Every finding on record at Jourdanton Nursing and Rehabilitation

Based on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #2) out of 3 residents reviewed for medical records. The facility did not ensure nurses document accurately on Resident #2's Treatment Administration Record on 07/03/2026 and 07/16/2026 regarding the resident's wound care. This failure could place residents at risk for missed treatments which could result in decline in healing and well-being. Findings included:Record review of Resident #2's face sheet, dated 07/27/2026, revealed the resident was a 49-years-old female and admitted to the facility on [DATE] with diagnosis of spastic diplegic cerebral palsy (primarily affects movement in the legs and it causes muscle stiffness, tightness, and jerky movements that make walking and balance difficult), muscle weakness, and neuromuscular dysfunction of bladder (the nerves that carry messages back and forth between he bladder and the spinal cord and brain don/t work the way they should). Record review of Resident #2's quarterly MDS, dated [DATE], revealed the resident's BIMS score was 13 out of 15, which indicated the resident was cognitively intact. Section GG (Functional Abilities), the resident was dependent (Helper does all of the effort) for most activities of daily living, such as chair to bed transfer, and Section M (Skin Conditions) indicated the resident had applications of ointments/medications other than to feet. Record review of Resident #2's comprehensive care plan, dated 02/03/2026, revealed [Resident #1] has PRESSURE ULCER RISK: At risk for pressure injury related to decreased bed mobility/transfers, bowel incontinence. For intervention - Keep skin clean and dry; use mild soap and water. Record review of Resident #2's physician order, dated 02/25/2026, revealed the resident had the order of wound care: triad cream to sacral redness daily, and as needed, every shift for redness to bottom. Record review of Resident #2's Treatment Administration Records from 07/01/2026 to 07/31/2026 revealed the resident received triad cream to her buttock area two times a day and scheduled at 7 am and 7 pm. Further record review of the resident's Treatment Administration Records revealed there were blanks (empty - no document) on 07/03/2026 at 7 am and 07/16/2026 at 7 pm. Interview on 07/27/2026 at 1:05 p.m., the DON said the nurses who worked 07/03/2026 at 7 am and on 07/16/2026 at 7 pm applied triad cream to Resident #2's buttock area, but they forgot documenting on the resident's Treatment Administration Record. The DON provided the nurses' telephone numbers. Interview on 07/27/2026 at 1:43 p.m., attempted to call the nurse who worked on 07/03/2026 at 7 am, no answer left voice message. Interview on 07/27/2026 at 2:05 p.m., LVN-B who worked on 07/16/2026 at 7 pm said that she applied triad cream to Resident #2's buttock area on 07/16/2026 at 7 pm, but she forgot to document on the resident's Treatment Administration Record because she was very busy. LVN-B stated it was her mistake and she should have documented on the resident's Treatment Administration Record after applying the cream to the resident to provide accurate information to other nurses. She said an inaccurate medical record could cause staff to provide incorrect care to the resident. Interview on 07/27/2026 at 3:23 p.m., the DON said the nurse who worked on 07/03/2026 at 7 am applied the cream to Resident #2 as ordered because the nurse conducted skin assessment on 07/03/2026 and administered the cream to the resident after skin check. The DON stated the nurses should have documented accurately on Resident #2's Treatment Administration Record because inaccurate medical record staff could provide the incorrect care to the resident. Record review of the facility policy, titled Documentation in Medical Record, undated, revealed Each resident's medical records shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 2. Documentation shall be completed at the time of services, but no later than the shift in which the assessment, observation, or care service occurred. b. Documentation shall be accurate, relevant, and complete containing sufficient details about the resident's care and/or responses to care.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for incontinence care. The facility failed to ensure while providing incontinent care to Resident #1 on 07/27/2026, CNA-A cleaned the resident's suprapubic area (the area of the abdomen located below the umbilical region) and separated the labia when cleaning the resident's genital area. This failure could place residents who require incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included:Record review of Resident #1's face sheet, dated 07/27/2026, revealed Resident #1 was a [AGE] year-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with the diagnoses of type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), chronic kidney disease-stage 2 (a long-term condition where the kidneys are damaged and lose the ability to filter waste and fluid out of the blood), and muscle weakness. Record review of Resident #1's annual MDS, dated [DATE], revealed the resident's BIMS was 15 out of 15, which indicated the resident was cognitively intact, the resident was dependent (Helper does all of the effort) for most activities of daily living, such as sit to stand and chair to bed transfer, and the resident was always bladder and bowel incontinent. Record review of Resident #1's comprehensive care plan, dated 06/08/2026, revealed the resident had the care plan of Incontinence of bowel and bladder mixed incontinence - Assist to toilet at his/her requests, reminded as needed. Monitor for dark, foul-smelling urine, burning/frequency with urination, and fever/chills. Observation on 07/27/2026 at 2:06 p.m. revealed CNA-A washed her hands with water, put on gloves, opened the old and dirty brief of Resident #1, then cleaned the resident's right and left groin areas and cleaned the resident's genital area without separating labia. CNA-A did not clean the resident's suprapubic area and turned the resident to side. When CNA-A turned Resident #1 to side, CNA-A cleaned the resident's rectum, right, and left buttock area, then put the new brief under the resident after changing gloves and closed the new brief. Interview on 07/27/2026 at 2:10 p.m., CNA-A stated she did not clean Resident #1's suprapubic area and did not separate the resident's labia when cleaning the resident's genital area because she was nervous so forgot it. CNA-A said she should have cleaned the resident's suprapubic area because that area was folded with belly fat and should have separated labia when cleaning the resident's genital area to prevent possible infection. Interview on 07/27/2026 at 3:23 p.m., the DON stated CNA-A should have cleaned Resident #1's suprapubic area and should have separated the resident's labia when cleaning the resident's genital area to prevent possible infection. Record review of the facility policy, titled Perineal Care, undated, revealed . 10. Re-position resident in supine position. Change gloves if soiled and continue with perineal care. 11. Female: . c. Separate the resident's labia with one hand, and cleanse perineum with the other hand by wiping in direction from front to back (from pubic area toward anus).

Based on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 4 resident (Resident #2) reviewed for infection control, in that: The facility failed to ensure CNA A sanitized between her fingers when sanitizing her hands, therefore not properly sanitizing her hands, while providing incontinent care for resident #2. These deficient practices could place residents at-risk for infection due to improper care practices.The findings were: Record review of Resident #2's face sheet, dated 07/17/2026, revealed an admission date of 03/04/2026. Resident #2 had diagnoses which included: Type 2 diabetes mellitus(high level of sugar in the blood) , Chronic kidney disease (gradual loss of kidney function), Major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety(A group of mental illnesses that cause constant fear and worry), Chronic bladder pain (long-term condition causing bladder pressure, pain, and urinary urgency) and, Cystostomy (alternative pathway for urine drainage when normal urination is blocked or impaired). Record review of Resident 2's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 08, which indicated moderate cognitive impairment. Resident #2 was indicated to always be incontinent of bowel and had an indwelling catheter. Record review of Resident 2's care plan, dated 03/11/2026, revealed a problem of INCONTINENCE: Potential forcomplications related to Bowel incontinence and an intervention of Provide proper perineal care and use barrier creams to protect the skin from urine/feces exposure. Observation on 07/16/2026 at 3:44 p.m. revealed CNA A changed her gloves two times between front and back cleaning and after cleaning Resident#2's buttocks, before touching the clean briefs. But while she used sanitizer between changed of gloves, she did not sanitize between her fingers, she only sanitized the top and bottom of the flat of her hands. During an interview with CNA A, on 07/16/2026 at 4 p.m., she stated she did not sanitize between her fingers because she was just using sanitizer and did not thing she needed to. She stated she received infection control training at least once a year. During an interview with the DON on 07/16/2026 at 4:30 p.m., she stated staff had to sanitize between their fingers while using sanitizer to prevent the spread of infection. She stated she provided infection control training at least annually and the staff's skills were checked annually and as needed. Record review of the facility's policy, titled Hand Hygiene, dated 2026, revealed Hand hygiene technique when using an alcohol-based hand rub: a. Apply to palm of one hand the amount of product recommended by the manufacturer. b. Rub hand together, covering all surfaces of hands and fingers until hands feel dry.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of their personal and medical records for 1 of 4 resident (Resident #2) reviewed for resident rights. The facility failed to ensure CNAs A and B completely closed Resident #2's privacy curtain while providing incontinent care for the resident. This deficient practice could place residents at risk of loss of dignity.The findings were: Record review of Resident #2's face sheet, dated 07/17/2026, revealed an admission date of 03/04/2026. Resident #2 had diagnoses which included: Type 2 diabetes mellitus(high level of sugar in the blood) , Chronic kidney disease (gradual loss of kidney function), Major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety(A group of mental illnesses that cause constant fear and worry), Chronic bladder pain (long-term condition causing bladder pressure, pain, and urinary urgency) and, Cystostomy (alternative pathway for urine drainage when normal urination is blocked or impaired). Record review of Resident 2's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 08, which indicated moderate cognitive impairment. Resident #2 was indicated to always be incontinent of bowel and had an indwelling catheter. Record review of Resident 2's care plan, dated 03/11/2026, revealed a problem of INCONTINENCE: Potential forcomplications related to Bowel incontinence and an intervention of Provide proper perineal care and use barrier creams to protect the skin from urine/feces exposure. Observation on 07/16/2026 at 3:44 p.m. revealed CNAs A and B provided incontinent care for Resident #2. During care CNAs A and B did not pull the curtain to offer privacy to the resident because the privacy curtain was broken. The privacy was partially hanging done detached from its hinges. Resident #2 could have been seen by someone opening the room's door. During an interview with CNAs A and B on 07/16/2026 at 4 p.m., CNAs A and B stated the privacy curtain was not closed while they provided care for Resident #2 but should have been. They were unable to completely close it because it was broken and therefore too short in length to surround the bed. CNAs A and B stated they received resident rights training from the DON within a year. During an interview with the DON on 07/16/2026 at 4:30 p.m., the DON stated privacy must be provided during nursing care and Resident #2's privacy curtain should have been closed completely to prevent loss of dignity for the resident. She stated the staff received resident rights training within the year, and skills were checked annually and as needed. Record review of the facility's policy titled, Resident rights dated 2026, revealed, The resident had a right to personal privacy and confidentiality [ .] Personal privacy includes accommodations, medical treatment [ .].

Based on observations, interviews, and record reviews, the facility failed to dispose garbage and refuse properly for 1 of 2 dumpsters (dumpster #1) on the premises. Three doors on dumpster #1 were opened. This failure could place the facility at risk of pests and rodents that could cause contamination of the foods stored in the kitchen and place the residents at risk of infection and illness. Observations and interview on 1/13/2026 at 10:00AM revealed dumpster #1 had 2 sliding doors opened on the sides and one of the black doors that closed on the top of the dumpster was opened. The [NAME] said she knew the doors should be closed so animals could not get into the dumpsters and garbage pickup was every Monday. Interview on 12/14/2026 at 12:03 PM the DM said it was important to keep the doors of the dumpsters closed because it could bring rats and roaches to the facility that could get into the food and cause food borne illness to the residents. Interview on 1/15/2026 at 2:28 PM the RD said it was important to keep the dumpsters closed to prevent rodents and pest contamination that could cause food borne illness if they get into the food supply. Record review of the facility policy titled, Disposal of Garbage and Refuse dated 12/1/2025 stated: 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shell be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: A bag of broccoli in the freezer was opened.A tub of peanut butter had peanut butter around the rim of the bucket.A bin of flour was opened.A box with oranges had mold. These failures could place residents who received food and/or snacks from the kitchen at risk for food borne illness.Observation on 1/13/2026 at 9:41AM the freezer revealed a box folded close with the corners of the four flaps tucked under one another that allowed a gap in the center that revealed an open bag of broccoli, exposing it to air in the freezer. Observation on 1/13/2026 at 9:46AM the dry food storage was used as an office. Ther was a closed tub of peanut butter with peanut butter around the rim of the tub. There was a bin of flour with the top not secured and opened. There was a box with that had been used with the remainder of the oranges in the bottom that had mold on 5 of the oranges. Interview on 1/14/2026 at 12:03PM DM said it was important to store food properly in the freezer to maintain the food's integrity and prevent freezer burn and cross contamination. He said the bin of the flour needed to be secured to prevent insects from getting inside and contaminating the food and the containers of food like the peanut butter needed to be clean after use to prevent pest or rodents. He said food that was expired or not fit for consumption due to mold, can cause food borne illness and needed to be discarded. Interview on 1/15/2026 at 2:28 PM The RD said food should be stored properly to prevent cross contamination and food borne illness to the residents. She said food that was rotten or moldy should not be kept or served to the residents because it could cause food borne illness to the residents. Record review of the facility policy titled, Food Safety Requirements dated 2025 stated in part: It is the policy of this facility food to be stored, prepared, distributed, and served in accordance with professional standards for food service safety. Under Policy Explanation and Compliance Guidelines b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms.

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 of 6 residents (Residents #11, and #49), reviewed for quality of care. The facility failed to ensure Resident #11's nebulizer mask and mouthpiece attachment was enclosed in a container or bag when it was not in use.The facility failed to ensure Resident #49's oxygen concentrator filter was clean. This failure could place residents at risk of illness, allergies, and worsening of respiratory symptoms. The findings were: 1. Record review of Resident #11's face sheet dated 1/15/26 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with readmission on [DATE]. Resident #11's diagnoses included 3. COPD (Chronic Obstructive Pulmonary Disease - lung disease restricting airways, making breathing difficult), and Vitamin B12 deficiency (the level of vitamin B12 in the blood is insufficient to maintain proper health), and legal blindness in the USA (visual acuity of 20/200 or less in the better eye with best correction, or a visual field of 20 degrees or less (tunnel vision), even with glasses/contacts, for a condition expected to last at least a year). Record review of Resident #11's quarterly MDS dated [DATE] indicated the resident was usually understood, could usually understand, and had a BIMS of 9 indicating the resident was moderately cognitively impaired. Record review of Resident #11's undated care plan revealed a problem for COPD initiated 4/21/25 with a goal the resident will remain free from signs of respiratory infection through the next review date. Interventions included pulmonary program exercises, monitor for signs of infection, and to notify the physician. Record review of Resident #11's physician orders revealed an order with a start date of 12/23/25 for Budesonide Inhalation Suspension 0.5 mg/2 ml, inhale orally every shift (twice daily). (a liquid medication used with a nebulizer for daily, long-term control and prevention of wheezing, coughing, and chest tightness by reducing airway inflammation). Record review of Resident #11's EMAR for December 2025 revealed Budesonide Inhalation Suspension 0.5 mg/2 ml, inhale orally every shift was refused by Resident #11 on the day shift on 12/26/25, and 12/28/25 through 12/31/25. And he received all evening doses from 12/23/25-12/31/25. Record review of Resident #11's EMAR for January 2026 revealed Budesonide Inhalation Suspension 0.5 mg/2 ml, inhale orally every shift was administered 4 days on the day shift (1/3/26-1-4/26, 1/7/26, and 1/12/26), all other day shift doses were refused. And the resident received all doses on the evening shift but refused his evening doses on 1/12/26 - 1/13/26. In an observation on 1/13/26 at 10:25 a.m. In Resident #11's room a nebulizer machine was plugged in and sitting on nightstand on the right side of the resident's bed. The oxygen tubing leading from the nebulizer machine was in the drawer of the nightstand and the nebulizer mask was laying loose in drawer with a knit hat half on top of it and was not in a container or bag. On the left side of the resident's bed was another nightstand with the drawer closed and two sets of oxygen tubing connection points were sticking up out of nightstand drawer on each end of the drawer and was being held in the air by the closed drawer. A nebulizer machine was inside the drawer with a nebulizer mouthpiece laying loose in drawer and was not in a container or bag. In an observation and interview on 01/13/2026 10:37 a.m. LVN A stated the nebulizer masks should be in bags and not loose in the drawers and the oxygen tubing ends should not be sticking out of the drawer. LVN A stated Resident #11 refused his Nebulizer treatment today and she was unsure when the resident last received it, she would have to look. In an interview on 1/16/26 at 10:05 a.m. the DON stated the nebulizer masks should be in bags. The DON stated the nurses were trained and were aware. The DON stated the possible consequences of the nebulizer mask or mouthpiece not being in bags could cause cross contamination issues. Review of the facility policy on nebulizer therapy with a copyright of 2025 indicated It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. 7. Once completely dry store the nebulizer cup and the mouthpiece in a zip lock bag. 2. Review of Resident #49's face sheet, dated 1/16/26, revealed she had a diagnosis including Chronic Obstructive Pulmonary Disease (A progressive lung disease characterized by persistent airflow limitation). Review of Resident #49's admission MDS assessment, dated 11/21/25, revealed her BIM score was 13 of 15 indicative of no cognitive impairment and she received oxygen therapy on a regular basis. Review of Resident #49's consolidated physician orders for January 2026 revealed an order for continuous oxygen at 2 to 4 liters. Further review revealed to maintain the oxygen concentrator and change out the tubing and humidifier bottle per facility policy. Observation and interview on 1/13/26 at 11:10 AM revealed Resident #49 sitting in a recliner receiving continuous 02 via nasal cannula at 2 liters per minute. Further observation revealed a vent cover full of white build up on the back of the oxygen concentrator. Resident #49 stated staff changed out the tubing and plastic bottle a day or so ago, but she did not see them clean the vent cover. Observation and interview on 1/14/26 at 1:30 PM revealed Resident #49 sitting in recliner receiving continuous 02 via nasal cannula at 2 liters per minute. Further observation revealed a vent cover full of white build up on the back of the oxygen concentrator. LVN A stated it looked like lint and that Hospice had provided the concentrator. She stated she had not checked it. LVN A stated night nurses who worked on Sunday's were responsible for changing out the tubing, humidifier and for cleaning the filters. LVN stated in this case the filter was an internal filter and the Hospice company would be responsible for ensuring the concentrator was serviced. However, nursing staff was responsible for letting the Hospice company know the filter needed cleaning. LVN stated it was important the filter was cleaned regularly because Resident #49 was receiving oxygen into her lungs. It could cause infections if the filter was dirty. Interview on 1/16/26 at 1:30 PM with the DON revealed night nurses were responsible for changing the oxygen tubing, the humidifier bottle and the filter. She stated if the filter was located internally then the MS would service the concentrator and clean the filter unless the resident was on Hospice services. The Hospice company would be responsible for servicing the concentrator, but their nursing staff would have to let Hospice know the concentrator needed servicing. The DON stated if the filter was dirty, it could cause the resident to get an infection or could cause other respiratory complications. Review of the facility policy titled oxygen concentrator with a copyright date of 2025 read in relevant part Care of concentrator: a. follow manufacturer's recommendations for the frequency of cleaning filters and servicing the device. B. Only trained individuals such as the Maintenance Director or supplier shall service the device.

