Every finding on record at Lake Merritt Healthcare Center LLC

Based on interview and record review, the facility failed to ensure Resident Representative (RP) was informed of a resident's change in condition for one out of two sampled resident (Resident 1) when Resident 1's family member (FM) was not notified of Resident 1's fall incidents on 10/9/25 and 10/19/25.This failure resulted in Resident 1's FM being uninformed and unaware of Resident 1's fall.During a review of Resident 1's Facility admission Record dated 3/4/25 the Facility admission Record indicated, Resident 1 was admitted in the facility on 9/5/25 with an admission diagnosis of traumatic subdural hemorrhage with loss of consciousness (a critical, life-threatening emergency caused by bleeding between the brain and its outer covering following a severe head injury), traumatic brain compression without herniation (increased pressure builds up inside the skull causing brain tissue compression following a head injury, but without the fatal shift of tissue) and unspecified dementia (a diagnosis used when symptoms of cognitive decline-such as memory loss, confusion, and impaired judgment-are present, but a specific cause cannot be determined). The Facility admission Record indicated the first name, relationship and phone number of Resident 1's FM in the contact list. The Facility admission Record indicated, Resident 1's FM's contact type was blank.During a record review of Resident 1's Acute Care Hospital (ACH) Face Sheet, undated, the ACH Face Sheet indicated, Resident 1's two FM were Emergency Contact (EC).During a phone interview on 4/14/26 at 11:44 a.m. with the Admissions Coordinator (AC) responsible for inputting the contact list in to the Facility admission Record stated, Resident 1's EC was one of the FM listed in the ACH Face Sheet. The AC stated the first and last name of Resident 1's FM who was Resident 1's EC. The AC stated the contact type for Resident 1's FM should have been EC in the Facility admission Record.During a record review of Resident 1's Minimum Data Set (MDS, an assessment used to guide plan of care) dated 9/9/25, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score was three out of 15, indicating severe cognitive impairment.During a review of Resident 1's SNF Visit Note, dated 9/7/25 and 10/7/25, indicated, Resident 1 had limited capacity to make medical decisions.During an interview on 3/4/26 at 1:30 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated resident's FM should be informed of resident's incident of fall. LVN 1 stated the resident's admission record would indicate who the RP or FM of a resident.During an interview on 3/5/26 at 11:55 a.m. with the Director of Nursing (DON), the DON stated Resident 1's FM was part of the care conference. The DON stated one of the goals in resident's care was to incorporate the FM in resident's changes in condition as a collective part of healthcare decision making.During a concurrent interview and record review on 4/14/26 at 11:13pm with the DON, Resident 1's Plan of Care Note, dated 9/12/25 was reviewed. The Plan of Care Note indicated, the Interdisciplinary Team (IDT) completed Resident 1's admission care conference on behalf of resident with RP via phone call. The Plan of Care Note indicated, FM applied for in-home support services (IHSS). The DON stated the RP who attended the care conference was the FM who applied for the IHSS.During a concurrent interview and record review on 4/14/26 at 3:21pm with the Infection Preventionist (IP), Resident 1's Health Status Note, dated 10/3/25, was reviewed. The Health Status Note indicated, Resident 1's RP is in the facility today for care conference, obtained consent for Flu, Covid-19 and Pneumonia (PNA) vaccine. The IP stated not remembering the name of the RP. The IP stated knowing FM was Resident 1's RP because social services invited the RP for care conferences. The IP stated obtaining verbal consent from Resident 1's RP for the vaccines.During a concurrent interview and record review on 3/5/26 at 11:58 a.m. with the DON, Resident 1's SBAR (Situation, Background, Assessment, Recommendation, a structured, four-component communication framework designed to improve patient safety and efficiency, particularly in critical healthcare situations) Communication Form, dated 10/9/25 was reviewed. The SBAR Communication Form did not indicate the name of family/health care agent notified of Resident 1's fall. The DON stated the facility policy did not indicate who to inform of changes in condition but the SBAR Communication Form prompted the nurse to review who the RP and make a notification.During a concurrent interview and record review on 4/14/26 at 11:05 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 1's SBAR Communication Form, dated 10/19/25 was reviewed. The SBAR Communication Form did not indicate the name of family/health care agent notified of Resident 1's fall. The MDSC stated a fall was a change in condition. The MDSC stated not remembering calling the FM to notify of Resident 1's fall.

Based on interview and records review, the facility failed to ensure appropriate monitoring and interventions were provided for one of one sampled resident (Resident 1) after Resident 1 bit his tongue on 12/3/25 at 9:40 p.m.This failure could result in potential harm to Resident 1 due to delay of treatment. Resident 1 was transferred to the hospital on [DATE] and treated for tongue laceration (a tear or cut) requiring stitches. During a review of Resident 1's admission Record, dated 12/16/25, the admission Record indicated Resident 1 was admitted in the facility on 4/22/25 with an admission diagnosis of metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body), morbid obesity (individuals having a calculated measure of weight relative to height of 40 or greater or weighing in excess of 100 pounds of one's ideal weight), and paroxysmal atrial fibrillation (occasional episodes of a fast, chaotic heart rhythm).During a record review of Resident 1's Minimum Data Set (MDS, an assessment used to guide plan of care) dated 10/29/25, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score was 15 out of 15, indicating intact cognitive response.During a record review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation, a structured, four-component communication framework designed to improve patient safety and efficiency, particularly in critical healthcare situations) Communication Form, dated 12/3/25, the SBAR Communication Form indicated, Licensed Vocational Nurse (LVN) 1 noted blood in Resident 1's mouth at 9:40 p.m. and Resident 1 stated he bit his tongue. The SBAR Communication Form indicated, Resident 1 refused to go to the hospital and the recommendation of the medical doctor (MD) was to continue to monitor.During a review of facility's policy and procedure (P&P) titled, Acute Condition Changes - Clinical Protocol, revision dated 3/2018, the P&P indicated, Monitoring and Follow-Up: 1. The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly. During a phone interview on 3/12/26 at 1:07 p.m. with LVN 1, the evening shift (3:00 p.m. to 11:30 p.m.) nurse for Resident 1 on 12/3/25, LVN 1 stated Resident 1 was monitored every 15 minutes after the bleeding. LVN 1 stated not remembering Resident 1's condition after every 15 minutes of monitoring. LVN 1 stated not remembering documenting Resident 1's condition after monitoring. During a phone interview on 3/12/26 at 1:29 p.m. with Registered Nurse (RN) 1, the night shift nurse on 12/3/25 at 11:00 p.m. up to 12/4/25 at 7:30 a.m. for Resident 1, RN 1 stated Resident 1's tongue continued to bleed towards the night. RN 1 stated not knowing how much bleeding was noted. RN 1 stated applying pressure to Resident 1's tongue when it continued to bleed. RN 1 stated being unsure if he had documented after monitoring Resident 1 and the interventions he provided. During a follow up phone interview on 3/16/26 at 1:20 p.m. with RN 1, RN 1 stated routinely monitoring Resident 1 during the night shift. RN 1 stated the purpose of documenting monitoring and intervention was to provide evidence during audit or review when questioned why there was no documented evidence of Resident 1's monitoring and interventions in the Progress Note.During a concurrent interview and record review on 3/12/26 at 2:10 p.m. with the Director of Nursing (DON), Resident 1's Progress Notes, dated 12/3/25 to 12/4/25 was reviewed. The Progress Notes showed no documented evidence that LVN 1 and RN 1 monitored Resident 1 and provided intervention on 12/3/25 after 9:40 p.m. up to 12/4/25 at 6:21 a.m. During a record review of Resident 1's SBAR Communication Form, dated 12/4/25, the SBAR Communication Form indicated, Resident 1 continued to bleed through the night and RN 1 informed the MD of Resident 1's prolonged bleeding at 6:21 a.m. The SBAR Communication Form indicated RN 1 called emergency services (EMS) and Resident 1 was sent to the hospital.During a record review of Resident 1's Acute Care Hospital (ACH) After Visit Summary, dated 12/4/25 at 11:42 a.m., the Acute Care Hospital (ACH) After Visit Summary indicated, Resident 1 was treated for tongue laceration (a tear or cut). The Acute Care Hospital (ACH) After Visit Summary indicated, the bleeding was significant due to Resident 1's use of blood thinner medication. The Acute Care Hospital (ACH) After Visit Summary indicated, several methods were used to stop the bleeding, including applying pressure, using special glue, and stitching the cut.

Based on observation, interview and record review, the facility failed to protect one of the two residents (Resident 1) from physical abuse when Resident 2 hit Resident 1 with a wooden hanger on the forehead. This failure resulted in Resident 1 suffering from a laceration (a tear or cut in the skin caused by blunt trauma or sharp objects) on the forehead and being sent to an acute care hospital for further care and treatment.During a record review of Resident 1's admission record, the record indicated Resident 1 was admitted to the facility on [DATE]. The admission record indicated Resident 1 has a diagnosis of metabolic encephalopathy (temporary or permanent brain dysfunction resulting from the body's inability to maintain a proper chemical environment for the brain) and unspecified Dementia (A condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems). During a record review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool used to evaluate a resident's functional capabilities, health needs, and clinical status), dated 12/04/25, the assessment indicated Resident 1 was rarely or never understood and was rarely or never able to make himself understood. The assessment also indicated that Resident 1 had a behavior of wandering (moving from place to place without a plan) every day. During a record review of Resident 2's admission record, the record indicated Resident 2 was admitted to the facility on [DATE]. The admission record indicated Resident 2 has a diagnosis of metabolic encephalopathy and unspecified Dementia, undifferentiated schizophrenia (a mental condition which makes it difficult to think clearly, have normal emotional responses, act normally in social situations, and tell the difference between what is real and what is not real). During a record review of Resident 2's MDS assessment dated [DATE], the record indicated Resident 2's Brief Interview for Mental Status (BIMS, an assessment for mental status) score was seven (7) out of 15, indicating severe cognitive impairment. During an observation on 3/6/26 at 10:00 a.m. in facility's activity room, Resident 1 was sitting in a chair listening to a CD player. When approached, Resident 1 smiled but did not respond. Activity Director (AD) 1 stated that Resident 1 does not speak and cannot answer questions. During an observation and interview on 3/6/26 at 10:02 a.m. Resident 2 was in the room sitting on the bed, cleaning his shoes. Resident 2 refused to participate in the interview. During an interview on 3/6/26 at 10:07 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 2 had the tendency to be agitated when people walked around his room. During an interview on 3/6/26 at 10:15 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was the assigned CNA for Resident 1 that day. CNA 1 stated Resident 1 often wandered in the facility hallways and did not have the ability to defend himself. During a phone interview on 3/6/26 at 11:49 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated that the incident between Resident 1 and Resident 2 happened a few weeks ago. CNA 2 stated he was coming out of the break room, and he noticed the charge nurse and other nurses were gathered in Resident 2's room. CNA 2 stated by the time he got there, Resident 1 was sitting on the floor with blood coming out of his head while Resident 2 was sitting on his bed. During a phone interview on 3/6/26 at 11:58 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated he was the assigned charge nurse for Resident 2 on 1/20/26, on the day of incident. LVN 3 stated he was in another resident's room, and he heard commotion (noisy/violent disturbing sounds). LVN 3 stated he went to Resident 2's room and saw Resident 1 was bleeding from the forehead, while Resident 2 had a wooden hanger in his hand. LVN 3 stated Resident 2 was using profanity (offensive, swear words) at that time. LVN 3 stated though he did not see Resident 2 hitting Resident 1, but it was evident that is what happened. LVN 3 stated Resident 1 had a laceration above left eyebrow, with moderate amount of bleeding and was sent out to the acute care hospital for further care. During record review of Resident 1's Progress Notes dated 1/20/26, Licensed Vocational Nurse (LVN) 2 documented, at 6:20 pm station 1 charge nurse heard very low voice from [Resident 2's room]. [Resident 2's] door was closed. Charge nurse opened the door and checked the resident. Charge nurse noted [Resident 1] sitting on the floor near the door. Charge nurse immediately separated both residents. Upon assessment [Resident 1] was noted to have a bleeding on the left forehead above eyebrow. During a record review of Resident 1's ED (Emergency Department) Provider Notes dated 1/19/26, the notes indicated assaulted with wooden hangar to head .laceration of forehead.3cm horizontal laceration left forehead. Provider notes dated 1/20/26, the notes indicated Laceration irrigated (washing or flushing of wound) and closed with steristrips (sterile strips applied to skin to close wounds). During an interview on 3/6/26 at 11:37 am with Director of Staff Development (DSD), DSD stated facility staff have been monitoring Resident 1 for wandering behavior, even before the incident occurred on 1/19/26, but they should have been more cautious about his whereabouts. During a review of facility policy titled, Abuse Prevention/Prohibition, the policy states, The facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment, and develops Facility policies, procedures, training programs and systems in order to promote an environment free from abuse and mistreatment. The process in this document states, Abuse is defined as the willful inflictions of injury. Types of abuse noted in this document state, Physical abuse is defined as hitting, slapping, pinching and or kicking.

