Every finding on record at Little Cottonwood Rehabilitation and Nursing

Based on interview and record review it was determined, for 5 out of 19 sampled residents, that the facility did not maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized. Specifically, a resident's assessment was labeled with another resident's name, a resident's laboratory results were located in another resident's medical records, and a resident's shower sheet had another resident's name listed on the form. Resident identifiers: 5, 13, 15, 27, and 38. Findings included:1. Resident 13 was admitted to the facility on [DATE] with diagnoses which included disorder of brain, major depressive disorder, epilepsy, post-traumatic stress disorder, and insomnia. The Shower Preference form located in resident 13's medical chart had resident 38's name printed on top and signed by resident 13. On 10/8/25 at 1:59 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the shower preference sheet should have had resident 13's name printed on it and not resident 38's name. LPN 1 stated that the printed name should be the correct name prior to the resident signing the form. LPN 1 stated that the shower sheet should have been corrected prior to placing the form in resident 13's chart. 2. Resident 38 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, unspecified psychosis, anxiety disorder, post-traumatic stress disorder, chronic pain, bipolar disorder, stimulant abuse, borderline personality disorder, and insomnia. On 10/6/25 through 10/8/25, resident 38's medical records were reviewed. Review of a form labeled Consents/Authorizations, dated 5/21/25, documented resident 15's name on the form. The form was located inside resident 38's medical records. On 10/07/25 at 12:22 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the document of consents/Authorizations for resident 15 was located in the wrong chart and that was her responsibility. The DON then stated that the signature on the consent form was resident 38's but that it had resident 15's name on the form. The DON was witnessed to cross out resident 15's name and hand write resident 38's name on the form. 3. Resident 5 was admitted to the facility on [DATE] with diagnoses which consisted of bipolar disorder, dementia, hypertension, insomnia, and drug induced subacute dyskinesia. On 10/6/25 through 10/8/25, resident 5's medical records were reviewed. Review of resident 5's laboratory results revealed a thyroid stimulating hormone (TSH) result, dated 6/3/25, for resident 27 that was located inside resident 5's medical records. On 10/8/25 at 9:29 AM, an interview was conducted with LPN 1. LPN 1 stated that resident 27's lab result should not be located inside resident 5's medical record. LPN 1 stated that both resident 5 and resident 27 had scheduled laboratory tests on 6/3/25. On 10/08/25 9:33 AM, an interview was conducted with the DON. The DON was informed of resident 27's TSH lab result that was located in resident 5's medical record. The DON stated that it was her again, and was observed to remove the lab result from resident 5's hard chart.

Based on interview and record review it was determined, for 1 of 20 sampled residents, that the facility did not ensure that the resident was free from abuse. Specifically, a resident who lacked the capacity to consent to sexual activity was found engaged in a sexual act with another resident. Resident identifier: 30 and 41. Findings included: 1. Resident 30 was admitted to the facility on [DATE] with diagnoses which consisted of Schizoaffective disorder bipolar type, cocaine dependence, and drug induced subacute dyskinesia. On 10/6/25 at 9:47 AM, an interview was conducted with resident 30 while the resident was ambulating down the hallway. Resident 30 stated that she did not want to die, and someone was going to kill her. Resident 30 then stated that someone programmed her to act the way she does. Resident 30 stated that she did not want to leave the facility because she had friends at the facility and that she did not have any problems with any of the other residents. Resident 30's thoughts and speech were tangential during the interview. On 10/6/25 at 10:17 AM, an observation was made of resident 30 in the dining room. Resident 30 was observed pointing at different men in the dining room and stated that they wanted to be with her. Resident 30 was observed to yell at no one to leave her alone. The facility abuse investigation documentation was reviewed. The Form 358 documented that the nurse on shift, Registered Nurse (RN) 1, Around 0200 [2:00 AM] hours on 08/23/2024. [RN 1] the Nurse on Duty noticed that [Resident 41's] walker was outside of the main bathroom, so [RN 1] went to see what was going on. When [RN 1] got there, he found [Resident 41] kissing one female resident [Resident 30] with his right hand on her left breast, on top of her clothing. [RN 1] said that [Resident 30] was not in any distress and smiling about it when the two residents were found kissing and touching. [RN1] also said that the police interviewed [Resident 30], and she said she's fine with it, she smiled and stated, 'he's just a horny guy'. Then [Resident 30] started talking about her delusional thoughts which is within normal with her. (sic) The form documented the immediate actions taken were that RN 1 separated both of the involved residents and