Based on observation, interview, and record review the facility failed to safeguard medical record information against loss, destruction, or unauthorized use to maintain accurate medical records for 1 of 4 (Resident #2) residents reviewed for change in condition The facility failed to document the of change of condition and transfer to the hospital for Resident #2. These failures could place the residents at risk of inadequate care and a diminished quality of life.The findings were: Record review of Resident #2's face sheet dated 01.14.2026 revealed a [AGE] year-old female was re-admitted to the facility on 1.13.2026 with diagnoses: depression, traumatic brain injury, chronic obstructive pulmonary disease (difficulty breathing due to progressive lung disease), and anxiety. Record review of Resident #2's Quarterly MDS dated 11.03.2025 revealed she had a BIMS score of 15, indicative of cognitively intact. Record review of Care Plan dated 12.10.2025 revealed she was care planned for heightened perception of events, deep vein thrombosis (blood clot), antidepressants, traumatic brain injury, and falls. Record review of Resident #2's progress notes reviewed for dates January 1-16, 2026, did not reveal the transfer to the hospital nor was there a change of condition done to explain the reason for the transfer. The only documentation noted was the call from RP due to her concern about Resident #2's behavior after she called her with complaints about someone was hurting her and people were trying to get her. Observation on 1.13.2026 at 10:00AM revealed Resident #2 was not in the facility during observations. CNA C said Resident #2 went out to the hospital. Interview and observation on 1/13/2026 at 4:20PM Resident #2's RP said Resident #2 was sent to the hospital 1.6.2026 because she called her confused and afraid that someone was hurting or trying to get her. She said she called the facility to inform them of her concerns, and she was then sent out to the hospital where she was treated for her symptoms. The RP said Resident #2 was much better. Resident #2 was in her electric wheelchair, clean and groomed. She was encouraged by her family member that it was okay to speak with the surveyor, and she said she felt fine. Interview on 1/15/2026 at 12:15PM the DON said Resident #2 was transferred to the hospital for a change in mental status. She confirmed there was no documentation in the Resident's record on why she was not in the facility and there was no change in condition in the record. She said it was important to document the condition of a resident, the disposition of a resident if transferred out of the facility, why they may have gone out to the hospital, and documentation of all who were notified of the transfer. She said it was important to have accurate documentation to update the resident's care plan as well if a resident returned to the facility with a new diagnosis. The DON said the RP was notified of the transfer. Record review of facility policy titled, Documentation in Medical Record dated 2025 stated: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide the resident's progress through complete, accurate, and timely documentation. Policy explanation and compliance guidelines stated: :1. Licensed staff shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on observation, interview, and record review, the facility failed to ensure that each resident has a right to secure and confidential personal and medical records for 1 of 1 facility reviewed for confidentiality: in that: The facility staff left the laptop open, unlocked, and unattended on the MA cart with the screen turned on and the EMAR visible to resident records and medications. This deficient practice could place residents at risk for having their medical information being unnecessarily exposed and their personal privacy violated.The findings included: In an observation and interview on 1/13/26 at 9:15 a.m. the MA cart was at the nurse's station facing outward toward people passing through the area. There was a laptop computer on the MA cart facing away from the nurses station, and the screen was on and open to resident EMARs. The computer was unattended. There was a resident standing to the right of the cart talking on the phone at the nurse's station, another resident standing to the left of the cart talking to LVN A who was seated behind the nurse's station. LVN A stated the cart and computer were MA B's. In an observation and interview on 1/13/26 at 9:16 a.m. MA B approached and closed the laptop screen. MA B stated she should not have left it open and unattended. In an interview on 1/16/26 at 10:05 a.m. the DON stated MA B should not have left the computer screen on and unattended. The DON stated MA B had been trained previously on resident records privacy. The DON stated the staff were re-trained the same day on 1/13/26. The DON stated the possible consequences of leaving the computer screen on and the EMAR open could possibly compromise private resident information.Review of HIPAA Privacy Rule Pre/posttest for MA B dated 9/22/25 revealed . 1. Protected health information includes any identifiable health information that is in electronic format, written on paper, and communicated verbally. Review of in-service training report dated 1/13/26 for all departments on HIPAA and leaving secured information unattended reflected summary of training any applications with secured and private patient information should be protected when away from working station. Laptops and kiosks should be locked, any patient information at nurses' station should be kept confidential and had the policy attached.Review of the facility policy for HIPAA sanctions with copyright 2025 indicated . 6. Examples of violations include, but are not limited to . e. leaving a secured application unattended while logged on.

Based on observation, interview and record review the facility failed to manage and account for the personal funds of the resident deposited with the facility for 1 of 1 Resident (Resident #41) reviewed for personal funds. The facility failed to disburse Resident #41's personal funds so that she could purchase incontinent supplies. This could contribute to feelings of frustration and helplessness for the residents. The findings were:Review of Resident #41's face sheet, dated 1/16/26, revealed she was admitted to the facility on [DATE] with diagnoses including hemiplegia, and hemiparesis (paralysis) following cerebral infarction (an ischemic stroke, occurs when blood flow to a part of the brain is interrupted, leading to tissue death due to lack of oxygen and nutrients) affecting left non-dominant side and borderline personality disorder (is a mental health condition that affects the way people feel about themselves and others, making it hard to function in everyday life.) Review of Resident #41's quarterly MDS assessment, dated 12/18/25, revealed her BIMS score was 15 out of 15 reflecting she did not have cognitive impairment and she was incontinent of bowel and bladder. Review of Resident #41's Care Plan, revised on 12/19/25, revealed Focus area: Urinary incontinence: I have history of bladder incontinence related to Dementia. Goal: I will remain free from skin breakdown due to incontinence and brief use through the review date. Observation and interview on 1/13/26 at 10:43 AM revealed Resident #41 was lying in bed. Resident #41 stated she had diarrhea during the last two weeks. She stated it was a chronic condition. Resident #41 stated she had not received her allowance for this month with which she planned to buy incontinence supplies She stated she talked with the BOM about withdrawing $250 last week to buy incontinence supplies. Interview on 1/16/26 at 4:10 PM with the BOM revealed Resident #41 requested to withdraw $250 last Wednesday (1/7/26). She stated the MS used to cash the trust fund checks and was supposed to cash the check on Friday (1/9/26) but he told her he forgot. The BOM stated he quit his job on 1/12/26 and she did not have anyone else to cash the check. She stated she mentioned it to the ADM but there was not a plan to cash the check. The BOM stated Resident #41 had the $250 dollars available in her account and had the right to have access to her funds as soon as possible. She stated because Resident #41 asked for more than most residents it took a day or two to get her funds. The BOM stated she had not talked to Resident #41 but was sure the Resident was probably upset and maybe even felt like they did not care about how she might be feeling or about her needs. Interview on 1/16/26 at 4:50 PM with the ADM stated she did not know the BOM was having problems with cashing the trust fund until today (1/16/26). She stated usually one of the employees had to cash the trust fund check because the corporation did not bank with any of the local banks. The ADM stated the MS used to cash the check but they did not have anyone else to do it. She stated they hired another MS and a housekeeping/laundry supervisor and would assign them to cash the trust fund check so this would not happen again. The ADM stated Resident #41 had a right to her funds and she was probably upset because they had not provided her with any monies and probably felt like she was not important. Review of a facility policy, Resident Right, copyright date 2025, read in relevant part The resident has a right to a dignified existence, self-determination, and communication with and access to person's and services inside and outside the facility.

Based on observation, interview and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 8 Residents (Resident #23) who was reviewed for call light placement. Nursing staff failed to ensure Resident #23's call light was within reach. Resident #23 asked for water and was not able to locate his call light because it was under the fall mat. This deficient practice could result in residents not being able to ask for assistance as needed. The findings were: Review of Resident #23's face sheet, dated 1/16/26, revealed he was admitted to the facility on [DATE] with diagnoses including Dementia (characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities). Review of Resident #23's quarterly assessment, dated 12/26/25, revealed his BIMS score was 99 indicating staff was unable to interview him. Further review revealed he was severely cognitively impaired, and he was dependent for most ADLs by 1 staff. Observation and interview on 1/13/26 at 10:33 AM revealed Resident #23 was lying in a low bed with a floor mat on the right side of the bed. Resident #23 asked for water. He was asked how he usually asked staff for assistance. Resident #23 stated he did not know the location of the call light. Further observation revealed the call light was on the floor underneath the floor mat. Observation and interview on 1/13/2026 at 11:25 AM revealed Resident #23's call light was on the floor underneath the floor mat. CNA D stated Resident #23's call light was underneath the floor mat. She stated it should be on top of the bed and clipped to the sheet. CNA D stated she did not put him to bed but had checked on the Resident and asked if he needed to get changed. She stated she should have checked for placement but did not check it. CNA D stated the call light should be within reach so Resident #23 could call for assistance otherwise he might not get the help he needed. Interview on 1/16/26 at 5PM with the DON revealed nursing staff should constantly check the placement of the call light so residents could ask for assistance, otherwise they would not be able to get staff's attention, and not get their needs met. Review of a facility policy, Resident Right, copyright date 2025, read in relevant part The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

Based on observation, interview and record review the facility failed to provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement for 1 of 5 Residents (Resident #1) whose records were reviewed for pharmacy services. 1.Nursing staff failed to contact the pharmacy to ask about the status of the pending order for Lyrica and consult with Resident #1's PCP to obtain a one-time order for Lyrica (pain medication) pending pharmacy delivery of the medication from 10/10/25 until 10/15/25. 2.LVN A failed to contact and consult with Resident #1's PCP and the pharmacy when Lyrica (pain medication) was not available for administration for Resident #1 per physician orders. This failure could place residents at risk of a decline in health status. The findings were: Review of Resident #1's face sheet, dated 10/15/25, revealed he was admitted to the facility on [DATE] with primary diagnoses including unspecified cirrhosis of the liver (permanent scarring that damages your liver and interferes with its functioning) and type 2 diabetes (a progressive, long-term condition that affects how the body regulates blood glucose levels) without complications. Review of Resident #1's quarterly MDS assessment, dated 9/22/25, revealed he did not complete his BIMS to establish a level of cognitive function. Further review revealed he frequently experienced pain and received PRN medication for pain. Review of Resident #1's Care Plan, dated 7/2/25, revealed COGNITION: Impaired cognitive function thought processes r/t pain. Administer medications as ordered by physician. Notify physician as needed. PAIN: I (Resident #1) have potential for altered comfort r/t Pain. I (Resident #1) will have complaints of pain relieved in timely fashion at all times daily through next 90day review. Monitor for s/s e.g.a) verbal c/o painb) guarding (defending, safeguarding, protecting)c) facial grimacingd) refusal to participate in ADL's or therapiese) agitationf) restlessness Notify MD as needed Pain Management Therapy. Review of Resident #1's consolidated physician orders for October 2025 revealed an order Lyrica Oral Capsule 50 MG (Pregabalin) Give 1 capsule by mouth two times a day for Pain management. Active 05/16/2025 and Gabapentin Oral Capsule 300 MG (Gabapentin) Give 1 capsule by mouth three times a day related to PAIN, UNSPECIFIED (R52); POLYNEUROPATHY, UNSPECIFIED (G62.9); GENERALIZED ABDOMINAL PAIN. In addition, Resident #1 had the following PRN orders for pain, Acetaminophen-Codeine Tablet 300-30 MG Give 1 tablet by mouth every 6 hours as needed for pain, and HYDROcodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain. Review of Resident #1's medication administration record for October 2025 revealed he did not receive Lyrica according to physician orders on 10/10/25, 10/11/25/ 10/12/25, 10/13/25, 10/14/25 and on 10/15/25. On 10/10/25 there were no initials to indicate the medication was administered. On 10/11/25 through 10/15/25, there was a code 19=Other-See Progress Note. Further review revealed that Resident #1 received HYDROcodone-Acetaminophen on 10/10/25, 10/13/25 and 10/14/25. It was noted as being effective for each date it was administered. Review of Resident #1's progress notes from 10/11/25 through 10/15/25 reflected Lyrica Oral Capsule 50 MG Give 1 capsule by mouth two times a day for Pain management, pending delivery. Further review revealed LVN A wrote the progress note for 10/15/25. Observation and interview on 10/14/25 at 1:22 PM Resident #1 was sitting on his bed. Resident #1 stated he often had pain related to swelling to the side of his face. Resident #1 stated he fell earlier this year in the bathroom, and his back would hurt, and he had a hernia that often caused a lot of pain. Resident #1 stated he received pain medications, but he had to beg for them, he had to keep asking staff for the medications. He stated the medications helped. Interview on 10/15/25 at 5PM the ADON revealed nursing staff should re-order a medication at least 7 days prior to the medication being out. He stated the pharmacy usually delivered medications on the same date or the day after being ordered. The ADON stated nursing staff should have called the pharmacy on 10/11/25 after the request for the refill was placed on 10/10/25 to determine why the medication had not been delivered because it had been days since it was ordered. In addition, nursing staff should let him and the DON know if there were any problems so they could assist with the process as needed. The ADON stated he learned it was not until 10/14/25 that one of the nurse's called for an update. He stated the pharmacy needed a new script for the Lyrica. He stated the same nurse should have also called Resident #1's PCP to obtain a one-time order to dispense the medication from the facility's Pyxus. He stated it had been days since the Lyrica was re-ordered. The ADON stated LVN A should have followed this same process on this date, 10/15/15, especially because Resident #1 had not received the medication in days. He stated LVN A should have called Resident #1's PCP to inform him of the status of the pending delivery so the PCP could provide guidance and make any medication adjustments as needed for the medication. He stated typically the PCP would provide a one-time order for the Lyrica, LVN A would then call the pharmacy to request access to the Pyxus and administer the medication. He stated Resident #1 received Lyrica for pain and stated he also had PRN pain medications for break through pain. However, he further stated there was no reason for Resident #1 to go without the medication which was determined effective for pain management. He stated the fact that nursing staff did not follow the facility's medication administration policy and procedures basically resulted in Resident #1 not receiving the pain medication per physician orders for 5 days. The ADON stated failure to call Resident #1's PCP basically resulted in Resident #1 not receiving his pain medication as ordered. Interview on 10/15/25 at 5:30 PM LVN A revealed the Lyrica order for Resident #1 was still in pending delivery status because the pharmacy had not delivered it. She stated she did not administer Resident #1's morning dose on this date, 10/15/25, and also wrote a progress note, pending delivery. LVN A stated she was provided with agent status (cleared by pharmacy to access Pyxus) to withdraw medications from the Pyxus and stated Lyrica was one of the medications available in the Pyxus. LVN A stated she had not think about obtaining the Lyrica from the Pyxus. She stated she did not call Resident #1's PCP to report Resident #1 had not been receiving the medication as of 10/10/25 or to request a one-time order from the Pyxus. LVN A stated it was necessary to inform Resident #1's PCP of the changes so the PCP could provide guidance and to ensure Resident #1 received the medication per physician orders. She stated as a result Resident #1 pain would not be managed and he could continue to experience pain. Interview on 10/15/25 at 6PM the DON revealed she found out today (10/15/25) there had been a delay in receiving Resident #1's order for Lyrica. She stated nursing staff should re-order medications 10 days before running out. The DON stated if the pharmacy did not deliver the medication within 24 hours, then nursing staff should follow up with a call to determine what was holding the order and take move forward with ensuring the medication was delivered. The DON stated nursing staff should let her and the ADON know when there were any problems so they could assist as needed. She stated anytime a resident did not receive a medication; the charge nurse should call the PCP to determine what steps to take to ensure the resident received medications per physician orders. The DON stated the facility had a pyxis and Lyrica was available and there was no reason why he did not receive the medication as ordered. She stated if the charge nurse was not an agent (did not have authorization to dispense medications), she or the ADON could dispense the medication. The DON stated Resident #1 often complained of pain to different areas of his body and there was no excuse why he should be in pain when they had the medication in stock and could easily administer it. The DON stated all nursing staff should follow the policy and procedures for obtaining, dispensing and administering medications, so the residents received the medications per physician orders and in Resident #1's case, so his pain was managed, and he did not experience unnecessary pain. The DON stated Resident #1 had PRN pain medications for break through pain. Review of facility policy, Notification Changes, revised on 5/16/25, read in relevant part The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences or commence a new form of treatment to deal with a problem. Review of facility policy, Medication Reordering, dated 6/15/25, read in relevant part It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services includingthe provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. Pharmaceutical services refers to the process of receiving and interpreting prescriber's orders (e.g., acquiring, receiving, storing, controlling, re-ordering medications, etc.). Acquiring medication is the process by which the facility requests and obtains a medication.Policy Explanation and Compliance Guidelines:1. The facility will utilize a systematic approach to provide or obtain routine and emergency medicationsand biologicals in order to meet the needs of each resident.2. Acquisition of medications should be completed in a timely manner to ensure medications areadministered in a timely manner.3. Each time a nurse is administering medications and observes (6) or less doses left of one kind, thatnurse will reorder the medication, time permitting.4. The nurse that is assigned to each medication cart will perform a medication cross match everyThursday night. (See Medication Cross Match Policy)5. In the event of new orders, the facility is allowed (24) hours to begin a medication unless otherwisespecified by the physician. 6. For stat medications, a supply of medications typically used in emergency situations will be maintained in limited supply by the pharmacy in a portable, but sealed emergency box or container (may be used if applicable).

Based on observation, interviews and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 4 residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded for a fall with injury that occurred on 09/04/2025, on his admission MDS assessment, signed as completed on 9/11/2025. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Record review of Resident #1's admission Record, dated 11/18/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #1's Diagnosis Report, dated 11/18/2025, reflected diagnoses included encephalopathy (a disease in which the function or structure of the brain is affected, typically caused by infection, tumor, or stroke), intracranial injury (an injury to the brain caused by an external force) with loss of consciousness of unspecified duration, and dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #1's Fall Assessment-Post Incident, dated 09/04/2025 by LPN A, reflected under reason for assessment, Recent Falls. Resident #1 was noted to have no history of halls, having had agitated behavior occur daily or more, having been confined to a chair and disoriented, and required hands-on assistance to move from place to place. Record review of Resident #1's Post Event Head to Toe Skin Check, dated 09/04/2025 by LPN A, reflected Resident #1 had a superficial pink abrasion on his left iliac crest (pelvic bone). Record review of Resident #1's admission MDS Assessment, dated 09/08/2025 and signed as completed on 09/11/2025, by the MDS Nurse, reflected assessment observation end date of 09/08/2025. Resident #1 had a BIMS score of 08, which indicated he was moderately cognitively impaired. Under Any Falls Since Admission/Entry or Reentry or Prior Assessment, Resident #1 was coded as having had a fall but with no injury since admission/entry or reentry or the prior assessment. The section for fall history was noted to have been signed as completed by the MDS Nuse. Record review of Resident #1's Care Plan Report, dated as last care plan review completed 09/26/2025, reflected Falls: At Risk for falls related to unsteady gait, date initiated 09/11/2025, and revised on 09/12/2025. Interventions included Call light within reach and Place frequently used items within reach, date initiated 09/04/2025. Record review of the facility report Incidents By Incident Type, dated 11/18/2025, for date range 09/01/2025 to 09/30/2025, reflected Resident #1 had an unwitnessed fall incident on 09/04/2025 at 04:50 p.m. During an observation and attempted interview on 11/19/2025 at 01:57 p.m., Resident #1 was observed sitting in his wheelchair with his side table and his call light within reach. Resident #1 did not respond when attempting to interview. During an interview on 11/19/2025 at 02:21 p.m., Resident #1's family member stated he was contacted regarding Resident #1's fall. Resident #1 stated he had no concerns regarding Resident #1's care or treatment. During an interview on 11/20/2025 at 10:28 a.m., the MDS Nurse stated when completing the MDS Assessments, she reviewed a resident's fall assessment and post head-to-toe assessment to determine if a resident had an injury due to a fall. She stated the only reason an injury could have been missed was if it was not in the assessment. The MDS Nurse stated an error on the MDS Assessment would not necessarily impact the resident's care if there was an order to observe or treat the injury. During an interview on 11/20/2025 at 12:56 p.m., the DON stated she would not imagine an error on the MDS Assessment would impact a resident's care. She stated the nursing staff did not look at the MDS Assessment for provision of care. They would look at the orders. During an interview on 11/20/2025 at 01:47 p.m., the ADMIN stated an error on the MDS Assessment would not impact Resident #1's care. She stated the facility staff would look at the doctor's orders and previous documentation on how they should be caring for the resident. She stated the nurses and CNAs did not look at the MDS Assessments. Record review of the facility's policy, Documentation in Medical Record, dated as Copyright 2024, reflected: Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of their personal and medical records for 1 of 1 resident (Resident #11) reviewed for resident rights. The facility failed to ensure CNAs H and I completely closed Resident #11's privacy curtain while providing perineal care for the resident. This deficient practice could place residents at risk of loss of dignity.The findings were: Record review of Resident #11's face sheet, dated 11/21/2025, revealed an admission date of 12/03/2014, and a readmission date of 10/19/2020. Resident #11 had diagnoses which included: Vascular dementia (decline in cognitive abilities), Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Hypertension (High blood pressure), Type 2 diabetes mellitus (high level of sugar in the blood), and Irritable bowel syndrome (chronic disorder affecting the large intestine, causing symptoms like abdominal pain, bloating, gas, constipation, or diarrhea) Record review of Resident 11's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 09, which indicated moderate cognitive impairment, and was indicated to always be incontinent of bowel and bladder. Record review of Resident 11's care plan, dated 09/26/2025, revealed a problem of Impaired Skin Integrity related to history of excoriation on the scrotum due to moisture, friction, or incontinence and an intervention of Maintain proper incontinence care. Observation on 11/20/2025 at 6:33 a.m. revealed CNAs H and I provided incontinent care for Resident #11. During care CNAs H and I did not pull the curtain to offer privacy to the resident. Resident #11 could be seen by his roommate and could have been seen by someone opening the room's door. During an interview with CNAs H and I on 11/20/2025 at 6:35 a.m., CNAs H and I stated the privacy curtain was not closed while they provided care for Resident #11 but should have been. They stated they were nervous and had forgotten. CNAs H and I stated they received resident rights training from the DON within a year. During an interview with the DON on 11/20/2025 at 7:11 a.m., the DON stated privacy must be provided during nursing care and Resident #11's privacy curtain should have been closed completely to prevent loss of dignity for the resident. She stated the staff received resident rights training within the year and skills were checked annually and as needed. Record review of the facility's policy titled, Resident rights dated 2025, revealed, The resident had a right to personal privacy and confidentiality [ .] Personal privacy includes accommodations, medical treatment [ .].

