Every finding on record at Leeway, Inc

Based on observations, clinical record reviews, facility documentation, facility policy and interviews for 4 of 12 residents (Resident # 10, Resident #15, Resident #22, and Resident # 23 reviewed for smoking, the facility failed to revise the care plan to indicate smoking privileges, concerns or restrictions. The findings included: 1. Resident #10 's diagnoses included necrotizing fasciitis, Fournier gangrene and anxiety disorder.The Resident Care Plan dated 11/24/2025 failed to identify smoking in the care plan. The admission Minimum Data Set assessment dated [DATE] identified Resident #10 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and required substantial maximum assistance for lower body dressing, toileting, partial moderate assistance with upper body dressing, bed mobility, transfer, set up assistance with hygiene, independent eating and no current tobacco use.2.Resident # 15's diagnoses included moderate protein calorie malnutrition, chronic obstructive pulmonary disease and nicotine dependence.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #15 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 and required supervision for hygiene, set up assistance for dressing and independent with eating, bed mobility, transfer, and toileting.The Resident Care Plan dated 11/18/2025 failed to identify smoking in the care plan.3. Resident #22's diagnosis included bipolar disorder, anxiety disorder and nicotine dependence.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #22 was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 and was independent with hygiene, dressing, toileting, bed mobility, transfers and eating.The Resident Care Plan revised dated 11/28/2025 identified as a safe supervised smoker- may not go on independent smoking due to safety. Interventions included ensure that the resident and responsible party are made aware of the facility smoking policy, all smoking materials will be stored in a secure location, ensure smoking occurs in designated smoking areas, ensure that no oxygen is located in the smoking area while the resident is smoking, no smoking materials or igniter's will be stored in the resident rooms, resident will be escorted 3 times a day for opportunity to smoke with supervision to ensure safety. The Resident Care Plan failed to identify unsafe smoking incidents on 8/1/2025, 8/13/2025 and 12/21/2025 or interventions related to a behavioral contract.4. Resident # 23's diagnoses included chronic obstructive pulmonary disease, adjustment disorder with depressed mood and nicotine dependence.The admission Minimum Data Set assessment dated [DATE] identified Resident # 23 was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 and required substantial maximum assistance with lower body dressing, partial moderate assistance with upper body dressing, toileting, bed mobility, transfers, set up assistance with hygiene and eating and current tobacco use.The Resident Care Plan dated 11/20/2025 failed to identify smoking in the care plan.Observation of smoking on 12/24/2025 at 11:11AM with 7 residents present, (Resident # 9, Resident #10, Resident #15, Resident #17, Resident #20, Resident #22, and Resident #29) were observed smoking accompanied by RN #2, NA #3, NA #4 and Front desk #2. Each resident was given 1 cigarette which was lit by Front desk #2. Observation identified all residents were able to smoke independently and extinguish smoking material in the self-extinguishing ashtray.Interview and clinical record review with Director of Nursing (DNS) on 12/29/25 at 10:52AM identified care plans are completed by the MDS Coordinator and the admission nurse, moving forward it will be completed by nursing. The care plan was updated with the care plan schedule. The DNS could not explain why the medical record failed to reflect current smoking care plans.Review of the Care Plans Comprehensive Person-Centered policy dated 2001 directed, in part, the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. And reflects currently recognized standards of practice for problem areas and conditions.Review of the Care Plan -Interdisciplinary Team policy dated 2001 directed, in part, comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team.

Based on clinical record reviews, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #34) reviewed for discharges, the facility failed to ensure the Ombudsman was notified of a hospitalization and a discharge to community and for ( Resident #7) reviewed for discharge, the facility failed to provide written notification to the resident's conservator explaining why the resident was being transferred to the hospital The findings included: 1 a. Resident #34 was admitted to the facility in [DATE] with diagnoses that included chronic hepatitis, and cardiomyopathy. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #34 had moderately impaired cognition. The nurse's note dated [DATE] at 11:52 PM identified Resident #34 was alert and oriented. Resident #34's left side of the chest where there was a pacemaker appeared swollen and the resident complained of itchiness. The Advanced Practiced Registered Nurse (APRN) was notified and gave an order to send Resident #34 to the emergency room for further evaluation. The nurse's note dated [DATE] at 12:21 AM identified Resident #34 was transferred to the emergency room for evaluation at 12:20 AM. A physician's order dated [DATE] directed to send Resident #34 to the emergency room for further evaluation. Resident #34's census report identified Resident #34 was sent to the hospital on [DATE] and was readmitted back to the facility on [DATE]. An Ombudsman notification dated [DATE] at 10:43 AM identified the hospitalizations for the month of June, month of July, and the month of [DATE] was submitted, but the report did not have Resident #34 listed for the hospitalization on [DATE]. This was submitted by Social Worker (SW #1). b. The nurse's note dated [DATE] at 2:10 PM identified Resident #34 had received last dose of Intravenous Therapy (IV) antibiotics and was seen by the infectious disease physician who cleared Resident #34 for discharge home. The social worker note dated [DATE] at 2:10 PM indicated Resident #34 was safely discharged home with home care services. The nurse's note dated [DATE] at 5:50 PM identified Resident #34 was discharged today with discharge papers and medications were given. Resident #34 left at 5:35 PM via taxi. Resident #34's census report identified Resident #34 was discharged on [DATE]. An Ombudsman notification dated [DATE] at 12:56 PM identified notification of routine monthly hospital discharges. Hospital discharges for month of [DATE] and [DATE] which did not identify Resident #34 was discharged home to the community. An attempt to interview with SW #1 was unsuccessful. Interview with the Administrator on [DATE] at 12:52 PM indicated the SW#1 was on vacation but was responsible for notifying the Ombudsman monthly of all residents sent to the hospital and all residents that were discharged voluntary and involuntary as needed for the month prior. The Administrator indicated there was only one social worker for the facility. The Administrator indicated he had the administrator assistant working on printing out the confirmation receipts to the Ombudsman's office for the monthly submissions. Interview with the Administrator on [DATE] at 1:01 PM indicated the social worker updated the Ombudsman on [DATE] for the hospitalizations for the months of June, July, and [DATE]. The Administrator indicated the discharges were not on these submissions and maybe the social worker did it on a separate piece of paper. The Administrator indicated SW #1 updated the ombudsman on [DATE] for September and [DATE]. The Administrator indicated on [DATE] for October and [DATE] discharges to the hospital. Interview with the Administrator on [DATE] at 2:00 PM indicated SW #1 was out of the country and would not return until [DATE]. The Administrator indicated he was aware that the Ombudsman must be notified of all discharges monthly and not just the hospitalizations. Review of the facility Transfer or Discharge Facility Initiated Policy identified Notice of transfer or discharge is provided to the resident and resident representative as soon as practicable before the transfer and to the long-term care Ombudsman when practicable (e.g. in a monthly list of residents that includes all notice content requirements). The facility will send a copy of the discharge notice to a representative of the office of the Longterm Care ( LTC) Ombudsman. Notice to the Office of the LTC Ombudsman will occur at the same time as the notice of discharge is provided to the resident and the resident's representative. Although requested a policy of ombudsman monthly notification requirements was not provided. 2.Interview with the Administrator on [DATE] at 12:52 PM indicated the SW #1who is on vacation is responsible for notifying the Ombudsman monthly of all residents sent to the hospital and all notification of discharges voluntary and involuntary as needed. There is only one social worker in the facility. The Administrator indicated he had an assistant administrator working on printing out the confirmation receipts to the Ombudsman's office. Interview with the Administrator on [DATE] at 1:01 PM indicated the social worker updated the Ombudsman of the June, July and [DATE] discharges on 8/14/ 25. The Administrator indicated SW#1 updated the ombudsman on [DATE] for September and [DATE]. The Administrator indicated on [DATE] for October and [DATE] discharges to the hospital. It is not completed monthly and is only for residents hospitalized , not discharged home. Interview with the Director of Nursing Services (DNS) on [DATE] 1:31 PM identified the nurse sending the resident out is responsible for ensuring a copy goes to the hospital, one to the resident, and one to social worker who places it in the chart. The DNS indicated the bed hold policy for the residents would be in the medical record or maybe the social worker has it since it is not in the old medical records. copy provided. Resident #34 were sent to the hospital on [DATE] and [DATE]. The DNS indicated they do not scan the bed hold policy provided to the residents. Interview with the DNS on [DATE] at 1:43 PM after review of the social worker bed hold 3 ring binder book in the social worker office with the DNS indicated there were no bed hold forms with Resident #34's name on it was not there. 3. Resident #7's diagnoses included urinary tract infection, acute on chronic congestive heart failure, Alzheimer's disease, schizophrenia, dementia with other behavioral disturbances.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had a Brief Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Resident # 7's Resident Care Plan (RCP) dated [DATE], identified the resident's code status as a full code. Interventions included for staff/medical professionals to attempt Cardiopulmonary Resuscitation (CPR) and life saving measures as needed when medically necessary. Review of Resident #7's clinical record identified nurses notes dated [DATE], [DATE], [DATE], [DATE] and [DATE] indicated the resident was transferred to the hospital. Further review failed to identify the facility notified the resident's conservator in writing of any of the transfers.Interview with facility Assistant Administrator, as well as the Administrator on [DATE] at 9:30 AM identified they could not locate any documentation related to updating Resident #7's conservator in writing notifying them of the resident's transfer, and why the resident was transferred to the hospital. The administrator stated, I didn't know that was a thing. At 10:53 AM, a call was placed to the resident's conservator to follow up regarding if the facility sent her/him in writing a reason for Resident #7's transfers. Surveyor received an automated message identifying the recipient had a voice mail box that had not been set up. Review of the Discharge-Planning policy, indicated, in part, that a copy of the written notification of a resident's planned transfer or discharge be provided to the resident and their representative are notified in writing of the following information: the specific reason for the transfer or discharge, including the basis under S483.15(c)(l)(i)(A)-(F); the effective date of the transfer or discharge; the specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is being transferred or discharged . Facility policy further indicates that under emergent circumstances, the notice (of transfer) is given as soon as it is practicable but before the transfer or discharge, and that notices are provided in a form and manner that the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments.