Based on observation, interview and record review, the facility failed to protect two of four sampled residents (Resident 1 and Resident 3) when Resident 2 pushed Resident 1 to the floor; and Resident 4 punched Resident 3 in the face during an altercation. This failure resulted in Resident 1 falling to the floor and sustained a laceration (a cut in the skin) of left shin and right knee. Resident 3 sustained swelling under the right eye on his face. During a record review of Resident 1's admission Record on 3/5/26, the record showed Resident 1 was admitted to the facility on 10 /25/11. During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used in identifying problems to be addressed in plan of care ) assessment dated [DATE], the assessment indicated Resident 1's Brief Interview for Mental Status (BIMS, short-term memory screening tool) score was 10 out of 15, indicating moderate cognitive impairment. During a record review of Resident 2's admission Record 03/5/26 the record showed Resident 2 was admitted to the facility on [DATE]. During a record review of Resident 2's Annual MDS assessment dated [DATE], the assessment indicated Resident 2's BIMS score was nine (9) out of 15, indicating moderate cognition. During an observation and interview on 3/5/26 at 2:05 p.m. Resident 1 was sitting in his wheelchair by the nursing station of the hallway. Resident 1 stated Resident 2 was angry and yelled at him. Resident 1 stated Resident 2 pushed him to the floor and pointed to his right shin and knee said cut. During an observation and interview with Resident 2 on 3/5/26 at 2:22 p.m. Resident 2 was lying in bed and refused the interview.During a phone interview on 3/6/26, at 10:40 a.m. with Registered Nurse (RN) 1, RN 1 stated on 12/20/25, while he was in the hallway, he heard yelling. RN 1 stated he went to the area of the yelling and saw Resident 1 and Resident 2 facing each other and were ready to pounce at each other. Resident 1 ended up on the floor after being pushed to the ground by Resident 2. Resident 1 acquired a laceration on the right knee and left shin. They were both very upset and it was hard to deescalate the situation. RN 1 stated he had to call the police for help. During a record review of Resident 1's clinical progress note dated 12/20/25, RN 1 documented observed [Residents 1 and 2] engaged in an escalating altercation. Both residents were holding chairs and positioned defensively, attempted to de-escalate the situation; however, the attempts were unsuccessful. [Resident 2] pushed [Resident 1], causing [Resident 1] to fall forward and off the wheelchair. Resident 1 sustained a laceration to the left shin and a laceration to the right knee.During a record review of Resident 3's admission Record dated 03/05/26 the record indicated Resident 3 was admitted to the facility on [DATE]. A record review of Resident 3's MDS assessment dated [DATE] indicated, Resident 3's BIMS score was four (4) out of 15, indicating severe cognitive impairment. During a record review of Resident 4's admission Record dated 03/05/26 the record indicated Resident 4 was admitted to the facility on [DATE]. During a record review of Resident 4's Annual MDS assessment dated [DATE], the assessment indicated Resident 4's BIMS score was 14 out of 15, indicating intact cognition. During an observation and interview with Resident 3 on 3/5/26 at 12:05 p.m., Resident 3 was sitting on his bed in his room. Resident 3 stated he was minding his own business, when Resident 4 started yelling about him making racist comments and then punched him on his face as he was leaving the room. During an interview with Resident 4 on 3/5/26 at 10:15 a.m., Resident 4 stated he punched Resident 3 on his face because he thought Resident 3 took his shirt.During a phone interview on 3/5/26, at 10:00 a.m., Certified Nursing Assistant (CNA) 1 stated she was the 1:1 sitter for Resident 4 on 12/10/25. CNA 1 stated [Resident 4] punched [Resident 3] on his face because he mistakenly thought [Resident 3] was wearing his shirt while he was being escorted to the activity room. I was not expecting for [resident 4] to charge at [resident 3] and punch him. During an interview on 03/09/2026 at 3:55p.m., CNA 2 stated Resident 4 had a history of punching people that is why he had a 1:1 sitter. [Resident 4] got up abruptly and charged at [resident 3] and punched him on the face. I was by resident 3's bedside setting up the food tray for lunch. [Resident 3] got up from seated position in a defensive posture and was visibly angry. I tried to calm [resident 3] down and a few minutes later, I notified LVN 1 of the incident and we relocated resident 3 to another room. During an interview on 3/6/26 at 12:55 p.m., Licensed Vocational Nurse (LVN) 1 stated Resident 3 suffered a swollen face when Resident 4 hit him on 12/10/25. During a record review of Resident 3's progress notes dated 12/10/25, LVN 1 documented, was called by [CNA 2] reported that resident was hit by his roommate below the right eye, the roommate was complaining he was wearing his shirt. He sustained a swelling below the right eye .Pain medication was administered, ice pack was applied. During a review of the facility's Policy and Procedure (P&P) titled, Abuse Reporting and Investigation and Residents Rights dated 05/2025 the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' rights to a dignified existence, to be treated with respect, kindness and dignity

Based on interview and record review, the facility failed to ensure an appropriate and resident centered discharge planning process for one of five sampled residents (Resident 5). Resident 5, with a known history of suicidal ideation, was discharged to an acute care hospital for suicidal attempt at the facility and facility refused to accept her back at the facility. This failure resulted in Resident 5's extended acute care hospital stay, and placed at risk for an unsafe and unplanned transition.During a record review of Resident 5's admission Record printed on 3/5/26, the record indicated Resident 5 was admitted to the facility on [DATE].Resident 5 has a diagnosis of Cognitive communication deficit, Unspecified Dementia with Agitation. During a record review of Resident 5's Minimum Data Set (MDS, a resident assessment tool used in identifying problems to be addressed in plan of care) assessment dated [DATE], the assessment indicated Resident 5's Brief Interview for Mental Status (BIMS, short-term memory screening tool) score was four (4) out of 15, indicating severe cognitive impairment. During a record review of Resident 5 Care plan dated 08/11/25, the care plan indicated Resident 5 had a language problem due to primary language being Russian. the care plan dated 08/29/25 indicated Resident 5 had a behavior of suicidal ideation related to Dementia and the staff was to Maintain close monitoring and implement suicide precautions. During a record review of Resident 5's progress dated 12/2/25 Licensed Vocational Nurse (LVN) 1 documented around 9:30 am [Resident 5] noted with a string used to turn on/off room light around her neck. Resident was holding the string tightly around her neck, resident was immediately approached and removed the string away from the room .Notified MD [Medical doctor] and RP [Responsible Party] about resident behavior . During a record review of resident 5's progress notes dated 12/2/25, indicated at 4pm police came, the officer tried to calm her down, Resident 5's behavior was out of control, police called ambulance, at 4:20 pm [medical] ambulance and resident left from the facility to the [acute care] hospital. During a phone interview, on 3/9/26 at 3:45 p.m. LVN 1 stated she was the charge nurse for Resident 5 on 12/2/25. LVN 2 stated Resident 5 often spoke native language, and at times it was hard to understand Resident 5 but staff were able to meet [Resident 1], needs by using hand gestures or pointing to items so the resident could communicate what was wanted. LVN1 stated this was her first time seeing Resident 5's suicidal behavior. LVN 1 stated to her knowledge, Resident 5 never expressed that there was a desire to leave the facility. During a phone interview on 3/9/25 at 10:55 a.m., the Medical Social Worker (MSW) at the Acute Care Hospital stated Resident 5 was considered ready for transport back to the facility on [DATE]. The MSW stated when MSW reached out to the Director of Nursing (DON) at the facility on 12/3/25, the DON declined to accept Resident 5 back due to resident's high risk for self harm and the facility's lack of trained staff to meet the resident's needs. The MSW further stated this was not the first time that facility had refused to readmit their residents back. During an interview with DON on 3/5/26 at 2:45 p.m. the DON stated the facility did not accept Resident 5 back to the facility in 12/2025 because facility did not have the staff to be able to communicate with Resident 5 due to the language barrier and she had never shown behaviors to self-harm prior to 12/02/25 (when Resident 5 was already identified with both issues in 8/2025). During a record review of Resident 5's acute care hospital progress note indicated, [acute care staff] call to facility's DON was made, the DON stated, facility will not be accepting her back citing high patient risk of self-harm.

Based on observation, interview and record review the facility failed to protect one of five sampled residents, (Resident 1), from physical abuse when Resident 2 hit Resident 1 in the head with a chair. This failure resulted in Resident 1 having a laceration (deep cut in the skin), on Resident 1's left forehead requiring transfer to an acute care hospital.During a review of Resident 1's admission Record printed on 1/6/26, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, (a brain disorder that slowly destroys memory and thinking skills.), Parkinson's Disease, (a chronic, progressive brain disorder affecting movement, and can contribute to memory loss) and agitation, (behavior marked by verbal outbursts and physical aggression).During a review of Resident 1's Minimum Data Set, (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 12/8/25, the MDS indicated Resident 1's Brief Interview for Mental Status Score, (BIMS, a scoring system used to determine the residents cognitive status in regard to attention, orientation, and ability to register and recall information), of four out of fifteen, indicating severe cognitive impairment, (significant problems with thinking, memory and orientation).During a review of Resident 2's admission Record printed on 1/6/26, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of metabolic encephalopathy, (brain dysfunction coming from chemical imbalances leading to memory loss and personality changes), anxiety, (when feelings of fear, worry or unease are excessive, persistent and interferes with daily life), and adjustment disorder with mixed disturbance of emotions and conduct, (stress-related condition where a person experiences both emotional symptoms and behavioral problems). During a review of Resident 2's MDS assessment dated [DATE], Section B, (Hearing and Speech), indicated Resident 2 sometimes makes himself understood and sometimes was able to understand others.During a concurrent observation and interview on 1/6/26 at 2:45 p.m. with Resident 1 in Resident 1's room, Resident 1 was sitting on his bed with his wife at his bedside, Resident 1 stated Resident 1 could not recall going to the Emergency Department of how resident 1's head was injured.During a concurrent observation and interview on 1/6/26 at 10:20 a.m. with Resident 2 in Resident 2's room, Resident 2 stated he hit Resident 1 in the head with a chair because Resident 2 was angry that Resident 1 woke Resident 2 up because Resident 1 wanted to talk to Resident 2. During a telephone interview on 1/9/26 at 8:41 a.m., Registered Nurse 1, (RN1), stated RN1 was on duty on 11/1/25. RN1 stated at 5:50 a.m. RN1 heard a sound and went to investigate. RN1 stated when RN1 arrived at the location of the sound, (room [ROOM NUMBER] belonging to Resident 2), RN1 observed Resident 1 sitting on the floor in the doorway of room [ROOM NUMBER] with blood coming from the left side of Resident 1's forehead. RN1 stated RN1 observed Resident 2 standing in his room, holding a chair and screaming. During a review of Resident 1's Progress Notes dated 11/1/25, the Progress Notes indicated Resident 1 was assessed by RN1 to have a laceration, (a deep cut in the skin), on the left side of Resident 1's forehead, resulting in resident 1 being transferred to the hospital by ambulance.During a review of Encounter Summary, (from the acute care hospital), dated 11/1/25 the Encounter Summary indicated Resident 1 sustained a 4 centimeter, (unit of measure), requiring stiches, (medical threads used to sew skin together to close wounds).During a review of Resident 2's care plan, (CP), dated 11/1/25, the CP indicated Resident 2 exhibits .physical and verbal aggression related to hitting, pushing, threatening and throwing objects as evidenced by observed aggressive behavior toward staff and residents . During a review of the facility's policy and procedure titled, Resident Rights, dated 02/21, indicated residents have the right to .be free from abuse, neglect, misappropriation of property and exploitation.

Based on observation, interview and record review the facility failed to ensure one ( Resident 1) of 3 sample residents with diagnosis of schizophrenia, a mental health condition, received appropriate treatment to address Resident 1 ' s paranoid delusions when Resident 1 ' s psychiatry recommendation to increase Olanzapine (antipsychotic medication) dosage was not implemented. {Paranoid delusions are fixed, false beliefs that others are intentionally trying to harm, deceive, or persecute the individual} This failure had the potential to cause Resident 1 increased emotional distress, decline in mental and psychosocial well-being. Findings: During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment and care guide tool), dated 12/9/24, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) Resident 1 ' s score was 13. Resident 1 had clear speech, able to express ideas and wants, make self-understood and understood others. Resident 1 ' s diagnoses included schizophrenia a disorder that affects a person ' s ability to think, feel and behave clearly. During a review of Resident 1 ' s Level I Preadmission Screening and Resident Review (PASRR, a federal requirement to ensure that residents are not inappropriately placed in nursing homes for long term care), dated 8/31/23, the PASRR indicated, Resident 1 ' s Level I screening result was positive for suspected MI (mental illness) and indicated a Level II mental health evaluation was required. During a review of Resident 1 ' s progress notes, dated 1/16/25, the progress notes indicated , Resident 1 alleged that staff were calling her names. During a concurrent observation and interview on 1/28/25 at 10:20 a.m. Resident 1 laid in bed, awake and verbally responsive. Resident 1 stated she did not want to discuss her allegation regarding staff calling her names. Resident 1 suddenly became upset, agitated and started yelling. During an interview on 1/28/25 at 10:28 a.m. with Certified Nursing Assistant (CNA1), CNA1 stated she was Resident 1 ' s care giver. CNA1 said Resident 1 got easily agitated, screamed and sometimes aggressive with staff. During a review of Resident 1 ' s Order Summary Report dated 6/3/24, the report indicated physician prescribed Resident 1 to receive Olanzapine tablet 10mg give one tablet by mouth one time a day for schizoaffective disorder bipolar type, manifested by paranoid delusion as exhibited by constant screaming to the point of exhaustion. During a review of Resident 1 ' s psychiatry follow up note and recommendations, dated 10/14/24, the psychiatry recommended to increase Resident 1 ' s Zydis (Olanzapine) to 15 mg by mouth every day for schizoaffective disorder, uncooperative with care, irritable, paranoid delusions, yelling. During a concurrent interview and record review on 1/28/25 at 11:40 a.m. with DON, Resident 1's positive PASRR Level 1 screening dated 8/31/23 and psychiatry recommendation dated 10/14/24 were reviewed. DON stated Resident 1's was not refered for Level II mental health evaluation. DON stated she was hired in December 2024 and was not aware of Resident 1 ' s psychiatry recommendation to increase Resident 1 ' s Olanzapine dose to 15 mg daily. DON stated the facility ' s process was that the medical record department received psychiatry consult reports , medical records gives copies of residents ' psychiatry reports to Licensed Nurses, who call the physician to approve or decline residents ' psychiatry recommendation and DON was primarily responsible for the follow-ups. During a concurrent interview and record review on 1/28/25 at 12:03 p.m. with Licensed Vocational Nurse (LVN1), Resident 1 ' s psychiatry recommendation dated 10/14/24 was reviewed. LVN1 stated she was a charge nurse. LVN 1 stated she was not aware of Resident 1 ' s psychiatry recommendation. LVN 1 stated the Director of Nursing (DON) followed up with residents psychiatry recommendations. During a concurrent interview and record review on 1/28/25 at 12:30 p.m. with DON, Resident 1 ' s Psychiatry recommendations report dated 10/14/24, physician orders, medication administration records, progress notes were reviewed with DON. DON stated there was no indication that Resident 1 ' s psychiatry recommendation dated 10/14/24 to increase Resident 1 ' s Olanzapine to 15 mg by mouth every day was followed up. The DON stated she was unable to find documentation if facility notified physician of Resident 1 ' s psychiatry recommendations.