Based on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 1 resident (Resident #11) reviewed for infection control, in that: 1. The facility failed to ensure CNAs H and I washed their hands before starting to provide incontinent care for Resident #11. 2. The facility failed to ensure CNA H sanitized his hands between change of gloves during incontinent care for Resident #11 . These deficient practices could place residents at-risk for infection due to improper care practices.The findings were: Record review of Resident #11's face sheet, dated 11/21/2025, revealed an admission date of 12/03/2014, and a readmission date of 10/19/2020. Resident #11 had diagnoses which included: Vascular dementia (decline in cognitive abilities), Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Hypertension (High blood pressure), Type 2 diabetes mellitus (high level of sugar in the blood), and Irritable bowel syndrome (chronic disorder affecting the large intestine, causing symptoms like abdominal pain, bloating, gas, constipation, or diarrhea). Record review of Resident #11's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 09, which indicated moderate cognitive impairment. Resident #11 was indicated to always be incontinent of bowel and bladder. Record review of Resident #11's care plan, dated 09/26/2025 , revealed a problem of Impaired Skin Integrity related to history of excoriation on the scrotum due to moisture, friction, or incontinence and an intervention of Maintain proper incontinence care. Observation on 11/20/25 at 6:33 AM revealed CNAs H and I did not wash their hands after entering Resident #11's room and before providing incontinent care for Resident #11. CNA H did not sanitize his hands between change of gloves, after cleaning the resident's buttocks and before touching the clean briefs. During an interview with CNAs H and I, on 11/20/2025 at 6:35 a.m., they stated they had not washed their hands before starting the care. CNA H stated he changed his gloves before touching the clean briefs but did not use sanitizer between change of gloves. They stated they forgot but knew hand hygiene was important to prevent infection for the residents. They stated they received infection control training at least once a year . During an interview with the DON on 11/20/2035 at 7:11 a.m., she stated staff had to wash their hands before starting to provide care for a resident and had to use sanitizer or wash their hands between change of gloves to prevent the spread of infection. She stated she provided infection control training at least annually and the staff's skills were checked annually and as needed. Record review of the facility's policy, titled Infection control guidelines for all nursing procedures, dated quarter 3 of 2018, revealed Employees must wash their hands for ten to fifteen seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents [ .] In most situations, the preferred methos of hand hygiene is with alcohol-based hand rub [ .] use an alcohol-based rub [ .] before moving from contaminated body site to clean body site during resident care [ .] after removing gloves.

Based on observation, interview, and record review the facility failed to in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 2 of 4 residents (Resident #2 and Resident #3) reviewed for clinical records. The facility failed to document 10 occasions for Resident #2 and 1 occasion for Resident #3's medication administration of Cefinir, and antibiotic on multiple occasions. This failure could place residents at risk of not receiving the care and services needed. The findings included: 1. Record review of Resident #2's admission Record, dated 11/18/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #2's Diagnosis Report, dated 11/18/2025, reflected diagnoses which included encephalopathy (a disease in which the function or structure of the brain is affected, typically caused by infection, tumor, or stroke), acute (quickly has become sever) cholecystitis (the swelling and irritation or inflammation of the gallbladder), and sepsis (a condition in which the body's extreme response to an infection become life-threatening). Record review of Resident #2's Progress Notes, dated 10/19/2025 to 10/26/2025 reflected: - An **Alert Charting Note, dated 10/19/2025 at 06:51 a.m. by LPN G, noted reason for charting as PNA/UTI with interventions P.O. ABT Cefdinir. - No progress notes mentioning an antibiotic or Cefdinir from 10/21/2025 through 10/20/2025 prior to 02:00 p.m. daily were documented. Record review of Resident #2's Quarterly MDS Assessment, dated 10/27/2025, reflected the resident had a BIMS score of 14, which indicated he was cognitively intact. He was noted as having taken an antibiotic during the last 7 days or since admission/entry or reentry with an indication noted. Record review of Resident #2's Order Summary Report, dated 11/18/2025 for Active Orders as of 11/18/2025, reflected Resident #2 did not have an active order for Cefdinir. Record review of Resident #2's CMA MAR, dated 11/18/2025 from 10/01/2025 to 10/31/2025, reflected the following order and administrations: - Cefdinir Capsule 300 MG Give 1 capsule by mouth every 12 hours for PNA/UTI for 10 Days - D/C Date- 10/27/2025 0733 with administration times noted as at 0600 (6:00 a.m.) and 1800 (6:00 p.m.). The first scheduled administration was on 10/18/2025 at 06:00 p.m. and was coded for resident hospitalized . The second scheduled administration, on 10/19/2025 at 06:00 a.m., was blank. The third, fourth, and fifth administrations (10/19/2025 and 10/20/2025 at 06:00 p.m., and 10/20/2025 at 06:00 a.m.) were documented as administered. The following six (6) 06:00 a.m. scheduled administrations (10/21/2025 to 10/26/2025) were blank but the 06:00 p.m. administrations were noted as administered. The administration on 10/27/2025 at 06:00 a.m. was the last scheduled administration for the order. CMA D was noted to have administered other medications to Resident #2 on 10/19/2025 and 10/26/2025 during the time of the blanks in documentation. LPN A was noted to have administered other medications to Resident #2 on 10/21/2025 to 10/25/2025 during the time of the blanks in administration documentation. Record review of Resident #2's CMA MAR, dated 11/18/2025 from 11/01/2025 to 11/30/2025, reflected the following order and administrations: - Cefdinir Capsule 300 MG Give 1 capsule by mouth every day and evening shift for PNA/UTI for 10 Days with administration times noted as at 6A TO .2P TO. Three (3) scheduled administrations, on 11/02/2025 for 6A TO .2P TO and on 11/03/2025 for 2P TO, were coded for Other-See Progress Note by LPN E. Other scheduled administrations were documented as administered. Record review of Resident #2's Progress Notes, dated 11/02/2025 and 11/03/2025, reflected no progress notes entered on these dates. During an observation and interview on 11/20/2025 at 10:35 a.m., Resident #2 was observed lying in bed with no visible injuries. Resident #2 stated the facility staff took care of him. When asked about medication administration, Resident #2 stated he had a sore throat the day prior, 11/19/2025 and the nurse gave him liquid medicine that was effective. During an interview on 11/20/2025 at 11:32 a.m., CMA D stated she believed a blank in the medication administration record meant the documentation of the administration was not there. She stated she recalled Resident #2 having a scheduled antibiotic and administered it. During an interview on 11/20/2025 at 11:39 a.m., LPN A stated she believed a blank in the medication administration record meant the medication had not been given. She stated she recalled Resident #2 had his antibiotic in the medication cart and was able to describe the medication. She stated Resident #2 would occasionally initially refuse his medications, but then when she re-offered, he would take them. She stated she believed she must have missed clicking in the medication record that the medication was administered. Attempted interview on 11/20/2025 at 11:46 a.m. with LPN E was unsuccessful. A message was left with call back request, but no return call was received. 2. Record review of Resident #3's admission Record, dated 11/18/2025, reflected a [AGE] year-old female. She was initially admitted to the facility on [DATE], readmitted on [DATE], and discharged on 11/07/2025. Her family member was noted as her Power of Attorney and Emergency Contact #3. Record review of Resident #3's Progress Notes, dated 10/28/2025 did not reveal note regarding antibiotic or Cefdinir administration. Record review of Resident #3's Entry MDS BIMS, dated 10/29/2025, reflected Resident #3 had severe cognitive impairment. Additional information included PNT has limited verbalizations and is unable to participate in the assessment due to cognitive-communication and speech-language impairments. Record review of Resident #3's Discharge Return Anticipated MDS Assessment, dated 11/06/2025, reflected the resident had taken an antibiotic during the last 7 days or since admission/entry or reentry with an indication noted. The most recent admission/entry or reentry date was noted as 10/27/2025. Record review of Resident #3's Diagnosis Report, dated 11/18/2025, reflected diagnoses included sepsis (the body's extreme reaction to an infection), acute respiratory failure with hypoxia (a sudden condition when the lungs cannot deliver enough oxygen to the blood), and pneumonia (a lung infection). Record review of Resident #3's Order Recap Report, dated 11/18/2025, for orders dated: 10/01/2025 to 11/30/2025, reflected the following orders: - Cefdinir Oral Capsule 300 MG (Cefdinir) Give 1 capsule by mouth every 12 hours for Sepsis, order status noted as discontinued, with order date and start date of 10/28/2025, and end date of 10/30/2025. Discontinue noted as effective 10/30/2025 at 11:11 a.m. with reason noted as Order clarification from MD. Record review of Resident #3's CMA MAR, dated 11/18/2025 from 10/01/2025 to 10/31/2025, reflected the following order and administration: - Cefdinir Oral Capsule 300 MG (Cefdinir) Give 1 capsule by mouth every 12 hours for Sepsis -D/C Date- 10/30/2025 11:11, with administration times noted as at 0800 (8:00 a.m.) and 2000 (8:00 p.m.). All scheduled administrations were documented as administered, except the scheduled administration on 10/28/2025 at 08:00 p.m. was blank. Last scheduled administration was documented on 10/30/2025 for 08:00 a.m. administration. CMA F was noted to have administered other medications to Resident #3 on 10/28/2025 during the time of the blank in administration documentation. During an observation on 11/13/2025 at 2:00 p.m., Resident #3 was observed to be a resident at another nursing facility, admitted on [DATE]. She was asleep and determined to be uninterviewable. Attempted interview on 11/20/2025 at 11:31 a.m. with CMA F. CMA F's phone would not allow a message for a return call request to be left. During an interview on 11/20/2025 at 12:56 p.m., the DON stated she considered a blank in a resident's MAR or TAR as an indication that no one documented the administration. She stated a see progress note code could be generated if the resident refused the medication or treatment, the medication was not available, or for another reason. She stated she would expect to be able to read a progress note if see progress note was entered into the MAR/TAR. During an interview on 11/20/2025 at 01:47 p.m., the ADMIN stated if she saw a blank in a resident's MAR/TAR, she would not know what happened, if the medication was given or no She stated it would be the same issue if see progress note was documented and there was not a progress note, she would have to bring that staff member back and make sure that they documented what happened. Record review of the facility's policy, Medication Administration, dated as Copyright 2025, reflected: .Policy Explanation and Compliance Guidelines:.20. Sign MAR after administered.23. Correct any discrepancies and report to nurse manager. Record review of the facility's policy, Documentation in Medical Record, dated as Copyright 2024, reflected: Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and service to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #11) resident reviewed for incontinent care and catheter care. The facility failed to ensure CNA H retract Resident #11's foreskin (the retractable roll of skin covering the end of the penis) while providing incontinent care . This deficient practice could place residents at-risk for infection and skin break down The findings were: Record review of Resident #11's face sheet, dated 11/21/2025, revealed an admission date of 12/03/2014, and a readmission date of 10/19/2020. Resident #11 had diagnoses which included: Vascular dementia (decline in cognitive abilities), Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Hypertension (High blood pressure), Type 2 diabetes mellitus (high level of sugar in the blood), and Irritable bowel syndrome (chronic disorder affecting the large intestine, causing symptoms like abdominal pain, bloating, gas, constipation, or diarrhea) Record review of Resident 11's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 09, which indicated moderate cognitive impairment. Resident #11 was indicated to always be incontinent of bowel and bladder. Record review of Resident 11's care plan, dated 09/26/2025, revealed a problem of Impaired Skin Integrity related to history of excoriation on the scrotum due to moisture, friction, or incontinence and an intervention of Maintain proper incontinence care. Observation on 11/20/2025 at 6:33 a.m. revealed while providing incontinent care for Resident #11, CNA H did not retract the foreskin of the resident, therefore not properly cleaning the head of Resident #11's penis. During an interview on 11/20/2025 at 6:35 p.m. with CNA H, he stated he did not retract the foreskin of Resident #11's penis. CNA H was unclear why he did not retract the foreskin but knew he had to clean underneath it. He stated he received incontinent care training from the DON. During an interview with the DON on 11/20/2025 at 7:11 a.m., she stated that in the case of an uncircumcised male resident, the foreskin should be retracted to provide proper hygiene and prevent infection and skin breakdown. She stated providing incontinent care training for the staff within the year. Skills were checked annually and as needed. Record review of the facility's policy titled Perineal care, dated 2024, revealed, gently retract the foreskin if applicable .

Based on observation, interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #2) reviewed for quality of care. The facility failed to complete weekly skin assessment for Resident #2 for 2 out of 10 weeks (week of 9/24/2025 and week of 11/06/2025) per the care plan and facility policy. This failure could place residents at risk of not receiving necessary medical care, harm, and hospitalization. The findings included: Record review of Resident #2's admission Record, dated 11/18/2025, reflected a [AGE] year-old male. He was admitted on [DATE]. Record review of Resident #2's Diagnosis Report, dated 11/18/2025, reflected diagnoses which included encephalopathy (a disease in which the function or structure of the brain is affected, typically caused by infection, tumor, or stroke), acute (quickly has become severe) cholecystitis (the swelling and irritation or inflammation of the gallbladder), and sepsis (a condition in which the body's extreme response to an infection become life-threatening). Record review of Resident #2's Quarterly MDS Assessment, dated 10/27/2025, reflected the resident had a BIMS score of 14, which indicated he was cognitively intact. He normally used a wheelchair and required partial/moderate assistance to roll left and right on in the bed, to move from sitting to lying, from sitting to standing, and to transfer from the chair/bed-to-chair. He was noted to be at risk of developing pressure ulcers/injuries, but to not have any present skin ulcers or injuries. Record review of Resident #2's Care Plan Report, dated as last care plan review completed 11/10/2025, reflected pressure ulcer: At risk for PI [Pressure Injury] r/t incontinence, date initiated and revised 09/10/2025. Interventions included Weekly skin assessment per facility protocol date initiated 09/10/2025. Record review of Resident #2's Order Summary Report, dated 11/18/2025 for Active Orders as of 11/18/2025, reflected Resident #2 did not have an order for weekly skin assessments. Record review of Resident #2's Standard Assessments tab in the EMR on 11/18/2025 at 04:14 p.m., reflected Resident #2 did not have a weekly skin assessment for the weeks of 09/24/2025 and 11/06/2025. Record review of Resident #2's Progress Notes, dated 09/17/2025 to 10/01/2025 did not reveal a progress note describing Resident #2's skin status. A progress note entered 09/24/2025 at 12:15 p.m. by LPN B, reflected .requires supervision to extensive assist of one with ADLs. Incontinent of B&B. Res denies pain or discomfort at this time.Caring for JP drains [a think flexible tube that drains fluid away from a wound after surgery] and surgical wounds. Record review of Resident #2's Progress Notes, dated 11/01/2025 to 11/19/2025, did not reflect a progress note describing Resident #2's skin status. Record review of Nursing Staff Assignments titled November 11/3 - 11/9, reflected LPN C was the facility nurse for day shift, 07:00 a.m. to 07:00 p.m. from 11/03/2025 - 11/06/2025 and 11/08/2025 - 11/09/2025. During an observation and interview on 11/20/2025 at 10:35 a.m., Resident #2 was observed lying in bed with no visible injuries. Resident #2 stated the facility staff took care of him and denied having any skin issues. During an interview on 11/20/2025 at 12:35 p.m., LPN C stated she could not recall completing a skin assessment on Resident #2 during the week of 11/06/2025. LPN C stated she knew a resident's skin assessment was due because it would show up on the nurses' Medication Administration Record but could not recall specifically if Resident #2 had one due. During an interview on 11/20/2025 at 12:56 p.m., the DON stated the weekly skin assessment would not show up on the Medication or Treatment Administration Record unless the assessment was ordered. The DON stated she felt the impact of a resident having missed a weekly skin assessment would depend on multiple variables. She stated she did not believe Resident #2 having missed a skin assessment would have been detrimental for him because his incontinence brief was changed as needed, so if he had any skin impairments, there would be someone whose eyes would have been on the skin to notify the appropriate people. During an interview on 11/20/2025 at 01:47 p.m., the ADMIN stated the impact of a resident having missed a skin assessment would depend on the resident, their dietary needs, and their functional needs. She stated for a resident that who had his incontinent brief changed frequently and had received shower assistance, the aides would have seen his skin multiple times per day. The ADMIN stated she did not believe Resident #2 would have been impacted by a missed skin assessment because he was constantly monitored by therapy staff, received incontinent care and shower assistance, and his meal intake was pretty good. Record review of the facility's policy, Skin Assessment, dated as Copyright 2025, reflected: Policy: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment.Policy Explanation and Compliance Guidelines:1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter.7. Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title. b. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.). c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). e. Document if resident refused assessment and why. f. Document other information as indicated or appropriate.

Based on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #3) of 3 residents reviewed for pharmacy services. The facility failed to ensure staff timely acquired and administered Resident #3's cefazolin (antibiotic used to treat and prevent bacterial infections. It is administered intravenously) per physician orders on 2/13/25 and 2/14/25. The failure could place residents at risk for exacerbation of health conditions, worsening of conditions, and physical/emotional discomfort. Findings included:Record review of Resident #3's face sheet, dated 7/9/25, revealed a [AGE] year-old male resident admitted on [DATE] and discharged on 2/17/25 with diagnoses of encounter for surgical aftercare following surgery on the nervous system (his back), partial traumatic amputation of two or more right lesser toes (two toes were surgically removed), type 2 diabetes mellitus with unspecified complications (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood glucose.), intraspinal abscess (collection of pus and infectious material in the spine, often resulting from a bacterial infection) and granuloma (localized area of inflammation that forms around an infection often as a response to the immune system's attempt to clear the infection), depression, osteomyelitis of vertebra- thoracolumbar region (an infection of the vertebrae in the spine), discitis (inflammation or infection that develops between the intervertebral discs of your spine), spondylosis without myelopathy or radiculopathy (degeneration of the vertebral column), schizophrenia (a chronic mental health condition characterized by symptoms of hallucinations (seeing or hearing things that are not there), delusions (false beliefs), disorganized thinking, and difficulty distinguishing reality from imagination.), and methicillin susceptible staphylococcus aureus infection (a type of bacterial infection caused by staphylococcus aureus). Record review of Resident #3'd discharge MDS assessment, dated 2/17/25, revealed the resident memory was severely impaired for daily decision making. Record review of Resident #3's admission and baseline care plan/summary, dated 2/13/25, revealed the Resident had an IV PICC to the left arm and had staples on his back from prior surgery. Record review of Resident #3's comprehensive care plan, dated 7/9/25, revealed he had impaired cognitive function process related to disease process with interventions to monitor/document/report physician changes in cognitive function, specifically changes in: a) decision making ability b) memory, recall and general awareness c) difficulty expressing self d) difficulty understanding others e) level of consciousness f) mental status, and notify the physician with an initiated date of 2/20/25. Record review of Resident #3's physician orders, dated 7/9/25, revealed an order for Cefazolin sodium injection solution reconstituted 2 grams, use 2 grams intravenously three times a day related to methicillin susceptible staphylococcus aureus infection until 5/2/25 to be given three times a day for 11 weeks. The order had a started date of 2/14/25 and an end date of 5/2/25. Record review of Resident #3's February MAR, dated 7/9/25, revealed an order for Cefazolin three times a day between 6 a.m.-10 a.m., 2 p.m.-6p.m., and 6p.m.-10 p.m. The MAR reflected the following administration records: -2/13/25 the 6 p.m.-10 p.m. dose was missed (order not entered until 2/14/25 at 3:15 p.m.)-2/14/25 the 6 a.m.- 10 a.m. dose was missed (order not entered until 2/14/25 at 3:15 p.m.) Record review of Resident #3's hospital #1's discharge paperwork, dated 2/12/25, reveled he needs to be on IV antibiotics 12 weeks followed by long-term oral antibiotics . Record review of Resident #3's hospital #2 admission record, dated 2/17/25, did not reveal much information and only stated AMS altered mental status under the stated complaint. Record review of Resident #3' hospital #3 admission record, dated 2/17/25, stated [Resident #3] . a significant past medical history of: Diabetes mellitus type 2, hypertension, hyperlipidemia, iron deficiency anemia, schizophrenia, infectious disease with osteomyelitis on the right foot toes. Patient who presents as a transferred from the outlying [Hospital 1] for higher level of care due to complaints of altered mental status and worsening of back pain, no history on note and patient is encephalopathy (broad term for any disease or disorder that affects the brain's function or structure. It can result from various causes including infections, toxins, metabolic issues, or lack f oxygen) unable to provide any history.At the initial evaluation the patient appears: confused, hypoxic (inadequate levels of oxygen in the tissues and cells of the body), somnolent (sleepy or drowsy). recommendation will be observation admission for medical management and evaluation.Hx Obtained From Prior medical records. During an interview on 7/10/25 at 1:30 p.m. LVN B stated the couple of times she had worked with Resident #3 he had behaviors of trying to get out of bed, playing with his feces, trying to eat the blinds, and pulling his PICC line. LVN B stated she made the ADON and provider aware of the resident's status. LVN B stated she was not the nurse who did the admission assessment for Resident #3 and was not aware of what his admission orders were. LVN B stated since then they used an admission check list form to track and communicate new admission orders. During an interview on 7/10/25 at 4:20 p.m. The ADON stated LVN D had not put the antibiotic order in when she admitted the resident on 2/13/25 because she needed clarification of the order and was not sure how to administer it. The ADON stated LVN D should have reported to the oncoming nurse LVN B that the order was not put in, but LVN D did not report this to LVN B at shift change. The ADON stated she entered the order herself the on 2/14/25. The ADON stated they also implemented the use of a new check list form since the incident. The ADON stated they had done several in-services over the incident because LVN D never input the order for the antibiotic on admission. The ADON stated LVN D no longer worked for the facility and was terminated due to another med error. The ADON stated the Resident was sent to the hospital on 2/17/25 for altered mental status. During an interview on 7/10/25 at 2:26 p.m. The MD stated he recalled Resident #3 pulled out his PICC line a few times and became more altered. The MD stated he was not able to remember if he was the physician on call that was contacted when the resident pulled out his PICC line and was having behaviors. The MD stated although Resident #3 may have missed a few doses of his antibiotic, that antibiotic had a good half-life (the time it takes a for the concentration of the drug in the bloodstream to decrease by half). The MD stated the resident also had a history of psychiatric disease and was admitted with the infection. The MD stated he did not think missing a few doses of the antibiotic would have contributed to his AMS. The MD stated he could not recall if he was notified of the initial missed doses and only knew of the doses of antibiotics that were missed from the resident pulling his PICC line. During an interview on 7/10/25 at 5:04 p.m. a pharmacist stated the facility ordered the 2 mg IV push of cefazolin on 2/14/25 at 2:41 p.m. and was delivered to the facility just after midnight on 2/15/25. The Pharmacist stated interrupted antibiotic therapy is not a good thing, but you would need to see labs or signs and symptoms to know if the infection had worsened. Record review of the facility's policy titled admission of a Resident, dated 5/16/25, stated Policy: The admission process is intended to obtain all possible information regarding the resident or the development of the comprehensive care plan, and to assist the resident in becoming comfortable in the facility. Residents are admitted to the facility under orders of the attending physician. Policy explanation and compliance guidelines.b. Once the resident/family had selected the facility, pre-admission information should be gathered. Preadmission information may include, but is not limited to.i. physician's orders.