Based on clinical record reviews, facility policy, review of documentation, and an interviews for 1 of 1 sampled resident (Resident #7) reviewed for hospitalization, the facility failed to develop and implement comprehensive care plans addressing ongoing recurrent diagnoses, which the resident was subsequently hospitalized and for (Resident #2) reviewed for a urinary tract infection (UTI), the facility failed to develop and implement a comprehensive care plan reflecting a new diagnosis post a hospitalization The findings included: 1.Resident #7's diagnoses included urinary tract infection (UTI), acute on chronic congestive heart failure (CHF), Alzheimer's disease, schizophrenia, dementia with other behavioral disturbances. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had a Brief Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Resident #7's Resident Care Plan (RCP) dated 12/30/25, identified the resident had congestive heart failure. Interventions included to encourage adequate nutrition, to offer small frequent feedings; to give cardiac medications as ordered and monitor the resident's intake and output (I & O). The RCP failed to identify the resident would be at an increased risk for rapid weight gain, shortness of breath, fatigue, increased swelling, increased cough, decreased oxygenation. The RCP also failed to identify Resident #7's reoccurring UTI diagnoses. The resident was hospitalized for complications from a UTI three times in the past six months, with discharge date s of 6/28/25, 9/9/25 and 10/8/25. The resident was also hospitalized for complications related to CHF complications, discharged on 7/6/25, 9/30/25, and 10/20/25. An interview with the Minimum Data Set (MDS) Coordinator on 12/30/25 at 11:11 AM identifies she is responsible for updating residents' care plans. She also identified that she is responsible for updating residents' care plans upon facility admission, falls, behaviors/symptoms, quarterly and comprehensively. She confirmed she should initiate a care plan for a resident with a UTI. The MDS Coordinator identified if the surveyor was unable to locate the resident's care plan under resolved care plans, that it was safe to conclude the care plan was not implemented, she stated yes, but I don't remember the resident (in question.) She also noted she would be responsible for updating residents' care plans when they are hospitalized and returning to the facility. The MDS Coordinator also was unable to provide an answer why the care plan was not done or updated following Resident #7's hospitalizations. When questioned regarding why a more comprehensive care plan for CHF was not implemented for the resident, as opposed to just encouraging adequate nutrition, offer small frequent feedings; to give cardiac medications as ordered and to monitor the resident's intake and output, she replied if weights were not ordered to be checked daily (by the physician), then I would not have care planned for it. She also identified the Nurse Aides (NA) are responsible for documenting I's & O for the resident, and that would be reflected in the electronic medical record, and not the resident's hard chart. Review of facility charting failed to reflect any evidence of NA's performing I &O monitoring for the resident. Review of Care Plans policy indicated, in part, that care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment and reflects currently recognized standards of practice for problem areas and conditions. Resident #2's diagnoses included chronic kidney disease, benign prostatic hyperplasia and endocarditis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview of Mental Status (BIMS) score of 11 indicating moderate cognitive impairment, and required substantial/maximal assistance for toileting hygiene, toilet transfer and lower body dressing. A review of the hospital transport handoff dated 12/17/25 identified Resident #2 was to start Cefuroxime (an antibiotic) oral tablet 250 Milligrams (MG), one tablet two times a day for 7 days, for a UTI. (Although hospital discharge documentation was requested from the facility, an interview with the DNS on 12/30/25 at 1:46 PM identified the facility was not in possession of the document as Resident #2 did not return with any paperwork.) A physician's order dated 12/19/25 directed to administer Cefuroxime Axetil (an antibiotic) oral tablet 250 Milligrams (MG), one tablet two times a day for 7 days, for a UTI. The Resident Care Plan dated 12/23/25 failed to identify Resident #2 had a care plan for UTI. Interview with the MDS Coordinator (RN) 1 on 12/30/25 at 11:11 AM identified she was responsible for initiating care plans, and it was facility policy to implement care plans on admission, with falls, behaviors and any other updates quarterly and comprehensively. A review of the current and completed care plans for Resident #2 with RN #1 failed to identify a present or completed care plan for a UTI. RN #1 identified a care plan for the diagnosis of a UTI should have been initiated but she could not identify why it was not done. Review of the Comprehensive Care Plan Policy directed in part that a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observations, clinical record reviews, facility policy and interviews for the only sampled resident (Resident #4) reviewed for limitation in range of motion, the facility failed to ensure the resident's right hand splint was applied per the Occupational Therapy ( OT) recommendation, an accurate physician's order to reflect the Occupational Therapy recommendations was in place and the care plan revised to include the current OT recommendation and for the only resident reviewed for hospice (Resident #5), the facility failed to follow physician's orders to obtain weights for a resident with Congestive Heart Failure The findings include: 1. Resident #4's diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side, schizophrenia and metabolic encephalopathy. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 and required partial moderate assistance with lower body dressing, supervision with upper body dressing, hygiene, toileting, transfers, set up assistance with bed mobility, eating and had functional limitation in range of motion on one side for both upper and lower extremities. An Occupational Therapy (OT) evaluation dated 3/7/2025 identified Resident #4 will tolerate right hand splint for 2 hours with no signs of impaired skin integrity and will tolerate right hand splint per wearing schedule. A physician's order dated 5/19/2025 directed to apply right hand splint for contracture as tolerated. An OT recertification, progress note and updated therapy plan dated 6/24/2025 through 7/21/2025 identified Resident #4 expressed a desire to wear the right-hand splint on after evening care and off before morning care. An OT clarification order dated 8/11/2025 directed right hand splint on with evening care and off with morning care. An OT clarification order dated 11/4/2025 directed right hand splint at night. Observation on 12/24/2025 at 1:33 PM, Resident #4 was in the dining room without the benefit of a right-hand splint on while in the wheelchair. The Resident Care Plan dated 12/28/2025 identified resident uses appliance for daily functioning, splint: right hand splint for contracture as tolerated. Interventions included applying right hand splint for contractures as tolerated. The current physician's orders 12/2025 failed to reflect right hand splint orders or a wear schedule. Resident #4's care card identified right hand brace/splint as ordered. Interview with the DNS on 12/29/2025 at 3:15 PM indicated hand splints are not signed off when they are applied and removed anywhere in the medical record. Therapy was able to enter electronic orders in the electronic medical record, and a communication sheet was placed in the orders in the paper chart. The DNS failed to identify evidence of physician orders for the right-hand splint. She further indicated that applying and removing the hand splint would be signed off in the Medication Administration or Treatment Administration Record (MAR). The DNS was unable to explain why the medical record failed to identify a physician order for the wear schedule for the right-hand splint. Observations on 12/30/2025 at 7:55 AM and 8:20 AM identified right hand splint was on the nightstand in Resident # 4's room. Resident # 4 indicated the right-hand splint had not been worn all night. Resident # 4 further indicated that she/he tried to wear the right hand splint every day. Interview with NA # 1 on 12/30/2025 at 8:30AM identified Resident # 4 was supposed to wear the splint at night when in bed. NA # 1 indicated he did not know why Resident #4 did not wear the hand splint last night, Resident #4 may have refused to wear it. Interview with RN #2 on 12/30/2025 at 10:31 AM identified Resident # 4 was supposed to wear the right-hand splint at night. RN # 2 was unable to explain why Resident #4 did not wear the right-hand splint. After surveyor request NA #1 applied the right-hand splint to ensure the hand splint fit appropriately. Resident #4 wore the hand splint during the day once it was applied. Although requested, a facility policy for Therapy Communication, splints and adaptive equipment were not provided. 2. Resident #5's diagnoses included emphysema, congestive obstructive pulmonary disease and congestive heart failure. The physician's order dated 9/18/25 directed to obtain weights weekly x 4 weeks, on admission then monthly. The physician's order active on 9/18/25 directed to obtain a monthly weight (between 1-7 of every month). The handwritten physician/provider order sheet dated 10/3/25 located in Resident # 5's physical chart identified Resident #5 was admitted to hospice with new orders consisting of medications to manage pain and orders to discontinue laboratory and x-ray (without any note to discontinue weights when reviewed by surveyor on 12/29/25). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had a Brief Interview of Mental Status (BIMS) score of 12 indicating intact cognition and required set up with eating and substantial/maximal assistance with toileting and dressing. The Resident Care Plan dated 10/10/25 identified nutritional problems related to COPD, CHF, respiratory failure and hypertension. Interventions included providing and serving the diet as ordered and obtaining weights as ordered. A physician's visit note dated 10/21/25 at 7:52 PM identified Resident #5 had chronic diastolic heart failure, was on a low sodium diet, currently euvolemic (normal balance of blood and fluid in the body), had no shortness of breath above baseline, no chest pain or leg swelling, and will monitor weights. A physician's regulatory visit note dated 12/11/25 at 2:03 PM identified Resident #5 had chronic diastolic heart failure, was on a low sodium diet, was currently euvolemic, had no shortness of breath above baseline, no chest pain or leg swelling, and will monitor weights. A review of the Treatment Administration Record for September 2025, October 2025, November 2025 and December 2025 failed to identify recorded weights. Interview and facility record review with Nurse Aide (NA) #2 on 12/29/25 at 2:38 PM identified the facility policy was that NA's obtain weights daily, weekly or monthly as specified on the assignment sheet then record on the assignment sheet or reported to the nurse. Review of the Assignment Sheet with NA #2 identified Resident #5 was a monthly weight, NA #2 could not identify why the weights were not obtained. Interview and record review with Registered Nurse (RN) #2 on 12/29/25 at 2:47 PM identified it was facility policy to obtain weights per physician's order and then document them in the electronic health record. Review of Resident #5's electronic health record identified he/she had active orders to obtain weekly weights for 4 weeks then monthly. A review of Resident #5's weights identified the only weight taken was on 9/18/25 of 167 pounds. RN #2 could not identify why the weights were not obtained but speculated Resident #5 might have refused or because the orders were discontinued by hospice. A review of Resident #5's physical chart with RN #2, including a handwritten physician's order sheet from hospice dated 10/3/25 failed to identify a recommendation or order to discontinue weights. Additionally, RN #2 stated that since the weights were not discontinued by hospice, the physician's order should have been followed, and weights should have been obtained. (Although the paper physician/provider orders dated 10/3/25 only specified to discontinue laboratory and x-rays when it was reviewed with RN #2 on 12/29/25 at 2:47 PM, copies of the document received 12/30/25 identified weights was added at the end of the sentence in a pen thickness that did not match the rest of the sheet). Although the electronic health record weights sheet was requested multiple times the facility failed to provide a copy. Review of the Heart Failure Clinical Protocol Policy directed in part that the physician will review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights, renal function, digoxin level, etc.) to monitor, when to report to the physician. Review of the Weight Assessment and Intervention Policy directed in part that weights are obtained upon admission and at intervals established by the interdisciplinary team. Weights are recorded in each individual's medical record.