Based on observation, interview, and record review, the facility failed to ensure a system to perform ongoing repairs and maintenance work when three of three sampled areas of the facility were affected by the following: 1. Floor tiles in resident care hallway were broken and coming off. 2. a. Baseboard on the walls for Room A and Room B was missing and broken at places, with broken dry wall and plaster pieces sticking out of the wall. b. The overbed tables for Resident 42 and Resident 31 were chipped and unfurnished with rough edges, posing a potential risk for them getting scratched and hurting themselves. c. Screen door for Room A shared among Residents 42, 31 and 17 was broken and off the track. d. Electric cable cord for the television and Resident 37's call light cord in Room B were taped to the wall. e. The wall clock in Room B displayed an inaccurate time, with a potential to cause confusion and disorientation of time. f. Shared bathroom between two residents' rooms (Room A and Room B) did not have soap for more than two consecutive days. 3. Smoking patio had broken, rusty metallic table and chairs with sharp edges coming out placing the residents visiting that area at risk of hurting themselves. Findings: 1. During an observation on 10/21/24 at 12:23 p.m. in the hallways, there were several cracked, broken, opened floor tiles in disrepair opposite residents' activity/dining room. During an interview on 10/23/24 at 9:56 a.m. with Administrator (Admin), Admin stated the opened floor tile located next to residents' activity/dining room had been there for sometime. Admin stated facility planned to make over all the floors in the residents' care area hallways. 2. a. During a concurrent observation and interview with Maintenance Supervisor (MS) on 10/22/24 at 11:06 a.m., two adjacent rooms (Room A and Room B) were observed. MS stated baseboard in Room A and Room B were broken, the dry wall and plaster was off and sticking out. MS stated he conducted room rounds every Friday; however, he did not notice the damaged baseboards on Friday, 10/18/24. When asked if it looked like a new damage to the baseboards, MS stated no. MS stated both rooms needed new baseboards because facility was old and constructions was done long time ago. b. During an observation and interview on 10/21/24 at 9:37 a.m. Resident 42 was sitting at the edge of the bed with his overbed table in front of him. The overbed table had rough and chipped all four sides of the top tray. Resident 42 stated facility staff was aware, and they could see his damaged overbed table. Resident 42 stated it made him feel that staff did not care about his damaged overbed table. During a concurrent observation and interview on 10/22/24 at 11:08 a.m. with MS, Resident 31 and Resident 42's overbed tables were observed. MS stated both tables had chipped and rough edges, and the rubber that goes around all four sides of the top tray that protects the residents from hurting themselves, was completely off. MS stated the top tray was made of compression wood and residents could easily stick their fingers/hands and could get splinters and hurt themselves easily. MS stated he did not identify need to repair/replace the overbed tables for Resident 31 and 42 on 10/18/24 during his room rounds. MS stated both tables needed to be replaced. c. During an observation and interview with MS on 10/22/24 at 11:10 a.m., Room A's screen door was half open, off the track, not latching, and MS was not able to close it all the way. MS stated he was aware that the screen door for Room A needed a replacement for last three weeks. MS stated he called a company from Google one week ago but was unable to provide the details. MS stated it was important to replace the screen door in a timely manner to prevent animals and bugs coming into the room. d. During an observation on 10/21/24 at 10:24 a.m., electrical cord for the television was taped with a blue scotch tape to the wall; and Resident 37's call light cord was taped with a yellow-colored scotch tape to the call light outlet. During an observation and interview with MS on 10/22/24 at 11:12 a.m., in Room B, two back colored television cords were taped onto the wall, additionally the call light cord for Resident 37 was taped to the call light outlet. MS stated he noticed the cable cords taped up to the walls on Friday 10/18/24, during his rounds but he did not remove the tape. MS stated taping the electric cords was not safe and he needed to staple the cords to affix them to the walls. MS stated he did not have a staple in the facility and needed to buy one. e. During an observation on interview on 10/22/24 at 11:12 a.m. with MS, the wall clock in Room B was off. MS stated the clock displayed 9:05 at that time. MS stated he was responsible for changing the battery for the clock. During another observation and interview on 10/23/24 at 12:32 p.m., the wall clock in Room B still displayed 9:05. Resident 37 was lying in the bed and stated the time on the clock made him confused because his cell phone and wall clock in the room did not match. During an interview and record review with MS on 10/22/24 at 11:21 a.m. at nursing station, facility's maintenance logbook from 7/2024 through 10/2024 was reviewed. MS stated staff used the maintenance logbook to report the need of repairs and maintenance in the facility/resident care areas. MS stated he was unable to find above issues being reported in the logbook. f. During an observation on 10/21/24 at 10:04 a.m. in shared bathroom between Room A and Room B, there was no soap in the soap dispenser. During an observation on 10/21/24 at 10:20 a.m., Resident 42 used the bathroom, walked out of the bathroom, when asked if there was any soap, Resident 42 stated what can you do? During a concurrent observation and interview on 10/21/24 at 10:26 a.m., Regional Registered Nurse 3 (RN 3) entered the shared bathroom between Room A and Room B. RN 3 turned the tap on to wash his hands and stated there was no soap in the liquid soap dispenser. RN 3 stated it was unusual to not have soap in residents' bathroom. During a concurrent observation and interview on 10/21/24 at 10:35 a.m. Janitor 1 walked into the shared bathroom and started refilling the soap dispenser. Janitor 1 stated housekeeping staff 1 (HSKP 1) told him around 1:30 pm on 10/18/24 that this bathroom needed soap replacement, but he forgot to replace it at that time, indicating the bathroom was out of soap for more than two (2) consecutive days. During an interview with HSKP 1 on 10/22/24 at 8:47 a.m. in hallway outside Room A and Room B, HSKP 1 stated she told Janitor 1 to replace the soap in the bathroom on 10/18/24 because she did not have the keys to the supply room where liquid soap supply was kept in the facility. 3.During a concurrent observation and interview with Director of Staff Development (DSD) on 10/22/24 at 9:09 a.m., in facility's smoking patio, a white colored round metal table and two white metal chairs were worn out. The DSD stated the furniture was rusty and had rough edges and sharp metallic meshy edges were coming out on the table and chairs. The DSD stated that area was dedicated for smoking residents, and they could cut their hands and get injured if they ever used that furniture. During an interview with Maintenance Supervisor (MS) on 10/22/24 at 11:06 a.m., MS stated he had to threw away the broken and rusty furniture that was kept in the smoking patio as it was not good anymore. During a review of facility's policy and procedure (P&P) titled Maintenance Service revised 12/2009, the P&P indicated, The Maintenance Department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times . 39939

Based on observation, interview, and record review the facility failed to store and prepare foods in a sanitary manner that prevented foodborne illness when: - One bag of sliced ham unlabeled and undated was stored in the refrigerator. - Kitchen vents, fans and window screens with dusty areas. These failures had the potential for residents to be exposed to food borne illness. Findings: During the initial tour of the kitchen on 10/21/24 at 9:22 a.m. accompanied by Dietary Aide (DA) and Dietary Manager (DM) one opened bag of sliced ham not labeled with use-by date was observed in the refrigerator. During a concurrent observation and interview on 10/22/24 at 8:47 a.m. with Maintenance Supervisor (MS) and DM in the Kitchen, vents, fans and window screens were dusty. MS stated he cleaned monthly. MS stated he did not have a record or documentation of the cleaning. During an interview on 10/22/24 at 9:02 a.m. with DA, DA stated she received training on labeling and dating food items. DA stated it was important to label with use-by date food items stored in the refrigerators. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, revised July 2014, the P&P indicated, All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated, The Maintenance Department will assist Food & Nutrition Services as necessary in maintaining equipment and in doing janitorial duties which the food & nutrition services employees cannot do and maintain maintenance records on all equipment.

Based on interview and record review facility failed to complete an annual performance review, commonly known as competency/skills checks for one of three sampled Certified Nursing Assistants (CNA 7). Facility did not complete and maintain records for competency/skills checks completed upon hire/orientation for two of three sampled CNAs (CNA 4 and CNA 6). CNA is an unlicensed health professional providing nursing or nursing-related services to residents in the facility. This failure placed facility's residents residing at the facility at risk for not receiving need-based care, compromised safety, and receiving care from incompetent CNAs. Findings: During a review of facility's undated and untitled Staff list, the list indicated CNA 4 was an active, on-call CNA since 5/3/24; CNA 6 was an active, full-time CNA since 1/26/24 ; and CNA 7 was facility's active and full-time employee as a CNA since 11/1/20. During an interview and record review on 10/23/24 at 3:27 p.m. with Director of Staff Development (DSD), in DSD's office, an electronic Excel spreadsheet with facility's staff names was reviewed. The DSD stated she created the spreadsheet for all staff to track their annual competency reviews, however she did not start using it yet. The DSD stated she was responsible for completing the orientation and annual performance reviews for CNAs. The DSD stated she did not complete anyone's competency/skills checks in the past two months, since she started working as a DSD. During an interview and record review on 10/23/24 at 3:30 p.m. with DSD, CNA 4's personnel file was reviewed. CNA 4's personnel file had a document titled Nursing Assistant Orientation and Competency Evaluation dated 5/3/24 with CNA 4's name written on it. The document indicated to fill in the Date and Result of skills check next to each Skills column, Comments section and Evaluator's signature section. The DSD stated document was not completed at all by anyone. The DSD then pulled another undated document titled Performance Evaluation with CNA's name and title written on it. The DSD stated facility used this document to evaluate CNA's performance during probation, quarterly and on an annual basis. The document had following sections: Goals, Specific areas of improvement needs, Comments, Date performance was discussed on; Employee and Supervisors' name, title, and signatures. The DSD stated CNA 4's performance evaluation document was left blank and only had CNA's printed name and signatures. During an interview and record review on 10/23/24 at 3:33 p.m. with DSD, personnel file for CNA 6 was reviewed. DSD stated CNA 6's file had a document titled Competency Evaluation and Performance Satisfactory Completion for Turning and Repositioning dated 2/1/24 signed by CNA 6 and the Evaluator indicated, there were no results documented if CNA 6 was competent or incompetent for that task. DSD stated rest of the competency/skills checks documents for adult brief application, Ambulation with Assistance, Hair and Scalp care, Gait belt application, Foot Care, Fingernail Care, Filling Liquid Oxygen, feeding a Resident, Emptying Urinary Drainage Bags, dressing a Resident, Perineal care, Blood Pressure, and Bed making had CNA 6's name written on them. DSD stated she was unable to find any documentation if CNA 6 was ever trained and/or evaluated for above skills. During an interview and record review on 10/23/24 at 3:37 p.m. with DSD, CNA 7's personnel file was reviewed. The DSD stated the file had a document undated titled CNA Core Clinical Competencies which indicated CNA 7 had an annual performance review completed on 6/20/23 and 6/23/23. The DSD stated she was unable to find any other/annual performance review for CNA 7 after 6/23/23. The DSD stated training, orientation to required procedures and annual performance reviews must be conducted to ensure residents' safety, to prevent harm, reduce errors in providing care, prevent falls, injuries, decline in residents' skin health. The DSD stated she was unsure how to anticipate staff's training needs. During an interview on 10/24/24 at 9:53 a.m. at facility's nursing station, the Administrator (ADM) stated all CNA's working at the facility needed to go through standard orientation upon hire. The ADM stated it was facility's policy that the DSD was responsible to assess CNA's competency upon hire, after 90 days of their date of hire and then on an annual basis, however, it was probably not happening. The ADM stated once DSD completed the competency evaluation for CNA's, he received a copy of the evaluation for review; however, he had not been receiving any evaluations for almost a year. The ADM stated they were in non-compliance with this requirement during previous annual recertification survey as well. During a review of facility's policy and procedure (P&P) titled Competency of Nursing Staff revised 05/2019, the P&P indicated, Competency in skills and techniques necessary to care for residents needs includes but is not limited to competencies in areas such as: Preventing abuse, neglect and exploitation of resident property; Dementia management; Resident rights; Person centered care . Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment.

Based on observation, interview, and record review, the facility failed to complete performance review and maintain competency/skills records for three of three sampled licensed nurses (LVN 1, RN 2, and RN 4). A Licensed Nurse is a healthcare professional who has met requirements by state board of nursing to practice nursing skills within defined scope. This failure placed facility to be unaware and address training needs for LVN 1, RN 2 and RN 4 and placed all residents receiving care from LVN 1, RN 2 and RN 4 for receiving care from incompetent licensed nurses. Findings: During an interview and record review with Director of Staff Development (DSD) and Licensed Vocational Nurse 1 (LVN 1) on 10/24/24 at 9:36 a.m., personnel file for LVN 1 was reviewed. The DSD stated LVN 1 was hired on 6/17/24 and she was only able to find background information, hiring application etc. in LVN 1's file. LVN 1 stated she never received an orientation/ training and/or a competency evaluation upon hire and/or after hire. During an interview and record review with the DSD on 10/23/24 at 2:40 p.m. a documented titled Licensed Nurse Clinical Checklist was reviewed. The DSD stated facility utilized this checklist to assess licensed nurses' competency upon orientation and on an annual basis. The checklist indicated to add S for satisfactory and U for unsatisfactory performance. The checklist indicated to assess licensed nurses in: 1. Comprehensive assessment 2. Resident plan of care 3. Validation of care 4. Resident outcome/delivery of care 5. Medication administration 6. Medication security 7. Nursing environment 8. Routine treatments 9. Feeding tubes 10. [Intravenous] therapy 11. Nursing management 12. Supervision role .in a. communicates resident status to [certified nursing assistants] & other staff b. coaches and praises for work performance and work habits c. conducts performance evaluations when applicable d. takes progressive disciplinary action when applicable. [13]. Discard used materials, dispose equipment used to appropriate trash bin, according to facility's policy, perform handwashing, clean/disinfect medical equipment used for the procedure using appropriate/ germicidal wipe. [14] Sign and document medication administration procedure accordingly. The checklist indicated to add licensed nurses' signature, title, date and Reviewer's signature, title and date. During an interview and concurrent record review with the DSD on 10/23/24 at 2:41 p.m. Registered Nurse 2 (RN 2)'s personnel file was reviewed. The DSD stated RN 2 was hired on 5/5/23, and she was unable to find any documentation to indicate if she received a competency evaluation since hire. (Cross Reference F880 and F755) During an interview and concurrent record review with the DSD on 10/23/24 at 2:47 p.m. Registered Nurse 4 (RN 4)'s personnel file was reviewed. DSD stated RN 4 was hired on 8/23/23, but did not have any documentation of training or competency evaluations. During an interview on 10/23/24 at 2:51 p.m. the DSD stated skills and competency evaluations were needed to ensure resident safety, prevent resident harm, reduce errors in providing care, prevent falls and injury, risk of wrong treatment, decline in skin health etc. DSD stated she was unsure of how to anticipate staff's training needs. The DSD stated the Director of Nursing (DON) was responsible for conducting licensed nurses' competency/skills evaluations because DSD herself was an LVN. DSD stated if licensed nurses received competency/skills evaluations, they must be kept and maintained in their personnel files. During an interview on 10/24/24 at 9:17 a.m., the DON stated she was responsible for competency evaluations for licensed nurses, however she had not completed any since she started working at the facility. The DON stated it was important to evaluate nurses' performance to best nursing practices in proving residents' care. During an interview on 10/24/24 at 9:53 a.m. at facility's nursing station, the Administrator (ADM) stated the DON was responsible for evaluated performance for licensed nurses working at the facility, however to knowledge this task was probably not happening. The ADM stated there was an issue with this requirement during previous annual recertification survey as well. During a record review of the Competency of Nursing staff policy and procedure (P&P) revised 05/2019, the P&P indicated , facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment, and The staff development and training program . is designed to train nursing staff to deliver individualized, safe, quality care and services for residents.