Based on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated and report the results of all investigations to the state survey agency within five working days of the incident for 5 (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 8 residents reviewed for abuse and neglect. The facility failed to thoroughly investigate 4 separate facility reported incidents involving Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 within five (5) days regarding allegations of abuse or neglect and submit a 3613-A of the findings. This deficient practice could place residents at risk of harm from neglect due to not having a thorough investigation done for facility reported incidents. The findings included. 1. Record review of Resident #2’s face sheet dated 7/10/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included severe protein-calorie malnutrition, lack of coordination, contracture to right and left knee, pain, muscle wasting, muscle weakness, unsteadiness of feet, fracture of the right foot, and need for assistance with personal care. Record review of Resident #2’s most recent quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills, required substantial/maximal assistance with transfers and was always incontinent of bowel and bladder. Record review of Resident #2’s comprehensive care plan with revision date 8/13/24 revealed the resident was impaired with physical functioning related to muscle weakness with interventions that included substantial/maximal assistance with transfers, and partial/moderate assistance with rolling left to right. During an observation and interview on 7/8/25 at 11:01 a.m., Resident #2 stated she reported to a family member about CNA C being rough with her when the CNA tried to reposition her while in bed. Resident #2 stated her family member reported the complaint to the former SW (Social Worker). Resident #2 stated, CNA C “would turn me over, and I would hit the wall.” Resident #2’s bed was placed up against the wall on the right side of the bed and a large piece of padded foam was observed covering the right side of the wall. Resident #2 stated the padded foam was placed on the right of the bed against the wall because CNA C would turn her and her legs, which were contracted and bent at the knee, “would bang her against the wall.” Resident #2 stated the former Administrator had informed her that he had talked to CNA C about the incident, had moved her to another hall, but then CNA C stopped working a short time later. During a telephone interview on 7/9/25 at 1:18 p.m., CNA C stated she had provided care to Resident #2 on several occasions and recalled being suspended because Resident #2 had accused her of hitting the resident’s legs against the wall when repositioning. CNA C stated, Resident #2 never complained to her about it and denied the allegation. During an interview on 7/9/25 at 1:27 p.m., the former SW stated she interviewed Resident #2 regarding the allegation that CNA C had hit her knees against the wall and the former SW then reported the incident to the former Administrator. The former SW stated she recalled doing interviews with other residents regarding abuse/neglect as part of the investigation but then the former Administrator and the former DON took over after that. During an interview on 7/10/25 at 3:47 p.m., the ADON stated the former Administrator at the time made himself in charge of doing the investigation portion that would have been submitted to the State Survey Agency. The ADON stated there was no documentation showing an investigation had been done for the incident involving Resident #2 and CNA C, reported on 1/26/25. 2. Record review of Resident #3’s face sheet, dated 7/9/25, revealed a [AGE] year-old male resident admitted on [DATE] and discharged on 2/17/25 with diagnoses of encounter for surgical aftercare following surgery on the nervous system (his back), partial traumatic amputation of two or more right lesser toes (two toes were surgically removed), type 2 diabetes mellitus with unspecified complications (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood glucose.), intraspinal abscess (collection of pus and infectious material in the spine, often resulting from a bacterial infection) and granuloma (localized area of inflammation that forms around an infection often as a response to the immune system’s attempt to clear the infection), depression, osteomyelitis of vertebra- thoracolumbar region (an infection of the vertebrae in the spine), discitis (inflammation or infection that develops between the intervertebral discs of your spine), spondylosis without myelopathy or radiculopathy (degeneration of the vertebral column), schizophrenia (a chronic mental health condition characterized by symptoms of hallucinations (seeing or hearing things that are not there), delusions (false beliefs), disorganized thinking, and difficulty distinguishing reality from imagination.), and methicillin susceptible staphylococcus aureus infection (a type of bacterial infection caused by staphylococcus aureus). Record review of Resident #3’d discharge MDS assessment, dated 2/17/25, revealed the resident memory was severely impaired for daily decision making. Record review of Resident #3’s admission and baseline care plan/summary, dated 2/13/25, revealed the Resident had an IV PICC to the left arm and had staples on his back from prior surgery. Record review of Resident #3’s comprehensive care plan, dated 7/9/25, revealed he had impaired cognitive function process related to disease process with interventions to monitor/document/report physician changes in cognitive function, specifically changes in: a) decision making ability b) memory, recall and general awareness c) difficulty expressing self d) difficulty understanding others e) level of consciousness f) mental status, and notify the physician with an initiated date of 2/20/25. Record review of Resident #3’s physician orders, dated 7/9/25, revealed an order for Cefazolin sodium injection solution reconstituted 2 grams, use 2 grams intravenously three times a day related to methicillin susceptible staphylococcus aureus infection until 5/2/25 to be given three times a day for 11 weeks. The order had a started date of 2/14/25 and an end date of 5/2/25. Record review of Resident #3’s February MAR, dated 7/9/25, revealed an order for Cefazolin three times a day. The MAR reflected the following administration records: -2/13/25 the 6 p.m.-10 p.m. dose was missed (order not entered until 2/14/25 at 3:15 p.m.) -2/14/25 the 6 a.m.- 10 a.m. dose was missed (order not entered until 2/14/25 at 3:15 p.m.) -2/14/25 the 2 p.m.- 6 p.m. dose was administered (not documented on the MAR but in a late entry nursing note on 2/17/25) -2/14/25 the 6 p.m.-10 p.m. dose was missed (pulled PICC line) -2/15/25 the 6 a.m.- 10 a.m. dose was missed -2/15/25 the 2 p.m.- 6 p.m. dose was administered -2/15/25 the 6 p.m.- 10 p.m. dose was administered -2/16/25 the 6 a.m.- 10 a.m. dose was administered -2/16/25 the 2 p.m.- 6 p.m. dose was administered -2/16/25 the 6 p.m.-10 p.m. dose was missed (pulled PICC line) Record review of nursing progress notes, dated 7/9/25 revealed the following notes: -2/14/25 at 5:30 p.m., written by LVN D, stated “resident is not cooperating staying in his chair or bed. he keeps trying to get up from chair and is rolling around everywhere. CNA tried to adjust him for him to feel comfortable but still is not cooperative” -2/14/25 at 10:38 p.m., written by LVN E, stated “resident pulled his PICC line out earlier, pending new insertion, no IV access at this time”. -2/15/25 at 1:19 p.m., written by LVN B, stated “Picc line placed to Left Upper Arm resident tolerated procedure well no complications or complaints. Pending x-ray results to verify placement to start IV medication.” -2/16/25 at 12:14 p.m., written by RN F, stated “… [Resident #3] continues to be confused and forgetful. Has attempted x1 to remove PICC, was stopped prior to removing bandage, PICC in place, bandage reinforced. He is able to feed himself but continues to try and transfer himself but is unable to stand well even with x2 staff full assist. He removes his clothing, brief and bed sheets/linen repeatedly. No s/s of pain or distress. States . who put me here. Call light within reach, however [Resident #3] does not appear to be able to use it appropriately as indicated by unclipping it and throwing on floor along with everything else. Staff continues to monitor.” -2/16/25 at 7:08 p.m., written by LVN B, stated “Resident continuously found hanging head off the side off the bed and legs/feet bed in lowest position against wall with fall mat in place. Resident pulled blinds completely off window and was trying to eat the pieces he pulled off. Resident cannot use call light or bed remote properly cords found wrapped around his arms.” -2/16/25 at 9:16 p.m., written by LVN B, stated “Notified by cna resident was in bed blood noted on sheets upon assessment midline had been pulled out and resident covered in fresh feces resident noted to be eating feces. ADON notified via text PCP paged. Midline found behind the bed line intact resident arm clean dry no bleeding noted.” -2/16/25 at 9:59 p.m., written by LVN B, stated “resident pulled midline out”. -2/17/25 at 12:58 p.m., written by LVN D, stated “resident threw sweet tea at the window and started to lick it off from it. reoriented resident and offer him a new drink” -2/17/25 at 1:23 p.m., written by LVN D, stated “called hosipital [sic] Atascosa to give report but no answer from the hospital x3” During an interview on 7/10/25 at 1:30 p.m. LVN B stated the couple of times she had worked with Resident #3 he had behaviors of trying to get out of bed, playing with his feces, trying to eat the blinds, and pulling his PICC line. LVN B stated she made the ADON and provider aware of the resident’s status. LVN B stated she was not the nurse who did the admission assessment for Resident #3 and was not aware of what his admission orders were. LVN B stated since then they used an admission check list form to track and communicate new admission orders. During an interview on 7/9/25 at 3:33 p.m. the ADON stated the previous Administrator had reported on 2/14/25 facility failed to notify MD that resident pulled out midline resulting in non-administration of meds. No hold order was obtained; no documentation obtained for monitoring the midline. Resident sent to hospital for assessment to the state. The ADON stated they did not have any investigation reports for this self-report. The ADON stated they had done several in-services over the incident because LVN D never in put the order for the antibiotic on admission. The ADON stated she entered the order herself the on 2/14/25. The ADON stated they also implemented the use of a new check list form since the incident. The ADON stated LVN D no longer worked for the facility and was terminated due to another med error. 3. Record review of Resident #4’s face sheet, dated 7/10/25, revealed a [AGE] year-old male resident admitted on [DATE] and readmitted on [DATE]. with diagnoses of hypo-osmolality and hyponatremia (lower than normal concentrations of solutes leading to low sodium levels in the blood), polydipsia (excessive thirst), and vascular dementia (cognitive impairment resulting from conditions that affect blood flow to the brain) with other behavioral disturbance. Record review of review of Resident #4’s quarterly MDS assessment, dated 6/18/25, revealed he had moderately impaired cognition for daily decision making. Record review of Resident #4’s care plan, revised 4/8/25, stated “I have angry outbursts at times when I don't get the response that I am seeking. I rummage through belongings that are not mine. I layer my clothing and take things that do not belong to me. At times I am observed having auditory and visual hallucinations. Resident to Resident: I pushed another resident and caused skin tears to arm.” Interventions included document behaviors, psych eval and medication review, refer to behavior health as needed, staff to explain care prior to and during process of care, staff to involve family as necessary to assist with behavioral management, and staff to redirect resident to other activities. Record review of Resident #5’s face sheet, dated 7/10/25, revealed an [AGE] year-old made resident admitted on [DATE], readmitted on [DATE], and discharged on 6/5/25 with diagnoses of chronic obstructive pulmonary disease (damage to the lungs leading to swelling and irritation in the airways that restrict airflow), type 2 diabetes (when the body cannot use insulin correctly and sugar builds up in the blood), and vascular dementia with other behavioral disturbances (cognitive impairment resulting from conditions that affect blood flow to the brain). Record review of Resident #5’s significant change MDS assessment, dated 5/6/25, revealed the resident cognition was severely impaired for daily decision making. Record review of Resident #5’s care plan, last revised 6/9/25, revealed the resident had potential for skin related issues related to poor hygiene, decreased mobility, squamous cell carcinoma of skin of scalp and neck (skin cancer), and bullous pemphigoid (rare skin condition that causes large fluid filled blisters), with intervention to provide wound care/ preventative skin care per order, skin checks weekly per facility protocol, document findings, treatment as ordered an x-ray to arm, and wound care consultation to evaluate and treat. Record review on 7/9/25 at 1:55 p.m. revealed an intake was submitted to the state agency reporting Resident #4 shoved Resident #5 on 2/13/25. No provider investigation report was available. During an interview on 7/9/25 at 3:14 p.m. the ADON stated the only documents they had related to this investigation was an in service. The ADON stated the previous Administrator was handling the self-reports. The ADON stated during the altercation Resident #4 pushed Resident #5 with his hands. Resident #5 already had skin tears on his arms that had scabbed over but reopened when he was pushed. The ADON stated the Residents were separated and monitored after. The ADON stated Resident #4 had more health-related issues recently and mostly used a wheelchair to ambulate and was no longer aggressive towards other residents. At the time of the interview Resident #4 was in the hospital for an unrelated health issue. 4. Record review of Resident #6’s face sheet, dated 7/10/25, revealed an [AGE] year-old made resident admitted on [DATE], readmitted on [DATE], with diagnoses of major depressive disorder single episode, legal blindness, anxiety disorder, post-traumatic stress disorder, attention and concentration deficit, and unspecified mood [affective] disorder. Record review of Resident #6’s Annual MDS assessment, dated 6/15/25, revealed the resident cognition was severely impaired for daily decision making. Record review of Resident #6’s care plan, last revised 4/8/25, revealed the “I get nervous and anxious at times. I repeatedly state help me even after staff have attempted to reassure me that I am okay. When asked what is wrong, I typically respond I don't know. I report symptoms of depression (feeling down, little pleasure in doing things, poor concentration, poor appetite, difficulty sleeping, feeling bad about myself) and sometimes relate them to experiences from my past.” Interventions included call resident by name, if upset redirect the conversation or task, offer things that are soothing, and avoid things that make the resident more anxious. Record review on 7/9/25 at 1:55 p.m. revealed an intake was submitted to the state agency reporting Resident #6 reported a staff member struck him in the face with an open hand on 1/31/25. Resident refused to provide a name of the staff member. No provider investigation report was available. During an interview on 7/10/25 at 7:21 p.m. Resident #6 stated something happened about 6 months ago but he did not want to talk about it. Resident #6 stated he felt safe at the facility. Resident #6 then stopped answering question and pursed his lips. During an interview on 7/9/25 at 3:12 p.m. the ADON stated they did not have any investigation reports related to the incident with Resident #6. The ADON stated she did recall they had done resident safe interviews but could not locate them. The ADON stated the resident reported this incident to his behavior health therapist. The ADON stated the resident is blind and provided a physical description of the alleged perpetrator but there was not staff that fit the description. The ADON stated they had the resident listen to staff who worked the day voices, and he denied it was any of those staff members. The ADON stated a full body assessment was done, and the resident had no marks. During a follow up interview on 7/10/25 at 6:09 p.m., the ADON stated she had contacted the former Administrator and was told he left all the facility investigation reports in the current Administrator’s office. The ADON stated the current Administrator was looking for the reports in the office but could not find them and were not made available to the survey team at the time of exit. The ADON was unfamiliar with official reporting requirements to the state. Record review of the facility document titled, Abuse Prevention Program, dated 2022 revealed in part, “…Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to…verbal, mental, sexual or physical abuse…As part of the resident abuse prevention, the administration will…Protect our residents from abuse by anyone including…staff, other residents, or any other individual…Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents…Implement measures to address factors that may lead to abusive situations…Identify and asses all possible incidents of abuse…Investigate and report any allegations of abuse within timeframes as required by federal requirements…”

Based on interview and record review, the facility failed to ensure residents had the right to be free from accidents for 1 of 5 residents (Resident # 196) reviewed for accidents and hazards. On 9/19/2024, Resident # 196 was not properly secured in the facility transport van and sustained a head laceration and a fractur to her right clavicle. The non-compliance was identified as past noncompliance. The IJ began on 9/19/2024 and ended on 9/19/2024. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of harm, serious injury, or death. Findings include: Record review of Resident # 196's face sheet revealed she was admitted [DATE] with an initial admission on 9/19/2023 with diagnoses of traumatic brain injury, transient ischemic attack (mini stroke), depression and alcohol abuse. Record review of Resident # 196's MDS indicated a BIMS score of 15 indicating no cognitive impairment. Record review of the Facility Incident Report, dated 9/23/2024, reflected the transport driver failed to buckle Resident # 196 prior to transportation to an appointment via the facility van. Record review of Resident #196's hospital record dated 9/19/2024 revealed: Acute oblique fracture of the right distal clavicle and right frontoparietal scalp contusion and laceration. Record review of a written statement from the van driver dated 9/19/2024 revealed: He admitted resident slid out of the wheelchair when he had to stop abruptly. Resident's head slid under the backseat causing a laceration. Van driver immediately transported the resident to the local hospital emergency room . Attempted to call van driver on 10/1/2024 at 9:30 am, no answer, unable to leave a message. Attempted to call van driver again on 10/2/24 at 1:00 pm, again no answer and unable to leave a message. No return call as of exit date. During a telephone interview on 10/1/2024 at 1:44 pm with CNA K, she stated that she, the resident's family member, and the van driver were all in the van when transporting Resident #196 to her appointment. The van driver made a sudden, abrupt stop due to a car stopping in front of him. This caused Resident #196 to slide out of her wheelchair and under the seat in front of her because she was not secured with lap belt or cross body strap. She stated the van driver pulled over to check on the resident and that the resident was bleeding from her head. The van driver immediately transported the resident to the local hospital emergency room . During an interview on 10/1/2024 at 1:25 pm with Resident # 196's family member, she stated that she was sitting in the seat in front of the resident during transport and that when the van came to a sudden, abrupt stop, she turned around and saw Resident #196 had slid out of the wheelchair and under her seat because the resident was not secured with a lap belt or cross body strap. She stated the resident's head was bleeding and that the van driver transported them to the local hospital emergency room immediately. Observation on 10/4/2024 at 9:20 am, of resident transportation on facility van by maintenance director- revealed maintenance director properly secured resident on the van lift, anchored the wheelchair in the van, and checked the seat belt and shoulder strap; no deficiencies or violations were noted. Record review of in-service training for Abuse and Neglect was provided to all staff on 9/19/2024. Record review of the Transportation Safety Checklist for 4 van drivers was completed by the administrator. Record review of in-service certification conducted on 9/19/2024 on transportation safety for 8 employees was conducted by the administrator. Record review of in-service certification conducted on 9/19/2024 on transportation safety for employees responsible for transportation was conducted by the administrator to include: Checking seat belts and wheelchair tiedowns to make sure they are operational and safe for use, Secure wheelchair using wheelchair tiedown, Place safety belt on resident, Double check wheelchair restraints and safety belt are secure, Re-eval of all transport drivers, Transportation safety checklist to include: Equipment is visually checked for proper working conditions prior to loading residents, Safety straps are not frayed, torn or broken, Vehicle is not started until all passengers are properly seated and secured. How and who to report neglect to. Record review of safety binder titled, Transportation Safety Checklist, revealed staff are using the safety checklist when transporting residents. Staff interview with DON on 10/4/2024 at 9:25 am, she stated she was in-serviced on key elements of transporting residents and the van safety checklist which included: Checking seat belts and wheelchair tiedowns to make sure they are operational and safe for use, secure wheelchair using wheelchair tiedown, place safety belt on resident, double check wheelchair restraints and safety belt are secure. Staff interview with HR personnel on 10/4/2024 at 9:40 am, she stated she was in-serviced on key elements of transporting residents and the van safety checklist which included: Checking seat belts and wheelchair tiedowns to make sure they are operational and safe for use, secure wheelchair using wheelchair tiedown, place safety belt on resident, double check wheelchair restraints and safety belt are secure. Staff interview with OT staff on 10/4/2024 at 9:55 am, she stated she was in-serviced on key elements of transporting residents and the van safety checklist which included: Checking seat belts and wheelchair tiedowns to make sure they are operational and safe for use, secure wheelchair using wheelchair tiedown, place safety belt on resident, double check wheelchair restraints and safety belt are secure. Staff interview with housekeeping staff on 10/4/2024 at 10:10: am, she stated she was in-serviced on key elements of transporting residents and the van safety checklist which included: Checking seat belts and wheelchair tiedowns to make sure they are operational and safe for use, secure wheelchair using wheelchair tiedown, place safety belt on resident, double check wheelchair restraints and safety belt are secure. Staff interview with activities staff on 10/4/2024 at 10:25 am, she stated she was in-serviced on key elements of transporting residents and the van safety checklist which included: Checking seat belts and wheelchair tiedowns to make sure they are operational and safe for use, secure wheelchair using wheelchair tiedown, place safety belt on resident, double check wheelchair restraints and safety belt are secure. Staff interview with business office staff on 10/4/2024 at 10:25 am, she stated she was in-serviced on key elements of transporting residents and the van safety checklist which included: Checking seat belts and wheelchair tiedowns to make sure they are operational and safe for use, secure wheelchair using wheelchair tiedown, place safety belt on resident, double check wheelchair restraints and safety belt are secure. Staff interview with medical records staff on 10/4/2024 at 10:35 am, she stated she was in-serviced on key elements of transporting residents and the van safety checklist which included: Checking seat belts and wheelchair tiedowns to make sure they are operational and safe for use, secure wheelchair using wheelchair tiedown, place safety belt on resident, double check wheelchair restraints and safety belt are secure. Staff interview with maintenance personnel on 10/4/2024 at 10:45 am, he stated he was in-serviced on key elements of transporting residents and the van safety checklist which included: Checking seat belts and wheelchair tiedowns to make sure they are operational and safe for use, secure wheelchair using wheelchair tiedown, place safety belt on resident, double check wheelchair restraints and safety belt are secure. The non-compliance was identified as a past non-compliance IJ. The non-compliance began 9/19/2024 and ended 9/19/2024. The facility had corrected the non-compliance before the investigation began on 10/1/2024.