Based on observations, clinical record reviews, facility documentation, facility policy and interviews for 2 of 12 residents (Resident # 10, and Resident # 29) reviewed for smoking, the facility failed to assess for smoking quarterly and for 1 of 3 residents at risk for smoking ( Resident # 22), the facility failed to investigation an allegation of smoking non-compliance and failed to develop intervention to ensure that all smoking material given to residents on Social Leave Absence are verified and returned to nursing staff and for 1 of 4 residents reviewed for accidents ( Resident # 4), the facility failed to assess the resident after a fall, implement measure to prevent future fall and monitor the resident 72 hours post fall monitoring per facility practice . The findings include: 1. Resident #10 's diagnoses included necrotizing fasciitis, Fournier gangrene and anxiety disorder.The admission nursing assessment dated [DATE] identified smoking evaluation was incomplete.The Resident Care Plan dated 11/24/2025 failed to identify smoking in the care plan. The admission Minimum Data Set assessment dated [DATE] identified Resident #10 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and required substantial maximum assistance for lower body dressing, toileting, partial moderate assistance with upper body dressing, bed mobility, transfer, set up assistance with hygiene, independent eating and no current tobacco use.2. Resident #29's diagnosis acquired absence of left leg above the knee, neuro muscular dysfunction of the bladder and systolic congestive heart failure.The smoking evaluation dated 8/28/2025 identified Resident #29 as an everyday smoker. No additional smoking evaluations were provided or noted in the medical record.The annual Minimum Data Set assessment dated [DATE] identified Resident #29 as moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 11 and required partial moderate assistance with hygiene, supervision with transfer, toileting, set up assistance with eating, independent with bed mobility and current tobacco use.The Resident Care Plan revision dated 12/12/2025 identified Resident #29 has been assessed as a safe supervised smoker while in the facility. Interventions including all smoking materials will be stored in a secure location and will be escorted 3 times a day for the opportunity to smoke with supervision to ensure safety.Observation of smoking on 12/24/2025 at 11:11AM with 7 residents present, (Resident # 9, Resident #10, Resident #15, Resident #17, Resident #20, Resident #22, and Resident #29) were observed smoking accompanied by RN #2, NA #3, NA #4 and Front desk #2. Each resident was given 1 cigarette and was lit by Front desk #2. Observed all residents were able to smoke independently and extinguish smoking material in the self-extinguishing ashtray.Interview and clinical record review with Director of Nursing Services (DNS) on 12/29/25 at 10:52AM identified the smoking assessment and care plan were completed by the MDS Coordinator and the admission nurse, moving forward it will be completed by nursing. The smoking assessments were completed upon admission, quarterly and with any changes. The care plan was updated with the care plan schedule. All of the smoking residents should have an assessment and should follow the MDS schedule, and the schedule should alert that an assessment was due under the Point Click Care (PCC) software assessments. Resident # 10 was identified on the admission assessment that she/he was a smoker and Resident # 29 did not have a current quarterly smoking assessment. The DNS could not explain why the medical record failed to reflect current smoking assessments or care plan.3. Resident # 22's diagnosis included bipolar disorder, anxiety disorder and diabetes.The quarterly Minimum Data Set assessment dated [DATE] identified Resident # 22 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and was independent with hygiene, dressing, bed mobility, transfers and eating.A nurse's note dated 8/1/2025 identified Resident #22 was previously on social leave of absence (SLOA) and due to repeated safety concerns Resident #22 was no longer permitted to leave. Resident #22 continued to fail to abide by smoking safely outside of the building. In addition, Resident #22 had given money away to others on multiple occasions despite prior education regarding financial safety, continued to smoke in room against facility policy and to hide smoking paraphernalia creating a significant fire risk. This behavior presents a danger to self and others particularly due to the presence of oxygen use by other residents within the building. Resident #22 was reeducated regarding facility smoking policy, safety regulations and risk associated with noncompliance. Interdisciplinary (IDT) team notified Resident #22 required staff supervision for all smoking activities and will only be permitted by SLOA with responsible party. On going monitoring continued and psych eval requested.A review of the Accident Incident report dated 8/1/2025 at 3:12 PM identified Resident # 22 had given money away to others to buy cigarettes, then accused the individual of taking money. The camera was checked and observed smoking in room against policy. Investigation contained statement by DNS, that staff called her because they found a lighter on the resident and had concerns about Resident # 22 in other residents' rooms. Camera checked and observed Resident #22 requested another resident buy cigarettes. No other witness statements or interviews provided.A nurse's note dated 8/13/2025 at 10:42 AM identified Resident #22 smoking status and safety awareness was discussed during the Interdisciplinary Team (IDT) meeting. Resident #22 received ongoing education regarding facility smoking policies and the fire safety procedures including the appropriate use and storage of lighters. Resident # 22 verbalized understanding of these safety guidelines and demonstrated the ability to articulate associated skills.A Nurse's note dated 8/13/2025 at 2:55 PM identified Resident # 22 was reported by security and other staff to have attempted to give money to individuals outside the building while requesting marijuana. When approached by nursing staff to discuss the incident, Resident # 22 stated I am weak. Nursing staff reviewed safety concerns with resident, including previously agreed upon safety protocols. Resident # 22 failed to adhere to these protocols during the incident. Due to ongoing safety concerns Resident # 22 will be restricted to supervised smoking and supervised leave of absences at this time.A review of the Accident Incident report dated 8/13/2025 identified Resident # 22 requested cigarette money for cigarettes from others and due to behavior concerns of giving money, Resident #22 agreed for safety to be a supervised smoker. No investigation or witness statements identified. Monitor by psychiatry and behavior contract.A behavioral contract dated 9/19/25 was issued in response to repeated violations of facility policy during independent social leave of absence. Resident # 22 had engaged in behaviors on multiple occasions: bringing drug paraphernalia and smoking related items into the facility, violating the facility's smoking policy, soliciting or distributing money to other residents and harassing or intimidating others before or after LOA. Resident # 22 agreed to no contraband, smoking policy compliance, respectful conduct and safe return protocol. The failure to comply with the agreement may result in suspension or revocation of independent SLOA privileges, implementation of supervised LOA, Involvement of the interdisciplinary team to reassess care plan and notification of appropriate authorities if illegal activity suspected. This was signed by Resident # 22.The Resident Care Plan dated revised 11/28/2025 identified socially inappropriate behavior as evidenced by asking for money from another resident, knocking on doors asking for cigarettes, not complying with smoking policy, (bringing a lighter to room, smoking in room) false accusations towards other residents and staff. Interventions included all staff to deal with resident consistently, assess resident's understanding of situation, may not go on independent leave of absence for safety, set goals with resident for appropriate behavior. The Resident Care Plan identified history of non-compliance with safety. Interventions included consulting with social services as needed, emphasizing positive aspects of compliance. The Resident Care Plan identified as a safe supervised smoker- may not go on independent smoking due to safety. Interventions included ensure that the resident and responsible party are made aware of the facility smoking policy, all smoking materials will be stored in a secure location, ensure smoking occurs in designated smoking areas, ensure that no oxygen is located in the smoking area while the resident is smoking, no smoking materials or igniter's will be stored in the resident rooms, resident will be escorted 3 times a day for opportunity to smoke with supervision to ensure safety.A Late Entry Note dated 12/21/2025 identified Resident # 22 returned from a supervised LOA. During this writer's medication pass, Resident # 22 was observed standing near the doorway of her/his room holding a cigarette and lighter. Items were immediately confiscated by this writer. Resident # 22 educated on the facility's smoking policy and safety risks. Resident # 22 verbalized understanding and agreed to a room search. A room search was conducted by 2 staff members, and no additional contraband was noted. The Director of Nursing (DNS) and Advanced Practice Nurse Practitioner (APRN) were notified, no new orders at this time.A nurse's note dated 12/22/2025 identified Resident # 22 continued to demonstrate noncompliance with the facility smoking policy. Over the weekend, the staff observed the resident smoking in her/his room and found smoking paraphernalia present, Resident #22 was reeducated regarding the facility's non-smoking policy within resident rooms and the significant safety risks posed to him/herself and others, particularly due to the presence of oxygen use within the building. Resident # 22 verbalized understanding of the safety concerns. Resident # 22 was reminded that per the facility policy and Centers for Medicare Medicaid Services (CMS) safety guidelines, continued violation of smoking rules may result in loss of supervised smoking privileges in order to maintain a safe environment for all residents and staff. Resident # 22 again verbalized understanding and agreement with the information provided. Will reinforce safety education and ensure adherence to facility policy.In an interview and clinical record review with the Director of Nursing Services (DNS) on 12/23/2025 at 1:49 PM regarding the smoking incident that occurred on 12/21/25. The DNS indicated Resident #22 did not actually light the cigarette but was going to when the medication nurse saw the resident and stopped Resident # 22. The medical record failed to accurately reflect the incident described. The DNS indicated that she wrote a note on 12/22/2025 but the staff called her on 12/21/2025 regarding the incident. Late entry nurse's notes were added to the medical record to indicate the incident that occurred on 12/21/2025. The DNS further indicated that the smoking materials were confiscated from Resident # 22 and Resident # 22 must have obtained a lighter when she was out on SLOA. The late Entry note indicated Resident # 22 consented to a room search by 2 staff members and no other smoking materials were found.An interview on 12/24/2025 at 11:20 AM with Licensed Practical Nurse (LPN # 2) identified that she was the charge nurse on the day Resident #22 had a lighter and cigarette in her/his possession in the room. LPN # 2 had difficulty recalling the events but thinks that Resident #22 went out with family and returned and staff smelled cigarette smoke on Resident # 22. Resident #22 was allowed to smoke with family and was given 2 cigarettes by security to take out. LPN #2 had the medication cart and moved it in front of Resident #22's room when LPN #2 noticed a cigarette aroma, it could have been from smoking prior when LPN #2 noticed a lighter. LPN # 2 told the DNS and Resident #22 agreed to a noninvasive search. No cigarettes or cigarette butts were found. There was no evidence that Resident #22 was actually smoking.In an interview and clinical record review with the DNS on 12/24/2025 at 1:05 PM, the clinical record failed to reflect documentation of an investigation for the smoking incident on 8/1/2025 or for 8/13/2025. Interview and review of logbooks on 12/29/2025 at 12:21 PM with Front desk #1 indicated that smoking materials including lighters are tracked by the front desk/security personnel by utilizing a logbook that indicates how many cigarettes and lighters were given out to residents going out. The lighters are not always written down in the book but sometimes verbally told to the staff. Security is on duty 24 hours /7 days a week. There is no policy on giving out and receiving back lighters. Front desk #1 was unable to explain how a staff member would know if a lighter was given out to a resident to look to receive it back when they returned. Review of the smoking policy revised 2025 directed, in part, prior to and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas and the extent to which the facility can accommodate their smoking or no smoking preferences. Smoking is only permitted in designated smoking areas which are located outside the building. Smoking is not allowed inside the facility under any circumstance. The resident will be evaluated on admission to determine if he/she is a smoker or non-smoker. If a smoker, the evaluation will include current level of tobacco consumption, method of tobacco consumption, desire to quit smoking and ability to smoke safely per a completed smoking evaluation. The staff shall consult with the attending physician and the Director of Nursing Services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the safe smoking evaluation. A resident's ability to smoke safely will be re-evaluated quarterly, upon significant change and as determined by the staff. Any smoking-related privileges, restrictions and concerns shall be noted in the care plan and all personnel caring for the resident shall be alerted to these issues. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. Residents are not permitted to give smoking articles to other residents. Only designated staff members and volunteer workers are permitted to purchase or provide any smoking articles for residents. All smoking materials will be held at the facility's security office and distributed to residents in accordance with their care plan and supervision requirements. The facility maintains the right to confiscate smoking articles found in violation of our smoking policies. Confiscated property will be itemized and ultimately returned to the resident, or legal representative. When the property is returned it will be determined during a meeting with the resident or representative regarding the circumstance that led to the confiscation.Review of the Accident and Incidents-investigating and reporting policy dated 2025 directed, in part, all accidents or incidents involving residents occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/charge nurse and department director or supervisor shall promptly initiate and document investigation of the accident or incident. The policy failed to identify when an Accident Incident is reportable to the state agency.4. a. Resident #4's diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side, schizophrenia and metabolic encephalopathy.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 and required partial moderate assistance with lower body dressing, supervision with upper body dressing, hygiene, toileting, transfers, set up assistance with bed mobility, eating and had 2 falls without injury and 1 fall with a major injury.The Resident Care Plan revised 12/28/2025 identified a fall on 1/15/2025, 2/16/2025, 2/26/2025, unwitnessed fall 3/10/2025, witnessed falls 4/13/2025, fall 5/23/2025 and unwitnessed fall 8/20/2025. Interventions included to continue interventions on the at risk plan, determine and address causative factors of the fall, frequent rounding, grabber bar for reaching items on floor away from resident, reminder to lock wheelchair, gripper socks to prevent slipping, monitor and document, report to physician as needed for 72 hours for signs or symptoms of pain, bruises, changes in mental status, new onset of confusion, sleepiness, inability to maintain posture or agitation, neuro checks for 72 hours, physical therapy consult for strength and mobility, redirection on self-release positioning belt, remind to ask for assistance with toileting and transfers, offer to move to a room closer to the nurses station for frequent monitoring, send to the emergency room for evaluation, staff to allow resident to pick out outfit for the next day prior to assisting to bed, x-ray to right shoulder, knees, hip, x- rays to shoulder humerus and clavicle.A physician's order dated 1/1/2025 through 5/5/2025 directed to assist with 1 staff for transfer to adaptive wheelchair with Roho cushion per positioning plan, independent mobility and repositioning with wheelchair. Assist of 1 staff with transfer to adaptive wheelchair and ambulation with hemi walker as tolerated.An Accident Incident report dated 1/15/2025 at 5:30PM identified Resident # 4 noted to be in a sitting position in front of the wheelchair and denies hitting head.A nurse's note dated 1/15/2025 at 9:46 PM identified Resident #4 was alert, verbal, oriented with garbled speech at baseline and was able to make needs known. Resident #4 was noted in a seated position in front of the wheelchair when asked what happened, Resident #4 stated s/he slid from wheelchair. Neurological checks initiated and within normal limits. Resident # 4 assessed by RN supervisor then assisted back to bed. Reminded of transfer status and urged to call for assistance for transfers. Resident #4 stated understanding, had been compliant thus far without visible injury noted, and denied pain or discomfort. At this time message left for conservator of person, awaiting return call for update. Call bell within reach.The Resident Care Plan failed to indicate a new intervention after the fall to prevent future falls.An Accident Incident report dated 2/26/2025 at 7:00PM identified Resident #4 was found on the right side of bed lying on the right side. Complaint of right sided pain. Right hip, shoulder and knee x-ray ordered.A nurse's note dated 2/26/2025 at 11:06 PM identified Resident #4 had an unwitnessed fall, the on-duty LPN for 3:00PM - 11:00PM shift notified RN supervisor Resident #4 was observed on the floor next to the wheelchair. Resident #4 did not say how they fell, RN assessment done, Range of Motion within normal limits, positive movement to left side of body. Hemiplegia and hemiparesis following cerebral infarction affected right dominant side, denied hitting head, no cuts, bruises or lacerations noted. Conservator and Advanced Practice Registered Nurse (APRN) notified. Resident #4 made complaints of pain on right side. x-ray ordered.The Resident Care Plan failed to indicate a new intervention after the fall to prevent future falls.An Accident Incident report dated 4/13/2025 at 8:00AM indicated Resident #4 was washing, tried to move his/her chair, did not lock it and slipped out while reaching for something. No injuries.A nurse's note dated 4/13/2025 at 3:44 PM indicated Resident # 4 was pleasant and alert. Upon entering Resident #4's room, s/he was noted to be washing and reached for an item on the bed and slipped out of the wheelchair because it was not locked. No injuries noted. APRN notified, conservator notified, message left, incident report completed as well as a screen for PT to eval on Monday.The medical record failed to identify evidence of an RN assessment after the fall.b. An Accident incident report dated 5/23/2025 at 10:00PM identified Resident #4 was found in a seated position on the right side of the bed.A nurse's note dated 5/23/2025 at 11:19 PM indicated the nurse was alerted to Resident #4's room by staff, upon arrival noted Resident # 4 in a seated position on the right side of bed. Resident #4 stated s/he was trying to get in bed from the wheelchair. Vital signs were stable, neurological checks initiated immediately and without deficit. No visible injury but facial grimacing noted when moving right leg. Refusing pain management at this time, assisted back to bed by staff. Gripper socks in place. Encouraged to call for assistance as needed and has been compliant thus far. Nurse Practitioner made aware with no new orders. A message left for conservator to call the facility for update. Awaiting return call. No complaints at this time, no distress noted, call light within reach. Safety maintained.The medical record failed to identify evidence of an RN assessment, and a 72 hour follow up nurse's note after the fall.Interview and record review with the DNS on 12/29/2025 at 3:15PM identified an RN assessment was to be completed after every fall and interventions were to be in place in the care plan to prevent future falls if there were interventions that could be put in place as well as follow up notes for 72 hours after a fall. The DNS failed to identify in the medical record new interventions in the plan of care for Resident #4 for the falls on 1/15/2025 and 2/26/2025. Additionally, the DNS could not identify in the medical record an RN assessment was completed and documented after the 4/13/2025 and 5/23/2025 falls or a 72 hour follow up note for the 5/23/2025 fall. The DNS indicated she did not know why this was not documented. The nursing staff were responsible for completing this documentation.Review of the Accident and Incidents-investigating and reporting policy dated 2025 directed, in part, all accidents or incidents involving residents occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/charge nurse and department director or supervisor shall promptly initiate and document investigation of the accident or incident.Review of Falls and Fall risk Managing policy dated 2001 directed, in part, if a resident continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling, instead of or in addition to those that have already been identified and also reconsider the current interventions. As needed and after an appropriately thorough review, the physician will document any uncorrectable risk factors and underlying causes.