Based on observation, interview and record review, the facility failed to follow it's smoking policy and procedure to prevent accidents hazards, complete smoking/safety evaluation, develop and implement care plan that promote smoking safety for three (Resident 19, 37 and 41) of three sampled residents when: 1. Resident 19 with amputated fingers, bilateral hands and non-compliance with smoking policy and procedure kept cigarettes and lighter in her possession. 2.Facility did not assess and complete a care plan for Resident 41 for safe smoking practices. Resident 41's charge nurses were unaware if Resident 41 smoked cigarettes, when direct care staff including Certified Nursing Assistants (CNA 1 and CNA 3) were aware that Resident 41 had always smoked at the facility. 3. Resident 37 did not receive smoking aprons, and cigarette holder per plan of care during smoking. 4. Facility staff (Janitor 1) smoked in the smoking patio when door to all rooms adjacent to smoking patio were left open with residents in the rooms. 5. Multiple smoking buds were disposed off in the flower planters instead of designated ash holders kept the smoking patio. This failure had the potential to cause residents to suffer accidents and injuries. Findings: 1. During a review of Resident 19's Annual-Minimum Data Set (MDS - Resident assessment and care guide tool), dated 5/24/24, the MDS indicated Resident 19's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 15 and indicated intact mental status. MDS indicated Resident 19 was able to recall the correct year, month and day of the week. Resident 19 had clear speech, able to express her ideas and wants, and understood what others said to her. Resident 19 needed substantial maximal assistance with personal hygiene, helpers lifts or holds trunk or limbs more than half the effort. Resident 19 currently used tobacco. Resident 19 diagnoses included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). During a concurrent observation and interview on 10/22/24 at 10:15 a.m. with Resident 19 in her room, Resident 19 was seated up in wheelchair, amputated fingers on right hand, left hand bandaged. Resident 19 stated she had been smoking at the facility for 5 years with no problems. Resident 19 stated she had cigarette and lighter in her possession. Resident 19 stated facility staff had not checked her for safety for many years. Resident 19 stated she did not smoke in her room. During a review of Resident 19's Admission Record (AR), the AR indicated, Resident 19 initial admitted to the facility on [DATE]. During a concurrent interview and record review on 10/23/24 9:29 a.m. with MDS coordinator (MDS)1, Resident 19's Smoking and Safetyevaluation dated 7/3/24 was reviewed. The smoking and safety evaluation indicated Resident 19 was non compliance (failing to act in accordance with a wish or command). Further review of Resident 19's Smoking and Safety evaluation dated 10/22/24, indicated Resident 19 had balance problems while sitting or standing. Resident 19 had limited or no ROM range of motion in arms or hands. Resident 19 had insufficient fine motor skills needed to securely hold tobacco. Resident 19 unable to light, hold and extinguish tobacco safely. During a review of Resident 19's 'Tobacco Use care plan, dated 7/10/24, the care plan indicated, Resident 19 was non adherence with smoking policy, refused to wear smoking apron, does not smoke in designated smoking area, does not follow smoking schedule, refused to be supervised by staff. Resident 19 kept smoking paraphernalia. During an interview on 10/24/24 at 3:23 p.m. with Activity Assistant (AA), AA stated Resident 19's sister sent money to facility. AA stated when Resident 19 request store run for cigarette AA said she goes as requested and bought cigarette for Resident 19. AA said Resident 19 keep her cigarette and lighter on herself. During an interview on 10/24/24 at 3:45 p.m. with Licensed Vocational Nurse (LVN4), LVN 4 stated Resident 19 was a long term resident at the facility. LVN 4 stated Resident 19 keeps her cigarette and lighter on herself. LVN 4 stated Resident 19 goes out to smoke by her self. LVN 4 stated Resident 19 will not give up her cigarette and lighter. LVN 4 stated resident was non compliance with smoking policy. During an interview on 10/24/24 at 4:05 p.m. with MDS 1, MDS 1 stated resident was assessed as unable to light, hold and extinguish tobacco and need to be supervised when smoking. 2. During a record review of Resident 41's Admission Record printed on 10/23/24, the record indicated Resident 41 was admitted to the facility on [DATE]. During an observation on 10/23/24 at 11:14 a.m., Room B (shared room between Resident 37 and Resident 41, adjacent to the smoking patio) had smell of cigarette smoke. Resident 41 was outside in the smoking patio by himself, sitting in a wheelchair, smoking a cigarette, without any staff's supervision. During an observation and interview on 10/23/24 at 12:31 p.m. in Resident 41's room, Resident 41 was sitting at the edge of the bed. Resident 41 stated he had always smoked since he had been there, though he was in process of quitting smoking. Resident 41 stated he kept the cigarettes with him, pointing at the pouch on his nightstand. Resident 41 stated staff did not supervise him, but they assisted to take him to the smoking patio. Resident 41stated Certified Nursing Assistant 1 (CNA 1) assisted him to go outside by opening the door to the smoking patio earlier that day. During an interview with CNA 1 on 10/23/24 at 12:39 p.m. outside the activity room, CNA 1 stated she was the assigned nursing assistant for Resident 41 that day and knew that he was a smoker since his admission to the facility. CNA 1 stated she was aware that he kept the cigarettes with himself but borrowed the lighter from the charge nurses. CNA 1 stated staff did not need to stay with Resident 41 when he smoked because he was alert and oriented. CNA 1 stated Resident 41's family brought his smoking supplies. During a concurrent interview and record review with Licensed Vocational Nurse 1 (LVN 1) on 10/23/24 at 12:26 p.m., Resident 41's Smoking Evaluation dated 9/2/24 was reviewed. LVN 1 stated she had been working with Resident 41 since his admission to the facility, but she was not aware if he was a smoker. LVN 1 stated she had not seen him smoking. LVN 1 stated the smoking assessment dated [DATE] indicated Resident 41 was a nonsmoker. During an interview with Minimum Data Set Coordinator (MDSC), accompanied by CNA 1 on 10/23/24 at 12:51 p.m., MDSC stated she did not know if Resident 41 was a smoker; while CNA 1 stated Resident 41 smoked at least two cigarettes during her morning shift (usual time- 7:00 am till 3:00 pm). During an interview with Certified Nursing Assistant 3 (CNA 3) on 10/24/24 at 3:23 p.m., CNA 3 stated she had observed Resident 41 smoking cigarettes in the smoking patio sometime last week. During a concurrent interview and record review with Licensed Vocational Nurse 2 (LVN 2) on 10/24/24 at 3:25 p.m., Resident 41's Smoking Evaluation and Smoking Care Plan dated 10/23/24 was reviewed. LVN 2 stated she assessed Resident 41 for smoking safety on 10/23/24 after facility's management discovered that Resident 41 was a Smoker. LVN 2 stated she did not review smoking policy, and/or share facility's smoking schedule with Resident 41. LVN 2 stated Resident 41's smoking evaluation indicated Resident 41 used Tobacco. The evaluation had following areas to assess: Poor vision or blindness, balance problems while sitting or standing, limited or no [Range of Motion] in arms or hands, insufficient fine motor skills needed to securely hold tobacco .lethargic/falls asleep easily during tasks or activities; Burned skin, clothing, furniture or other; Drops ashes on self; Follows the facility's policy on location and time of smoking. LVN 2 stated she marked 'yes' for balance problems while sitting or standing as she knew the resident, but she did not assess all other areas. LVN 2 also stated she did not assess Resident 41 if he was unable to light, hold, extinguish tobacco, and use ashtray safely. LVN 2 stated she did not alert Resident 41's attending physician and/or all direct care staff who took care of Resident 41, that he was a smoker. LVN 2 further stated the Registered Nurse who created the Non-Compliance with smoking policies and procedures care plan for Resident 41 on 10/23/24, was not even a nurse who worked at this facility, rather she was a director of nursing at a sister facility, indicating no actual oversight and/or knowledge of Resident 41. During an interview on 10/24/24 at 3:54 p.m., Registered Nurse 1 (RN 1) stated she worked with Resident 41 on 10/23/24 evening but was not made aware of him being a smoker. 3. During a record review of Resident 37's Admission Record printed on 10/22/24, the record indicated Resident 37 was admitted to the facility on [DATE]. During a review of Resident 37's Minimum Data Set (MDS, an assessment used to guide plan of care) dated 3/10/24, the assessment indicated Resident 37 used Tobacco; and had diagnosis of Schizophrenia and opioid dependence, in remission. During a review of Resident 37's Smoking Evaluation dated 10/21/24, the assessment indicated Resident 37 used Tobacco, had balance problems while sitting or standing; Resident 37 was to use Cigarette holder, and a smoking apron while smoking. During a concurrent interview and record review with MDS Coordinator (MDSC) on 10/23/24 at 12:24 p.m., Resident 37's Smoking Evaluations in electronic and paper chart were reviewed. MDSC stated Resident 37 was not assessed for safe smoking until 10/21/24. MDSC stated facility should conduct smoking evaluation upon admission. During an observation with Director of Staff Development (DSD) on 10/22/24 at 9:09 a.m., in facility's smoking patio, there were no smoking aprons observed in the smoking patio at that time. During an observation on 10/23/24 at 11:14 a.m., in facility's smoking patio, there were no smoking aprons. During an interview with Resident 37 on 10/23/24 at 12:56 p.m., Resident 37 stated he had never used a smoking apron and/or a cigarette holder and was unsure of what they looked like. During an interview with Certified Nursing Assistant 3 (CNA 3) on 10/24/24 at 3:47 p.m., CNA 3 stated she had seen a smoking apron one time in the past eight months. CNA 3 stated she was aware that Resident 37 was a smoker, however he never used a smoking apron and/or a cigarette holder. During an interview with Registered Nurse 1 (RN 1) on 10/24/24 at 3:54 p.m., RN 1 stated she was aware that Resident 37 was a smoker but had never seen a smoking apron in the facility. RN 1 stated she was not aware where to find smoking aprons in the facility. During an observation of the smoking patio on 10/24/24 at 4:10 p.m., there were still no smoking aprons available for use. During a review of facility's policy and procedures (P&P) titled Smoking Policy- Residents titled 07/2017, the P&P indicated, This facility shall establish and maintain safe resident smoking practices .6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If smoker, the evaluation will include a. Current level of tobacco consumption; b. Method of tobacco consumption; c. Desire to quit smoking, if a current smoker; and d. Ability to smoke safely with or without supervision .7. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation 14. Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision . During an observation on 10/22/24 at 11:31 a.m. in Room A, with Registered Nurse 2 (RN 2) screen door was open and the room had smell of cigarette smoke. RN 2 peeked through the door and stated it was Janitor 1 smoking in the smoking patio. During an observation and interview with Janitor 1, accompanied by RN 2 on 10/22/24 at 11:35 a.m. Janitor 1 standing in the smoking patio, actively smoking a cigarette. Janitor 1 stated he smoked in that patio sometimes indicating it was not the first time he was smoking there. Glass door to all six adjacent rooms to the smoking patio were open with residents in the rooms. Janitor 1 stated he did not pay attention to residents' rooms being open while he smoked in the patio because residents wanted the doors to be left open. Janitor 1 stated when I see the smoke going to the side, I know where the wind is blowing. RN 2 stated residents rooms' doors adjacent to the smoking patio should be closed when staff/residents smoked in the patio. RN 2 stated secondhand smoke was not good for residents; or some residents did not want to smell the smoke; the smoke could get into their respiratory track; could cause upto and including lung cancer. RN 2 stated secondhand smoke was more serious than firsthand smoke. 5. During an observation with Director of Staff Development (DSD) on 10/22/24 at 9:09 a.m., in facility's smoking patio, there were multiple smoking butts were in large sized flower planter next to stand-alone ash holder. The DSD stated cigarette butts should not be disposed off in the flower planters as it posed a risk for fire and hurt vulnerable residents at the facility. 39939

Based on interview and record review, the facility failed to ensure two of two sampled resident's (Resident 44 and 37) Preadmission Screening and Resident Review (PASRR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings.) was completed and referred to the appropriate state mental authority for Level II evaluation and determination when: 1. Resident 44's PASRR Level 1 Screening was not resubmitted when Resident 44 remained in the facility longer than 30 days. 2. Resident 37 PASRR Level 1 Screening completed inaccurately. This failure placed Resident 44 and 37 at risk for inappropriate placement in the facility and prevent Resident 44 and 37 from receiving appropriate required mental health services. Findings: 1. During a review of Resident 44's undated Admission Record, printed on 10/21/24, the Admission Record indicated, Resident 44 was admitted to the facility on [DATE]. The record also indicated; Resident 44 had diagnoses that included Unspecified Dementia with Psychotic Disturbance (a medical condition that can include psychotic symptoms like hallucinations, delusions, paranoia, and suspiciousness), Anxiety Disorder (a mental health condition that involves persistent and uncontrollable feelings of fear and anxiety that can significantly impact a person's life), Paranoid Personality Disorder (a psychiatric disorder distinguished by a pervasive pattern of distrust and suspiciousness of others, leading to impairments in psychosocial functioning), Depression (a mental health condition that causes a long-lasting low mood and a loss of interest in activities that used to be enjoyable) and Auditory Hallucinations (hear voices or noises that don't exist in reality). During a review of Resident 44's Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 5/8/24, The MDS indicated the PASRR was coded zero-meaning, Resident 44 was not considered by the State Level II PASRR process to have a serious mental illness. However, Resident 44's diagnoses included Unspecified Dementia with Psychotic Disturbance, Anxiety Disorder, Paranoid Personality Disorder, Depression and Auditory Hallucinations. During a concurrent interview and record review on 10/24/24 at 8:17 a.m. with the DON, Resident 44's PASRR Level I Screening, dated 4/30/24 was reviewed. The PASRR Level 1 Screening indicated, Resident 44's PASRR Level 1 screening was completed at the acute care hospital prior to admission to the facility. The DON stated PASRR Level I Screening doesn't need to be completed again once it was done. During a review of Resident 44's Department of Health Care Services letter, dated 4/30/24, the Department of Health Care Services letter indicated, Resident 44's PASRR Level 1 Screening did not identify Resident 44 as an individual with suspected mental illness. The letter also indicated; Resident 44 does not require a Level II mental health evaluation. The letter further indicated; the facility should resubmit a new Level 1 Screening for individuals remaining in the nursing facility longer than 30 days. During a review of the facility's policy and procedure (P&P) titled, Pre-Admission Screening and Resident Review (PASRR), dated 12/17, the P&P indicated, If the individual's facility stay lasts longer than thirty (30) days, a Level 1 Screening must be performed within forty (40) days of admission. 2. During a record review of Resident 37's Admission Record printed on 10/22/24, the record indicated Resident 37 was admitted to the facility on [DATE]. During a review of Resident 37's physician orders dated 3/4/24, the order indicated Resident 37 was receiving Trazadone, a psychotropic medication (any drug that affects brain activities associated with mental processes and behavior; psychotropic drugs include, but are not limited to the following categories: anti-depressants, anti-anxiety, and hypnotics) HCI 50 milligrams (mg) for Depression (a state with persistent depressed mood or loss of interest in activities causing impairment in daily life) manifested by inability to sleep. During a review of Resident 37's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) dated 9/9/24, the assessment indicated Resident 37 had an active diagnosis of Depression and Schizophrenia (a mental condition which makes it difficult to think clearly, have normal emotional responses, act normally in social situations, and tell the difference between what is real and what is not real). During a review of Resident 37's Preadmission Screening and Resident Review (PASARR) Level 1 screening assessment dated [DATE], the assessment indicated it was marked as No to Question 10. Does the individual have a serious diagnosed mental disorder such as Depressive Disorder .Schizophrenia/Schizoaffective mental disorder .? and No for Question 12. [if] the individual has been prescribed psychotropic medications for mental illness. The assessment indicated Resident 37 did not require further Level II mental health evaluation. During a concurrent interview and record review with Director of Nursing (DON) on 10/23/24 at 9:32 a.m., Resident 37's PASARR assessment dated [DATE] was reviewed. The DON stated she did not think the assessment was inaccurate because even though Resident 37 had Schizophrenia, but he was not receiving any medications for that disorder. The DON also stated Trazadone medication was not a psychotropic medication and did not need to be reflected on Resident 37's PASARR. During a concurrent interview and record review with MDS Coordinator (MDSC) on 10/23/24 at 9:54 a.m., Resident 37's PASARR assessment dated [DATE] was reviewed. The MDSC stated Resident 37's PASARR assessment was inaccurate in terms of reflecting the mental illness and use of psychotropic medications. The MDSC stated even though Acute Care Hospitals were responsible for completing the PASARR assessment prior to the facility admitting the residents, it was facility's responsibility to review the assessment for accuracy. The MDSC stated accurate completion of Level 1 screening could have prompted Resident 37 to receive mental/behavior health help such as psyche referrals. During another interview and record review with MDSC on 10/23/24 at 10:23 a.m., the MDSC stated she was unable to find any records for psyche referrals or consults in Resident 37's electronic or paper chart. 49498