Based on interviews and record reviews, the facility failed to provide a full code resident with AED use during CPR as per facility policy for 1 (Resident #4) of 7 residents reviewed for Advanced Directives. The facility failed to provide a full code(full support which includes cardiopulmonary resuscitation (CPR), if the patient has no heartbeat and is not breathing.) for Resident#4 with AED use during CPR as per facility policy. The non-compliance was identified as past non-compliance (PNC). The PNC IJ began on [DATE] and ended on [DATE] . The facility had corrected the non-compliance before the state's investigation began on [DATE] at 9:30 AM. This failure could place residents at risk for not receiving correct CPR as per facility policy. The findings included: Record review of Resident #4's face sheet dated [DATE] reflected Resident #4 was admitted initially on [DATE] with a readmission of [DATE] with diagnoses of DM2, s/p left above knee amputation, congestive heart failure, COPD, hypertension, anxiety, arteriosclerotic heart disease, peripheral vascular disease, end stage renal disease with dialysis on M-W-F. Record review of Resident #1's state optional MDS assessment, dated [DATE] , reflected Resident #1 had a BIMS score of 15 , indicative of cognitively aware. Record review of Resident #1's care plan dated, [DATE], reflected Resident #1 had chosen to be a full code and requested to have CPR if needed. With interventions of CPR will be performed as ordered and follow facility protocol for identification of code status. Record review of Nurses note, authored by LVN A dated [DATE] at 7:15 AM reflected- note text: 4:00 AM CNA B noted resident without respirations. 4:03 AM called nurse, 4:05 AM This nurse noted no respirations or pulse, started CPR. 4:09 AM EMS called. 4:12 AM EMS arrived along with county deputy . 4:52 AM EMS left facility after receiving orders from their MD to cease CPR. Resident was pronounced deceased on [DATE] at 4:45 am. In an observation on [DATE] at AM revealed at the main nurses station had an AED hanging on the wall. And a crash cart positioned near it. During a telephone interview on [DATE] at 11:39 am CNA B stated she went into Resident #4's room to do the 4:00 am check and found Resident #4 in his bed in normal lying position with HOB elevated, not breathing. She stated she immediately called out to the nurse(LVN A) who was at the nurses' station to come quick something was wrong. She further revealed LVN A immediately came to Resident #4's room, checked Resident #4 with her stethoscope, and stated he was not breathing. CNA C was told to go get the crash cart by LVN A and to call 911. CNA B stated she and LVN A performed CPR until EMS arrived. When asked if AED was used, CNA B stated, I did not think about it at the time. During a telephone interview on [DATE] at 12:34 pm LVN A stated she was at the nurses' station when she heard CNA B call out to come to Resident #4's room because something was wrong with him. LVN A immediately went to Resident #4's room and observed no respirations or pulse, immediately started CPR. CNA C was told by LVN A to go get crash cart and 911- EMS was called. LVN A stated at 4:12 am EMS arrived and at 4:52 am EMS left after receiving orders from their MD to cease CPR. She stated the resident was pronounced at 4:45 am by EMS. When asked if AED was used, LVN A stated, I did not think of it at the time. During an interview on [DATE] at 1:00 pm with the facility DON she stated it was the policy of the facility to use the AED during a code or CPR. Record review of facility policy titled Automatic External Defibrillator, Use and Care of , date Quarter 3, 2018: Personnel have completed training on initiation of cardiopulmonary resuscitation (CPR) and basic life support(BLS), including defibrillation, for victims of sudden cardiac arrest. 3. The automatic external defibrillator (AED) will be used to try to restore normal cardiac rhythm when arrhythmia is strongly suspected. The facility took the following measures after the event on [DATE] and prior to surveyor entrance: 1. Suspended LVN A immediately pending investigation. 2. In-services on Abuse and Neglect, AED, CPR and mock codes with 100% of their staff. 3. Clinical staff had mock code on [DATE]. 4. Ad Hoc QAPI determined monthly mock codes on each shift will be done for 6 months. Record review of In-Service Sign in sheet started on [DATE], reflected the following topics: In-services on Abuse and Neglect, AED, CPR and mock codes with 100% of their staff. During interviews starting on [DATE] at 9:45 AM through [DATE] 4:00 PM 10 staff interviews : to include 3 night shift nursing staff, 2 day shift housekeeping, 5 nursing staff who work days and evening shifts indicated they had received training on Abuse and Neglect, AED, CPR and mock codes. Ad-Hoc QAPI meeting was held to discuss the incident. Additionally, local EMS and police department were notified. Facility suspended LVN A pending investigation.

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibit neglect for 4 of 12 residents (Residents # 9, # 11, # 12, and # 15) whose care was reviewed for safe smoking, in that: 1. Resident # 9 required constant supervision, had his cigarettes and lighter with him, was smoking in a No Smoking area close to a propane tank and a high voltage panel without supervision, and was not supposed to be allowed to have his smoking material with him. 2. Resident #11 had her cigarettes and lighter with her and pulled them from her eye glass case and was not supposed to be allowed to have her smoking material with her. 3. Resident # 12 had been given cigarettes by the facility staff when he smoked at the facility and had not been assessed with [REDACTED]. 4. Resident # 15 was assessed as being an independent smoker and could have his smoking material in a secured box in his room but the material was not secured. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on 6/17/14. While the IJ was removed on 6/19/14, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was not an immediate jeopardy due to the facility not yet completing in-service training for all staff on enforcement of the smoking policy and counseling all residents who smoked and their families regarding rules for smoking at the facility. These failures could result in fire hazard with injury and could affect the 16 residents on the 200 and 300 halls. The findings were: 1. Resident # 9's face sheet dated 2/22/14 revealed he was admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident # 9's RCCT (Reality Comprehension Clock Test used to measure resident's cognitive factors) revealed a score of 16 out of 67 which indicated the resident was Moderately Severe in the functioning range and had a functioning age of 5XXX[AGE] years with this score. Record review of Resident # 9's last MDS dated [DATE] revealed his Cognitive Decision making skills were scored at a 10 indicating moderately impaired cognition. Record review of Resident # 9's Care Plan dated 3/3/14 revealed he was "a smoker and had been talked to about not keeping cigarettes and lighter on his person...continued to be non-compliant." The goal of his care plan was to ensure that he would not smoke without supervision through his review date of 6/1/14. The interventions the team put into place were the resident "required supervision while smoking" and the resident's smoking supplies were to be stored at the Nurses' station in the smoker box. Observation on 6/17/14 at 10:25 a.m. from the kitchen door window (exit to the outside area) revealed Resident # 9 smoking a cigarette while sitting down on a chair that was in front of the kitchen door. Further observation revealed Resident # 9 placing a cigarette lighter into his right side front pocket of his pants and extinguishing the cigarette and tucking the cigarette butt inside the fold of his cap that he was wearing. The surveyor notified the DS (Dietary Supervisor) of the observation. Interview with the DS at this time, during continued observation of Resident # 9, revealed that the door to the outside from the hallway was left open so that residents could go outside. The DS stated he was aware that Resident # 9's care plan included the resident's smoking. The DS added that the resident had a history of [REDACTED]." Observation of the Activity Director (AD) on 6/17/14 at 11:00 a.m. revealed she was at her desk in the conference room putting 1 or 2 cigarettes into individual bags and labeling each for the specific residents. An interview with the AD at the same time, revealed that there were " 8 " smokers in the facility. She stated that she prepared the bags for several days in advance so the residents would have their cigarettes. She then took the box containing the individual bags out of the room and locked up the rest of the packs of cigarettes in a closet in the conference room. Record review of Resident # 9's MDS Kardex dated 6/17/14 revealed he was a smoker but smoked in non designated areas and hid and kept cigarettes and lighters. He needed "constant supervision." Record review of Resident # 9's Safe Smoking Evaluation dated 6/17/14 by the MDS Coordinator revealed he was determined to be a safe smoker with constant supervision. The Safe Smoking Evaluation revealed the following areas were assessed: -Type of Smoke (Cigarettes, Cigars, Pipe, E Cigarette, or other) -Cognition and Communication -Vision -Dexerity -Safety Observation -Determination (1. the residents were determined to be either safe or unsafe 2. Degree of supervison needed while smoking. The categories were no supervision required, Occasional supervision required, Frequent supervision, Constant supervision, or 1:1 Assist with smoking) -Cessation Materials (if the resident was interested and provided the information) -Notes (if any) -Signature Record review of a revised care plan for Resident # 9 dated 6/17/14 revealed the resident was observed smoking in non designated areas and keeping/hiding cigarettes/lighter. The goal remained the same with a target date of 8/31/14. The interventions were to instruct the resident about the facility's policy on smoking: locations, times, safety concerns. The charge nurse was to be notified immediately if it was suspected the resident had violated the facility's smoking policy. Record review of Resident # 9's Nurses noted dated 3/2/14 at 2:26 p.m. by LVN R revealed "Resident continues to be non-compliant with smoking, always wants his lighter> Previous shift reported resident was smoking in his room while in bed. Lighter confiscated by LVN S." Attempted to interview LVN R and LVN S without success, as they were no longer employed at the facility. Record review of Resident # 9's Nurses notes dated 4/8/14 at 6:34 p.m. by LVN G revealed "Resident witnessed smoking unsupervised outside of smoke break. When questioned he state someone gave me this. When questioned who someone was, resident smiled. Denied having lighter." Record review of Resident # 9's Nurses notes dated 4/8/14 at 8:40 p.m. by LVN G revealed "Witnessed resident outside smoking independently several times this shift. Resident refused to relinquish cigarettes or light. ADON aware." Interview on 6/19/14 at 3:00 p.m. with the ADON revealed she was not aware of the incident on 4/8/14. She stated she was new and had only been at the facility for three weeks. Interview on 6/19/14 at 3:30 p.m. with LVN G revealed Resident # 9 was caught many times smoking outside in non designated areas and was unsupervised during that time. She stated he had been confronted numerous times by the staff about the smoking policy and remained non-compliant. Record review of Resident # 9's Nurses notes dated 4/13/14 at 5:33 p.m. by LVN S revealed "Resident # 9 was again observed smoking with another resident in between smoke breaks. Resident refuses to cease smoking and hand over smoking materials despite multiple attempts to redirect. He states that the rules are for everyone but him and that the bosses are aware of what he does." Record review of Resident # 9's Nurses notes dated 4/15/14 at 6:59 a.m. by LVN T revealed: Resident observed with a cigarette lighter. Resident refused to give up either to nurse, Will notify the Administrator when he arrives to work." Attempted to interview LVN T but she was no longer employed at the facility. Record review of Resident # 9's Nurses notes dated 4/29/14 at 6:50 p.m. by LVN G revealed "Unsupervised smoking noted earlier in shift. Resident refused to be redirected." Record review of Resident # 9's Nurses notes dated 5/13/14 at 7:33 p.m. LVN G revealed "Witnessed resident smoking cigarettes multiple times this shift unsupervised. Denied having cigarettes or light when questioned." Record review of Resident # 9's Nurses notes dated 5/22/14 at 5:30 p.m. by LVN G revealed "Resident witnessed to be smoking independently. Denied having cigarettes or light when questioned." Record review of Resident #9's Nurses notes dated 5/29/14 at 5:58 p.m. by LVN G revealed "witnessed patient smoking unsupervised on back patio. When questioned patient denied having cigarrettes or lighter. Patient is own RP and aware of smoking unsupervised. Will continue to monitor." Observation of the designated smoking area on 6/17/14 at 1:55 p.m. revealed the residents were smoking and RA M was assisting the residents. An interview with RA M, at the time of the observation, also revealed the safe smokers were Resident # 9, Resident # 16, Resident # 22, and Resident # 11. She stated that when a new resident was admitted to the facility the nurses let the staff know if the resident smokes and what kind of supervision was needed. She stated the staff members were responsible for the supervision of the smokers and that the kitchen staff was responsible for the am time then the next one was the nurses or the CNAs. She stated they knew who was a safe smoker and who wore an apron. Interview on 6/17/14 at 1:25 p.m. with the DS revealed that cigarettes were removed "in the past" from Resident # 9 because he would have them in his possession (room/person). The DS also noted that the lighter was removed from the resident. The DS stated that the Administrator was handling the situation from this point on. Interview on 6/17/14 at 2:00 p.m. with CNA C revealed that there were 8 residents who smoked present in the smoking area and 2 were still in their rooms. CNA C stated that the nurse assigned to supervise the smoking area was not available so she filled in for that nurse. She stated that there were safe and unsafe smokers and that there was a book with names, but that she was familiar with the residents. CNA C stated that cigarettes were in a box in the "med room" and that she had to ask the nurse for the box. CNA C stated that once the supplies to smoke were obtained, the staff would make an announcement of the smoke break. CNA C stated that if cigarettes or a lighter were found on a resident, she would report that to the CN, DON or Administrator. CNA C stated that once the residents completed the smoke break the staff was required to collect the lighter and cigarette box and secure the "baggies" (that held the resident cigarettes). CNA C stated that housekeeping, maintenance or staff supervising would empty the ashtray. Interview on 6/17/14 at 3:13 p.m. with Cook H revealed that she supervised the 8:30 a.m. smoke break. She stated that the cigarettes were at the nurse's station under a cabinet, "maybe a cart." She stated that she asked the nurses to identify the "safe smokers" and provided those residents with cigarettes and assisted some residents with aprons. She would "light everyone's cigarettes ... no one should have a lighter." She stated that if she saw a resident with a lighter or cigarettes on them, she would report that resident to the nurse on staff. Cook H stated that she had not had any problems with Resident # 11 during smoke break and had seen Resident # 9 smoke by himself before (not clear on date) and had reported it to the CN. Interview on 6/17/14 at 3:25 p.m. with the DS revealed that the cigarettes were in a Tupperware box with a blue lid. That container had all the cigarettes for each resident labeled with each resident's name. The DS stated that he or the staff would announce the smoke break, residents would smoke 1 cigarette per break, more or less, and the staff would light the cigarettes for each resident. He stated that he would empty the ashtray in the "red bucket," which should be outside the fence. The DS stated that he would know if residents were "safe or not" to smoke from the morning meetings, the facility network system (PCC- computer software used by the facility), on his dietary assessment or the Admission Nursing Assessment. He stated that once he was aware of the smoking status he would inform his staff due to supervising the smoke breaks. The DS stated that about 2 weeks ago he had seen Resident # 9 smoking without supervision and told the resident that he was not to be in possession of the cigarettes and lighter on his person, so he took them away and reported the incident to the CN. The DS stated that he was aware that Resident # 9's Care plan was that the resident had to be supervised while smoking. Interview on 6/17/14 at 4:30 p.m. with the Maintenance Director revealed that the distance from where Resident # 9 was smoking by the kitchen exit to the generator with a "No smoking sign " was 27 feet, 8 inches. The Maintenance Director revealed that the generator had diesel fuel which was "flammable." The Maintenance Director stated that Resident #9 was next to a barbecue grill which had a propane container about half-full of propane, which was "still flammable." The Maintenance Director stated that the areas we were observing included the kitchen exit door, the dining room exit door, and the area by the vending machines and exit from the conference room, were "non-smoking areas." Further observation during this time revealed that against the wall by the exit door of the kitchen where Resident # 9 was sitting and smoking unsupervised was a "High Voltage" panel with a "No Smoking" sign. Observation on 6/18/14 at 10:34 a.m. in the smoking area revealed the Housekeeping/Laundry Director was monitoring the smoke break. Resident # 9 was being