Based on review of the clinical record, facility documentation, and interviews for 1 of 2 residents (Resident #23) reviewed for bladder and bowel incontinence, the facility failed to ensure Resident #23 was started on a bladder retraining program. The findings included: Resident #23 was admitted in October 2025 for short term rehabilitation with diagnoses that included a new cerebral infarction (stroke) with left side weakness, adjustment disorder with depressed mood, and cognitive communication deficit. The admission Minimum Data Set assessment dated [DATE] identified Resident #23 with a Brief Interview for Mental Status score of 15 indicating cognitively intact and required moderate assistance with toileting transfers, was frequently incontinent, and not on a urinary toileting trail plan. Resident #23's Bladder and Bowel Screener assessment dated [DATE] identified Resident #23 as a good candidate for bladder retraining program.The Care Plan dated 11/20/25 identified occasional bladder incontinence. Interventions included establishing voiding patterns, checking for incontinence every 2 hours, and monitoring for signs and symptoms of a urinary tract infection and reporting to physicians. The care plan failed to reflect a bladder retraining program for Resident #23. The physician's orders dated 12/9/25 identified Resident #23 was independent with toileting.Interview with Resident #23 on 12/23/25 at 11:10AM identified that he/she had a recent decline in urinary function and did not have good control of urine since having a stroke.A three-day voiding pattern assessment tool reviewed on 12/24/25 dated 10/28/25-10/30/25 revealed that out of 35 voiding occurrences, Resident #23 was very wet with urine 20 times, a little wet with urine 15 times and no episodes of being dry. Interview with LPN #1 on 12/24/25 at 11:20AM identified she was unaware of any bladder retraining for Resident #23 and that she believed that therapy would be responsible for doing bladder retraining. Furthermore, she indicated that she could not locate any bladder retraining documentation for Resident #23 and nursing did not perform bladder retraining with Resident #23. LPN #1 stated she was unaware of the facility policy related to bladder retraining and who exactly is responsible for ensuring it is completed once a bladder incontinence assessment is completed determining a resident is good candidate for bladder retraining. Interview with the Occupational Therapist (OT #1) identified therapy does not perform any bladder retraining and it would be nursing that is responsible for completing any bladder retraining for Resident #23. OT #1 indicated that therapy worked Resident #23 regarding transferring on and off the toilet and managing incontinence independently to prepare for discharge home.Although requested a policy on bladder retraining was not provided.The policy Urinary Continence and Incontinence- Assessment and Management dated 2001, directed, in part, as a part of the initial and ongoing assessment, the nursing staff and physician will screen for information related to urinary continence. Examples of sources of such information may include the resident, family or a hospital discharge summary. Relevant information related to urinary continence includes history of urinary incontinence including signs and symptoms, pertinent diagnoses, and previous treatment management attempts and responses to interventions.

Based on observation and interview, the facility failed to ensure the facility daily census and staffing data was posted with complete staffing for the upcoming 24-hour period and posted in a location easily visible to residents and visitors. The findings include: On 12/24/2025 at 1:02 PM an observation and interview with the front desk supervisor, Security/ Front Desk #1 and the security officer, Security/ Front Desk #2 pointed out the daily facility census and staffing located to the far right on the top shelf in a tall, closed glass cabinet (display case). Security/Front desk #2 indicated security staff fill out the form after verifying each staff member had arrived to work for the shift. She/he further indicated there was no policy or procedure they were told by the administrator to ensure the form was accurate. Security/Front desk #2 indicated security staff are on duty 24-hours and staffing for each shift is completed by the person on duty, and prior daily sheets were in a binder behind the security reception desk. Review of the binder found prior 24-hour census staffing sheets completed for all 3 shifts (24 hours total). An interview and observation with the Administrator and the Administrator in training on 12/30/2025 at 11:08 AM identified the daily census staffing sheet located in the same place on the top shelf of the display cabinet with only the 7-3 PM shift staffing and the daily census data. The Administrator in training indicated the 11-7 AM shift was responsible for completing the form for the 24 hours. The Administrator indicated the way it was being completed was more accurate than posting the full 24 hours at a time. The Administrator further indicated she/he understands having shifts blank did not allow visitors and residents to know the expected staffing for 24 hours. Further observation on the skilled nursing unit with the Administrator and administrator in training identified no posting of the daily census and staffing allowing residents on the unit easy access to the data especially if they were unable to leave the unit. The administrator provided a form labeled Proper way to fill out a daily census log for the display case on 12/30/2025 at 1:50 PM indicating the security/front desk #1 provided the form to the security staff. No facility policy and procedure was provided.

Based on a review of the facility Infection Control Program and staff interviews, the facility failed to ensure the Infection Prevention and Control Nurse received a specialized training certificate. The findings include: Interview with the Director of Nurses Services (DNS) on 12/29/25 at 11:04 AM identified the Infection Prevention nurse was on vacation and she was currently covering for him from time to time even though she herself does not hold a certificate. Additionally, the DNS identified the Infection Prevention nurse started working at the facility on 4/25/22 and conveyed to her he had completed the Centers for Disease Control (CDC) training. However, the DNS at time did not have the certificate on hand but indicated she would obtain the certificate. Additional attempts to obtain a copy of the specialized training Infection Control certificate for the Infection Control nurse were made on initial entrance to the facility on [DATE] at 9:30 AM, during the review of the Infection Control task on 12/29/25 at 10:30 AM, on 12/30/25 at 12:04 PM prior to exciting the facility, and again on 12/31/25 at 10:35 AM, but were unsuccessful.

Based on clinical record review, facility documentation, and staff interview for three of three residents (Resident #1, Resident #2, Resident #3) reviewed for accidents, the facility failed to ensure the approved LOA list was checked prior to allowing a resident to sign out on a Leave of Absence. The findings include: Resident #1 was admitted during June 2024 with diagnoses of schizophrenia, antisocial personality disorder, and psychoactive substance abuse. An admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 was alert and oriented, independent with care and transfers, and had no wandering behavior exhibited. The Resident Care Plan (RCP) dated 7/22/2024 identified Resident #1 was at risk for falls and uses psychoactive medication. Interventions include call bell within reach and monitor side effects and adverse reactions to medications. Record review identified Resident #1 had a court appointed Conservator of Person (COP). Additional review identified Resident #1 had no orders for Leave of Absence (LOA) from the facility. Facility incident report dated 8/21/2024 at 11 PM identified Resident #1 was independent with mobility with rolling walking and with a wheelchair, signed him/herself out of the facility at 9:30 PM and did not return. The facility contacted Resident #1 who reported that he/she was on the city Green, the local police, COP, and APRN were notified. Review of the Release of Responsibility for Leave of Absence identified Resident #1 left the faciity on 8/21/2024 at 9:28 PM. The nursing note dated 8/22/2024 at 12:54 AM identified the evening nurse attempted to locate Resident #1, was unable to find him/her and identified Resident #1 had left the building. Resident #1 was contacted on his/her cell phone and he/she reported to be safe on the city Green. The nursing note dated 8/22/2024 at 11 AM identified Resident #1 returned to the facility at 8:20 AM. Interview with Security Guard #1 on 9/11/2024 at 12:05 PM identified when he signed Resident #1 out on the LOA on 8/21/2024, he did not check the LOA book to see if the resident was allowed LOA privileges. Interview failed to identify why Security Guard #1 did not verify LOA privileges prior to allowing Resident #1 leave the facility, or why he did not contact the nurse. Interview with the DNS on 9/11/24 at 12:40 PM identified although Resident #1 should have had LOA privileges, there was no order for LOAs. The DNS stated the security guard should have verified the resident's LOA status prior to allowing Resident #1 to leave the facility.

Based on clinical record review, and interviews for one sample resident (Resident #22) who was admitted to the facility within the past six months, the facility failed to ensure physician's orders were signed and dated in a timely manner The findings include: Resident #22's diagnoses included Kaposi's sarcoma, malnutrition, neoplasm related pain, anemia, and depression. The admission MDS assessment dated [DATE] identified Resident #22 was admitted to the facility on [DATE], was without cognitive deficits, required extensive assistance with bed mobility, toileting, hygiene, transfers and was non-ambulatory. Review of the physician's orders from January/2024 through 6/4/24 identified the physician's orders were not signed and/or dated for that period of time. The admission orders should have been signed and then the orders should have been renewed every thirty days for ninety days and then renewed every sixty days thereafter. Interview with the DNS on 6/4/24 at 10:00 AM identified the physician's orders should be signed on admission and renewed every 60 days for resident with Medicaid as the payor source. She identified that she thought the provider was signing the physician's orders after reviewing them. She further identified that all physicians will be educated on signing the physician orders electronically. Interview with APRN #1 on 6/5/24 at 10:00 AM identified that he was reviewing the physician's orders, but he was not signing the physician's orders because he did not have access to the electronic health record system allowing him to sign the physician's orders electronically. Subsequent to surveyor inquiry, he was given access permitting him to be able to sign the physician's orders electronically The Physician Visit policy identified that the attending physician must make the visits in accordance with applicable state and federal regulations. Non-physician practitioners may perform required visits (initial and follow-up), sign orders and sign certification/re-certifications as permitted by state and federal regulations.