Based on interview and record review, the facility failed to follow its Grievance/Complaints, Filing policy and procedure to make prompt efforts to respond and resolve grievances/complaints for two (Resident 5 and 26) sampled residents when; the facility did not follow up with Resident 5 and 26's complaint of missing personal items made during the resident council meeting. This deficient practice had the potential to cause residents emotional distress. Findings: During a review of the facility's record titled, Resident Council Minutes, dated 9/27/24, the document indicated, Resident 5 complained of missing purple colored brassiere with stars symbols and Resident 26 complained of missing two [NAME] spots shirts. During a review of Resident 5's Minimum Data Set (MDS - Resident assessment and care guide tool), dated 9/14/24, the MDS indicated Resident 5's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 13 and indicated intact mental status. The MDS indicated Resident 5 was able to recall the correct year and month. MDS indicated Resident 5 had clear speech, able to express her ideas and wants, and understood what others said to her. During a review of Resident 26's Minimum Data Set (MDS - Resident assessment and care guide tool), dated 8/8/24, the MDS indicated Resident 26's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 15 and indicated intact mental status. The MDS indicated Resident 26 was able to recall the correct year, month and day of the week. The MDS indicated Resident 26 had clear speech, able to express his ideas and wants, and understood what others said to him. During an interview on 10/23/24 at 8:47 a.m. with Resident 26, Resident 26 stated he was missing two [NAME] sport shirts about three months ago. Resident 26 stated he reported to staff and at the resident council meeting. Resident 26 stated no one assisted him to look for the tee shirts. Resident 26 said he would like to have his shirts back. During an interview on 10/23/24 at 9:01 a.m. with Activity Director (AD), AD stated Resident 26 complained of missing two [NAME] shirts and Resident 5 missing purple colored brassiere during resident council meeting that was held on 9/27/24. AD stated she informed staff with a referral for response form but they have not returned it. AD stated she left referral for response in the social services mailbox. During an interview on 10/23/24 at 9:53 a.m. with Social Services (SW), SW stated she was not informed of residents missing items and had not followed up with Resident 5 and 26 complaints. SW stated she did not received referral related to missing items in her mail box. During an interview on 10/23/24 at 12:43 p.m. with Administrator (Admin), Admin stated he was not aware of Resident 5 and 26 complaints/ grievances regarding missing personal items. Admin stated that he will follow up with AD. Admin stated the expectation was for complaints/grievance from resident council meetings to go to appropriate department and completed in a week. Admin stated he reviewed for completion. Admin said he will follow up with September 2024 complaints/grievances from resident council meeting. During a review of the facility's policy and procedure (P&P) titled, Grievances/Complaints, Filing, revised April 2017, the P&P indicated, Residents and their representatives have the rights to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representatives.

Based on observation, interview, and record review, the facility failed to maintain and observe infection control practices when: 1. Registered Nurse (RN) 2 did not perform hand hygiene during medication administration. 2. Nutritional feeding pole in Resident 33's had multiple dried light brown stains. These failures had the potential for cross contamination and spread of infections among residents at the facility. Findings: 1. During medication preparation observation on 10/22/24 at 8:21 a.m. with RN 2, RN 2 was preparing Resident 17's nine medications, poured the tablets and capsule in a medication cup and mixed the laxative powder with 4 ounces (oz) of orange juice in a plastic cup. During medication administration observation on 10/22/24 at 8:28 a.m. with RN 2 in Resident 17's room, RN 2 handed Resident 17 the medication cup and the 4 oz of orange juice placed on the medication tray, Resident 17 poured the tablets and capsules into his mouth and drank the 4 oz of orange juice. RN 2 took the empty medication cup and 4 oz plastic cup from Resident 17's hands and discarded the cups in the garbage can attached to the left lower side of the medication cart located by Resident 17's room door. RN 2 donned a pair of gloves without performing hand hygiene and sanitized the medication tray. During medication preparation observation on 10/22/24 at 8:31 a.m. with RN 2, RN 2 took out Resident 20's one bottle of eye drops from the first left medication drawer of the medication cart. RN 2 donned a pair of gloves without performing hand hygiene and pushed in the medication cart lock with her right gloved hand. During medication administration observation on 10/22/24 at 8:35 a.m. with RN 2 in Resident 20's room, RN 2 pulled Resident 20's left and right lower eyelids with the same gloved hands to administer the eye drops. RN 2 proceeded to screw the white eye drop cap into the bottle with the same gloved hands. RN 2 removed and discarded the gloves in the garbage can and returned the eye drops bottled inside the first left medication drawer of the medication cart. During medication preparation observation on 10/22/24 at 8:39 a.m. with RN 2, RN 2 prepared Resident 302's inhaler medication. RN 2 donned a pair of gloves without performing hand hygiene, pushed in the medication cart lock and proceeded to walk into Resident 302's room. During medication administration observation on 10/22/24 at 8:41 a.m. with RN 2 in Resident 302's room, RN 2 handed Resident 302's inhaler medication, Resident 302 shook the inhaler and inhaled two puffs. Resident 302 rinsed his mouth after inhaling the medication. RN 2 took the inhaler from Resident 302's hand and took the medication cart key from her pocket with the same gloved hands. RN 2 returned Resident 302's inhaler in the medication drawer while wearing the gloves. RN 2 then pulled the bottom medication drawer and took disinfecting wipes and disinfected the medication tray using the same gloved hands. During an interview on 10/22/24 at 8:44 a.m. with RN 2, RN 2 stated hand hygiene should be performed before and after glove use to prevent the transfer of bacteria and virus to other residents. During an interview on 10/23/24 at 10:52 a.m. with the Infection Preventionist (IP), the IP stated, gloves should be removed before leaving resident's room and hand hygiene should be performed after removing gloves to prevent transmission of infections among residents and staff. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 8/19, the P&P indicated, The facility considers hand hygiene the primary means to prevent the spread of infections . Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after direct contact with residents; Before preparing or handling medications; After contact with resident's intact skin; After contact with objects in the immediate vicinity of the resident; After removing gloves. 2. During an observation on 10/21/24 at 10:46 a.m. in Resident 33's room, the IV pole (a medical device that holds bags of fluids or medicine in place while they are administered to a patient) where Resident 33's nutritional feeding machine was attached was observed with multiple dried light brown stains. During a concurrent observation and interview on 10/21/24 at 10:48 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 33's room, the IV pole in Resident 33's had multiple dried light brown stains. LVN 1 stated the IV pole was cleaned daily by the IP. LVN 1 stated the IV pole needed to be cleaned and doesn't look like it had been cleaned daily. During a concurrent observation and interview on 10/21/24 at 10:56 a.m. with the IP in Resident 33's room, the IV pole in Resident 33's had multiple dried light brown stains. The IP stated the IV pole was cleaned either by her or the housekeeping. The IP stated there was no documentation of when the IV pole was cleaned. The IP stated the IV pole doesn't look like it had been cleaned daily. During a review of the facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces, dated 6/09, the P&P indicated, Environmental surfaces will be cleaned and disinfected according to current Center for Disease Control and Prevention) CDC recommendation for disinfection of healthcare facilities .Non-critical surfaces will be disinfected with an Environmental Protection Agency (EPA - protects people and the environment from significant health risks, sponsors and conducts research, and develops and enforces environmental regulations)-registered disinfectant according to the label's safety precautions and use direction. During a review of an online publication by the CDC titled, Environmental Cleaning Procedures, dated 3/24, indicated, Common high-touch surfaces included IV poles . Portable or stationary noncritical patient care equipment incudes IV poles. (https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html)

Based on observation, interview and record review, the facility failed to administer medication as ordered by the physician for one of five sampled residents (Resident 20) when Registered Nurse (RN) 2 thought Resident 20's eye drop medication was not available. This failure had the potential for Resident 20 to experience adverse effect from missed eye drop dose. Findings: During a concurrent medication administration and interview on 10/22/24 at 8:31 a.m. with RN 2, RN 2 took out Resident 20's one eye drop bottle labeled Simbrinza (a combination eye drop containing two medications: brinzolamide and brimonidine, a medication used to treat glaucoma and high pressure in the eye) and one eye drop bottle labeled Artificial Tears (eye drops used to lubricate dry eyes and help keep moisture on the outer surface of your eyes) from the first left medication drawer of the medication cart. RN 2 stated Resident 20 had an order for Brinzolamide (medication used to treat glaucoma and high pressure in the eye) eye drop but the eye drop bottle was not inside the medication cart after looking. RN 2 stated she doesn't know how long the Brinzolamide eye drop was not available but will re-order from the pharmacy. RN 2 proceeded to administer Resident 20's Artificial Tears eye drops. During a review of Resident 20's Order Summary Report, dated 10/27/23, the Order Summary Report indicated, Resident 20 had an order for Artificial Tears one drop to both eyes three times a day for dry eyes and Brinzolamide-Brimonidine Tartrate 0.2% one drop in left eye three times a day for Glaucoma (group of eye diseases that can damage the optic nerve and lead to vision loss or blindness). During a review of Resident 20's Progress Notes, dated 10/22/24, the Progress Notes indicated, RN 2 documented the Brinzolamide eye drop will be administered once available. During a review of Resident 20's Visual Function Care Plan, dated 5/4/21, the Visual Function Care Plan indicated, Resident 20 had a diagnosis of Glaucoma and one of the plan of care was to instill eye medicine as ordered. During an observation and interview on 10/23/24 at 12:49 a.m. with RN 2, RN 2 took out Resident 20's two eye drop bottle of Simbrinza from the medication cart drawer. RN 2 stated one eye drop bottle of Simbrinza was the old supply and the other one eye drop bottle of Simbrinza was refilled by the pharmacy. RN 2 stated she thought the Simbrinza and Brinzolamide were two different eye drops. RN 2 stated the Brinzolamide eye drop was in the medication cart drawer all along. During a review of facility's policy and procedure (P&P) titled, Administering Medication, dated 12/12, the P&P indicated, Medications shall be administered as prescribed.

Based on observation, interview and record review, the facility failed to ensure staff attempted to use appropriate measures to communicate with one of three sampled non-English speaking residents (Resident 43) when; Resident 43's communication tool/binder was not used. This failure placed Resident 43 at risk for not feeling understood, unmet needs and decline in health. Findings: During a review of Resident 43's Admission-Minimum Data Set (MDS - Resident assessment and care guide tool), dated 7/10/24, the MDS indicated Resident 43's preferred language was Chinese. MDS indicated Resident 43 needed and wanted an interpreter to communicate with doctor or health care staff. Resident 43's diagnoses included Depression (a mental health condition that causes a persitent low mood and loss of interest in activities). During a concurrent observation and interview on 10/23/24 at 8:36 a.m. with CNA 5, Resident 43's laid in bed in her room, Resident 43 spoke in her native language. A communication binder laid on Resident 43's bedside table. CNA 5 stated she could only communicate with Resident 43 through gestures and pointing. CNA 5 stated she did not know that Resident 43 had a communication binder. During an interview on 10/23/24 at 10:09 a.m. with Director of Staff Development (DSD), DSD stated the expectation was for CNAs to use communication binder for non English speaking residents. DSD stated she had not provided CNAs in-service training about use of communication tools for non English speaking residents. During an interview on 10/23/24 at 2:26 p.m. through a language line interpreter (ITP), via telephone, Resident 43 stated she spoke cantoneese. Resident 43 stated facility staff did not understand her native language. Resident 43 stated it appeared there was missing messages. Resident 43 stated she did not understand staff when they communicate with her. Resident 43 stated she would like to transfer to a place where residents spoke Resident 43's native language. During an interview on 10/23/24 at 10:54 a.m. with Admininistrator (Admin), Admin stated facility did not have an interpreter access phone line. Admin stated facility was working on getting a translator phone line and staff could use google to translate. During a review of the facility's policy and procedure (P&P) titled Translation and/ or Interpretation of Facility Services, revised November 2020, the P&P indicated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. 51692

Based on observation, interview and record review, the facility failed to assess and provide an appropriate wheelchair to one of 15 sampled residents (Resident 37), for seven months, since admission to the facility. This deficiency placed Resident 37 at risk for physical decline and resulted in Resident 37 feeling worthless, and hopeless about his personal goals of discharge from the facility. Findings: During a record review of Resident 37's Admission Record printed on 10/22/24, the record indicated Resident 37 was admitted to the facility on [DATE] with left hip contracture (a medical condition with hardening of muscles leading to deformity and rigidity in joints). During a record review of Resident 37's contracture care plan, initiated on 3/4/24, the care plan indicated to, use assistive device as/if ordered. During a record review of Resident 37's discharge planning review dated 6/25/24 and 9/16/24, the assessments indicated Resident 37's goal was to go back to the community with home health services. During observation and concurrent interview on 10/21/24 at 11:54 a.m. Resident 37 was lying in bed with linen covers on his both legs. Resident 37 stated he needed help with wheelchair as he stayed in bed most of the time. Resident 37 stated he got out of bed once or twice a week using a Geri-chair (a large, padded, reclining wheelchair with adjustable back). Resident 37 stated he needed a bigger wheelchair appropriate for his size. During an interview on 10/21/24 at 12:04 p.m. with Licensed vocational nurse (LVN 1) stated Resident 37, does fit in geri-chair, but was unaware of geri-chair weight limit. LVN 1 stated facility had only one geri-chair and residents took turns to use it. During an observation and interview with the Social Worker (SW) on 10/21/24 at 12:28 p.m. in Resident 37's room, Resident 37 was lying SW stated Resident 37 was bedbound and she had never seen him up in a wheelchair. During an interview and concurrent observation on 10/21/24 at 12:46 p.m. in Resident 37's room, a black colored manual wheelchair was observed at Resident 37's bedside. Social worker (SW) stated manual wheelchair at Resident 37's bedside was not suitable in size and had no working brakes. During an observation on 10/22/24 at 11:46 a.m. Resident 37 requested to leave resident council meeting in the middle of it. Resident 37 stated geri-chair he was using was too small and uncomfortable to sit in. During an interview on 10/24/24 at 11:03 a.m. with Regional Social Services Director (RSS) stated Rehab Department was responsible for evaluating the need of medical equipment. During an interview and record review on 10/22/24 12:03 p.m. with Director of Rehab (ST 1), Resident 37's therapy progress notes were reviewed. ST 1 stated therapist was responsible for completing the wheelchair evaluation upon admission, at the facility. ST 1 stated there was no documentation of wheelchair evaluation in Resident 37's therapy treatment records since his admission to the facility. During another observation on 10/23/24 at 8:32 a.m. Resident 37 stated geri-chair was too small and made his knees hurt. During observation and concurrent interview on 10/24/24 at 9:22 a.m. Resident 37 was found lying on right side in his bed. Resident 37 stated staying in bed most of the time, made him feel like he was never going home and never getting his children back. Resident 37 stated him and his family were very sad about him missing the birth of first grandchild. Resident 37 stated he felt worthless in bed all day and he felt so separated from his whole family. Resident 37 stated It was important for him to be able to get into a car when discharged from the facility, but he was often left in the bed. During a review of facility's Policy and Procedure (P&P) dated Quality of Life-Dignity revised 8/2009, the P&P indicated, Each resident shall be care for in a manner that promotes and enhances quality of life .