the nurse notified the police department. The facility abuse investigation concluded that the allegation was Not Verified due to The facility deemed the incident to be a consensual sexual behavior after the internal investigation due to [Resident 30] response such as smiling and expressing that she's totally fine with the incident without any complaint nor in any distress. On 10/6/25 through 10/8/25, resident 30's medical records were reviewed. On 7/12/24, resident 30's quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 00, which indicated a severe cognitive impairment. The assessment documented that resident 30's depression screening (PHQ-9) score was 11, which would indicate moderate depression. The assessment documented that resident 30 had hallucinations and delusions. On 9/12/25, the quarterly MDS documented a BIMS score of 00, PHQ-9 score 12, and had hallucinations and delusions. Resident 30's progress notes revealed the following: a. On 5/15/24 at 8:15 AM, the provider note documented, HPI [history of present illness] ***Patient does endorse episodes of psychosis at this time. Has recognized episodes of auditory, visual and/or tactile hallucinations since previous encounter. Continues to take medications without issue and does not endorse side effects. Staff have not recognized any significant events since last visitation. Delusional content persists, however remains unconcerned and eupporic [sic]. From previous note/encounters: She continues to smile and laugh easily, but has little insight due to delusional ideas She does have some Erotomanic delusions referring to a [NAME], of which he does not exist. From previous note/encounters:[AGE] year old female who currently resides at a SNF [skilled nursing facility], due to inability to care for self She present as delusional and psychotic stating I am the queen of Switzerland, and overall a poor historian She presents with bizarre content and does appear to be responding to internal stimuli. She has odd beliefs and struggles to participate in her examination as a result ***Psychiatric Exam: Behavior: cooperative and eye contact is good. Mood: euthymic. Thought Processes: shows loosening of associations and is tangential. Thought Content: delusions. Appearance: clean. Perception: auditory hallucinations. b. On 6/7/24 at 6:36 PM, the nursing note documented, Speech often incoherent, but Res [resident] able to make needs known. Occ [occasional] difficulty understanding others r/t [related to] confusion, behavior, refusing to listen. BEHAVIOR & MNGT [management]: Episodes of restlessness, anxiety, delusion, hallucination, outburst, paranoia, mood swing, fixation, repetitive. Behavior occ exacerbates but has been manageable and able to redirect with current meds and behavior mngt. c. On 6/12/24 at 8:15 AM, the psych follow up provider note documented, *** HPI***she continues to be desired and display delusional content. However she continues to be relatively calm and pleasant and takes medications without issue. The side effects witnessed or endorsed this time. From previous note/encounters: she continues to wander the halls mumbling in talking to herself. She appears to be responding to internal stimuli but does not appear distressed or bothered. She's pleasant and friendly and smiles often. Staff report that she takes medications without issue and there are no obvious forms of side effects. d. On 6/26/24 at 8:15 AM, the psych follow up provider note documented, *** HPI ***She continues to be psychotic and delusional and has bizarre beliefs. However, she continues to be pleasant and does not appear to be distressed. e. On 7/10/24 at 8:15 AM, the psych follow up provider note documented, ** HPI ***'I remember you, and did you know that I have a son now'. She continues to make bizarre comments and statements that are delusional in nature. However she is very pleasant and cooperative and does not endorse any feelings of distress or concerns. f. On 7/11/24 at 12:58 PM ,the psychosocial note documented, Resident irrelevantly talks non-stop and mumbles at times. Resident wanders but can easily be redirected for a short time. Resident keeps re-arranging [sic] her clothes on her bed for no reason. Resident is incoherent and has illogical flow of ideas, she talks about her [NAME] children who's [sic] father is [NAME] (for a moment) but in the same conversation she said that [NAME] is her son born after [NAME], and that they all live downstairs. Then out of nowhere she suddenly talks about a lady named [NAME] who she said is running this facility. Resident is pleasant and smiling during the conversation and can express her needs known. She denies any concern. Resident shows little interest or pleasure in doing things, feeling tired/little energy. No current discharge plans this time. g. On 8/7/24 at 10:46 AM, the health status note documented, WEEKLY NURSING ASSESSMENT: COGNITION: Resident alert with confusion. Responsive. Speech often incoherent, but Res able to make needs known. Occ difficulty understanding others r/t [related to] confusion, behavior, refusing to listen. BEHAVIOR & MNGT: Episodes of restlessness, anxiety, delusion, hallucination, outburst, paranoia, mood swing, fixation, repetitive, arguementative [sic] at times. Behavior occ exacerbates but has been manageable and able to redirect with current meds and behavior mngt [management]. h. On 8/23/24 at 9:14 AM, the health status note documented, Late Entry: Note Text: Reported by night nurse that resident found w [with] male resident @ 2am in the BR [bathroom] kissing and male resident touching her breast outside her shirt, Resident not on any distress when found. Police was called ny [sic] the nurse on duty, during the interviewed (sic)- Resident stated male resident 'just a horny guy' then started talking w [with] her delusion thought. Interviewed resident today for fup [follow-up], re- early am incident, resident aware of the sexual behavior w a male resident, stated she's okd [okay] w it and smiling about it. Resident alert w confusion, but able to make needs known and make her own decision and she knows exactly what she wants and not. Resident responsible to self, No POA [power of attorney]. Resident often w delusional thought and mostly sexual- like talking about being pregnant, had sex w different names that resident will say. Resident occ [occasionally] making comments of not having sex life and it's upsetting for her not having sex life. Resident behavior w episodes of exacerbation wc [unknown abbreviation] resident gets more delusional, fixation, paranoia, hallucination, restless, anxiety. Behavior goes on a cycle of being manic to being calmer, but still able to make her needs known, and making her own decision. i. On 9/2/24 at 1:29 PM, the health status note documented, Resident alert, w confusion, episodes of being incoherent. Behavior been increasing for last 4 to 5 day, l [sic] on manic state, talking and fast pacing most of the time even through the noc [night], hardly been sleeping, yelling, screaming, argumentative, delusion, hallucination, paranoia, restless, anxiety, fast pacing, fixation. Resident talking baout [sic] sexual activity. Behavior been difficult to redirect/ re orient.Md [Medical Doctor] notified, ordered to increase depakote to 500mgpo [milligram by mouth] bid [two times daily] and check level w routine sched [scheduled] labs on Oct. Rn explained order to resident and stated ok. j. On 9/12/24 at 4:50 PM, the health status note documented, Resident alert, w confusion. but able to make needs known. Resident been on hyper state for the last 3 wks, talking/ yelling often, w inapp [inappropriate] verbal/ sexual comments, delusion, hallucination, restless, fast pacing, paranoia, argumentative. Behavior been continuing even at noc. Resident not sleeping much at noc then up about early am. Behavior only able to redirect ffor [sic] less than 2 min then start again. Behavior affecting other residents and complaining w her behavior. Resident had haldol inj [injection] this wk [week] but behavior still continue.Md notified of above, ordered to increased [NAME] [haldol] to 150mg im [intramuscular] q [every] 14 days, increase Seroquel to 300mg po [by mouth] bid. Rn explained order to resident and agreed w it. On 8/7/24, the MD note documented, .Delusional with tangential speech. Believes she is [NAME] and just gave birth to twins. Requires frequent redirection by staff due to poor insight and memory. On 3/20/24, the resident had a court order for mental health treatment. The court order documented that the subject had a civil commitment order that required the resident to abide/comply with the providers plan for continued treatment for their mental health condition. The order was to stay in place unless terminated by the court or the provider. The order was in effect and last reviewed on 8/6/25. On 6/16/23, the Pre-admission Screening and Resident Review (PASRR) Level II documented that resident 30 was unable to care for herself and needed daily management of her medical and psychiatric needs. The assessment documented a long history of schizophrenia including auditory hallucinations, disorganization, and avolition. The assessment documented that resident 30 was chronically delusional/conversations had delusion content at baseline. Her thought was tangential, disorganized and delusional. She told stories about a man, none of which made sense. On 4/13/23, resident 30 had a care plan initiated for Alteration in thought process related to poor safety judgement, confusion, incoherent, behaviors, anxiety, restless, delusions, hallucination, paranoia, outburst, and mood swings. Interventions identified on the care plan included the following: assess the resident's level of consciousness, approach calmly, orient resident as needed, redirect attention as needed, provide prompting, monitor and record behavior, assist with problem solving and decision making, check resident often, notify MD of worsening behavior, and firm approach with set limits. On 7/12/24, resident 30 had a Sexual Activity Capacity to Consent assessment completed. The assessment described the residents cognitive status as alert with confusion and her behavior fluctuated between manic and calm. When resident calm, resident more coherent and make decision (sic) and judgement. The form documented that the resident had repetitive sexual comments but had not initiated any sexual activity. The form documented the resident's psychiatric symptoms of delusions, hallucinations, paranoia, restlessness, anxiety, yelling, outburst and mood swings. The form documented that resident 30 was able to express a consistent choice and understood relevant information. No documentation could be found to