Based on observations, review of facility policy and interviews, the facility failed to ensure foods were dated and labeled appropriately, discard expired foods, and utilize hygienic practices during the handling of prepared food. The findings include: Observations with the Food Service Manager on [DATE] at 2:45 PM identified the reach-in refrigerator contained the following food items that were covered in plastic wrap but were undated and unlabeled: Two peanut butter and jelly sandwiches A round dough like substance A salami sandwich Three eggs in a bowl A plate containing chicken and roasted potatoes A chicken salad sandwich A pan containing mixed vegetables and ground beef A metal bin containing yellow colored rice in a metal bin Scrambled eggs in a white bowl Shredded cheese in a plastic bin A metal bin containing cooked ziti Thirteen containers of individual servings of sour cream and salsa Interview with the Food Service Manager on [DATE] at 3:00 PM regarding the undated and unlabeled food items identified that the date of preparation or the date of expiration of the identified food items was not identified. He noted that all prepared food should be labeled when it is prepared and kept for no more than three days from the preparation date. Food that is not prepared but removed from another container should be labeled with the original expiration date. The Food Service Manager identified that he did not know why the staff had not labeled or dated any of the food items. Observation on [DATE] at 3:02 PM with the Food Service Supervisor identified the following in the walk-in freezer: Hot Dog/Sausage type meat opened and wrapped in saran wrap with no date label affixed Metal rectangular pan covered with foil labeled with black marker Sheperd's Pie [DATE] Onion rings with no date/label in a plastic bag open to air Noodles frozen in a bag with no date/label 3 bags of alfredo sauce in a box with one pouch opened with a best by date labeled on the box of [DATE] 3 loaves of French bread wrapped in saran wrap with no date/label 2 boxes of veal/beef patties open to air with date of best by [DATE] Pepperoni in a box open to air with a received-on date of [DATE] Mini quiches in a box open to air with a [DATE] received on date on the label A box of French fries containing two bags open to air with no date/label 1 bag of meatballs opened in a plastic bag with a knot tied at the top no date/label A whole cooked turkey wrapped in saran wrap with a cooked date of [DATE] and a use by date of [DATE] Three bags of guacamole with a use by date of [DATE] A box of crab cakes with a received date of [DATE] with an open to air plastic bag inside Sweet potato pie wrapped in saran wrap with no date/label Peach pie wrapped in saran wrap with no date/label Hash browns in a plastic bag open to air with no date/label affixed Gluten free rolls in a plastic bag with no date/label affixed Interview with the Food Service Manager on [DATE] at 3:22 PM identified he would throw away all of the opened to air and undated food items. He also identified that the items in the freezer should be labeled when opened and would be good for 6 months then they should be thrown out and noted it was his responsibility or anyone who sees the items to throw them away if they are past their expiration date or have been in the freezer over 6 months. Observation on [DATE] at 3:25 PM with the Food Service Manager identified the following outdated and/or undated food items in the dry storage area: Ranch dressing mix with no date/label affixed A box of Rituals Orange pekoe black tea in a box labeled best by [DATE] A box of Rituals Orange pekoe black tea in a box labeled best by [DATE] 2 individual serving boxes of Scooter cereal with a best by date of [DATE] 2 bags of marshmallows without an expiration/use by date and/or a date received 2 large cans of ravioli with a black marker dated ,d+[DATE] (no year identified) and no expiration date noted Interview with the Food Service Manager on [DATE] at 3:38 PM identified the expired items in the dry storage should have been thrown out, which he proceeded to do. He further noted that once items are received, he tries to complete a rotation with the food and believes the expired ravioli cans came from the emergency supply that he was trying to rotate into use. Observation on [DATE] at 3:40 PM with the Food Service Manager of the walk-in refrigerator identified the following undated and/or unlabeled food items: A ham sandwich Seven small bowls of apple crisp covered in plastic wrap Thee muffins wrapped in plastic wrap A lunch bag with the letters R.C. on it with a metal drink bottle next to it Interview with the Food Service Manager on [DATE] at 3:52 PM identified the items in the walk-in refrigerator should have a label identifying the date of preparation, and within three days of the preparation date. He further noted that staff lunch boxes should not be stored in the refrigerator, and indicated there was a refrigerator available for the staff to utilize. Observation of the tray line/food preparation on [DATE] at 12:20 PM identified that during the process of transferring green beans from a cooking tray to a metal bin Dietary Aide #1 without the benefit of gloves, used his hand to guide the green beans into the metal bin. Interview with the Food Service Manager on [DATE] at 12:30 PM identified that Dietary Aide #1 should have not touched the food with his bare hands and should have donned gloves. Review of the Food Receiving and Storage policy directed that refrigerated and frozen foods stored in the refrigerator or freezer should be covered, labeled, and dated (use by date). Dry foods that are stored in bins are removed from original packaging, labeled, and dated (use by date). Review of the Food Preparation and Service Policy directed that during food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single use items and are discarded after each use.

Based on observations, review of facility policy and interviews for one of eight sampled residents (Resident #8) observed for dining, the facility failed to provide a dignified dining experience. The finding includes: Resident #8's diagnoses included muscle weakness (generalized), contracture of the left hand, and unspecified abnormal involuntary movements. The quarterly MDS assessment dated [DATE] identified Resident #8 had severely impaired cognition and was dependent for eating, oral hygiene, toileting, bathing and dressing. Resident #8's care plan dated 5/15/24 identified an ADL (activities of daily living) self-care performance deficit and noted the resident required extensive to total assist related to impaired balance, limited mobility, and limited range of motion. Care plan interventions directed: supervise and feed as tolerated, sit upright at a 90-degree angle with eating and drinking, encourage small bites, assist with all meals (total feed). Observation of the lunch meal on 6/4/24 at 12:57 PM identified two of the three residents at a dining table in the main dining area were served their meals. At 1:00 PM, Resident #8 was served his/her meal. The two other residents at the table were eating while Resident #8's meal remained in front of him/her with the cover in place over the plate. At 1:12 PM NA#1 came over to Resident #8 to assist with feeding the resident. NA#1 stood to the left side of Resident #8 and fed him/her lunch, the discrepancy. Interview with the Administrator on 6/4/24 at 1:25 PM identified that NA#1 should be seated while feeding Resident #8. The Administrator then approached NA#1 and instructed NA #1 to sit down. Once seated NA#1 was able to assist Resident #8 with the remainder of the meal. Interview with NA #1 on 6/4/24 at 1:32 PM identified she was aware that she should be seated while feeding residents; however, she found it more difficult due to her being short and the resident being tall. She further identified that Resident #8 is usually in bed for lunch. The facility did not have a policy regarding the practice of having the nurse aides sit down while providing assistance during dining. A training on customer service in the dining room was received and it identified that eye contact should be maintained during the dining experience.

Based on observations, review of facility policy, and interviews for two sampled residents (Resident #17 and Resident #26) reviewed for positioning and range of motion (ROM), the facility failed to ensure that the use of an assistive device was included in the comprehensive care plan. The findings included: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus without complications, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, chronic pain syndrome, blindness of the right eye. The quarterly MDS assessment dated [DATE] identified Resident #17 had moderately impaired cognition, was dependent with toilet transfers and chair to bed or chair to chair transfers and required maximum assistance for upper and lower body dressing. The assessment further identified a functional limitation in range of motion to one side of both the upper and lower extremities. The care plan dated 3/13/2024 identified Resident #17 required assistive devices for mobility and identified the resident used a custom wheelchair. Additionally, the care plan identified the resident used a bed rail to assist themselves with ADLs. The physician's orders dated 5/10/2024 identified orders for a physical therapy evaluation and treatment 3 to 5 times weekly for therapeutic exercises, therapeutic activities, neurology re-education, and gait training, occupational therapy evaluation and treatment as indicated 3 to 5 times per week for 8 weeks to include bilateral upper extremities, and self-care training. Observation on 6/4/2024 at 1:11 PM identified Resident #17 in the dining room, seated in the wheelchair feeding himself/herself lunch. He/she had a sling on the left arm. Interview with the Therapy Director on 6/5/2024 at 9:56 AM identified Resident #17 was last evaluated on 5/26/24 when the resident returned from a hospitalization . PT and OT services continued once the resident was readmitted to the facility. The Therapy Director further identified that Resident #17 previously had an order for a sling but when he/she returned from the hospital the sling order was not reordered. She further noted that the occupational therapist must have missed it on her evaluation. Additionally, she noted that she had the MDS Coordinator add the orders and update the care plan to include the use of the sling. Interview with the DNS and Administrator on 6/5/2024 at 2:38 PM identified that when a resident utilizes a sling, they would expect the care plan to include the use and the care involved with regards to the use of the sling. They did not identify whether or not there needed to be a physician's order in place when there is a splint in place. Subsequent to surveyor inquiry, Resident #17's care plan was updated to reflect that he/she prefers to wear the left upper arm sling while out of bed with the exclusion of showers, as tolerated for comfort. 2. Resident #26 was admitted to the facility in March of 2024 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness, and dysarthria and anarthria. The physician's orders dated 5/23/2024 directed for a right AFO (ankle foot orthosis) on as tolerated when getting out of bed every day and evening shift. Resident #26's care plan dated 4/4/2024 identified the use of a bed rail to assist with ADLs. The Admission MDS assessment dated [DATE] identified Resident #26 had severe cognitive deficit, required substantial to maximal assistance with lower body dressing and partial to moderate assistance with upper body dressing, chair to bed transfers, and toilet transfers. Observation on 6/3/24 at 4:26 PM identified Resident #26 had an ill-fitting blue and white colored sling on the right upper extremity. The right arm appeared contracted. Observation on 06/04/24 at 1:12 PM identified Resident #26 eating lunch in the dining room with a sling on the right arm. Interview with the Therapy Director on 6/4/24 at 1:35 identified Resident #26 had been using a right leg AFO and a sling to the right arm. The Therapy Director identified that there should be a physician's order for the sling and the use of the sling should be included in the resident's care plan. She further noted she was not sure if the sling was considered a splint and uncertain if the sling should have an order. Interview with the Therapy Director on 6/5/24 at 9:56 AM identified Resident #26 did not have a sling in place when he/she was admitted to the facility. The Therapy Director further identified that she had applied the sling to the right arm during therapy because the arm was in the way and Resident #26 conveyed that the sling felt good, and it had been utilized since that time. Additionally, the Therapy Director identified she had not notified occupational therapy and the use of the sling had not been assessed. She further identified that the use of the sling had not been incorporated into the resident's plan of care. Observation of Resident #17 on 6/5/24 at 1:11 PM identified the resident had a sling to the right arm while feeding himself/herself with the left arm. Interview with the DNS and the Administrator on 6/5/24 at 2:38 PM identified that when a resident utilizes a sling, the expectation would be that the use of the sling be addressed in the plan of care. Subsequent to surveyor inquiry, the use of the sling was added to the care plan with an intervention that it be utilized as tolerated for comfort when out of bed on 6/5/24. Interview with the MDS Coordinator on 6/5/24 at 11:02 AM identified the Therapy Director gave her a list of residents that needed to have updated orders. The MDS Coordinator identified that usually, for therapy orders, the therapists put them into the paper chart and flags the doctor and then the doctor signs the orders. The MDS Coordinator identified that when the Therapy Director tells her to add the orders, she doesn't contact the doctor. She identified that the residents have been evaluated, she assumed the orders are signed, and she just put the orders in. Interview with APRN #1 on 6/5/ 24 at 11:16 AM identified she considered a sling a splint that the resident should be assessed for and should have a provider order in place if utilized. She further noted that she usually would order the sling per therapy's specifications. Interview with the DNS on 6/5/24 at 1:45 PM regarding splinting and sling placement identified that the expectation for appliance use should be in the care plan in order to direct the plan of care. Additionally, if it is something that the CNA's or nurses should apply, then it should be included in the TAR (treatment administration record) so it can be marked off. Review of the Care Plans, Comprehensive Person-Centered policy identified that a comprehensive, person-centered care plan that included measurable objectives and timetables to meet a resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the facility assessment identified that the facility focuses on person centered care; all needs are met on an individual basis according to their individual preferences. Care plans are developed upon admission and updated as necessary.

