On 01/04/22 at 8:25 a.m., a tour of the kitchen of was conducted. The following observations were made: a. End caps were missing off of plastic sleeves on lights, b. Water was leaking from the gasket area on the faucet located on the three compartment sink, c. The wood around the air conditioner wall unit was bare and not finished, d. There was visible daylight around the window, e. The floor was peeling upward and/or missing around, and/or under equipment, e. There was brown water marks on the ceiling tiles, f. There was an accumulation of black residue the floor under equipment and along the base boards, g. There was paint peeling off of the wall behind the ice machine, and h. There was a gap and daylight was visible under the back door in the kitchen next to the three compartment sink. On 01/05/22 at 10: 50 a.m., the DM was asked what the policy was for maintenance and cleaning issues. He stated they reported maintenance issues to the maintenance department for repairs and they cleaned as they went. He was shown the above observations.