Based on observation, interview, and record review the facility failed to ensure proper medication storage for one of one sampled medication room and one of one sampled resident (Resident 31) when: 1. An unauthorized staff had access to the medication room. 2. Unlabeled, undated medication cup filled with white creamy substance was left unattended on top of Resident 31's overhead light fixture for over 24 hours. This failure had the potential for loss or diversion of medications and residents' accidental access to unknown substance. Findings: 1. During a concurrent observation and interview on 10/23/24 at 8:36 a.m. with the CSS, the CSS unlocked the medication room door with a key from a set of keys he was holding. The CSS stated the key to the medication room was given when he started working at the facility. The CSS stated he ordered over the counter medication for the facility and stored in the medication room. During an interview on 10/23/24 at 10:16 a.m. with the DON, the DON stated, the CSS can open the medication room to access over the counter medication even without a nurse. During a follow up interview on 10/23/24 at 12:59 p.m. with the DON, the DON stated, the CSS was not a person authorized to prepare and administer medication. During a review of the facility's policy and procedure (P&P) titled, Storage of medication, dated 4/07, the P&P indicated, Only persons authorized to prepare and administer medications shall have access to the medication room. 2. During an observation on 10/21/24 at 9:53 a.m., a clear plastic 30 milliliter (ml) medication cup, filled with white creamy substance was on the overhead light fixture for Resident 31, while Resident 31 was lying in bed. The medication cup was unlabeled and undated. During an observation on 10/22/24 at 8:30 a.m., the unlabeled and undated medication cup with white creamy substance was still on top of the overhead light fixture for Resident 31. During an observation and interview on 10/22/24 at 11:40 a.m. with Registered Nurse 2 (RN 2), in Resident 31's room, the medication cup with white creamy substance was on top of Resident 31's overhead light fixture. RN 2 stated based on the texture of the substance, she thought it was Eucerin (a moisturizer) cream in the medication cup, however she was not sure because cup was not labeled. RN 2 stated medication cups must be discarded after use. RN 2 stated facility had confused and ambulatory residents who could easily access the medication cup and eat the creamy substance. 49498

Based on observation, interview, and record review the facility failed to provide an ongoing and effective activity program to meet resident activity preferences, physical and psychosocial goals for one of 15 sampled residents (Resident 37). This failure placed Resident 37 at risk for mental and psychosocial decline. Findings: During a record review of Resident 37's Admission Record printed on 10/22/24, the record indicated Resident 37 was admitted to the facility on [DATE] A review of Resident 37's Admission Minimum Data Set (MDS, an assessment used to plan care) dated 3/10/24 indicated, it was very important for Resident 37 to do his favorite activities. During a record review of Resident 37's discharge planning review completed on 9/16/24, the assessment indicated Resident 37 enjoys activities including drawing and painting. During a record review of Resident 37's activity care plan dated 03/2024, the care plan indicated to, allow resident choices and provide resident with outdoor activities. During an observation on 10/21/24 at 11:00 a.m. Resident 37 was lying in the bed with both legs flexed, with a linen on top of his legs. Resident 37 stated he was mostly just lying in bed because he did not have a proper wheelchair to go around the facility. (Cross Reference F684). Resident 37 stated he enjoyed drawing and painting, but facility did not provide him enough materials like paper for him to do his activity. During an observation on 10/23/24 at 11:14 a.m., Resident 37 was lying in his bed, not engaged in any activity. During an observation and interview on 10/24/24 at 9:22 a.m. Resident 37 was lying in bed and stated he felt worthless sitting in bed all day. During interview on 10/22/24 at 10:48 a.m. with activity assistant (AA), the AA stated Resident 37 received three visits per week for art and games at bedside. AA stated Resident 37 was given some art supplies but he had requested more frequent visits to meet his activity needs. AA stated Resident 37 comes to the activity room only twice a month. During a concurrent interview and record review with AA on 10/22/24 at 11:00 a.m. Resident 37's Activity participation logs were reviewed. AA stated activities staff was supposed to use the log to indicate date, type of activity and residents' response to activity on the log for each visit. AA stated she was unable to find any documentation of one-on-one activity participation in activity log since 07/07/2024. During a record review of facility's Policy and Procedure (P&P) titled Activity Programs revised 6/2018, the P&P indicated, Activity programs are designed to meet the interests of and support the physical, mental and psychological well-being of each resident.

Based on interview and record review, the facility failed to ensure there were no significant medication errors for one of four sampled residents (Resident 4). Resident 4 did not receive the physician ordered intravenous (IV - delivered through a vein and into the blood) antibiotics on 2/14/17 or 2/15/17. This failure resulted in Resident 4 developing an elevated body temperature and being sent to the hospital emergency room . Findings: Review of Resident 4's hospital Most Recent After Visit Summary, admitted [DATE], indicated Resident 4 had [DIAGNOSES REDACTED]. Review of Resident 4's hospital Medication Administration Record [REDACTED]. Review of Resident 4's Nursing Notes, dated 2/14/17, at 9 p.m., indicated Resident 4 was admitted to the facility on [DATE] at 5:30 p.m. The Nursing Notes did not indicate an assessment of the condition of Resident 4's IV insertion site or documentation of the plan to begin administration of the IV antibiotics. The Nurse's notes also indicated .Faxed all resident medications to pharmacy. Per pharmacy all her (Resident 4's) medications will receive tonight Review of the facility pharmacy Delivery Manifest, dated 2/15/17, at 10:53 a.m., indicated the facility received Resident 4's [MEDICATION NAME] antibiotic on 2/15/17 at 10:50 a.m. In an interview with the Director of Staff Development (DSD) on 3/9/17, at 1 p.m., the DSD stated she could not locate Resident 4's MAR indicated [REDACTED]. In an interview with Licensed Vocational Nurse (LVN) 1 on 5/4/17, at 9:15 a.m., LVN 1 stated she did not give any antibiotics to Resident 4 on the evening of 2/14/17 because she was not certified or licensed to give IV medications. LVN 1 stated she informed the Registered Nurse (RN) on the same shift that she (LVN 1) was not able give the antibiotics to Resident 4 and only an RN could administer the IV medication. LVN 1 stated Resident 4 did not receive any antibiotics while in the facility. LVN 1 worked with Patient 4 the next evening (2/15/17) and was told to transfer Resident 4 to the hospital emergency room so she could receive the antibiotics. Review of the discharge nursing note on 2/15/17, at 6 p.m., indicated Resident 4 returned to the hospital to receive her antibiotic treatment. Review of Resident 4's Emergency Department Progress, dated 2/15/17, indicated Resident 4 was admitted to the hospital for IV antibiotics because the facility was Unable to give IV antibiotics or check labs . The Emergency Department Progress notes also indicated on admission to the emergency room , Resident 4 had a body temperature of 100.8 degrees Fahrenheit (°F) that rose to 101.1 (°F) (normal is 98.6 °F).

Based on observation, interview, and record review, the facility failed to ensure resident safety for one of three sampled residents (Resident 1), when Resident 1 was transferred from wheelchair to bed without an assistive device as recommended on the hospital discharge summary dated 1/10/17. This failure resulted in Resident 1 sustaining a 1 centimeter (cm) by 0.2 cm abrasion and bruising around the right eye. Findings: Review of Resident 1's Minimum Data Set, (MDS - an assessment tool used to direct resident care), dated 2/16/17, indicated Resident 1 was a able clearly think, reason, remember, and make his needs known. The MDS also indicated Resident 1 was totally dependent (full staff performance of activity) on two staff persons for transfers from the bed to wheelchair. During an observation and concurrent interview with Resident 1 on 5/3/17 at 1:03 p.m., Resident 1 had purplish discoloration under the right eye and yellowish-blue discoloration on the side of the right eye. Resident 1 stated, I fell in my room, hit the table. During an interview with Certified Nursing Assistant (CNA) 1 on 5/3/17 at 2:53 p.m., CNA 1 stated Resident 1 was in his room getting ready to go back to bed on the afternoon of 4/9/17. CNA 1 stated, since everybody else (other staff) was busy, she decided to transfer Resident 1 by herself. CNA 1 stated while Resident 1 was in a standing position, and ready to pivot to sit on the bed, Resident 1 started to lean to the right side. CNA 1 stated she was standing behind Resident 1 to assist with transfer, but was not able to hold Resident 1's weight. CNA 1 stated she fell on the floor with Resident 1 and the wheelchair on top of her. According to CNA 1, Resident 1's right eye hit the over bed table in the process. CNA 1 stated she never used a mechanical lift to transfer Resident 1 and only requested help from other CNAs when they were available. Otherwise, CNA 1 stated she had to do transfers by herself. CNA 1 further stated she was 4 feet and 11 inches tall while Resident 1 was 5 feet and 10 and a half inches tall and weighed 180 pounds. Review of Resident 1's Nurse's Notes, dated 4/9/17, indicated Resident 1 and CNA 1 were found on the floor on 4/9/17 at 4:30 p.m. The Nurse's Notes also indicated Resident 1 was noted with an abrasion to the side of his right eye that measured 1 cm (centimeter) by 0.2 cm. During an interview with the Director of Nursing (DON) on 5/3/17 at 1:30 p.m., the DON stated Resident 1 required two staff persons to assist with transfers. Review of Resident 1's Fall Risk Assessment, dated 5/18/16, indicated a score of 15 (score of 10 or higher represents high risk for falls) and a higher fall risk score of 19 on 8/16/16. Review of the facility's policy and procedure titled, Falls and Fall Risk, Managing last revised December 2007, indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. During an interview with the DON and concurrent record review on 5/3/17 at 2:10 p.m., the DON confirmed there was no care plan developed to address Resident 1's high risk for falls. There was no care plan to show how much staff assistance or how many staff were needed to transfer Resident 1 from bed to wheelchair and back. Review of Resident 1's Hospitalist Discharge Summary, dated 1/12/17, indicated Resident 1 was transferred to the hospital on [DATE] for right side weakness and leaning to the right side. While at the hospital, Resident 1 underwent imaging of the brain to evaluate for stroke. Resident 1 was evaluated by physical therapy (PT) while in the hospital and was given the following recommendation upon discharge; Recommend (patient) return to (facility) and staff at SNF (skilled nursing facility) to use lift for transfers for safety. The hospital PT evaluation also indicated Resident 1 was not able to walk, was dependent on staff for transfers, and was on falls precautions (a variety of actions to help reduce the number of accidental falls). During an interview with CNA 2 on 5/3/17 at 2:46 p.m., CNA 2 stated he transferred Resident 1 from the bed and onto the wheelchair every morning with extensive assist (staff provides weight bearing support, resident helps) and a licensed nurse never told him to use a mechanical lift (with Resident 1). During an interview with Licensed Vocational Nurse (LVN) 1 on 5/3/17 at 3:26 p.m., LVN 1 stated Resident 1 was never transferred from wheelchair to bed with a mechanical lift. LVN 1 also stated CNAs who had a heavier build were able to transfer Resident 1 with one person assist because Resident 1 was able follow instructions.

Based on observation, interview, and record review, the facility failed to provide an environment free from accident hazards for one of five sampled residents (Resident 5) when an electrical wire below Resident 5's bed sparked and caused a burn on the floor as a result of faulty and exposed wiring. This failure resulted in power outage in three resident rooms and the potential for fire. The Director of Nursing (DON) was verbally notified on 5/18/17, at 1:15 p.m., that Immediate Jeopardy (IJ), was identified in the facility related to the potential fire hazard caused by frayed electrical wires beneath Resident 5's bed. Findings: During an interview on 5/18/17 at 10:05 a.m., the DON stated a certified nursing assistant had unplugged a bed which created a spark and caused a power outage. In another interview with the DON on 5/18/17, at 11:10 a.m., the DON stated Certified Nursing Assistant 1 (CNA 1), had unplugged a resident's bed from an electrical outlet and there was a spark. As a result, Room 19, 20 and 21 had lost electrical power. In a concurrent observation and interview with CNA 1 on 5/18/17, at 11:15 a.m., CNA 1 stated Resident 5 was a total care resident (total care: requires full assistance with bathing, eating, toileting, moving in bed, and getting out of bed). CNA 1 stated Resident 5's bed brakes did not work. When he would turn Resident 5 in bed with the brakes engaged, the bed moved, and the wheels had been rolling side to side over electrical cords on the floor below the bed. CNA 1 stated at approximately 10 a.m., on 5/18/17, as he was repositioning Resident 5 in her bed, he noticed sparks shoot up from under the bed. At the time of the incident, Resident 5 was laying on an inflated air mattress (an air-filled mattress intended to prevent skin breakdown or wounds). The air mattress control device box (electrical device used to inflate the air mattress), was located at the foot of the bed. The electrical cord attached to the control device box was below the bed, on the floor, running from the bottom of the bed to the top and then plugged into an electrical outlet. CNA 1 showed the electrical cord which was the source of the spark. The cord was worn through in three spots and bare wire was exposed. There was an approximately 5-6 inch burn mark noted on the floor below the bed. CNA 1 stated he had written the faulty brakes on the maintenance log several times (maintenance log- list of items/equipment which needed to be repaired with a column for check off and date completed by the maintenance director) Review of the document titled, Maintenance Log, showed an entry dated 2/17/17. The work request showed, the bed weels (sic) won't lock. Further review of the Maintenance log indicated another work request entry dated 2/21/17 to Change the bed completely. The Maintenance Log entry dated 2/17/17 and 2/21/17, was dated and signed indicating it was repaired on 3/8/17. During a concurrent observation and interview on 5/18/17 at 12:10 p.m., CNA 1 stated Resident 5's bed continued to roll when locked even after the bed had been changed. CNA 1 demonstrated how Resident 5's bed continued to roll when the bed wheels were locked. During a concurrent observation and interview with a licensed electrician (LE), who had been called by the facility, on 5/18/17 at 2:22 p.m., the LE stated, if the exposed, sparked wiring had been laying next to combustible materials, (for example sheets and blankets), the incident could have started a fire. Review of the facility's policy and procedure titled, Maintenance Service, dated 12/2009, indicated, Maintenance services shall be provided to all areas of the building, grounds, and equipment .Maintenance Department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times Functions of maintenance personnel include, but are not limited to: .Maintaining the building in good repair and free from hazards. During a concurrent observation and interview with the DON, on 5/18/17, at 3:45 p.m., the DON stated the immediate plan of correction was the LE had ensured the electrical system was safe and Resident 5's air mattress and power equipment had been replaced. The DON was notified verbally the IJ was lifted on 5/18/17 at 3:45 p.m. The Administrator was not available in the facility for notification.