Based on review of the clinical records, review of facility documentation, review of facility policy, and interviews for two of five sampled residents (Resident #2 and Resident #5) reviewed for unnecessary medication, the facility failed to ensure that physician's orders were transcribed and accurately implemented. The findings include: Resident #2's diagnoses included disorder of the immune mechanism, bipolar, type 2 diabetes mellitus, end stage renal disease, depression, and congestive heart failure. The admission MDS assessment dated [DATE] identified Resident #2 had moderately impaired cognition, required moderate assistance with personal hygiene and positioning, required maximal assistance with transfers, and utilized antipsychotic (for managing mental health disorders) medication that the assessment noted to be a high-risk medication. The care plan dated 4/1/24 identified Resident #2 used psychoactive medication with interventions that included administer medication as ordered, monitor, record, report to MD side effects and adverse reaction of the psychoactive medications such as unsteady gait, shuffling gait, and ridged muscles shaking (tardive dyskinesia). Review of physician's orders from April/2024 through June 6, 2024, directed to administer Lurasidone/Latuda 60 milligrams (mg) one tablet by mouth once daily for bipolar disorder. According to Latuda.com, the use of the medication may cause serious side effects such as a decrease in blood pressure (orthostatic hypotension). The Psychiatric Nurse Practitioner's (APRN #2) order dated 4/7/24 directed orthostatic blood pressures once weekly times four weeks. Review of Resident #2's clinical record failed to identify that the orthostatic blood pressure was completed as ordered by APRN #2. Interview with the Charge Nurse (LPN #2) on 6/4/24 at 1:00 PM identified that the order for orthostatic blood pressures was entered into the electronic health record directly by APRN #2, but APRN #2 neglected to indicate scheduled times for the blood pressures to be completed. LPN #2 further identified that when a time is not indicated for an action to be done, it does not populate on the Medication Administration Record (MAR) for staff to complete, thus the orthostatic blood pressures were not completed as ordered. Resident #5's diagnoses included disorder of the immune mechanism, schizophrenia, and post-traumatic stress disorder. The admission MDS assessment dated [DATE] identified Resident #5 had moderately impaired cognition, required moderate assistance with personal hygiene, maximal assistance with transfers, and utilized antipsychotic (for managing mental health disorders) medication that the assessment noted to be a high-risk medication. The care plan dated 4/15/24 identified Resident #5 used psychoactive medication with interventions that included: administer medication as ordered, monitor, record, report to MD side effects and adverse reaction of the psychoactive medications such as unsteady gait, shuffling gait, ridged muscles shaking (tardive dyskinesia), and frequent falls. The physician's orders dated 4/12/24 directed to administer Zyprexa/Olanzapine 5 milligrams (mg) by mouth two times daily for schizophrenia. According to the Nursing 2023 Drug Handbook the use of Zyprexa (antipsychotic medication) may cause the adverse reaction of orthostatic hypotension (a dropping of the blood pressure when going from a lying or sitting position to standing). The Pharmacy Medication Regimen Review by Consultant Pharmacist dated 4/16/24 recommended was admitted orthostatic blood pressure monitoring once weekly for four weeks due to Resident #5 being on Zyprexa. The Psychiatric Nurse Practitioner (APRN #2) reviewed the Consultant Pharmacist recommendation dated 4/18/24 and agreed with the recommendation and wrote an order directing orthostatic blood pressures once weekly times four weeks. Review of Resident #5's clinical record failed to identify that the orthostatic blood pressure was taken as ordered by APRN #2. Interview with the Staff Development Nurse (LPN #1) on 6/5/24 at 11:05 AM identified that she re-entered the orders written by APRN #2 for Resident #2 and Resident #5 in the electronic health record system on 6/4/24 as APRN #2 had written the orders without a scheduled time for the orthostatic blood pressures to be completed. LPN #2 further noted that APRN #2 was updated on 6/4/24 of the issue. She further identified the facility conducts a 24-hour chart check on the 11:00 PM to 7:00 AM shift of the provider orders in the paper chart but do not check the orders entered into the electronic health record. Interview with APRN #2 on 6/5/24 at 12:30 PM identified that normally inputs her orders into the electronic health record system, and would update the nurse on duty, the DNS, and document in a red binder at the nurse's station of the changes that were made. APRN #2 added that she entered the physicians order for Resident #2 and Resident #5 directing orthostatic blood pressure once weekly times four weeks. APRN #2 identified that she was not formally trained by the facility to input orders into the computerized health record system and was shown briefly by a nurse on the unit. She added that orthostatic blood pressure monitoring would be ordered for residents starting a new psychotropic medication, or with changes made to their current antipsychotic medications. Additionally, APRN #2 identified orthostatic blood pressure monitoring would be required in order to assess side effects and tolerance to the medication. Further, she indicated that there wasn't a need to follow-up whether the orthostatic blood pressure was completed because if there was a concern with the reading the facility would have notified her. Interview with the DNS on 6/5/24 at 1:16 PM identified that she was responsible for reviewing the orders written by the APRN #2 as a result of pharmacy recommendations. The DNS added that she reviewed the orders in the computer but did not check to ensure that it was inputted thoroughly. The DNS identified that the facility's system was to complete a 24-hour chart check of the written orders in the paper chart and not of the electronic health record system. The DNS added that APRN #2 probably had not received formal training on inputting orders in the computer as she was onboarded quickly when the facility lost their previous Psychiatric Nurse Practitioner. The DNS identified that the facility does have an issue with the orthostatic blood pressure orders and was moving forward to address the issue. Review of the Written Orders policy identified that the order entry would include the instructions from the physician or physician representative with date and time. The policy further identified that written orders may only be reviewed by licensed personnel and orders must be written in the electronic health record.

Based on review of clinical records, review of facility policy, review of facility documentation, and interviews for one of five sampled residents (Resident #26), reviewed for immunizations, the facility failed to offer and/or assess for pneumococcal upon admission as required. The findings include: Resident #26 was admitted to the facility in the month of March of 2024 with diagnoses that included disorder of the immune mechanism, schizophrenia, and post-traumatic stress disorder. The Admission MDS assessment dated [DATE] identified Resident #26 had moderately impaired cognition. Review of the immunization records for Resident #26 on 6/5/24 at 1:50 PM failed to identify that the pneumococcal vaccine was offered and/or assessed for past immunization. Interview with the Infection Preventionist Nurse (RN #2) on 6/6/24 at 10:42 AM in regards to resident immunizations identified that he asked Resident #26 if he/she wanted to receive the pneumococcal vaccine and he/she refused the vaccine. RN #2 identified that he had failed to document the encounter with the resident in the clinical record. RN #2 further identified that Resident #26 had a conservator and noted that he thought that social services would contact the conservator regarding the resident's vaccination status, but he had failed to follow-up with social services. Additionally, RN #2 noted it was his responsibility to assess, and to offer vaccinations to residents and obtain signed consent from the resident and/or responsible party. Subsequently, RN #2 identified that he approached Resident #26 on 6/6/24 regarding the pneumococcal vaccine and he/she agreed to receive the vaccine. Review of the Pneumococcal Vaccine policy identified that each resident would be assessed for pneumococcal immunization upon admission and would be offered within thirty (30) days of admission to the facility, unless medically contraindicated. The policy further identified that assessment of pneumococcal vaccination status within five working days of the resident's admission or prior. In addition, if refused by the resident/representative appropriate documentation would be documented in the resident's medical record.

Based on review of clinical records, review of facility policy, review of facility documentation, and interviews for two of five sampled residents (Resident #2 and Resident #26) reviewed for immunizations, the facility failed to offer and/or assess for COVID-19 immunizations upon admission. The findings include: Resident #2 was admitted to the facility in December of 2023 with diagnoses that included disorder of the immune mechanism, type 2 diabetes mellitus, end stage renal disease, and congestive heart failure. Review of the immunization records for Resident #2 on 6/5/24 at 1:50 PM failed to identify that the COVID-19 vaccine was offered and/or history of past vaccination obtained. Interview with the Infection Preventionist Nurse (RN #2) on 6/6/24 at 10:42 AM identified he was unable to provide any documentation of Resident #2's COVID-19 vaccinations as he did not review their vaccination status upon admission. RN #2 identified that it was his responsibility to assess and to offer vaccine to residents as appropriate, and to ensure that the consent forms were completed prior administration. In addition, RN #2 added it was the practice of the facility for the Infectious Disease physician to review vaccination consent forms and direct the appropriate vaccine for the resident prior to administration. Subsequent to surveyor's inquiry, RN #2 identified that he assessed and offered Resident #2 the COVID-19 vaccination on 6/6/24 and reviewed vaccine consent form with the resident. Resident #26 was admitted to the facility in March of 2024 with diagnoses that included disorder of the immune mechanism, schizophrenia, and post-traumatic stress disorder. The Admission MDS assessment dated [DATE] identified Resident #26 had moderately impaired cognition. Review of the immunization records for Resident #26 on 6/5/24 at 1:50 PM failed to identify that the COVID-19 vaccine was offered and/or assessed for past immunization. Interview with the Infection Preventionist Nurse (RN #2) on 6/6/24 at 10:42 AM identified that he had asked Resident #26 and he/she refused the vaccine but failed to document such encounter with the resident. RN #2 added that Resident #26 had a conservator in which he thought that social services would contact regarding the resident's vaccination status, but he failed to follow-up with social services. He added that it was his responsibility to assess, and to offer vaccination to resident wherein a consent form regarding the vaccination would have been given to the resident/responsible party to review and sign. After which he would give the consent form to the Infectious Disease physician to review for appropriateness prior to administration. RN #2 added that he approached Resident #26 on 6/6/24 regarding the vaccine and he/she agreed to receive the vaccine. RN #2 added vaccination status should be assessed and offered on admission and failed to identify why it was not done and when refused why he had not documented. Subsequent to surveyor's inquiry, Resident #26 was offered COVID-19 vaccination as identified on faxed sent to the Resident #26's conservator on 6/6/24 at 9:20 AM. Review of the COVID-19 Vaccination of Residents policy identified that COVID-19 vaccinations would be offered to each resident unless medically contraindicated or the resident is fully immunized. The policy further identified that residents would be screened for prior vaccination before being offered the vaccine.