demonstrate what relevant information was discussed and understood by resident 30. The assessment documented under Describe risk and / or consequences of their choice: Resident will engaged w other resident in sexual activity. It should be noted that no documentation was found to demonstrate resident 30's understanding of relevant information or what that relevant information included. Additionally, no documentation could be found to demonstrate that resident 30 was able to verbalize the risks or consequences of her choice and what those included. The evaluation determination documented that resident 30 had the capacity to make a decision to engage in sexual intimacy with others. On 10/7/25 at 9:47 AM, an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated that resident 30's behaviors were wandering, pacing, and yelling. CNA 1 stated that when this occurred she would tell resident 30 to calm down, guide her back to her room, and speak calmly to her. CNA 1 stated that resident 30 had delusions and hallucinations and she would talk to people who were not there. CNA 1 stated that resident 30 did not have any hyper-sexual behaviors. CNA 1 stated that she was not aware of resident 30 having had any sexual conduct with other male residents. CNA 1 stated that if that would occur she would redirect resident 30. She is like a little girl with little girl behaviors. CNA 1 stated she should be notified of any sexual behaviors because she would monitor the resident for those behaviors. CNA 1 stated that it was not like resident 30 to be sexual with anyone and that would be unusual for her. CNA 1 stated that they document behaviors in the ADL charting. It should be noted that resident 30's behavior documentation did not have any behaviors documented by the CNAs. On 10/7/25 at 10:12 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 30's behaviors were that she was married to [NAME] Kennedy; she was of royal blood and very descriptive delusions of how she was pregnant; and she had one of [NAME]'s children. LPN 1 stated that they provided redirection, 1:1 monitoring, and attempted to call her mom when resident 30 had behaviors. LPN 1 stated that most of the time those interventions worked for a short period of time. LPN 1 stated that resident 30 did not have any hyper-sexual behaviors that were actionable, but would talk about it. LPN 1 stated that resident 30 believed the other male residents were her lovers or she wanted them to be her lovers. LPN 1 stated that resident 30 never had any sexual contact or interaction with the male residents at the facility. LPN 1 stated she was not aware of resident 30 having any sexual contact with other residents that included kissing or touching of the genitals. LPN 1 stated that she would separate the residents if they were found engaging in sexual contact; would assess for any injury; and report it to the Administrator (ADM) and Director of Nursing (DON). LPN 1 stated that documentation of any incidents and who was notified would be located in a progress note and an incident report. LPN 1 stated if something like that had occurred she needed to be made aware of it to keep it from happening again. On 10/7/25 at 2:41 PM, an interview was conducted with the ADM. The ADM stated that he and the Resident Advocate (RA) worked together on the abuse investigations. The ADM stated that he typically filled out the form and submitted it to the State Survey Agency (SSA). If he was not present then the RA would submit it on his behalf. The ADM stated he did not indicate sexual abuse as an allegation when it was reported to the SSA because it was consensual sexual behavior. The ADM stated that he would need to speak with the DON to determine why it was determined consensual. I was not present at the time. The ADM stated that the DON let him know that the situation was consensual and the DON would have done an evaluation to make the determination that resident 30 had the capacity to consent to sexual activity. On 10/8/25 at 8:01 AM, an interview was conducted with the DON. The DON stated that resident 30 had confusion but knows what she wants. The DON stated that resident 30 was alert and oriented times 2-3 to person, place and sometimes situation. The DON stated that resident 30 was more confused and delusional now, but had always been delusional. The DON stated that resident 30's delusions were centered around famous people. The DON stated that resident 30 believed she had nine children with [NAME]. The DON stated that a year ago resident 30 was more stable than she was currently. The DON stated that resident 30 had said she was okay with the incident that occurred with resident 41. The DON stated that she did not really know why resident 30 was court ordered for treatment but assumed it was because she did not want to be at the facility and wanted to go home. The DON then stated that resident 30 was deemed not capable to care for herself and needed assistance with medication management. The DON stated that resident 30's mother had stated that resident 30 was non-compliant with her medications. The DON stated that resident 30 had moments of clarity with confusion, but was able to make her own decisions. The DON stated that when she questioned resident 30 about the incident that occurred on 8/23/24 the resident gave the same explanation of the events, was content with it, and