argumentative with the Housekeeping/Laundry Director. He warned Resident # 9 that if he was not going to be appropriate and respectful in reference to the smoking rules in the smoking area, he would ask him to go inside. Resident #9 complied but starred down (gave a mean look) the Housekeeping/Laundry Director. Interview on 6/18/14 at 11:30 a.m. with the Housekeeping/Laundry Director revealed that residents would not listen: they were not following the smoking rules. The Housekeeping/Laundry Director stated that Resident # 9 was not to have cigarette butts on his person or a lighter. The "red can" was to be outside the gate in order to avoid the residents getting into the container and taking out the cigarette butts. The ash tray was to be emptied into the "red can" and returned to the smoking area for the unsupervised smokers. The Housekeeping/Laundry Director stated that he instructed his housekeepers to check the ash tray before they left for the day. He stated that he checked it also throughout the day and would empty it. Observation during this interview revealed 2 cigarette butts by the barbecue grill and as the Maintenance Director was retrieving the cigarette butts on the ground, the surveyor observed Resident #22 with his hand inside the "red bucket" (where the ashtray was emptied). The Maintenance Director called the resident and brought it to his attention that he was not to be looking through the container. The Maintenance Director stated that the "red bucket" needed to be moved outside the fence to keep the residents from retrieving cigarette butts to smoke. On 6/17/14 the Administrator was asked if he was going to follow his policy. The discussion was that if the resident had violated the policy on the first offense, the resident would receive a warning and on the second offense, the resident would be given a notice of discharge due to endangerment to the health and safety of residents. The Administrator stated that he was not aware of the previous violation. The surveyor informed him that the nurses ' notes in May 2014 reflected that Resident # 9 had been counseled by one of the nurses at that time for having his smoking material with him and that he was not smoking when and where he should have been. The Administrator said he would check on this and see what needed to be done. On 6/17/14 at 5:10 p.m. the Administrator stated that he was not aware of Resident # 11 having her cigarettes and lighter with her but stated that the facility staff had deemed her to be a safe smoker and she could buy a lock box to keep her supplies in. He stated that he would give Resident # 11 a warning since this was her first violation of the smoking policy. Resident # 9 would be given a notice of discharge due to today was the residents' 2nd violation of the policy. Interview on 6/20/14 at 7:45 a.m. with the MDS nurse revealed that surveyor had requested information on how visitors and family members are notified of the smoking policy. The MDS nurse stated that the facility would provide the notice to the family/visitors in reference to the smoking policy and include a notice to residents upon admission to the facility in reference to the smoking policy (was not in the admission packet). Observation of the Smoking area on 6/20/14 at 8:40 a.m. revealed the residents were being supervised by the Administrator and the MDS Coordinator. The residents assessed to require the use of the smokers' aprons were wearing them. The Administrator stated he was continuing with the in-services and would be at the facility to finish the in-services with the staff on Saturday, 6/21/14. On 6/20/14 at 9:30 a.m. the Regional Clinical Director was informed that the IJ was lifted as of 6/19/14. Observation on 6/20/14 at 10:50 a.m. in the smoking area revealed residents wearing smoking aprons and the Housekeeping/Laundry Director supervising the residents that were smoking. During this observation the Housekeeping/Laundry Director stated that during the weekend his staff supervised the residents during the smoke break at 10:30 a.m. and that dietary supervised the residents at 8:30 a.m., but that nursing covered the smoke breaks throughout the rest of the day, from 1:30 p.m. on. Interview on 6/20/14 at 3:38 p.m. with CNA W revealed that she works on weekends and assisted the facility to supervise residents that smoked. CNA W stated that residents wear aprons and that after the smoke break; she emptied the ashtray and returned it to the smoking area for the non-supervised smokers. Observation on 6/20/14 at 6:34 p.m. of the smoking area revealed that CNA W was monitoring the resident smoke break. Some of the residents were wearing aprons. CNA W would provide each resident a cigarette and light. The ashtray was offered and each resident would extinguish the cigarette and drop it inside the ashtray. Interview on 6/20/14 at 7:25 p.m. with RN X revealed that the residents were supervised during their smoke break by dietary, housekeeping, laundry and nursing. The times she was familiar with were: 10:30 a.m., 1:30 p.m., 3:30 p.m., 6:30 p.m., and 8:30 p.m. RN X stated that the DON had contacted her by phone and informed her of some new information to follow for the residents during their smoke breaks. She stated that the ashtray was to be emptied outside the gate in the container and that 2 residents were unsupervised. 2. Review of Resident # 11's face sheet (dated 6/17/14) revealed that Resident # 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 11's Annual MDS (dated 3/17/14) revealed that the resident was moderately impaired cognitively and used tobacco. Resident # 11's 60 day Medicare assessment (dated 6/2/14) revealed that the resident was cognitively intact. Review of Resident # 11's safe smoking evaluation (dated 3/15/14) revealed that the resident was determined to be a safe smoker with occasional supervision required. Review of Resident # 11's care plan (Revision dated 2/20/14) revealed the resident was "a smoker ... and the goal was to not suffer injury from unsafe smoking practices through the review date: The resident requires SUPERVISION while smoking. The resident's smoking supplies are stored in the smoker box at the nurses' station." Observation on 6/17/14 at 1:40 p.m. with the DON in the outside patio/smoking area revealed Resident # 11 smoking a cigarette without supervision. The DON stated that residents who smoked "normally should be supervised." Review of an Incident/Accident Report (dated 6/17/14) revealed that she was smoking a cigarette and admitted to having a lighter and cigarettes. The DON confiscated the lighter and cigarettes and informed her of safety. Interview on 6/17/14 at 3:13 p.m. with Cook H revealed that she supervised the 8:30 a.m. smoke break. Cook H stated that she had not had any problems with Resident # 11 during smoke break. Interview on 6/17/14 at 1:40 p.m. with Resident # 11 revealed (in Spanish) that she kept her cigarette and her lighter with her: "los tengo alsados." The DON discussed the smoking policy with the resident and permitted her to finish her cigarette but removed the lighter from her. The resident had the lighter and her cigarettes in her eyeglass pouch. 3. Resident # 12 was admitted to the facility on [DATE] per the face sheet dated 1/31/14. The [DIAGNOSES REDACTED]. Record review of Resident # 12's record revealed no Safe Smoking Evaluation. During an interview on 6/19/14 at 9:30 a.m. with Resident # 12 in the area near the Nurses' Station, Resident # 12 stated that if he didn't get a cigarette that he was going to refuse everything and showed his arm with his [MEDICAL TREATMENT] shunt. LVN L was asked if Resident # 12 smoked and the surveyor informed her of what the resident said. She stated no, she had never seen Resident # 12 smoke before. She then asked the Activity Director if she knew if the resident smoked and the Activity Director stated that Resident # 12 had no money to buy any cigarettes. Both staff members stated that the facility was the resident's family but the resident had no money. The Activity Director then stated that she has given Resident # 12 a cigarette whenever he gets worked up and anxious to calm him down. The DON was informed of the resident wanting a cigarette otherwise he was going to refuse everything. The DON was not aware that the resident was a smoker but he said he would check into it. The staff assessed the resident and the assessment and care plan were given to the survey team. The assessment revealed he was a Safe smoker with Occasional supervision, his Kardex was up-dated to reflect that he was a safe smoker and required occasional supervision and his care plan was also up-dated and revealed he was a smoker requiring occasional supervision and his supplies were stored in the activities department. Resident # 12's Re-Admission Nursing Admission Data Collection form dated 3/13/14 revealed in Section F the resident was a past smoker. Resident # 12's last MDS revealed a cognitive score of 15 (no impairment). During the same interview on 6/19/14 at 9:30 a.m., LVN L confirmed that Resident # 12 was not on the list of smokers. 4. Review of Resident # 15 face sheet (dated 6/17/14) revealed that the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the quarterly MDS (dated 6/6/14) revealed that the resident was cognitively intact. Review of Resident # 15's Safe Smoking Evaluation (dated 6/6/14) revealed that the resident was a safe smoker with no supervision required. Review of Resident # 15's Care Plan with the date initiated on 3/6/14 revealed: -he has a potential to be verbally aggressive with staff r/t paranoid [MEDICAL CONDITION]: intervention included to allow choices within individual ' s decision making abilities. -he is a smoker: intervention included the resident is able to keep smoking materials in a secure area in his room and go out to smoke without supervision. On 6/23/14 at 1:07 p.m. Resident # 15 was interviewed about the smoking policy and the surveyor observed the resident's cigarettes and lighter were in his shoes and not in the lock box that he had in his room. The resident was lying down in his bed. Review of Resident # 15's Care Plan with the revision date of 6/17/14 revealed:he is a smoker: intervention included the resident is able to keep smoking materials in a secure area in his room lock box when materials were not on his person. -LN (Licensed Nurses) will check proper securement of smoking materials QD Review of a facility statement signed by the Administrator and Resident #15 (dated 6/23/14) revealed: "re-educate (him) on the smoking policy ...that all his smoking materials should be kept in his safe at all times except when he is going out to smoke and as soon as he is done he is to return his smoking materials to the safe. Record review of the facility's Resident Council Meeting Minutes dated 4/9/14 revealed the resident council was concerned that smokers were not being supervised and were not smoking in the designated area. Interview on 6/17/14 at 11:00 a.m. with the Resident Council President revealed the Resident Council had addressed a concern that some of the smokers should not be left unsupervised when they smoked and were not staying in the designated areas for smoking. She stated the council was concerned about the smokers being endangered and endangering other residents. Interview on 6/17/14 at 1:25 p.m. the Regional Clinical Director stated the staff will make out an Incident Report about the resident having his lighter with him. The staff stated also that another resident sometimes gave Resident # 9 some cigarettes. The Administrator stated that the families would be informed and sign papers on the smoking policy. He also stated that Resident # 9 would be taken to the bank when the resident received his check and then would buy his cigarettes and lighter. He then stated that the resident ' s family and friends, possibly, buy or bring him the smoking materials. The Regional Clinical Director stated that the safe smoker assessments were done either by the Activity Director or someone in the Nursing Department. She also stated that on admission it was done by the Charge Nurse. She stated that the smoking assessments were done on quarterly bases, sometimes done by the Week-end Supervisor. The Administrator, the DON, and the Regional Clinical Director on 6/17/14 at 1:25 p.m. were informed that the survey team had identified an IJ (Immediate Jeopardy). The Regional Clinical Director stated the facility staff would be working on a plan to have the IJ removed ASAP. The staff stated that the next break would be at 1:30 p.m. and that all were supervised and no one would have their cigarettes or lighter with them. The plan of removal of the IJ was accepted on on 6/17/14 at 5:29 p.m. The facility took the following actions to remove the IJ: -All smokers were immediately assessed for safe smoking and the residents' care plans were up-dated. The Kardex sheet for the staff to also use for the residents' care were also up-dated with the new assessment information and resident specific interventions. -All smoking residents were educated on the smoking policy and signed the form; Families were also informed of the smoking policy -Resident # 9 was given his discharge notice -Facility wide staff training was conducted 8immediately about the smoking policy and the staff were not permitted to assume their responsibilities untile they had completed this education. -The first infraction of the Safe Smoking Policy would result in a warning to both the resident and their family member or representative. The second infraction of the Safe Smoking Policy would result in a notice of discharge. -The Administrator and the DNS (Director of Nursing Service) will monitor compliance with this plan on a daily basis for 1 month and then monthly thereafter until the Quality Assurance and Performance Improvement Committee (QAPI) believes that the facility can sustain compliance with the plan. -The QAPI Committee will monitor compliance monthly. Interview on 6/17/14 at 6:10 p.m. with the Regional Clinical Director and the Administrator revealed the smoking assessment was reflected in the care plans of the residents. She stated that the assessments were done quarterly with the MDSs and done within the reference period of the MDS. She stated that the team was going to discuss the 12 residents and get information from the other disciplines if they had seen anything or had any important information about the residents and the team was going to do new assessments on the residents and match up the care plans to the assessments. The Smoking policy was to be signed today and discussed with the residents and a letter to be sent to the residents ' Responsible Parties also. The Administrator stated that Resident # 22 was also going to be given a warning and notice to his mother too. The Regional Clinical Director stated that the list of supervision required of the smokers would be on the Kardex at the nurses ' station and with the smoking material container. The survey team asked for the updated assessments and care plans. She stated that after the re-assessments of the residents, a list of the smokers and their required supervision would also be placed with the box with the smoking material. Interview on 6/17/14 at 6:30 p.m. with CNA U revealed that she had received training before going outside to supervise the residents smoking. CNA U stated that the residents had a designated place to smoke and time. She also understood that if a resident did not follow the rules they would receive a first warning. Observation on 6/17/14 at 6:35 p.m. revealed that CNA U was monitoring the smoke break for the residents. The CNA provided each resident a cigarette and lit it for them. She also provided aprons for those on the list that were to receive aprons. At the end of the smoke break, CNA U collected all the cigarette butts, emptied the ashtray into the "red bucket" and returned the empty ashtray to the smoking area. Observation on 6/17/14 at 6:50 p.m. of the smoking area revealed the Administrator was there and talking to the residents about the policy and telling them that the residents would need to sign the policy the next day (6/18). Record review of a Training Attendance list received on 6/17/14 revealed 26 staff members were in-serviced on the smoking policy and 3 contracted staff members were also in-serviced. The residents had been reassessed the night before on 6/17/14 and the following was information from the Safe Smoking Evaluation assessments and was noted on the Kardex and their care plans were up-dated with this information: Resident 18 - Safe Smoker with Frequent supervision Resident 17- Safe Smoker with Constant supervision Resident 10 - Unsafe Smoker with Constant supervision with an Apron Resident 23 - Unsafe smoker with Constant supervision with an Apron Resident 15 --- Safe smoker with No supervision, may keep smoking material in a secure area in his room and go out to smoke with supervision; nurse to check proper securement of the smoking material QD Resident 22 --- Unsafe smoker with Constant supervision with an Apron Resident 19 --- Safe smoker with Frequent supervision; the care plan also indicated that he goes outside independently and searches for butts and will attempt to smoke Resident 21--- Unsafe smoker with Constant Supervision with an Apron Resident 16 --- Safe smoker with No supervision, may keep smoking material in a secure location; nurse to check proper securement of the smoking material QD Resident 11 --- Safe smoker with Occasional supervision Resident 20 --- Safe smoker with Frequent supervision Record review of the up-dated smoking evaluations, Kardexs, and care plans, completed on 6/17/14 and provided 6/18/14, for the residents who smoked revealed the following: Resident 18 --- Safe smoker with Constant supervision; a cognitive score of 14 (no impairment); and care plan revealed the resident was a safe smoker Resident 10 --- Unsafe smoker with Constant supervision with an Apron; a cognitive score of 13 (no impairment); care plan revealed she was a smoker with Supervision and required a smoking apron Resident 16 --- Safe smoker with no supervision; cognitive score of 15 (no impairment); care plan revealed