Based on review of the facility assessment, review of facility policy and interviews, the facility failed to ensure their licensed staff and CNAs received competency trainings annually. Review of the competency training binder for the facility on 6/6/2024 at 9:30 AM identified that the competency signoffs were blank for the majority of the staff. The staff development provided this binder that was supposed to contain the competency training for the facility staff. Interview and training review with the Staff Development nurse on 06/06/24 at 12:37 PM identified this LPN had been in the staff development position since 4/2023 and is overseen by the DNS. The staff development nurse identified that no training or competency records were turned over to her when she took over the position. Staff Development nurse identified that she is sometimes pulled to do other tasks and is also the MDS coordinator and responsible for the quarterly assessments, annual assessments and admission and discharge assessments and the care plans. I had to put the training on a back burner. There are 11 nurses and 13 CNAs. Of the 24 staff members, 6 (3 nurses/3 CNAs) have competencies for 2023. There were not any records for the 2022 for annual competencies. No competencies have been done in 2024. In-services are done depending on case by case, like if an issue is identified or if we are getting a new patient (i.e. non-binary resident) prior to admission so we are able to provide the care. The Relias trainings are scheduled every month. The employee gets emails reminders that they have trainings to complete. We use the Relias for the annual Abuse and Dementia trainings, and it is a verbal education for anything specific. HR is responsible to keep track of the trainings. Interview with RN #2 on 06/06/24 at 1:16 PM identified he served as the Staff Development person from May 2022 through summer of 2023. He stated he conducted competencies related to hand hygiene and PPE donning and doffing because it was during COVID. He identified that there were not any other competencies addressed at that time. These competencies were identified to be in a manila folder, but the facility is not able to locate this folder. RN #2 identified the facility is implementing a skills fair coming up this year with the hands-on competencies. Interview with the Administrator on 06/06/24 at 1:16 PM identified all of the training and competencies that are done through Relias. This interview also identified the facility underwent a state and federal survey in 2022 and was fined regarding the competencies. The administrator identified there is an upcoming competency fair and was not aware that the competency checks should have been implemented timelier. Interview with the DNS on 06/06/24 at 1:38 PM regarding staff annual competency review and identified that the facility did not have the competencies completed. We were scheduled to do a competency in-service this week but then you guys got here. If you had come next week, then we would have been all set. Review of the facility assessment identified that Licensed staff should receive yearly staff competencies in 14 care areas to include personal protective equipment, Wound care, Ostomy care, enteral tube care, enteral tube feeding bolus/pump, indwelling catheter insertion, PICC line dressing, needle safety, glucose testing, hand hygiene, gait belt, Hoyer lift, IV certification, PCA pump. Additionally, the facility assessment identified the CNA staff received yearly competencies to include personal protective equipment, care of a resident with an indwelling catheter, perineal care, hand hygiene, vital signs, gait belt, Hoyer lift, basic IV therapy, CNA documentation review.

Based on review of clinical records, review of facility policy and interviews for 4 of 5 sampled residents (Residents #5, #9, #29, & #631), reviewed for Advanced Directives the facility failed to establish advanced directives related to code status and other life sustaining treatments with newly admitted and readmitted residents. The findings include: 1. Resident #5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5-day MDS assessment dated [DATE] identified Resident #5 was readmitted from the hospital on [DATE]. The assessment further noted that Resident #5 was cognitively intact, required total assistance with bed mobility and transfers, was independent with eating and did not ambulate. A physician's order dated [DATE] identified Resident #5 was a full code (meaning a person will allow all interventions needed to get their heart started) with direction to not intubate. A hospital discharge summary identified Resident #5 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE] and noted a code status of DNR (do not resuscitate). Interview with Resident #5 on [DATE] at 11:00 AM identified he/she was responsible for self but appointed his/her family member as the conservator. Interview and clinical record review with RN#1 on [DATE] at 12:27 PM indicated the code status should be addressed with the resident on the day of admission by the charge nurse or the nursing supervisor. Once the resident signs the form indicating full code or DNR (do not resuscitate) the form goes into the APRN/MD book to be signed by the APRN or physician and they also document in a progress note and the form is placed in the clinical record. RN #1 further indicated that if the resident is conserved, the nurse should call the conservator and get the code status. RN #1 also identified the ,d+[DATE] shift nurses are responsible for ensuring the forms are completed and then the DNS does an audit for code status to follow up. RN #1 identified that Resident #5 did not have a completed code status (advanced directives) form located in his/her clinical record. Interview with Unit Secretary #1 on [DATE] at 12:30 PM in the presence of RN #1 indicated that all the documents have been filed and if it was not in the chart there was not completed advanced directives form. Interview with SW #1 on [DATE] at 12:40 PM indicated it was the nurse's responsibility to do the code status on admission and if the nurse doesn't get the code status on admission the nurse will then ask her to call and follow up with the conservator or family. SW #1 noted that she will call or send the code status form to the conservator to sign. SW #1 further indicated that she does not write on or sign the code status form only the family or conservator must be present and sign the form. In addition, SW #1 indicated that her responsibility was to discuss code status at the quarterly care plan meetings with the resident or family. Interview with the DNS on [DATE] at 8:48 AM indicated that ideally when the resident is admitted , the social worker is responsible for obtaining the code status within 48 hours of the admission and once the resident or family signs the form, the APRN or MD will sign the form and write the order for a full code or DNR and add code status to their admission note. The DNS further identified that the completed form is then placed in the chart where it should remain. The DNS indicated that code status is not addressed for readmissions unless there was a significant change in condition. The DNS reviewed the clinical record for Resident #5 and noted there was not a code status form in the clinical record signed by conservator or physician. Interview with SW #1 on [DATE] at 9:00 AM with the DNS present indicated she mailed the forms for code status yesterday to the conservator but did not call him/her. Interview with RN #1 on [DATE] at 9:04 AM with the DNS present indicated she had not yet called the conservator for Resident #5 to obtain a code status. The DNS informed RN #1 to call the conservator. On [DATE] at 9:06 AM via speaker phone with Person #1, DNS, and RN #1, Person #1 (Resident #5's conservator) indicated she and Resident #5 wanted a code status of DNR and DNI (do not intubate). A physician's order dated [DATE] at 9:48 AM identified an order indicating the code status of DNR and DNI. The nurse's note dated [DATE] at 1:23 PM indicated the advance directives form was faxed to the APRN, and they were awaiting its return. The code status was also discussed with Resident #5 who was in agreement with the change in code status from full code to DNR/DNI. Review of the facility's Do Not Resuscitate Order policy identified that a do not resuscitate order must be completed and signed by the attending physician and resident or legal surrogate and placed in the front of the resident's medical record. Review of facility's Advanced Directives policy indicated that upon admission; the resident will be provided with written information concerning the right to formulate advanced directives if he/she chooses to. 2. Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet in the electronic clinical record identified Resident #9 was responsible for him/herself. The admission MDS assessment dated [DATE] identified Resident #9 had intact cognition and required extensive assistance of one with bed mobility and dressing. Resident #9's clinical record failed to indicate Advanced Directives were completed with Resident #9 who was responsible for him/herself. Subsequent to survey team inquiry, a physician's order dated [DATE] was obtained that identified Resident #9 was a full code. A subsequent physician's order dated [DATE] directed Resident #9 was a Full Code inclusive of cardiopulmonary resuscitation, intubation, intravenous hydration and no tube feeding. 3. Resident #29's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An inter-agency patient referral report from the hospital dated [DATE] identified Resident #29's code status (the choice of choosing to have cardio pulmonary resuscitation performed in the event that the heart stops or choosing to not have it performed) was Full Code (this designation indicates that the resident wants all life sustaining measures performed in the event that the heart stops). The care plan dated [DATE] identified Resident #29 had adjustment issues due to admission with interventions that directed: encourage resident to participate in conversation with staff and residents daily, provide the resident with as many situations as possible to give the resident control over his/her environment and care delivery. An admission MDS assessment dated [DATE] identified Resident #29 had intact cognition, required extensive assistance for bed mobility, transfers, locomotion and personal hygiene. A nurse's note dated [DATE] identified Resident #29 was confused, could not follow simple instructions, and was admitted to the hospital. An inter-agency patient referral report from the hospital dated [DATE] identified Resident #29 was admitted to the hospital with altered mental status and a code status of full code. The physician's note dated [DATE] identified Resident #29 was recently hospitalized for altered mental status and returned to the facility for further care. The note further identified Resident #29 was alert and oriented with no complaints of depression or anxiety. Review of the After Visit Summary dated [DATE] identified Resident #29 went to the hospital emergency department for abdominal pain and no code status was identified in the documentation. Review of Resident #29's clinical record failed to identify documentation that the resident's code status had been discussed with the resident following admission and readmission to the facility. Subsequent to surveyor inquiry, Advanced Directive Statement dated [DATE] was signed by Resident #28 and identified that in the event he/she could not eat he/she did not want a feeding tube and if unable to accept hydration by mouth, hydration could be administered via intravenous line. In addition, the documentation identified that Resident #29 wanted to receive cardiopulmonary resuscitation in the event that the resident's heart stopped and identified that he/she could be intubated. Physician's orders dated [DATE] directed Full Code and no nutrition via tube feeding. Interview with the DNS on [DATE] at 12:30 PM identified that when Resident #29 was admitted to the facility and/or when the resident returned from the hospital the social worker, charge nurse or the supervisor should have reviewed the advance directives with the resident. Interview with Social Worker #1 on [DATE] at 1:00 PM identified she did not review the advance directives with Resident #29 when the resident was admitted from the hospital because it was the responsibility of the admitting nurse or supervisor. Interview with RN #1 on [DATE] at 1:15 PM identified she was the nursing supervisor that admitted Resident #29 to the facility, but she could not recall if the code status was reviewed. A review of the facility's advance directive policy identified that upon admission the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so. 4. Resident #631 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment dated [DATE] identified Resident #631 was alert and oriented to person, place, time, and situation and required total dependence on staff for bed mobility, transfers, and personal hygiene. A nursing note dated [DATE] at 10:59 PM identified Resident #641's code status was full code. A review of physician's orders from [DATE] through [DATE] failed to address the resident's code status and other advanced directive wishes. A review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #641's advance directive was discussed. A review of social work progress notes from [DATE] through [DATE] failed to identify Resident #641's advance directive wishes were discussed. The initial care plan dated [DATE] failed to identify Resident #641's advance directive wishes. An interview with Resident #641 on [DATE] at 12:07 PM identified that no one had discussed advance directives with him/her, and he/she definitely wanted his/her wishes to be known. Resident #641 identified he/she did not want to be intubated but preferred to have a [CONDITION(S)] placed instead if assistance with breathing was needed. An interview with LPN #1 on [DATE] at 12:20 PM identified Resident #641 did not have a code status order located in the electronic medical record nor was it addressed in the resident's paper chart. LPN #1 further identified that if an emergency occurred Resident #641 would be treated as a full code with the initiation of cardiopulmonary resuscitation and intubation if needed. An interview with RN #1 on [DATE] at 12:30 PM confirmed that Resident #641's advanced directives were not addressed and identified that it was the responsibility of the admitting nurse to address advance directives with the resident or the resident's representative upon admission. She further noted that the form used to indicate the resident's wishes should be placed in the provider book for either the APRN (advanced practical registered nurse) or physician to review and sign. RN #1 also noted that the 11:00 PM to 7:00 AM nurse checks to see that the advance directives are completed, and the DNS also checks for admissions on the daily 24-hour report and to ensure that advance directives are completed. RN#1 further identified that if the resident or resident's representative is unable to complete the advance directive then the social worker will follow up with the resident or resident's representative until it is completed. An interview with Social Worker (SW) #1 identified she did not follow up with the advanced directives for Resident #641 and is updated by nursing if an advanced directive needs to be followed up on. SW#1 further identified that she was not made aware that an advanced directive needed to be addressed with Resident #641. A physician's order was placed on [DATE] identifying Resident #641 was a full code. An interview with Resident #641 on [DATE] at 10:15 AM in the presence of RN #1 identified he/she did not want to be intubated but wanted to have CPR performed. Resident #641 conveyed, I don't want to wake up with a tube down my throat I am only consenting to having a [CONDITION(S)]. Resident #641 was shown his/her signed advanced directives that indicated CPR and intubation can be performed but [CONDITION(S)] preferred written in. Resident #641 identified that he/she would consider being intubated until he/she got to the hospital and had a [CONDITION(S)] placed. RN #1 identified that the APRN would address the advanced directives again with Resident #641 to ensure that his/her wishes are followed. An interview with the DNS on [DATE] at 10:44 AM identified the advanced directives should be addressed upon admission for residents who are responsible for themselves and Resident #641's advanced directives should have been completed, reviewed, and signed by a physician or APRN and a physician's order placed in the record identifying the Resident's wishes; additionally, the care plan should address the resident's advance directive wishes. A review of the facility policy for advance directives identified that upon admission the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so. The facility policy also directs the social services director or designee will inquire of the resident, his/her family members, or legal representative of the existence of any written advance directives. The policy further directed that information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record and a plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive.