Based on interviews and record reviews the facility failed to implement their abuse prevention policy and procedure to report abuse and protect one, (Resident 1), of two sampled residents, from abuse. The activity assistant, (AA), observed Certified Nursing Assistant 1, (CNA 1), slap and verbally abuse Resident 1. The AA did not intervene to protect Resident 1. She failed to report the abuse until seven days later. At that time, CNA 1 was suspended pending an investigation and then terminated. The AA was allowed to continue to work at the facility without being disciplined, or being retrained in her responsibility as a mandated reporter, which placed all 55 residents at risk for physical and/or psychological harm. It was determined that all residents were in Immediate Jeopardy (IJ) due to the failure of staff to protect the residents from further abuse and the failure to report the abuse, by the continued employment of the AA without retraining or discipline. The director of nursing, (DON), was notified of the Immediate Jeopardy on 7/14/16 at 2:53 p.m., in the absence of the administrator. The IJ was removed on 7/14/16 at 3:40 p.m., after the facility administrator stated he planned to terminate the employment of the AA immediately and inservice all the staff members on abuse, and their responsibilities as mandated reporters. Findings: Record review on 5/25/16 of the document titled, Admission Record, showed the facility admitted Resident 1 on 4/9/15 with multiple [DIAGNOSES REDACTED]. During an interview on 5/25/16 at 9:45 a.m., the AA stated, on 3/16/16, between 7:00 and 8:00 a.m., she was sitting next to Resident 1's roommate inside Resident 1's room. CNA 1 was observed feeding Resident 1. Some of the food fell out of Resident 1's mouth and onto CNA 1's pant leg. CNA 1 then slapped Resident 1 on her cheek twice. The AA stated, after CNA 1 left the room, Resident 1 moved out of the bed and onto the floor. The AA said she called the charge nurse and told her Resident 1 was on the floor. The AA stated when CNA 1 came back into the room she appeared, Mad. CNA 1 asked Resident 1, Why did you do that? CNA 1, then left the room to get clean linen. When she came back to the room Resident 1 was,Wiggling around on the floor. CNA 1 stated, Why are you doing that? You are so stupid. CNA 1 then hit Resident 1 across the face with a towel. The AA stated she reported the incident to the Activity Director on 3/23/16. The AA stated staff are supposed to report abuse when it happens. She said she was, Scared, to report it when it happened since CNA 1, Had the nerve to do it in front of me. The AA said she was not sure what CNA 1 was capable of doing since she, Knew I was in the room. During a telephone interview on 6/28/16 at 10:19 a.m., the facility's Activity Director, (AD), stated, on 3/23/16, the activity assistant came into her office and said she had something to tell her and it was a secret. She said she witnessed CNA 1 slap Resident 1 with a diaper, and told her she was, Retarded. Record review of the facility's policy and procedure titled, Abuse Prevention, (not dated), showed, It is the policy of this facility to take every proactive measure to prevent the occurrence of abuse/alleged abuse to any resident. Staff information on how and whom they may report concerns without fear of retribution will be provided during orientation. Facility will identify, correct, and intervene in situations in which abuse are more likely to occur. If the suspected perpetrator is an employee, remove employee immediately from the care or vicinity of the resident. Suspend employee during the investigation. All mandated reporters are required by law to report incident of known abuse. During an interview on 7/14/16 at 2:53 p.m. the DON confirmed the AA was still an employee at the facility. After the DON was informed of the IJ the Administrator arrived at the facility. The Administrator agreed to terminate the AA's employment effective immediately.

Based on interviews, and record reviews, the skilled nursing facility failed to implement their abuse prevention policy and procedure to report abuse and protect one of two sampled residents, (Resident 1), from abuse. The Activity Assistant, (AA), did not protect Resident 1 and did not report the abuse until seven days after she observed Certified Nursing Assistant 1, (CNA 1), slap and verbally abuse Resident 1. CNA 1 was suspended pending investigation and then terminated. The facility continued to allow the AA to work in the facility. This failure resulted in harm for Resident 1 from the abuse from CNA 1. Resident 1 was also subjected to the knowledge that AA witnessed the abuse, and did not act to protect her from further abuse, or report the abuse. Findings: Record review on 5/25/16 of the document titled, Admission Record, showed the facility admitted Resident 1 on 4/9/15 with [DIAGNOSES REDACTED]. Review of the document titled, Minimum Data Set, dated dated [DATE], showed Resident 1 was severely impaired and unable to speak. Record review of the Annual Comprehensive MDS, (Minimum Data Set assessment tool), dated 11/3/15, showed Resident 1 had both short and long term memory difficulties, was unable to recall the current season, location of her room, staff names, or that she was residing in a nursing home. Her ability to make decisions regarding tasks of daily life was described as, Severely Impaired. Record review of the document titled, Resident Care Plan, dated 5/16, showed Resident 1 was totally dependent on staff for hygiene, bathing, and dressing, was unable to stand or walk, and had agitation behaviors. In an interview on 5/25/16 at 9:45 a.m., the AA stated, on 3/16/16, between 7 and 8 a.m., she was sitting with Resident 1's roommate inside Resident 1's room. CNA 1 was feeding Resident 1. Some of the food fell out of her mouth and onto CNA 1's pant leg. CNA 1 then slapped Resident 1, On her cheek twice. CNA 1 said, Why did you do that? Resident 1 was then put back to bed. Resident 1 was at risk for falls and therefore had a bed close to the ground with a thick pad on the floor next to the bed. The AA stated, after CNA 1 left the room, Resident 1 moved out of the bed and onto the floor. CNA 1 then came into the room and the AA described her as, Mad. CNA 1 was observed asking Resident 1, Why did you do that? CNA 1 then left the room to get clean linen. When she came back to the room Resident 1 was, Wiggling around on the floor. CNA 1 stated, Why are you doing that? You are so stupid. CNA 1 then hit Resident 1 across the face with a towel. The AA stated she reported the incident to the Activity Director on 3/23/16. The AA stated staff are supposed to report abuse when it happens. She said she was, Scared, to report it when it happened since CNA 1, Had the nerve to do it in front of me. The AA said she was not sure what CNA 1 was capable of doing since she, Knew I was in the room. In an interview on 6/28/16 at 10:19 a.m., the facility's Activity Director, (AD), stated, on 3/23/16, the AA came into her office and said she had something to tell her and it was a secret. She said she witnessed CNA 1 slap Resident 1 with diapers and told her she was, Retarded. The AD then told the AA that this information could not be kept secret and she then immediately reported it to the Director of Staff Development and the Director of Nursing. The AD then reminded the AA of the importance of reporting witnessed abuse, Right away. In an interview on 6/28/16 at 10:25 a.m., Licensed Vocational Nurse 1, (LVN 1), stated she was the nurse in charge at the time of the incident on 3/16/16. LVN 1 stated she was not made aware of CNA 1 slapping Resident 1 until, One week later. Record review of the facility's policy and procedure titled, Abuse Prevention, (not dated), showed, It is the policy of this facility to take every proactive measure to prevent the occurrence of abuse/alleged abuse to any resident. If a resident incident is reported, discovered or suspected, where the health, welfare or safety of the resident is involved, this facility will take the following steps: If the suspected perpetrator, (person inflicting harm), is an employee, remove employee immediately from the care or vicinity of the resident.

Based on interviews and records review,the facility failed to follow safety measures to ensure one of three sampled residents (Resident 1) was free from accident hazards when Resident 1 was not provided with a wheelchair seatbelt during transportation. As a result of this failure Resident 1 leaned forward and fell out of the wheelchair and obtained multiple injuries including a broken thigh, broken foot bone and multiple skin tears. Findings: Resident 1's closed record was reviewed at the facility on 4/7/16 at 1:55 p.m. Resident 1's admission Minimum Data Set ( MDS-assessment tool ) dated 3/29/16 included [DIAGNOSES REDACTED]. On the MDS Section B1000 for vision, revealed severely impaired (no vision or sees only light, colors or shapes; eyes do not appear to follow objects). During an interview with the Activity Assistant on 5/4/16 at 1:40 p.m., she stated the incident happened when Resident 1 came off the transportation bus from the dialysis (removes harmful substances from the blood when the kidney cannot) center. She said she was pushing Resident 1 in a wheelchair towards the building, Resident 1 leaned forward and fell . The Activity Assistant stated Resident 1 was not wearing a seatbelt and she was not aware Resident 1 should wear a seatbelt during transportation. According to the Interdisciplinary Post Fall Assessment form dated 4/1/16, on 4/1/16 at 2:00 p.m. on returning from dialysis the transportation van dropped Resident 1 and the Activity Assistant off in front of the building. The Activity Assistant was pushing Resident 1 back to the building when she came running in to report Resident 1 fell from her wheelchair on the side walk. 911 was called and Resident 1 was transported to the local acute hospital. Review of the acute hospital Service record dated 4/1/16 indicated Resident 1 presented as a level 2 (emergency medical services requiring coverage that include an orthopedic surgeon) trauma after fall from her wheelchair. The documentation further indicated Resident 1 had a left femur (thigh bone) fracture on imaging (X-ray) and right phalynx (foot bone) fracture. Resident 1 was evaluated by the orthopedics (bone specialist) who recommended a left leg brace and non weight bearing for left leg. Review of the Nurses Notes dated 4/2/16, indicated Resident 1 came back from the acute hospital with multiple skin tears on her face, bilateral (both) arms, hands and feet. Review of Resident 1's care plan dated 3/18/16 under concerns and problem indicated totally dependent all hygiene, bathing, dressing and max (maximum) transfer assist(assistance) non-ambulatory(not able to walk-or leave a building unassisted) to wheelchair. One of the approach plan was for a seatbelt and foot pedals (support the foot while on a wheelchair) in place at all times. During an interview with the Director of Nursing (DON) on 4/7/16 at 2:45 p.m., she stated, during the investigation the facility found out Resident 1, did not have a seatbelt on when the activity assistant was pushing her and she fell . She has to wear one at all times when in the wheelchair.

Based on observation, interview and record review, the facility failed to follow a policy and procedure that required two or more people to assist and supervise while showering a resident on a shower bed. One CNA attempted to shower one of two sampled residents on a shower bed, (Resident 1), by herself. This failure resulted in Resident 1 falling from the shower bed and sustaining a laceration on her forehead that required sutures. This deficient practice placed other residents who were showered on a shower bed at risk for falls. Findings: In an observation on 4/22/14 at 2:05 p.m., Resident 1 was in bed. She did not respond verbally. There was a healing cut with a dark colored, scabbed area on the upper, center edge of her forehead. Review of the admission face sheet for Resident 1 on 4/22/14, showed she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual assessment, dated 11/22/13, showed she required total assistance of one to two people with her activities of daily living. Resident 1's speech was unclear, she was rarely/never understood, but she usually understood others. She had both long and short term memory problems. Resident 1 had functional limitations in range of motion on the left side of her upper and lower extremities. A nurse's notes dated 4/11/14 at 10:00 a.m., reflected, "Called by CNA (certified nursing assistant 2) at 9:15 a.m., to the shower room. Found resident on the floor alert, has laceration (cut) on right forehead and pressure was applied." The note reflected that CNA (2) reported that Resident 1 fell off the shower bed (a narrow, waist high, waterproof platform on wheels, with rails on either side, held in place by locking pins) and was agitated. She was turned to her left side, holding on the side rails and her (right) arm was shaking the side rail. The side rail got loose and fell down, then the Resident fell off. 911 was summoned. Resident 1's emergency room physician history and physical dated 4/11/14, showed Resident 1 sustained a 4 x 3 centimeter (cm) laceration (cut) to her forehead with minimal hematoma (a black and blue area on the skin that often occurs after a trauma to the soft tissue), and she received sutures to the wound. Resident 1's discharge instructions from the hospital showed she needed a follow-up appointment with the trauma clinic, pain medication, antibiotic ointment to the suture line, and there were instructions for cleaning and monitoring the suture line. Review of facility's nurse's notes dated 4/11/14 at 6:00 p.m., showed, "Returned from acute hospital emergency room at 6 p.m., right forehead 4 cm x 3 cm laceration with minimal discoloration, right upper arm with 4-5 longitudinal scratches." The facility policy and procedure for use of a shower bed dated 4/6/12, contained the following instructions, "Before transferring resident to bed, lock wheels. Two or more person assist to do shower (depending on stature or behavior etc.)" In an interview with CNA 2 on 4/22/14 at 12:30 p.m., she stated, "I was giving her (Resident 1) a shower by myself. I turned her to her left side and she was holding on the side rail with her good (right) arm. She was agitated. She gets agitated a lot of the time when we are showering her. She was constantly moving her right hand around and shaking the rail on the shower bed. The rail on the shower bed went down so quickly as I was washing her. The rail went down and caused her to fall, because she was holding on to the rail. She fell and hit the right side of her forehead on the floor. I quickly moved the shower bed out of the way, calling out for assistance. The nurses came and the charge nurse called 911. I was not in-serviced on the shower bed." In an observation and interview with the director of nurses (DON) on 4/22/14 at 1:00 p.m., she shook the shower bed rails and stated, "It's impossible for the rails to fall down if they are locked." In an interview with the DON on 4/25/14 at 11:30 a.m., she stated, "The shower bed in-service was not listed on our orientation form. We had a new Director of Staff Development who had no way of knowing whether CNA 2 received instructions on how to use the shower bed or not. CNA 2 had another CNA help her to put Resident 1 on the shower bed but the other CNA did not accompany CNA 2 into the shower room. CNA 2 should have made sure she had help to shower Resident 1."