was happy with it. The DON stated that resident 30 was fine with the other resident touching her. The DON stated that resident 30 had episodes of mania, with some sexual behaviors such as believing she was having sex with famous people and having children with them. The DON stated that resident 30 never made sexual comments about other residents. The DON stated that when she evaluated resident 30 for the capacity to consent to sexual activity she asked resident 30 if she knew that she could get hurt if she invited other people to touch her. The DON stated that resident 30 stated she understood. The DON stated that at the time of the evaluation resident 30 was able to recall what she did prior to being admitted to the facility and that she had been admitted to a psychiatric inpatient unit. The DON stated that resident 30 understood that she could not go home. The DON stated that during the sexual capacity to consent evaluation she told resident 30 that her sexual activity and verbal comments were inappropriate and could invite other people to do stuff with her. The DON stated that she asked resident 30 if she was okay with that and could she handle that, i.e. the sexual activity. The DON stated that resident 30 replied that she was alright with that behavior. It should be noted that the evaluation did not specify what risks were associated with sexual activity and if resident 30 was able to understand those risks and the consequences of them. Additionally, the evaluation did not demonstrate that resident 30 had the cognitive ability to consent to sexual activity, only that she appeared to want the contact. The DON stated that the RA signed the evaluation form with her but was not present during the evaluation. The DON stated that no one else was present with her during resident 30's evaluation for capacity to consent to sexual activity. The DON stated that resident 30 had delusions with moments of clarity at the time of the evaluation. The DON stated that resident 30's cognitive ability had declined since the incident.

Based on interview and record review it was determined, for 1 out of 20 sampled residents, that the facility did not ensure that alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and the State Survey Agency (SSA). Specifically, an allegation of sexual abuse was not reported to the state survey agency for approximately 12 hours after the incident occurred. Resident identifiers: 30 and 41. Findings included:Resident 30 was admitted to the facility on [DATE] with diagnoses which consisted of Schizoaffective disorder bipolar type, cocaine dependence, and drug induced subacute dyskinesia. On 10/6/25 through 10/8/25, resident 30's medical records and the facility abuse investigation were reviewed. The facility abuse investigation documentation was reviewed. The Form 358 documented that the nurse on shift, Registered Nurse (RN) 1, Around 0200 [2:00 AM] hours on 08/23/2024. [RN 1] the Nurse on Duty noticed that [Resident 41's] walker was outside of the main bathroom, so [RN 1] went to see what was going on. When [RN 1] got there, he found [Resident 41] kissing one female resident [Resident 30] with his right hand on her left breast, on top of her clothing. The Form 358 documented that the SSA was notified of the incident on 8/23/24 at 2:13 PM. It should be noted that this was 12 hours after the incident occurred. On 10/07/25 at 2:41 PM, an interview was conducted with the Administrator (ADM). The ADM stated that he and the Resident Advocate (RA) worked together on the abuse investigations. The ADM stated that he typically filled out the form and submitted it to the State Survey Agency (SSA). If he was not present then the RA would submit it on his behalf. The ADM stated he did not indicate sexual abuse as an allegation when it was reported to the SSA because it was consensual sexual behavior. On 10/08/25 at 1:54 PM, a follow-up interview was conducted with the ADM. The ADM stated that the incident was not reported to the SSA immediately because there was no harm or serious bodily injury. [Cross-refer F600]

Number of residents sampled: 20Number of residents cited: 0 Based on interview and record review, it was determined the facility did not ensure that any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, was competent to provide nursing and nursing related services; and completed a training and competency program, or a competency evaluation program approved by the State. Specifically, a Nurse Assistant (NA) was employed at the facility on a full-time basis, for approximately 9 months without completion of training and competency evaluation program. Findings included:On 10/6/25, a list of employees with their start date was requested from the facility Administrator.NA 1's employee file was reviewed and documented with a start date of 10/17/23, as a housekeeper.On 10/8/25 at 1:17 PM an interview with the Director of Nursing (DON) was conducted. The DON stated that NA 1 started in housekeeping, they trained her initially as a hospitality aide, and continued her training to be a CNA. The DON stated that NA 1 completed her clinical nursing assistant training in May 2024. The DON stated that NA 1 still needed to complete her classroom hours before she could take the exam. The DON stated that NA 1 was scheduled and worked as a full-time nursing assistant since January of 2025.