Based on facility documentation and interviews for 1 of 1 sampled residents (Resident #18) reviewed for a concern during resident council, the facility failed to address the concern that was brought up for three consecutive months in resident council meetings. The findings include: Resident #18's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly MDS assessment dated [DATE] identified Resident #18 with intact cognition, required limited assist of 1 with bed mobility and bathing, extensive assist of 1 with transfers and toileting. Resident Council meeting minutes dated July 2021 identified Resident #18 spoke about a hygiene issue of the resident who shared the bathroom with him/her. The minutes further indicated that the Therapeutic Recreation Director (TRD) reported the concern to the Director of Housekeeping and to nursing. Resident Council meeting minutes dated August 31, 2021, indicated Resident #18 stated his/her bathroom always smelled and there was feces on the floor from the resident who shared the bathroom. Additionally, there was no documentation that Housekeeping responded to the July 2021 issue of Resident #18's complaints of a soiled bathroom. Resident Council meeting minutes dated September 28, 2021 indicated Resident #18 reported that the odor from the shared bathroom continued to be a problem and that the TRD reported to the Housekeeping Manager and the DNS. Additionally, there was no documentation that Housekeeping responded to the August 31, 2021 issue of Resident #18's complaints of a soiled bathroom. Interview with the TRD on 3/15/22 at 12:02 PM identified that she was present at the Resident Council meetings and when there was an issue at Resident Council, he/she sends emails or notes to all the department directors, they respond back by email and it is put in the resident council notes, if it was urgent he/she tells the department manager immediately and the follow up should be in the Resident Council notes. Further interview and review of the Resident Council minutes with the TRD identified the minutes contained a heading of old business with nothing identified below the heading. The TRD indicated that if nothing seems pertinent, she does not document anything under old business. Interview with the TRD on 3/15/22 at 11:00 AM identified that she was unable to locate emails/correspondence with Housekeeping related to Resident #18's bathroom being soiled. Interview with the Director of Housekeeping (with a Spanish interpreter present) on 3/17/22 at 10:30 AM identified she could not recall if the TRD had notified her that another resident frequently left the bathroom shared by Resident #18 in a soiled condition. Additionally, the Director of Housekeeping indicated that she cleaned Resident #18's bathroom daily, did not monitor the bathroom more frequently and only cleaned it more than daily if staff reported it was soiled. The facility failed to respond to a grievance reported by Resident #18 for three consecutive months.

Based on clinical record review, review of facility policy and interviews for 1 sampled resident (Resident #9) who was admitted to the facility with the presence of stage 4 pressure ulcer, the facility failed to ensure the resident care plan was comprehensive in the identification of the presence of the use of a low air loss mattress (LAL), the directions for the settings for the inflation level of the mattress and the use of a ROHO (pressure reducing cushion used to treat pressure ulcer) cushion. The findings include: Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound tracking documentation dated 12/14/21 identified Resident #9 had a Stage 4 sacral pressure ulcer measuring 11 cm in length by 8 cm in width by 2 cm in depth. The care plan dated 12/15/21 identified Resident #9 had actual skin impairment with interventions that included, avoid scratching, keep hands and body parts from excessive moisture, keep fingernails short, educate caregivers of causative factors and follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The admission MDS assessment dated [DATE] identified Resident #9 was cognitively intact, required extensive assistance of one for bed mobility and dressing, required total assistance of two for transfers and total assistance of one for bathing and toilet use. The MDS also identified that Resident #9 had the presence of a Stage 4 pressure ulcer on admission. Review of the clinical record identified a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the order failed to identify specific settings for the LAL mattress. Weekly pressure ulcer tracking dated 3/11/22 identified the Stage 4 pressure ulcer measured 6 cm by 5.5 cm by 0.8 cm in depth. Observations on 3/14/22 at 10:15 AM, 3/15/22 at 11:00 AM, 3/16/22 and 3/17/22 at 9:00 AM identified Resident #9 was out of bed and seated in a customized wheelchair, The LAL mattress was on the bed and set at 5/float. Review of the clinical record failed to reflect instructions for the setting for the LOL mattress. The care plan and nurse aide care card also failed to identify resident specific instructions for the LOL mattress settings. Interview and observation of the LAL mattress setting with RN #1 (Nursing Supervisor) on 3/17/22 at 9:00 AM identified that all LAL mattresses were set at 5/floating unless otherwise directed by the physician. Interview with NA #1 on 3/17/22 at 10:28 AM identified although she was assigned to Resident #9, she does not touch the LAL mattress settings. Review of the NA care card with NA #1 failed to reflect Resident #9 utilized a LAL mattress. Interview with the DNS on 3/17/22 at 10:50 AM identified that a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS further identified the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/16/22 at 11:00 AM observation of Resident #9 identified he/she was in customized wheelchair seated on a Roho cushion. On 3/17/22 at 11:00 AM, an interview and observation of Resident #9 with the Director of Physical Therapy identified she provided the Roho cushion for Resident #9 to reduce pressure when Resident #9 was in the wheelchair, and she monitors the Roho cushion monthly for inflation, integrity, and cleanliness (monthly screening verified). Review of Resident #9's RCP, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to indicate settings for a LAL mattress when ordered by the physician and failed to include the use of a Roho cushion and LAL mattress in the RCP. The NA care card also failed to include the use of a Roho cushion and LAL mattress to ensure NA's were aware of the plan of care for Resident #9.

Based on clinical record reviews, review of facility documentation and interviews for 1 of 4 sampled residents (Resident # 1) reviewed for medication errors, the facility failed to ensure a medication was transcribed onto the Medication Administration Record [REDACTED]. The findings include: Resident #1's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had no cognitive impairments and required extensive one person assistance with eating. A laboratory report dated 2/15/16 identified the Potassium level was 3.7 (normal range 3.3-5.1). A physician's orders [REDACTED]. The laboratory report dated 2/19/16 identified the Potassium Level was 3.3. A physician's orders [REDACTED]. Review of the February 2016 Medication Administration Record [REDACTED]. The laboratory report dated 2/22/16 identified the Potassium level had questionable results and suggested a redraw. A physician's orders [REDACTED]. The laboratory report dated 2/23/16 identified the Potassium level was 1.7, a critical level with the test results repeated. The nurse's note dated 2/23/16 at 1:29 PM identified the laboratory results called in were called and faxed to the Advanced Practice Registered Nurse (APRN). The note indicated Resident #1 was transferred to the hospital. A physician's orders [REDACTED]. Review of the MAR from 2/19/16 through 2/23/16 identified that Resident #1 did not receive seven (7) doses of Potassium Chloride 80 mEq. The Reportable Event Form dated 2/23/16 identified the lab called with the facility with the critical result of the Potassium level at 1.7. The report identified the Potassium Chloride 80 mEq twice daily order was not transcribed onto the MAR indicated [REDACTED]. Review of the hospital discharge summary dated 2/26/16 identified Resident #1 was admitted for [DIAGNOSES REDACTED] and [MEDICATION NAME] most likely due to the side effect of [MEDICATION NAME] B. The summary identified that on admission the Potassium level was 1.9, in the emergency department the resident received Potassium 20 mEq intravenously times two (2) doses, Potassium 100 mEq by mouth times one (1) dose and then started on D5 ½ NS with Potassium Chloride 40 mEq/liter at 100 cubic centimeters (cc). The summary identified the potassium level on 2/26/16, day of discharge, was 3.7. Interview with the 7-3PM charge nurse, Registered Nurse (RN) #1 on 3/9/16 at 9:30 AM identified she was aware the APRN had seen Resident #1 on 2/19/16 but she did not have the resident's chart on the unit so she did not check for physician orders, nor did she report to the oncoming shift that the chart need to be reviewed. Interview with the Director of Nurses (DON) on 3/9/16 at 10:30 AM identified that she was made aware of the critical lab value on 2/23/16. The DON stated the APRN was made aware and ordered the resident to receive Potassium Chloride 80 mEq times two immediately and to send the resident to the hospital for evaluation. The DON stated that during the investigation she identified that RN #1 failed to note and transcribe the order during the day and evening shift she worked. The DON indicated when the order was noted by RN #2, the 11-7AM charge nurse, on 2/20/16 at 3:30 AM, RN #2 had discontinued the Potassium Chloride 40 mEq but failed to write the new order of Potassium Chloride 80 mEq twice daily. The DON stated that when she spoke to RN #2 she stated that she was tired and must have missed the order. The Department of Public Health requested an action plan on 3/9/16 that included inservice education to all licensed staff including agency staff prior to the start of the shift, chart audits of all residents to ensure all orders are carried out correctly and each of the shifts will review the previous shift to ensure orders are transcribed. The action plan identified the DON was to be accountable the audits were completed to ensure compliance. Several attempts to contact RN #2 were unsuccessful.

Based on review of the clinical record, review of facility documentation for the only sampled resident who exhibited exit seeking behaviors (R#14), the facility failed to provide adequate supervision to ensure the resident remained in the facility and/or failed to assess the resident's risk for elopement, and/or failed to initiate a plan of care to prevent elopement resulting in a finding of immediate jeopardy. The findings include: Resident # 14's [DIAGNOSES REDACTED]. Nurse's notes dated 3/17/11 at 12 midnight noted that the resident was found standing on a main street nearby. The resident had left the facility via the gazebo/smoking area. On 7/6/11, nursing notes indicated that a nurse aide saw the resident at a nearby gas station at 12:20 AM and the resident was found and returned to the facility at 12:45 AM. On 9/8/11, the resident was heard threatening to leave. Nurse's notes dated 11/4/11 identified that the charge nurse observed the resident at 12:15 AM in her/his room. At approximately 6:45 AM, the resident could not be found in the facility. A search outside of the facility noted the resident's hat was observed outside of the fence near the gazebo/smoking area. The Police department was notified and inquiries were made at the local hospital's. Nurse's notes dated 11/5/11 identified the resident returned to the facility at 9:15 AM accompanied by a NA who found him/her. The resident reported that he/she had spent the night at a shelter and complained that his/her back hurt due to jumping the fence when leaving the facility. Subsequently, a wander guard was placed on the resident's wrist and one on one supervision was initiated. Interview, review of the clinical record, and review of facility documentation on 11/4/11 at 1:45 PM with the DNS identified that the alarm on the gazebo/smoking area door had not been enabled on the night that the resident left the facility. The DNS also noted that although the security log located at the main entrance contained a picture of the resident and identified an elopement risk, the clinical record lacked a comprehensive assessment for elopement risk. Review of the RCP with the DNS at that time identified that although the resident had left the faciity on [DATE] and 7/6/11, the facility failed to address and/or implement interventions to prevent further elopement. Additionally, to date the facility lacked a policy that directed an initial/quarterly assessments for elopement risk and/or the development of preventative care plans. The above findings resulted in finding of immediate jeopardy. The facility was notified on 11/4/11 and an immediate action plan was initiated. The plan of correction was reviewed on 11/7/11 and the immediate jeopardy was removed at that time. In addition; Based on clinical record review and staff interview for one of three residents in the survey sample reviewed for accidents (R#8), the facility failed to assess and/or revise the resident care plan after the resident was found smoking in his/her room. The findings include: 1. Resident # 8's (R #8) [DIAGNOSES REDACTED]. A smoking assessment dated [DATE] determined that the resident could smoke safely independently, but that staff must hold all smoking materials. A care plan dated 8/2/11 identified the resident was a safe smoker. Interventions included cigarettes held at nurse's station and observe for any unsafe smoking behaviors. A subsequent note on the care plan dated 10/20/11 indicated the resident smokes safely, and holds own cigarettes without issue. No unsafe incidents noted this past quarter. A nurse's noted dated 10/18/11 at 12:30 AM noted the resident was smoking in his/her room. Explanation was given regarding fire safety. The lighter was confiscated and no other cigarettes were found. An interview on 11/3/11 at 2:00 PM with the DNS indicated that he did not recall that R #8 was found smoking in his/her room. He indicated that when a resident is found smoking in an unauthorized area they are given a warning and the issue is addressed by the Wellness Team. At that time he was unable to provide documentation of an assessment and/or revision of the resident care plan after the resident was found smoking in his/her room. The DNS was unable to explain why the care plan noted on 10/20/11 that the resident smoked safely after an incident had just occurred.