Because of the facility's failure to ensure a safe environment for all residents, when some residents smoked, Immediate Jeopardy was called, on 9/26/13 at 2:20 p.m., with the facility's Administrator and Director of Nursing. On 9/26/13 at 6:30 p.m., the administrator present a draft plan of correction action to the surveyor. The draft plan of correction consisted of the following elements: 1) Regular re-enforcement of compliance with the facility smoking policy and no smoking allowed around oxygen. 2) All staff will be inserviced to alert them of their responsibility to enforce the Smoking Policy and Policy for Residents Who Smoke and Require Oxygen at Bedside, by 10/1/13. 3) The Director of Staff Development will review weekly for staff awareness of smoking safety and enforcement. 4) The Activity Director will discuss smoking safety and smoking only in designated areas at Resident Council. 5) The Housekeeping Supervisor will observe for evidence of resident non-compliance during staff cleaning and report. 6) The Director of Nursing will assure documentation is complete, especially on plan of care. 7) The Administrator will gather information from respective department heads at daily meetings for CQI and presentation for recommendations at Quality Assurance on Wed., 10/2/13. On 9/26/13 at 6:30 p.m., the surveyor met with the Administrator and Director of Nursing and informed them the Immediate Jeopardy was abated. Based on observation, interview and record review, the facility failed to provide a safe environment, adequate supervision and monitoring of smoking, did not implement the individualized care plan for smoking or follow the policies and procedures established for smoking for one (Resident 1) of three sampled residents. This failure resulted in a flash burn (a burn caused by sudden intense heat (Reference: http://www.encyclopedia.com/doc/1O999-flashburn.html)) causing first and second degree facial burns (an injury involving the first and second layers of the skin. The skin has three layers.) for Resident 1 and had the potential of causing a fire and endangering the lives of the other residents. Findings: Review of the medical record, on 8/19/13, showed Resident 1 was receiving five liters of oxygen continuously through a nasal cannula (NC, a hollow plastic tubing with short plastic prongs leading to each nostril) for chronic obstructive lung disease (COPD) and she was a smoker. Nurse's notes, dated 8/17/13 at 12:30 p.m., indicated Resident 1 was found sitting on the side of her bed yelling, "I'm on fire." Her gown was wet and she was receiving oxygen through a NC. Resident 1 had "soot " from the bridge of her nose to her chin. When asked if she had been smoking, Resident 1 replied, "I did it to myself." The notes also indicated, "a red lighter was found on side table under a towel." The emergency room record, dated 8/17/13 at 1:16 p.m., stated Resident 1 had first and second degree burns to nose and upper lip after smoking with oxygen and would require care at a burn clinic. Notes from a scheduled follow up visit at the emergency room , on 8/19/13, showed multiple facial blisters. Resident 1 was evaluated and treated by a plastic surgeon at the regional burn center 8/23/13 and 9/3/13. The notes of 8/23/13 indicated partial thickness ...losses to face/lips..." and treatment of [REDACTED]. She was also followed by the facility wound specialist through 9/5/13 for debridement (removal of dead tissue). Observation, on 8/19/13 at 10:30 a.m., showed Resident 1's room faced the front of the building and had a common outside patio. There were "No Smoking" signs posted on the outside door sill, on the oxygen machine (concentrator) and above her bed. On 8/19/13, during the investigation, Resident 1 was out of the facility. During a concurrent observation and interview, on 8/27/13 at 10:30 a.m., Resident 1 sat on the side of the bed receiving oxygen at 5 liters per minute via a NC. Resident 1 had a broad round face. On the right, the skin on her face was red and raw from the bridge of her nose outward to the hairline and followed the jaw bone to her lower lip. On the left, the skin was red and raw from the bridge of the nose to the hairline and straight down even with the chin. The skin on the left, from the bridge of the nose to the left inner eye to the bottom of the lower lip was raised. It was red and raw with some softened scabbing. The chin was a darker red with signs of healing. The tip of her nose and upper lip were bright red, raw and raised. Inside and out of both nostrils had crusted dark scabbing. To the left of the chin was a small open area of yellow tissue. On the right side of her face, from the middle of the nose to the upper lip and in a half circle, was an area of open yellow tissue approximately 1.5 inches by 1 inch, surrounded by a 0.5 inch raised bright red raw border. A photograph was taken with Resident 1's written consent. When asked about the burns, Resident 1 became teary and stated, "I don't know why I did it. I just lit up. I know better." She stated she had a pack of cigarettes and two lighters in her room at the time. She stated a friend had given one lighter and she had purchased the other from a liquor store. She had the lighters "for a while" and kept them in her purse. She purchased cigarettes from the store and some were given to her by friends. When asked how she was, Resident 1 stated, "Can't go to sleep. It comes back to me." Resident 1 stated she usually went to the patio outside her room to smoke, that she did not like to go to the smoking patio because there was no privacy. She knew she was not supposed to smoke on the patio outside her room but the staff usually didn't say anything. Asked who lit her cigarettes for her, Resident 1 stated she did it herself. In an interview, 9/26/13 at 2:30 p.m., Resident 1 sat on the side of her bed. She received oxygen thru a NC and stated she, "Doesn't want to smoke - too scared." There were no open wounds on her face. In an interview, on 8/19/13 at 3:40 p.m., the Director of Nursing (DON), stated the designated smoking area was the patio outside of the laundry room. The patio outside Resident 1's room was changed to a non-smoking area approximately one year before and Resident 1 was notified. Resident 1 wanted the door to the hallway kept closed. Resident 1 continued to smoke in the doorway of her room to that patio and that another resident lit her cigarettes. The DON stated Resident 1 did not like to go to the smoking patio. "We do tell her about the rules but she doesn't always follow them. She's independent." The DON stated that since the injury, Resident 1 was being taken to the parking lot, outside the kitchen, to smoke because it was closer to her room than the designated smoking area. In an interview, 8/19/13 at 4:05 p.m., Resident 2, who lived in the next room, stated at least once a week, prior to the injury, she smelled smoke and stated she had told staff. Resident 2 stated Resident 1 was argumentative and she didn't want to talk with Resident 1. "Nobody can stop her." In an interview, in the hallway, 8/19/13 at 4:10 p.m., Resident 3, who lived two rooms away from Resident 1, on the same side of the building, stated he had smelled smoke coming from outside but didn't know where it came from. Resident 3 was a smoker, was able describe the location of the smoking patio and stated that was where he smoked. On 8/19/13 at 4:30 p.m., Resident 3 and Resident 4 were observed just outside the exit door, near the laundry room, sitting in their wheelchairs smoking. When asked why they were not using the smoking patio, Resident 4 stated, "Here's OK. We're outside." Asked about lighting cigarettes for Resident 1, Resident 4 stated it had been a long time since he had lit a cigarette for her, that the nurses did it. In an interview, 8/19/13 at 5 p.m., the DON stated she knew residents smoked outside the exit doors and she had told them to stay clear of the door, as they might get hit when it was opened. In an interview, 8/27/13 at 10:20 a.m., Resident 5 was sitting outside the exit door near rooms 20 and 21. Resident 5 stated people smoke everywhere on both patios and the walkways. He stated he was a smoker. In an observation, 8/27/13 at 10:25 a.m., the patio between Rooms 8, 9, 12, and 14 had a sign designating it as a smoking area. There were three metal ashtrays and a fire extinguisher in the area. In an interview, 9/26/13 at 3 p.m., a housekeeper (HSK) stated no inservices had been provided about a smoking policy. When asked if smoking while on oxygen was OK, HSK stated that was a nursing issue. In an interview, 9/26/13 at 3:10 p.m., when asked about a smoking policy, Certified Nursing Assistant (CNA) 3 was able to identify the smoking patio and that there were smoking times for Resident 1. In an interview, 9/26/13 at 3:40 p.m., CNA 2 when asked to identify the smoking area, stated, "outside." Asked for further clarification, CNA 2 went outside the door between Rooms 14 and 15 and pointed to a chair just outside the door and stated, "This is where I take them." The area was not the designated smoking area. In an interview, 9/26/13 at 3:50 p.m., a Cook was able to identify the smoking patio but stated there were a few resistant residents and some staff, Cook included, go outside the kitchen, near Room 7 to smoke. Cook stated residents weren't supposed to go there but there was an ashtray there. When questioned if it was a smoking area, Cook stated, "Maybe that why I'm not supposed to," go there. Observation with the Cook showed there was a standing ashtray between two benches to the left of the exit door. In an interview, 8/20/13 at 10:45 a.m., CNA 1 stated, before the injury, Resident 1 liked the hall and outside doors closed. When she would open the door from the hall, on most days the room smelled of cigarette smoke. In an interview and record review , 8/19/13 at 3:15 p.m., Registered Nurse (RN) 1 stated, and showed, Resident 1's name was the only current resident on a "may not have lighters" list, taped at the nurse's station. She stated the same list had been posted since 8/12. She stated residents were given the lighters or had cigarettes lit by the staff when requested. She had never lit any cigarettes for Resident 1. In an interview, 8/19/13 at 3:30 p.m. the activity assistant stated Resident 1 purchased five cigarettes one to two days before to the injury and then five to seven days before that. In an interview, 8/20/13 at 2:45 p.m., Licensed Vocational Nurse (LVN) 2 stated, on the day of the injury, she heard Resident 1 calling from behind her closed door, "I'm on fire!" LVN 2 stated Resident 1 kept the door closed, had music playing loudly and would not have heard her calling if she (LVN 2) had not been right outside the door passing medications. LVN 2 stated there was soot on Resident 1's face from the bridge of her nose to the chin, straight down and the NC was separated between the prongs. LVN 2 stated she did not smell smoke in the room that day. In an interview, 8/27/13, LVN 2 stated Resident 1 had previously told LVN 2 that she went outside, on her own patio, to smoke and LVN 2 had never been asked to light a cigarette. In an interview 8/27/13 at 11:55 a.m., LVN 1 stated, before the injury, Resident 1 smoked on the smoking patio, out by the kitchen and on the patio by her room and Resident 1 was able to light her own cigarettes, LVN 1 never lit a cigarette for her. LVN 1 was aware Resident 1 was "going to smoke and did smoke." LVN 1 stated that Resident 1 was, "under the radar" and "not much noticed" since she was able to transfer to her wheelchair and was mobile. LVN 1 stated that since the injury, Resident 1 was being monitored hourly to check on her whereabouts, smoking status and needs since the injury. LVN 1 reviewed the Resident Specific Plan for Smoking Safety care plan, dated 8/20/13, which stated monitoring was to be done every 30 minutes and the monitoring log which indicated hourly monitoring was done beginning 8/17/13 with no changes to time of monitoring on 8/20/13. Asked who was responsible for communicating and implementing the care plan, LVN 1 stated it was done through shift endorsement. Asked if the, 8/20/13, care plan for monitoring had been carried out, every thirty minutes, as written, LVN 1 stated, "No." In an interview, 8/20/13 at 12:15 p.m., the DON stated, since the injury, Resident 1 would be taken out the back door by the kitchen and sheds without her oxygen to smoke. She felt felt the time would be brief as Resident 1 would become short of breath without the oxygen. The DON stated the area was designated as non-smoking but the smoking patio was too far for Resident 1 to go without her oxygen and be able to smoke. In an interview, 8/28/13 at 4:25 p.m., RN 2 stated, prior to the incident, she had never seen Resident 1 outside smoking but she did smell smoke in the resident's room and that Resident 1 kept the hallway door closed. When RN 2 asked, the resident told her she did not smoke, that she had given it up. There was a smoking care plan in Resident 1's chart written by the DON. RN 2 had never lit a cigarette for Resident 1. Review of the admission orders [REDACTED]. MDSs (a resident assessment tool), dated 11/12/12 and 12/21/13, and the POLST (Physician order [REDACTED]. Review of care plans dated 3/5/09 (COPD), 3/26/09 (Severe Heart Disease) and 9/22/11 (COPD) showed oxygen was ordered, as needed, and the resident was to be encouraged not to smoke. On 9/1/10 a care plan for COPD and smoking showed Resident 1 had oxygen ordered as needed, smoking was to be discouraged and to "ensure she smokes in designated areas only. She goes to it independently." The care plan dated, 12/12/11, for COPD and smoking showed, "smokes in room at times" as a concern. Approaches were oxygen use, as needed, "no smoking in room, knows designated area - monitor to ensure she goes to it." A care plan, dated 9/3/12, showed a concern of, "found smoking in her room, put cigarette butt in water pitcher lid. Thinks she did nothing wrong." Approaches show a" lighter was taken and supervised lighting of cigarettes on smoking designated patio only...informed she may not smoke in room or have a lighter." A care plan, dated 3/27/13, for chronic shortness of breath showed Resident 1 had an oxygen concentrator at the bedside and she knew how to turn it on and off. A 3/27/13 care plan showed behavior issues, "labile, irritable, verbally abusive, poor judgement, poor insight" and staff knew Resident 1 well and how to handle her moods. Review of the care plan conference summary, dated 5/20/13, indicated Resident 1 was oxygen dependent through a NC and was still smoking but stated she had stopped. Review of unsigned nurse's notes, dated 8/20/13 at 3:30 p.m., stated, "Resident and staff was advised to go to kitchen exit to assist ...to smoke." Nurses notes, of 8/20/13 at 10 p.m., stated, " resident assisted to smoke once by the kitchen exit." Review of nurse's notes, dated 9/3/10 at 10 a.m., written by the DON, indicated she, the Administrator (ADM), a charge nurse and a rehabilitation nursing assistant visited Resident 1 in her room after a report of the resident smoking in her room. The notes indicated the room smelled like smoke and "multiple cigarettes" were in the top of a water pitcher. Review of smoking assessments showed Resident 1 was considered an independent smoker from 5/9/09 through 9/3/12. The 9/3/12 and 2/21/13, smoking assessments indicated Resident 1 did not demonstrate a safe technique for putting out matches or lighter and disposing of ash or an understanding to use only designated smoking area. She was identified as a dependent smoker because she had smoked in her room. Lighters were removed and Resident 1 would need to ask for a light while on the smoking patio. The smoking assessment, of 3/27/13, indicated Resident 1 did not demonstrate the ability to safely light and smoke cigarettes and continued to lack understanding to use only the designated smoking area. She was identified as an independent smoker with a note to see comments. The smoking assessment form indicated an "Independent smoker - answers yes to all questions." Comments showed, "no light in room so she will ask for light and only will be lit in designated area." Comments also showed that the resident agreed. The assessment and recommendations were reviewed without change on 5/29/13. Review of the smoking privilege informed consent and compliance agreement dated 8/27/12, signed by Resident 1, indicated she understood the health and safety risks of smoking, agreed to comply with the safety rules and procedures and "understands no lighter. It must be lit by staff in smoking area." The agreement also included the statement, "Repeated non-compliance may result in suspension of smoking privileges." Review of the medical record did not indicate that smoking privileges, for Resident 1, were suspended at any time. Review of the Smoking Policy, last reviewed 4/12/13 per the DON, indicated it's purpose was to provide, "maximum safety to all resident at all times." Residents and staff would be informed of the smoking policy and a resident smoking assessment would be done upon admission. Smoking was prohibited in resident rooms and near oxygen equipment. Smoking would be allowed in designated areas only. Smoking procedures would be posted on the bulletin board in the same location as the Resident Rights. Review of the Smoking Regulations, last reviewed 4/12/13 per the DON, indicated smoking material for "deemed not responsible shall be kept only at the nursing station." Review of the policy and procedure for residents who smoke and require oxygen at bedside, dated 5/1/12, and last reviewed 4/12/13 per the DON, directed residents who utilize oxygen at the bedside and are smokers, shall not have lighters or matches at the bedside, "under any circumstances," nursing staff was to ensure "full compliance," and care plans would be based on "needs/concerns for smoking." In an interview , 9/26/13 at 2:20 p.m. with the ADM and DON, the DON stated no inservices had been provided to the staff about the smoking policy. The ADM stated they would be done. In a concurrent review of the smoking policy and procedures and regulations and interview, 8/19/13 at 4:55 p.m., and observation of the bulletin boards, the DON stated the smoking areas were not identified on the policies and regulations.and were not posted on the bulletin boards. The smoking procedures were not posted on the bulletin boards. In a concurrent review of the smoking policy and procedures and regulations and interview, 9/26/13 at 6 p.m., and observation of the bulletin boards, the ADM stated the smoking areas were not identified on the policies and regulations.and were not posted on the bulletin boards. The smoking procedures were not posted on the bulletin boards. He posted a smoking policy that did not designate any smoking areas and stated he would add the information and get the smoking area identified on the facility map posted near the nurse's station.

Based on observation, interview and record review, the facility failed to follow their established smoking policy. A staff member smoking outside the designated smoking area created a potential fire hazard and reduced the safety of all residents. Findings: On 11/14/13 a revisit was conducted to follow up on the facility's failure to provide a safe environment, adequate supervision of smoking, lack of an individualized care plan for smoking that led to facial burns for one resident and had the effect of endangering the lives of other residents. On 11/14/13 at 3:10 p.m., Licensed Vocational Nurse (LVN) 1 was observed smoking on the walkway behind a three-bed resident room. In a concurrent interview, LVN 1 pointed to the patio when asked where the smoking area was. When asked if the walkway was part of the smoking area, LVN 1 shrugged her shoulders and said, "I guess I should put it out," referring to the cigarette. LVN 1 went to the ash tray, in the designated smoking area, and put the cigarette out. On 8/27/13 at 10:25 a.m. and 11/14/13 at 3:10 p.m., the patio between Rooms 8, 9, 12, and 14 had a sign designating it as a smoking area. There were three metal ashtrays and a fire extinguisher in the area. There was a facility map showing the designated smoking area posted on the bulletin board next to the nurse's station. On 9//26/13 and 11/14/13, review of the Smoking Policy, last reviewed on 4/12/13, indicated its purpose was to provide, "Maximum safety to all resident at all times...These regulations apply to all residents, volunteers, visitors and staff. "Smoking would be, "Allowed in designated areas only." In an interview, 11/14/13 at 2:45 p.m., testing the results of training provided by the facility, CNA 2 stated he had been given training about the smoking policies and was able to identify the location of the smoking patio. In an interview, 9/26/13 at 3:40 p.m., CNA 2 was unable to state where the smoking area was. In an interview on 11/14/13 at 4 p.m., the Director of Nursing (DON) stated the smoking policy applied to employees, as well as residents, that there was not a separate policy for employees. Employees were to smoke in the designated smoking area. In an interview on 11/14/13 at 4:05 p.m., the Administrator stated the same smoking policy applied to employees and residents.