Based on observation, interview and record review the facility failed to ensure that the residents' environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 4 of 12 residents (Residents # 9, # 11, # 12, and # 15) whose care was reviewed for safe smoking, in that: 1. Resident # 9 required constant supervision, had his cigarettes and lighter with him, was smoking in a No Smoking area close to a propane tank and a high voltage panel without supervision, and was not supposed to be allowed to have his smoking material with him. 2. Resident #11 had her cigarettes and lighter with her and pulled them from her eye glass case and was not supposed to be allowed to have her smoking material with her. 3. Resident #12 had been given cigarettes by the facility staff when he smoked at the facility and had not been assessed with [REDACTED]. 4. Resident #15 was assessed as being an independent smoker and could have his smoking material in a secured box in his room but the material was not secured. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on 6/17/14. While the IJ was removed on 6/19/14, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was not an immediate jeopardy due to the facility not yet completing in-service training for all staff on enforcement of the smoking policy and counseling all residents who smoked and their families regarding rules for smoking at the facility. These failures could result in fire hazard with injury and could affect the 16 residents on the 200 and 300 halls. The findings were: 1. Resident # 9's face sheet dated 2/22/14 revealed he was admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident # 9's RCCT (Reality Comprehension Clock Test used to measure resident's cognitive factors) revealed a score of 16 out of 67 which indicated the resident was Moderately Severe in the functioning range and had a functioning age of 5XXX[AGE] years with this score. Record review of Resident # 9's last MDS dated [DATE] revealed his Cognitive Decision making skills were scored at a 10 indicating moderately impaired cognition. Record review of Resident # 9's Care Plan dated 3/3/14 revealed he was "a smoker and had been talked to about not keeping cigarettes and lighter on his person...continued to be non-compliant." The goal of his care plan was to ensure that he would not smoke without supervision through his review date of 6/1/14. The interventions the team put into place were the resident "required supervision while smoking" and the resident's smoking supplies were to be stored at the Nurses' station in the smoker box. Observation on 6/17/14 at 10:25 a.m. from the kitchen door window (exit to the outside area) revealed Resident #9 smoking a cigarette while sitting down on a chair that was in front of the kitchen door. Further observation revealed Resident # 9 placing a cigarette lighter into his right side front pocket of his pants and extinguishing the cigarette and tucking the cigarette butt inside the fold of his cap that he was wearing. The surveyor notified the DS (Dietary Supervisor) of the observation. Interview with the DS at this time, during continued observation of Resident #9, revealed that the door to the outside from the hallway was left open so that residents could go outside. The DS stated he was aware that Resident # 9's care plan included the resident's smoking. The DS added that the resident had a history of [REDACTED]." Observation of the Activity Director (AD) on 6/17/14 at 11:00 a.m. revealed she was at her desk in the conference room putting 1 or 2 cigarettes into individual bags and labeling each for the specific residents. An interview with the AD at the same time, revealed that there were "8" smokers in the facility. She stated that she prepared the bags for several days in advance so the residents would have their cigarettes. She then took the box containing the individual bags out of the room and locked up the rest of the packs of cigarettes in a closet in the conference room. Record review of Resident # 9's MDS Kardex dated 6/17/14 revealed he was a smoker but smoked in non designated areas and hid and kept cigarettes and lighters. He needed "constant supervision." Record review of Resident #9's Safe Smoking Evaluation dated 6/17/14 by the MDS Coordinator revealed he was determined to be a safe smoker with constant supervision. The Safe Smoking Evaluation revealed the following areas were assessed: -Type of Smoke (Cigarettes, Cigars, Pipe, E Cigarette, or other) -Cognition and Communication -Vision -Dexerity -Safety Observation -Determination (1. the residents were determined to be either safe or unsafe 2. Degree of supervison needed while smoking. The categories were no supervision required, Occasional supervision required, Frequent supervision, Constant supervision, or 1:1 Assist with smoking) -Cessation Materials (if the resident was interested and provided the information) -Notes (if any) -Signature Record review of a revised care plan for Resident # 9 dated 6/17/14 revealed the resident was observed smoking in non designated areas and keeping/hiding cigarettes/lighter. The goal remained the same with a target date of 8/31/14. The interventions were to instruct the resident about the facility's policy on smoking: locations, times, safety concerns. The charge nurse was to be notified immediately if it was suspected the resident had violated the facility's smoking policy. Record review of Resident # 9's Nurses noted dated 3/2/14 at 2:26 p.m. by LVN R revealed "Resident continues to be non-compliant with smoking, always wants his lighter> Previous shift reported resident was smoking in his room while in bed. Lighter confiscated by LVN S." Attempted to interview LVN R and LVN S without success, as they were no longer employed at the facility. Record review of Resident # 9's Nurses notes dated 4/8/14 at 6:34 p.m. by LVN G revealed "Resident witnessed smoking unsupervised outside of smoke break. When questioned he state someone gave me this. When questioned who someone was, resident smiled. Denied having lighter." Record review of Resident # 9's Nurses notes dated 4/8/14 at 8:40 p.m. by LVN G revealed "Witnessed resident outside smoking independently several times this shift. Resident refused to relinquish cigarettes or light. ADON aware." Interview on 6/19/14 at 3:00 p.m. with the ADON revealed she was not aware of the incident on 4/8/14. She stated she was new and had only been at the facility for three weeks. Interview on 6/19/14 at 3:30 p.m. with LVN G revealed Resident # 9 was caught many times smoking outside in non designated areas and was unsupervised during that time. She stated he had been confronted numerous times by the staff about the smoking policy and remained non-compliant. Record review of Resident # 9's Nurses notes dated 4/13/14 at 5:33 p.m. by LVN S revealed "Resident #9 was again observed smoking with another resident in between smoke breaks. Resident refuses to cease smoking and hand over smoking materials despite multiple attempts to redirect. He states that the rules are for everyone but him and that the bosses are aware of what he does." Record review of Resident # 9's Nurses notes dated 4/15/14 at 6:59 a.m. by LVN T revealed: Resident observed with a cigarette lighter. Resident refused to give up either to nurse, Will notify the Administrator when he arrives to work." Attempted to interview LVN T but she was no longer employed at the facility. Record review of Resident # 9's Nurses notes dated 4/29/14 at 6:50 p.m. by LVN G revealed "Unsupervised smoking noted earlier in shift. Resident refused to be redirected." Record review of Resident # 9's Nurses notes dated 5/13/14 at 7:33 p.m. LVN G revealed "Witnessed resident smoking cigarettes multiple times this shift unsupervised. Denied having cigarettes or light when questioned." Record review of Resident # 9's Nurses notes dated 5/22/14 at 5:30 p.m. by LVN G revealed "Resident witnessed to be smoking independently. Denied having cigarettes or light when questioned." Record review of Resident #9's Nurses notes dated 5/29/14 at 5:58 p.m. by LVN G revealed "witnessed patient smoking unsupervised on back patio. When questioned patient denied having cigarrettes or lighter. Patient is own RP and aware of smoking unsupervised. Will continue to monitor." Record review of the facility's Safe Smoking Policy (OP2 0302.00 revised 1/13 revealed "All unsafe smokers should be supervised at all times. An evaluation is conducted upon readmission on all residents who smoke in order to assess the resident's cognitive status to determine if the resident is capable of safe smoking. Interview the resident to determine their ability to verbalize and understand the smoking rules and observe the resident's ability to smoke in a safe manner. Smoking occurs in designated locations that are environmentally separate from all resident care areas. The first infraction of the Safe Smoking Policy results in a warning. This warning may be verbal. The warning is given to both the resident and his or her family member or representative. A safe smoking re-evaluation of the resident is performed The second infraction of the Safe Smoking Policy results in a notice of discharge. Discharge procedures are initiated and pursued to completion. The reason for discharge is endangerment to the health and safety of residents." Review of the Resident Smoking Schedule was as follows and included the staff who were to supervise the resident: Time Week Day Staff Weekend Staff 8:30 a.m. Dietary Dietary 10:30 a.m. Housekeeping/Laundry Housekeeping/Laundry 1:30 p.m. Activity Director Treatment Nurse 3:30 p.m. Restorative Aide Nurse / RCS pm shift 6:30 p.m. Nursing Department Nurse / Med Aide 8:30 p.m. Nursing Department RCS pm shift The charge nurse is responsible for assigning which RCS will be assisting Residents during designated smoke break times at the beginning of each shift. Review of the facility Safe Smoking Policy (Revision Date: January 2013) revealed: -Residents, their families, visitors, and staff are instructed not to share lighted cigarettes or other smoking materials with any resident... Observation of the designated smoking area on 6/17/14 at 1:55 p.m. revealed the residents were smoking and RA M was assisting the residents. An interview with RA M, at the time of the observation, also revealed the safe smokers were Resident # 9, Resident # 16, Resident # 22, and Resident # 11. She stated that when a new resident was admitted to the facility the nurses let the staff know if the resident smokes and what kind of supervision was needed. She stated the staff members were responsible for the supervision of the smokers and that the kitchen staff was responsible for the am time then the next one was the nurses or the CNAs. She stated they knew who was a safe smoker and who wore an apron. Interview on 6/17/14 at 1:25 p.m. with the DS revealed that cigarettes were removed "in the past" from Resident # 9 because he would have them in his possession (room/person). The DS also noted that the lighter was removed from the resident. The DS stated that the Administrator was handling the situation from this point on. Interview on 6/17/14 at 2:00 p.m. with CNA C revealed that there were 8 residents who smoked present in the smoking area and 2 were still in their rooms. CNA C stated that the nurse assigned to supervise the smoking area was not available so she filled in for that nurse. She stated that there were safe and unsafe smokers and that there was a book with names, but that she was familiar with the residents. CNA C stated that cigarettes were in a box in the "med room" and that she had to ask the nurse for the box. CNA C stated that once the supplies to smoke were obtained, the staff would make an announcement of the smoke break. CNA C stated that if cigarettes or a lighter were found on a resident, she would report that to the CN, DON or Administrator. CNA C stated that once the residents completed the smoke break the staff was required to collect the lighter and cigarette box and secure the "baggies" (that held the resident cigarettes). CNA C stated that housekeeping, maintenance or staff supervising would empty the ashtray. Interview on 6/17/14 at 3:13 p.m. with Cook H revealed that she supervised the 8:30 a.m. smoke break. She stated that the cigarettes were at the nurse's station under a cabinet, "maybe a cart." She stated that she asked the nurses to identify the "safe smokers" and provided those residents with cigarettes and assisted some residents with aprons. She would "light everyone's cigarettes ... no one should have a lighter." She stated that if she saw a resident with a lighter or cigarettes on them, she would report that resident to the nurse on staff. Cook H stated that she had not had any problems with Resident # 11 during smoke break and had seen Resident # 9 smoke by himself before (not clear on date) and had reported it to the CN. Interview on 6/17/14 at 3:25 p.m. with the DS revealed that the cigarettes were in a Tupperware box with a blue lid. That container had all the cigarettes for each resident labeled with each resident's name. The DS stated that he or the staff would announce the smoke break, residents would smoke 1 cigarette per break, more or less, and the staff would light the cigarettes for each resident. He stated that he would empty the ashtray in the "red bucket," which should be outside the fence. The DS stated that he would know if residents were "safe or not" to smoke from the morning meetings, the facility network system (PCC- computer software used by the facility), on his dietary assessment or the Admission Nursing Assessment. He stated that once he was aware of the smoking status he would inform his staff due to supervising the smoke breaks. The DS stated that about 2 weeks ago he had seen Resident # 9 smoking without supervision and told the resident that he was not to be in possession of the cigarettes and lighter on his person, so he took them away and reported the incident to the CN. The DS stated that he was aware that Resident # 9's Care plan was that the resident had to be supervised while smoking. Interview on 6/17/14 at 4:30 p.m. with the Maintenance Director revealed that the distance from where Resident # 9 was smoking by the kitchen exit to the generator with a "No smoking sign " was 27 feet, 8 inches. The Maintenance Director revealed that the generator had diesel fuel which was "flammable." The Maintenance Director stated that Resident #9 was next to a barbecue grill which had a propane container about half-full of propane, which was "still flammable." The Maintenance Director stated that the areas we were observing included the kitchen exit door, the dining room exit door, and the area by the vending machines and exit from the conference room, were "non-smoking areas." Further observation during this time revealed that against the wall by the exit door of the kitchen where Resident # 9 was sitting and smoking unsupervised was a "High Voltage" panel with a "No Smoking" sign. Observation on 6/18/14 at 10:34 a.m. in the smoking area revealed the Housekeeping/Laundry Director was monitoring the smoke break. Resident # 9 was being argumentative with the Housekeeping/Laundry Director. He warned Resident # 9 that if he was not going to be appropriate and respectful in reference to the smoking rules in the smoking area, he would ask him to go inside. Resident #9 complied but starred down (gave a mean look) the Housekeeping/Laundry Director. Interview on 6/18/14 at 11:30 a.m. with the Housekeeping/Laundry Director revealed that residents would not listen: they were not following the smoking rules. The Housekeeping/Laundry Director stated that Resident # 9 was not to have cigarette butts on his person or a lighter. The "red can" was to be outside the gate in order to avoid the residents getting into the container and taking out the cigarette butts. The ash tray was to be emptied into the "red can" and returned to the smoking area for the unsupervised smokers. The Housekeeping/Laundry Director stated that he instructed his housekeepers to check the ash tray before they left for the day. He stated that he checked it also throughout the day and would empty it. Observation during this interview revealed 2 cigarette butts by the barbecue grill and as the Maintenance Director was retrieving the cigarette butts on the ground, the surveyor observed Resident #22 with his hand inside the "red bucket" (where the ashtray was emptied). The Maintenance Director called the resident and brought it to his attention that he was not to be looking through the container. The Maintenance Director stated that the "red bucket" needed to be moved outside the fence to keep the residents from retrieving cigarette butts to smoke. On 6/17/14 the Administrator was asked if he was going to follow his policy. The discussion was that if the resident had violated the policy on the first offense, the resident would receive a warning and on the second offense, the resident would be given a notice of discharge due to endangerment to the health and safety of residents. The Administrator stated that he was not aware of the previous violation. The surveyor informed him that the nurses ' notes in May 2014 reflected that Resident # 9 had been counseled by one of the nurses at that time for having his smoking material with him and that he was not smoking when and where he should have been. The Administrator said he would check on this and see what needed to be done. On 6/17/14 at 5:10 p.m. the Administrator stated that he was not aware of Resident # 11 having her cigarettes and lighter with her but stated that the facility staff had deemed her to be a safe smoker and she could buy a lock box to keep her supplies in. He stated that he would give Resident # 11 a warning since this was her first violation of the smoking policy. Resident # 9 would be given a notice of discharge due to today was the residents' 2nd violation of the policy. Interview on 6/20/14 at 7:45 a.m. with the MDS nurse revealed that surveyor had requested information on how visitors and family members are notified of the smoking policy. The MDS nurse stated that the facility would provide the notice to the family/visitors in reference to the smoking policy and include a notice to residents upon admission to the facility in reference to the smoking policy (was not in the admission packet). Observation of the Smoking area on 6/20/14 at 8:40 a.m. revealed the residents were being supervised by the Administrator and the MDS Coordinator. The residents assessed to require the use of the smokers' aprons were wearing them. The Administrator stated he was continuing with the in-services and would be at the facility to finish the in-services with the staff on Saturday, 6/21/14. On 6/20/14 at 9:30 a.m. the Regional Clinical Director was informed that the IJ was lifted as of 6/19/14. Observation on 6/20/14 at 10:50 a.m. in the smoking area revealed residents wearing smoking aprons and the Housekeeping/Laundry Director supervising the residents that were smoking. During this observation the Housekeeping/Laundry Director stated that during the weekend his staff supervised the residents during the smoke break at 10:30 a.m. and that dietary supervised the residents at 8:30 a.m., but that nursing covered the smoke breaks throughout the rest of the day, from 1:30 p.m. on. Interview on 6/20/14 at 3:38 p.m. with CNA W revealed that she works on weekends and assisted the facility to supervise residents that smoked. CNA W stated that residents wear aprons and that after the smoke break; she emptied the ashtray and returned it to the smoking area for the non-supervised smokers. Observation on 6/20/14 at 6:34 p.m. of the smoking area revealed that CNA W was monitoring the resident smoke break. Some of the residents were wearing aprons. CNA W would provide each resident a cigarette and light. The ashtray was offered and each resident would extinguish the cigarette and drop it inside the ashtray. Interview on 6/20/14 at 7:25 p.m. with RN X revealed that the residents were supervised during their smoke break by dietary, housekeeping, laundry and nursing. The times she was familiar with were: 10:30 a.m., 1:30 p.m., 3:30 p.m., 6:30 p.m., and 8:30 p.m. RN X stated that the DON had contacted her by phone and informed her of some new information to follow for the residents during their smoke breaks. She stated that the ashtray was to be emptied outside the gate in the container and that 2 residents were unsupervised. 2. Review of Resident # 11's face sheet (dated 6/17/14) revealed that Resident # 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 11's Annual MDS (dated 3/17/14) revealed that the resident was moderately impaired cognitively and used tobacco. Resident # 11's 60 day Medicare assessment (dated 6/2/14) revealed that the resident was cognitively intact. Review of Resident # 11's safe smoking evaluation (dated 3/15/14) revealed that the resident was determined to be a safe smoker with occasional supervision required. Review of Resident # 11's care plan (Revision dated 2/20/14) revealed the resident was "a smoker ... and the goal was to not suffer injury from unsafe smoking practices through the review date: The resident requires SUPERVISION while smoking. The resident's smoking supplies are stored in the smoker box at the nurses' station." Observation on 6/17/14 at 1:40 p.m. with the DON in the outside patio/smoking area revealed Resident # 11 smoking a cigarette without supervision. The DON stated that residents who smoked "normally should be supervised." Review of an Incident/Accident Report (dated 6/17/14) revealed that she was smoking a cigarette and admitted to having a lighter and cigarettes. The DON confiscated the lighter and cigarettes and informed her of safety. Interview on 6/17/14 at 3:13 p.m. with Cook H revealed that she supervised the 8:30 a.m. smoke break. Cook H stated that she had not had any problems with Resident # 11 during smoke break. Interview on 6/17/14 at 1:40 p.m. with Resident # 11 revealed (in Spanish) that she kept her cigarette and her lighter with her: "los tengo alsados." The DON discussed the smoking policy with the resident and permitted her to finish her cigarette but removed the lighter from her. The resident had the lighter and her cigarettes in her eyeglass pouch. 3. Resident # 12 was admitted to the facility on [DATE] per the face sheet dated 1/31/14. The [DIAGNOSES REDACTED]. Record review of Resident # 12's record revealed no Safe Smoking Evaluation. During an interview on 6/19/14 at 9:30 a.m. with Resident # 12 in the area near the Nurses' Station, Resident # 12 stated that if he didn't get a cigarette that he was going to refuse everything and showed his arm with his dialysis shunt. LVN L was asked if Resident # 12 smoked and the surveyor informed her of what the resident said. She stated no, she had never seen Resident # 12 smoke before. She then asked the Activity Director if she knew if the resident smoked and the Activity Director stated that Resident # 12 had no money to buy any cigarettes. Both staff members stated that the facility was the resident's family but the resident had no money. The Activity Director then stated that she has given Resident # 12 a cigarette whenever he gets worked up and anxious to calm him down. The DON was informed of the resident wanting a cigarette otherwise he was going to refuse everything. The DON was not aware that the resident was a smoker but he said he would check into it. The staff assessed the resident and the assessment and care plan were given to the survey team. The assessment revealed he was a Safe smoker with Occasional supervision, his Kardex was up-dated to reflect that he was a safe smoker and required occasional supervision and his care plan was also up-dated and revealed he was a smoker requiring occasional supervision and his supplies were stored in the activities department. Resident # 12's Re-Admission Nursing Admission Data Collection form dated 3/13/14 revealed in Section F the resident was a past smoker. Resident # 12's last MDS revealed a cognitive score of 15 (no impairment). During the same interview on 6/19/14 at 9:30 a.m., LVN L confirmed that Resident # 12 was not on the list of smokers. 4. Review of Resident # 15 face sheet (dated 6/17/14) revealed that the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the quarterly MDS (dated 6/6/14) revealed that the resident was cognitively intact. Review of Resident # 15's Safe Smoking Evaluation (dated 6/6/14) revealed that the resident was a safe smoker with no supervision required. Review of Resident # 15's Care Plan with the date initiated on 3/6/14 revealed: -he has a potential to be verbally aggressive with staff r/t paranoid schizophrenia: intervention included to allow choices within individual ' s decision making abilities. -he is a smoker: intervention included the resident is able to keep smoking materials in a secure area in his room and go out to smoke without supervision. On 6/23/14 at 1:07 p.m. Resident # 15 was interviewed about the smoking policy and the surveyor observed the resident's cigarettes and lighter were in his shoes and not in the lock box that he had in his room. The resident was lying down in his bed. Review of Resident # 15's Care Plan with the revision date of 6/17/14 revealed:he is a smoker: intervention included the resident is able to keep smoking materials in a secure area in his room lock box when materials were not on his person. -LN (Licensed Nurses) will check proper securement of smoking materials QD Review of a facility statement signed by the Administrator and Resident #15 (dated 6/23/14) revealed: "re-educate (him) on the smoking policy ...that all his smoking materials should be kept in his safe at all times except when he is going out to smoke and as soon as he is done he is to return his smoking materials to the safe. Record review of the facility's Resident Council Meeting Minutes dated 4/9/14 revealed the resident council was concerned that smokers were not being supervised and were not smoking in the designated area. Interview on 6/17/14 at 11:00 a.m. with the Resident Council President revealed the Resident Council had addressed a concern that some of the smokers should not be left unsupervised when they smoked and were not staying in the designated areas for smoking. She stated the council was concerned about the smokers being endangered and endangering other residents. Interview on 6/17/14 at 1:25 p.m. the Regional Clinical Director stated the staff will make out an Incident Report about the resident having his lighter with him. The staff stated also that another resident sometimes gave Resident # 9 some cigarettes. The Administrator stated that the families would be informed and sign papers on the smoking policy. He also stated that Resident # 9 would be taken to the bank when the resident received his check and then would buy his cigarettes and lighter. He then stated that the resident ' s family and friends, possibly, buy or bring him the smoking materials. The Regional Clinical Director stated that the safe smoker assessments were done either by the Activity Director or someone in the Nursing Department. She also stated that on admission it was done by the Charge Nurse. She stated that the smoking assessments were done on quarterly bases, sometimes done by the Week-end Supervisor. The Administrator, the DON, and the Regional Clinical Director on 6/17/14 at 1:25 p.m. were informed that the survey team had identified an IJ (Immediate Jeopardy). The Regional Clinical Director stated the facility staff would be working on a plan to have the IJ removed ASAP. The staff stated that the next break would be at 1:30 p.m. and that all were supervised and no one would have their cigarettes or lighter with them. The plan of removal of the IJ was accepted on on 6/17/14 at 5:29 p.m. The facility took the following actions to remove the IJ: -All smokers were immediately assessed for safe smoking and the residents' care plans were up-dated. The Kardex sheet for the staff to also use for the residents' care were also up-dated with the new assessment information and resident specific interventions. -All smoking residents were educated on the smoking policy and signed the form; Families were also informed of the smoking policy -Resident # 9 was given his discharge notice -Facility wide staff training was conducted 8immediately about the smoking policy and the staff were not permitted to assume their responsibilities untile they had completed this education. -The first infraction of the Safe Smoking Policy would result in a warning to both the resident and their family member or representative. The second infraction of the Safe Smoking Policy would result in a notice of discharge. -The Administrator and the DNS (Director of Nursing Service) will monitor compliance with this plan on a daily basis for 1 month and then monthly thereafter until the Quality Assurance and Performance Improvement Committee (QAPI) believes that the facility can sustain compliance with the plan. -The QAPI Committee will monitor compliance monthly. Interview on 6/17/14 at 6:10 p.m. with the Regional Clinical Director and the Administrator revealed the smoking assessment was reflected in the care plans of the residents. She stated that the assessments were done quarterly with the MDSs and done within the reference period of the MDS. She stated that the team was going to discuss the 12 residents and get information from the other disciplines if they had seen anything or had any important information about the residents and the team was going to do new assessments on the residents and match up the care plans to the assessments. The Smoking policy was to be signed today and discussed with the residents and a letter to be sent to the residents ' Responsible Parties also. The Administrator stated that Resident # 22 was also going to be given a warning and notice to his mother too. The Regional Clinical Director stated that the list of supervision required of the smokers would be on the Kardex at the nurses ' station and with the smoking material container. The survey team asked for the updated assessments and care plans. She stated that after the re-assessments of the residents, a list of the smokers and their required supervision would also be placed with the box with the smoking material. Interview on 6/17/14 at 6:30 p.m. with CNA U revealed that she had received training before going outside to supervise the residents smoking. CNA U stated that the residents had a designated place to smoke and time. She also understood that if a resident did not follow the rules they would receive a first warning. Observation on 6/17/14 at 6:35 p.m. revealed that CNA U was monitoring the smoke break for the residents. The CNA provided each resident a cigarette and lit it for them. She also provided aprons for those on the list that were to receive aprons. At the end of the smoke break, CNA U collected all the cigarette butts, emptied the ashtray into the "red bucket" and returned the empty ashtray to the smoking area. Observation on 6/17/14 at 6:50 p.m. of the smoking area revealed the Administrator was there and talking to the residents about the policy

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect of residents for 4 of 12 residents (Residents # 9, # 11, # 12, and # 15) whose care was reviewed for safe smoking, in that: 1. Resident # 9 required constant supervision, had his cigarettes and lighter with him, was smoking in a No Smoking area close to a propane tank and a high voltage panel without supervision, and was not supposed to be allowed to have his smoking material with him. 2. Resident #11 had her cigarettes and lighter with her and pulled them from her eye glass case and was not supposed to be allowed to have her smoking material with her. 3. Resident # 12 had been given cigarettes by the facility staff when he smoked at the facility and had not been assessed with [REDACTED]. 4. Resident # 15 was assessed as being an independent smoker and could have his smoking material in a secured box in his room but the material was not secured. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on 6/17/14. While the IJ was removed on 6/19/14, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was not an immediate jeopardy due to the facility not yet completing in-service training for all staff on enforcement of the smoking policy and counseling all residents who smoked and their families regarding rules for smoking at the facility. These failures could result in fire hazard with injury and could affect the 16 residents on the 200 and 300 halls. The findings were: Review of the facility Abuse and Neglect Prohibition (Revision date: June 2013) revealed that: - Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. - Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness... - Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident. -Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring. Record review of the facility's Safe Smoking Policy (OP2 0302.00 revised 1/13 revealed: - "All unsafe smokers should be supervised at all times. - An evaluation is conducted upon readmission on all residents who smoke in order to assess the resident's cognitive status to determine if the resident is capable of safe smoking. - Interview the resident to determine their ability to verbalize and understand the smoking rules and observe the resident's ability to smoke in a safe manner. - Smoking occurs in designated locations that are environmentally separate from all resident care areas. - The first infraction of the Safe Smoking Policy results in a warning. This warning may be verbal. The warning is given to both the resident and his or her family member or representative. A safe smoking re-evaluation of the resident is performed - The second infraction of the Safe Smoking Policy results in a notice of discharge. Discharge procedures are initiated and pursued to completion. The reason for discharge is endangerment to the health and safety of residents." Review of the facility Safe Smoking Policy (Revision Date: January 2013) revealed: -Residents, their families, visitors, and staff are instructed not to share lighted cigarettes or other smoking materials with any resident... 1. Resident # 9's face sheet dated 2/22/14 revealed he was admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident # 9's RCCT (Reality Comprehension Clock Test used to measure resident's cognitive factors) revealed a score of 16 out of 67 which indicated the resident was Moderately Severe in the functioning range and had a functioning age of 5XXX[AGE] years with this score. Record review of Resident # 9's last MDS dated [DATE] revealed his Cognitive Decision making skills were scored at a 10 indicating moderately impaired cognition. Record review of Resident # 9's Care Plan dated 3/3/14 revealed he was "a smoker and had been talked to about not keeping cigarettes and lighter on his person...continued to be non-compliant." The goal of his care plan was to ensure that he would not smoke without supervision through his review date of 6/1/14. The interventions the team put into place were the resident "required supervision while smoking" and the resident's smoking supplies were to be stored at the Nurses' station in the smoker box. Observation on 6/17/14 at 10:25 a.m. from the kitchen door window (exit to the outside area) revealed Resident # 9 smoking a cigarette while sitting down on a chair that was in front of the kitchen door. Further observation revealed Resident # 9 placing a cigarette lighter into his right side front pocket of his pants and extinguishing the cigarette and tucking the cigarette butt inside the fold of his cap that he was wearing. The surveyor notified the DS (Dietary Supervisor) of the observation. Interview with the DS at this time, during continued observation of Resident # 9, revealed that the door to the outside from the hallway was left open so that residents could go outside. The DS stated he was aware that Resident # 9's care plan included the resident's smoking. The DS added that the resident had a history of [REDACTED]." Observation of the Activity Director (AD) on 6/17/14 at 11:00 a.m. revealed she was at her desk in the conference room putting 1 or 2 cigarettes into individual bags and labeling each for the specific residents. An interview with the AD at the same time, revealed that there were " 8 " smokers in the facility. She stated that she prepared the bags for several days in advance so the residents would have their cigarettes. She then took the box containing the individual bags out of the room and locked up the rest of the packs of cigarettes in a closet in the conference room. Record review of Resident # 9's MDS Kardex dated 6/17/14 revealed he was a smoker but smoked in non designated areas and hid and kept cigarettes and lighters. He needed "constant supervision." Record review of Resident # 9's Safe Smoking Evaluation dated 6/17/14 by the MDS Coordinator revealed he was determined to be a safe smoker with constant supervision. The Safe Smoking Evaluation revealed the following areas were assessed: -Type of Smoke (Cigarettes, Cigars, Pipe, E Cigarette, or other) -Cognition and Communication -Vision -Dexerity -Safety Observation -Determination (1. the residents were determined to be either safe or unsafe 2. Degree of supervison needed while smoking. The categories were no supervision required, Occasional supervision required, Frequent supervision, Constant supervision, or 1:1 Assist with smoking) -Cessation Materials (if the resident was interested and provided the information) -Notes (if any) -Signature Record review of a revised care plan for Resident # 9 dated 6/17/14 revealed the resident was observed smoking in non designated areas and keeping/hiding cigarettes/lighter. The goal remained the same with a target date of 8/31/14. The interventions were to instruct the resident about the facility's policy on smoking: locations, times, safety concerns. The charge nurse was to be notified immediately if it was suspected the resident had violated the facility's smoking policy. Record review of Resident # 9's Nurses noted dated 3/2/14 at 2:26 p.m. by LVN R revealed "Resident continues to be non-compliant with smoking, always wants his lighter> Previous shift reported resident was smoking in his room while in bed. Lighter confiscated by LVN S." Attempted to interview LVN R and LVN S without success, as they were no longer employed at the facility. Record review of Resident # 9's Nurses notes dated 4/8/14 at 6:34 p.m. by LVN G revealed "Resident witnessed smoking unsupervised outside of smoke break. When questioned he state someone gave me this. When questioned who someone was, resident smiled. Denied having lighter." Record review of Resident # 9's Nurses notes dated 4/8/14 at 8:40 p.m. by LVN G revealed "Witnessed resident outside smoking independently several times this shift. Resident refused to relinquish cigarettes or light. ADON aware." Interview on 6/19/14 at 3:00 p.m. with the ADON revealed she was not aware of the incident on 4/8/14. She stated she was new and had only been at the facility for three weeks. Interview on 6/19/14 at 3:30 p.m. with LVN G revealed Resident # 9 was caught many times smoking outside in non designated areas and was unsupervised during that time. She stated he had been confronted numerous times by the staff about the smoking policy and remained non-compliant. Record review of Resident # 9's Nurses notes dated 4/13/14 at 5:33 p.m. by LVN S revealed "Resident # 9 was again observed smoking with another resident in between smoke breaks. Resident refuses to cease smoking and hand over smoking materials despite multiple attempts to redirect. He states that the rules are for everyone but him and that the bosses are aware of what he does." Record review of Resident # 9's Nurses notes dated 4/15/14 at 6:59 a.m. by LVN T revealed: Resident observed with a cigarette lighter. Resident refused to give up either to nurse, Will notify the Administrator when he arrives to work." Attempted to interview LVN T but she was no longer employed at the facility. Record review of Resident # 9's Nurses notes dated 4/29/14 at 6:50 p.m. by LVN G revealed "Unsupervised smoking noted earlier in shift. Resident refused to be redirected." Record review of Resident # 9's Nurses notes dated 5/13/14 at 7:33 p.m. LVN G revealed "Witnessed resident smoking cigarettes multiple times this shift unsupervised. Denied having cigarettes or light when questioned." Record review of Resident # 9's Nurses notes dated 5/22/14 at 5:30 p.m. by LVN G revealed "Resident witnessed to be smoking independently. Denied having cigarettes or light when questioned." Record review of Resident #9's Nurses notes dated 5/29/14 at 5:58 p.m. by LVN G revealed "witnessed patient smoking unsupervised on back patio. When questioned patient denied having cigarrettes or lighter. Patient is own RP and aware of smoking unsupervised. Will continue to monitor." Observation of the designated smoking area on 6/17/14 at 1:55 p.m. revealed the residents were smoking and RA M was assisting the residents. An interview with RA M, at the time of the observation, also revealed the safe smokers were Resident # 9, Resident # 16, Resident # 22, and Resident # 11. She stated that when a new resident was admitted to the facility the nurses let the staff know if the resident smokes and what kind of supervision was needed. She stated the staff members were responsible for the supervision of the smokers and that the kitchen staff was responsible for the am time then the next one was the nurses or the CNAs. She stated they knew who was a safe smoker and who wore an apron. Interview on 6/17/14 at 1:25 p.m. with the DS revealed that cigarettes were removed "in the past" from Resident # 9 because he would have them in his possession (room/person). The DS also noted that the lighter was removed from the resident. The DS stated that the Administrator was handling the situation from this point on. Interview on 6/17/14 at 2:00 p.m. with CNA C revealed that there were 8 residents who smoked present in the smoking area and 2 were still in their rooms. CNA C stated that the nurse assigned to supervise the smoking area was not available so she filled in for that nurse. She stated that there were safe and unsafe smokers and that there was a book with names, but that she was familiar with the residents. CNA C stated that cigarettes were in a box in the "med room" and that she had to ask the nurse for the box. CNA C stated that once the supplies to smoke were obtained, the staff would make an announcement of the smoke break. CNA C stated that if cigarettes or a lighter were found on a resident, she would report that to the CN, DON or Administrator. CNA C stated that once the residents completed the smoke break the staff was required to collect the lighter and cigarette box and secure the "baggies" (that held the resident cigarettes). CNA C stated that housekeeping, maintenance or staff supervising would empty the ashtray. Interview on 6/17/14 at 3:13 p.m. with Cook H revealed that she supervised the 8:30 a.m. smoke break. She stated that the cigarettes were at the nurse's station under a cabinet, "maybe a cart." She stated that she asked the nurses to identify the "safe smokers" and provided those residents with cigarettes and assisted some residents with aprons. She would "light everyone's cigarettes ... no one should have a lighter." She stated that if she saw a resident with a lighter or cigarettes on them, she would report that resident to the nurse on staff. Cook H stated that she had not had any problems with Resident # 11 during smoke break and had seen Resident # 9 smoke by himself before (not clear on date) and had reported it to the CN. Interview on 6/17/14 at 3:25 p.m. with the DS revealed that the cigarettes were in a Tupperware box with a blue lid. That container had all the cigarettes for each resident labeled with each resident's name. The DS stated that he or the staff would announce the smoke break, residents would smoke 1 cigarette per break, more or less, and the staff would light the cigarettes for each resident. He stated that he would empty the ashtray in the "red bucket," which should be outside the fence. The DS stated that he would know if residents were "safe or not" to smoke from the morning meetings, the facility network system (PCC- computer software used by the facility), on his dietary assessment or the Admission Nursing Assessment. He stated that once he was aware of the smoking status he would inform his staff due to supervising the smoke breaks. The DS stated that about 2 weeks ago he had seen Resident # 9 smoking without supervision and told the resident that he was not to be in possession of the cigarettes and lighter on his person, so he took them away and reported the incident to the CN. The DS stated that he was aware that Resident # 9's Care plan was that the resident had to be supervised while smoking. Interview on 6/17/14 at 4:30 p.m. with the Maintenance Director revealed that the distance from where Resident # 9 was smoking by the kitchen exit to the generator with a "No smoking sign " was 27 feet, 8 inches. The Maintenance Director revealed that the generator had diesel fuel which was "flammable." The Maintenance Director stated that Resident #9 was next to a barbecue grill which had a propane container about half-full of propane, which was "still flammable." The Maintenance Director stated that the areas we were observing included the kitchen exit door, the dining room exit door, and the area by the vending machines and exit from the conference room, were "non-smoking areas." Further observation during this time revealed that against the wall by the exit door of the kitchen where Resident # 9 was sitting and smoking unsupervised was a "High Voltage" panel with a "No Smoking" sign. Observation on 6/18/14 at 10:34 a.m. in the smoking area revealed the Housekeeping/Laundry Director was monitoring the smoke break. Resident # 9 was being argumentative with the Housekeeping/Laundry Director. He warned Resident # 9 that if he was not going to be appropriate and respectful in reference to the smoking rules in the smoking area, he would ask him to go inside. Resident #9 complied but starred down (gave a mean look) the Housekeeping/Laundry Director. Interview on 6/18/14 at 11:30 a.m. with the Housekeeping/Laundry Director revealed that residents would not listen: they were not following the smoking rules. The Housekeeping/Laundry Director stated that Resident # 9 was not to have cigarette butts on his person or a lighter. The "red can" was to be outside the gate in order to avoid the residents getting into the container and taking out the cigarette butts. The ash tray was to be emptied into the "red can" and returned to the smoking area for the unsupervised smokers. The Housekeeping/Laundry Director stated that he instructed his housekeepers to check the ash tray before they left for the day. He stated that he checked it also throughout the day and would empty it. Observation during this interview revealed 2 cigarette butts by the barbecue grill and as the Maintenance Director was retrieving the cigarette butts on the ground, the surveyor observed Resident #22 with his hand inside the "red bucket" (where the ashtray was emptied). The Maintenance Director called the resident and brought it to his attention that he was not to be looking through the container. The Maintenance Director stated that the "red bucket" needed to be moved outside the fence to keep the residents from retrieving cigarette butts to smoke. On 6/17/14 the Administrator was asked if he was going to follow his policy. The discussion was that if the resident had violated the policy on the first offense, the resident would receive a warning and on the second offense, the resident would be given a notice of discharge due to endangerment to the health and safety of residents. The Administrator stated that he was not aware of the previous violation. The surveyor informed him that the nurses ' notes in May 2014 reflected that Resident # 9 had been counseled by one of the nurses at that time for having his smoking material with him and that he was not smoking when and where he should have been. The Administrator said he would check on this and see what needed to be done. On 6/17/14 at 5:10 p.m. the Administrator stated that he was not aware of Resident # 11 having her cigarettes and lighter with her but stated that the facility staff had deemed her to be a safe smoker and she could buy a lock box to keep her supplies in. He stated that he would give Resident # 11 a warning since this was her first violation of the smoking policy. Resident # 9 would be given a notice of discharge due to today was the residents' 2nd violation of the policy. Interview on 6/20/14 at 7:45 a.m. with the MDS nurse revealed that surveyor had requested information on how visitors and family members are notified of the smoking policy. The MDS nurse stated that the facility would provide the notice to the family/visitors in reference to the smoking policy and include a notice to residents upon admission to the facility in reference to the smoking policy (was not in the admission packet). Observation of the Smoking area on 6/20/14 at 8:40 a.m. revealed the residents were being supervised by the Administrator and the MDS Coordinator. The residents assessed to require the use of the smokers' aprons were wearing them. The Administrator stated he was continuing with the in-services and would be at the facility to finish the in-services with the staff on Saturday, 6/21/14. On 6/20/14 at 9:30 a.m. the Regional Clinical Director was informed that the IJ was lifted as of 6/19/14. Observation on 6/20/14 at 10:50 a.m. in the smoking area revealed residents wearing smoking aprons and the Housekeeping/Laundry Director supervising the residents that were smoking. During this observation the Housekeeping/Laundry Director stated that during the weekend his staff supervised the residents during the smoke break at 10:30 a.m. and that dietary supervised the residents at 8:30 a.m., but that nursing covered the smoke breaks throughout the rest of the day, from 1:30 p.m. on. Interview on 6/20/14 at 3:38 p.m. with CNA W revealed that she works on weekends and assisted the facility to supervise residents that smoked. CNA W stated that residents wear aprons and that after the smoke break; she emptied the ashtray and returned it to the smoking area for the non-supervised smokers. Observation on 6/20/14 at 6:34 p.m. of the smoking area revealed that CNA W was monitoring the resident smoke break. Some of the residents were wearing aprons. CNA W would provide each resident a cigarette and light. The ashtray was offered and each resident would extinguish the cigarette and drop it inside the ashtray. Interview on 6/20/14 at 7:25 p.m. with RN X revealed that the residents were supervised during their smoke break by dietary, housekeeping, laundry and nursing. The times she was familiar with were: 10:30 a.m., 1:30 p.m., 3:30 p.m., 6:30 p.m., and 8:30 p.m. RN X stated that the DON had contacted her by phone and informed her of some new information to follow for the residents during their smoke breaks. She stated that the ashtray was to be emptied outside the gate in the container and that 2 residents were unsupervised. 2. Review of Resident # 11's face sheet (dated 6/17/14) revealed that Resident # 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 11's Annual MDS (dated 3/17/14) revealed that the resident was moderately impaired cognitively and used tobacco. Resident # 11's 60 day Medicare assessment (dated 6/2/14) revealed that the resident was cognitively intact. Review of Resident # 11's safe smoking evaluation (dated 3/15/14) revealed that the resident was determined to be a safe smoker with occasional supervision required. Review of Resident # 11's care plan (Revision dated 2/20/14) revealed the resident was "a smoker ... and the goal was to not suffer injury from unsafe smoking practices through the review date: The resident requires SUPERVISION while smoking. The resident's smoking supplies are stored in the smoker box at the nurses' station." Observation on 6/17/14 at 1:40 p.m. with the DON in the outside patio/smoking area revealed Resident # 11 smoking a cigarette without supervision. The DON stated that residents who smoked "normally should be supervised." Review of an Incident/Accident Report (dated 6/17/14) revealed that she was smoking a cigarette and admitted to having a lighter and cigarettes. The DON confiscated the lighter and cigarettes and informed her of safety. Interview on 6/17/14 at 3:13 p.m. with Cook H revealed that she supervised the 8:30 a.m. smoke break. Cook H stated that she had not had any problems with Resident # 11 during smoke break. Interview on 6/17/14 at 1:40 p.m. with Resident # 11 revealed (in Spanish) that she kept her cigarette and her lighter with her: "los tengo alsados." The DON discussed the smoking policy with the resident and permitted her to finish her cigarette but removed the lighter from her. The resident had the lighter and her cigarettes in her eyeglass pouch. 3. Resident # 12 was admitted to the facility on [DATE] per the face sheet dated 1/31/14. The [DIAGNOSES REDACTED]. Record review of Resident # 12's record revealed no Safe Smoking Evaluation. During an interview on 6/19/14 at 9:30 a.m. with Resident # 12 in the area near the Nurses' Station, Resident # 12 stated that if he didn't get a cigarette that he was going to refuse everything and showed his arm with his [MEDICAL TREATMENT] shunt. LVN L was asked if Resident # 12 smoked and the surveyor informed her of what the resident said. She stated no, she had never seen Resident # 12 smoke before. She then asked the Activity Director if she knew if the resident smoked and the Activity Director stated that Resident # 12 had no money to buy any cigarettes. Both staff members stated that the facility was the resident's family but the resident had no money. The Activity Director then stated that she has given Resident # 12 a cigarette whenever he gets worked up and anxious to calm him down. The DON was informed of the resident wanting a cigarette otherwise he was going to refuse everything. The DON was not aware that the resident was a smoker but he said he would check into it. The staff assessed the resident and the assessment and care plan were given to the survey team. The assessment revealed he was a Safe smoker with Occasional supervision, his Kardex was up-dated to reflect that he was a safe smoker and required occasional supervision and his care plan was also up-dated and revealed he was a smoker requiring occasional supervision and his supplies were stored in the activities department. Resident # 12's Re-Admission Nursing Admission Data Collection form dated 3/13/14 revealed in Section F the resident was a past smoker. Resident # 12's last MDS revealed a cognitive score of 15 (no impairment). During the same interview on 6/19/14 at 9:30 a.m., LVN L confirmed that Resident # 12 was not on the list of smokers. 4. Review of Resident # 15 face sheet (dated 6/17/14) revealed that the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the quarterly MDS (dated 6/6/14) revealed that the resident was cognitively intact. Review of Resident # 15's Safe Smoking Evaluation (dated 6/6/14) revealed that the resident was a safe smoker with no supervision required. Review of Resident # 15's Care Plan with the date initiated on 3/6/14 revealed: -he has a potential to be verbally aggressive with staff r/t paranoid [MEDICAL CONDITION]: intervention included to allow choices within individual ' s decision making abilities. -he is a smoker: intervention included the resident is able to keep smoking materials in a secure area in his room and go out to smoke without supervision. On 6/23/14 at 1:07 p.m. Resident # 15 was interviewed about the smoking policy and the surveyor observed the resident's cigarettes and lighter were in his shoes and not in the lock box that he had in his room. The resident was lying down in his bed. Review of Resident # 15's Care Plan with the revision date of 6/17/14 revealed:he is a smoker: intervention included the resident is able to keep smoking materials in a secure area in his room lock box when materials were not on his person. -LN (Licensed Nurses) will check proper securement of smoking materials QD Review of a facility statement signed by the Administrator and Resident #15 (dated 6/23/14) revealed: "re-educate (him) on the smoking policy ...that all his smoking materials should be kept in his safe at all times except when he is going out to smoke and as soon as he is done he is to return his smoking materials to the safe. Record review of the facility's Resident Council Meeting Minutes dated 4/9/14 revealed the resident council was concerned that smokers were not being supervised and were not smoking in the designated area. Interview on 6/17/14 at 11:00 a.m. with the Resident Council President revealed the Resident Council had addressed a concern that some of the smokers should not be left unsupervised when they smoked and were not staying in the designated areas for smoking. She stated the council was concerned about the smokers being endangered and endangering other residents. Interview on 6/17/14 at 1:25 p.m. the Regional Clinical Director stated the staff will make out an Incident Report about the resident having his lighter with him. The staff stated also that another resident sometimes gave Resident # 9 some cigarettes. The Administrator stated that the families would be informed and sign papers on the smoking policy. He also stated that Resident # 9 would be taken to the bank when the resident received his check and then would buy his cigarettes and lighter. He then stated that the resident ' s family and friends, possibly, buy or bring him the smoking materials. The Regional Clinical Director stated that the safe smoker assessments were done either by the Activity Director or someone in the Nursing Department. She also stated that on admission it was done by the Charge Nurse. She stated that the smoking assessments were done on quarterly bases, sometimes done by the Week-end Supervisor. The Administrator, the DON, and the Regional Clinical Director on 6/17/14 at 1:25 p.m. were informed that the survey team had identified an IJ (Immediate Jeopardy). The Regional Clinical Director stated the facility staff would be working on a plan to have the IJ removed ASAP. The staff stated that the next break would be at 1:30 p.m. and that all were supervised and no one would have their cigarettes or lighter with them. The plan of removal of the IJ was accepted on on 6/17/14 at 5:29 p.m. The facility took the following actions to remove the IJ: -All smokers were immediately assessed for safe smoking and the residents' care plans were up-dated. The Kardex sheet for the staff to also use for the residents' care were also up-dated with the new assessment information and resident specific interventions. -All smoking residents were educated on the smoking policy and signed the form; Families were also informed of the smoking policy -Resident # 9 was given his discharge notice -Facility wide staff training was conducted 8immediately about the smoking policy and the staff were not permitted to assume their responsibilities untile they had completed this education. -The first infraction of the Safe Smoking Policy would result in a warning to both the resident and their family member or representative. The second infraction of the Safe Smoking Policy would result in a notice of discharge. -The Administrator and the DNS (Director of Nursing Service) will monitor compliance with this plan on a daily basis for 1 month and then monthly thereafter until the Quality Assurance and Performance Improvement Committee (QAPI) believes that the facility can sustain compliance with the plan. -The QAPI Committee will monitor compliance monthly. Interview on 6/17/14 at 6:10 p.m. with the Regional Clinical Director and the Administrator revealed the smoking assessment was reflected in the care plans of the residents. She stated that the assessments were done quarterly with the MDSs and done within the reference period of the MDS. She stated that the team was going to discuss the 12 residents and get information from the other disciplines if they had seen anything or had any important information about the residents and the team was going to do new assessments on the residents and match up the care plans to the assessments. The Smoking policy was to be signed today and discussed with the residents and a letter to be sent to the residents ' Responsible Parties also. The Administrator stated that Resident # 22 was also going to be given a warning and notice to his mother too. The Regional Clinical Director stated that the list of supervision required of the smokers would be on the Kardex at the nurses ' station and with the smoking material container. The survey team asked for the updated assessments and care plans. She stated that after the re-assessments of the residents, a list of the smokers and their required supervision would also be placed with the box with the smoking material. Interview on 6/17/14 at 6:30 p.m. with CNA U revealed that she had received training before going outside to supervise the residents smoking. CNA U stated that the residents had a designated place to smoke and time. She also understood that if a resident did not follow the rules they would receive a first warning. Observation on 6/17/14 at 6:35 p.m. revealed that CNA U was monitoring the smoke break for the residents. The CNA provided each resident a cigarette and lit it for them. She also provided aprons for those on the list that were to receive aprons. At the end of the smoke break, CNA U collected all the cigarette butts, emptied the ashtray into the "red bucket" and returned the empty ashtray to the smoking area. Observation on 6/17/14 at 6:50 p.m. of the smoking area revealed the Administrator was there and talking to the residents about the