Based on record review and interview, the facility did not ensure that the resident assessment accurately reflected the resident's status. Specifically, for 3 out of 20 sampled residents, the facility coded a resident as having received insulin during the seven day Minimum Data Set (MDS) observation period when the resident had not received any insulin. Resident Identifiers: 2, 7, and 28.1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included secondary parkinsonism, disorder of brain, schizoaffective disorder, depressive type, personality disorder, and type 2 diabetes mellitus. Review of resident 2's medical record was completed on 10/6/25 through 10/8/25. Resident 2's Quarterly Minimum Data Set (MDS) assessment dated [DATE], was reviewed. The MDS assessment documented that Resident 2 received insulin on one of seven days of the seven-day lookback observation period. Resident 2's Quarterly MDS assessment dated [DATE], was reviewed. The MDS assessment documented that Resident 2 received insulin on one of seven days of the seven-day lookback observation period. Resident 2's Quarterly MDS assessment dated [DATE], was reviewed. The MDS assessment documented that Resident 2 received insulin on one of seven days of the seven-day lookback observation period. Resident 2's order history was reviewed. There were no orders for insulin after 10/1/24. Resident 2's Medication Administration Record (MAR) was reviewed. There was no documentation that Resident 2 had received any insulin after 10/1/24. 2. Resident 7 was admitted to the facility on [DATE] with diagnoses which included disorder of brain, schizoaffective disorder, bipolar type, and type 2 diabetes mellitus. Review of resident 7's medical record was completed on 10/6/25 through 10/8/25. Resident 7's Quarterly MDS assessment dated [DATE], was reviewed. The MDS assessment documented that Resident 7 received insulin on one of seven days of the seven-day lookback observation period. Resident 7's Quarterly MDS dated [DATE], was reviewed. The MDS assessment documented that Resident 7 received insulin on one of seven days of of the seven-day lookback period. Resident 7's order history was reviewed. There were no orders for insulin after 10/1/24. Resident 7's Medication Administration Record (MAR) was reviewed. There was no documentation that Resident 7 had received any insulin after 10/1/24. On 10/8/25 at 1:04 PM, an interview with the Director of Nursing (DON) was conducted. The DON stated that she was the person that completes and submits the MDS reports. The DON stated that none of the residents in the facility were ordered insulin. The DON stated there were three residents that had a physician's order for Ozempic. However, resident 28 orders were recently discontinued. The DON stated that for residents 2 and 7 they were ordered to receive one Ozempic injection once a week. The DON stated that Ozempic was considered an insulin since it was injected and it is like a long-acting thing that controls blood sugar. According to the Ozempic website, Non-insulin Ozempic works with your body's own ability to lower blood sugar and [glycated hemoglobin] A1C. Ozempic helps your body release its own insulin. And it's designed to respond when your blood sugar rises. https://www.ozempic.com/faqs.html 3. Resident 28 was admitted to the facility on [DATE] with diagnoses including, but not limited to disorders of brain, schizoaffective disorder bipolar type, and idiopathic gout. A review of Resident 28's medical record was completed from 10/6/25 through 10/8/25. Resident 28's Quarterly MDS dated [DATE], was reviewed. The MDS assessment documented that Resident 28 received insulin on one of seven days of the seven-day lookback period. Resident 28's Quarterly MDS dated [DATE], was reviewed. The MDS assessment documented that Resident 28 received insulin on one of seven days of the seven-day lookback period. Resident 28's Annual MDS dated [DATE], was reviewed. The MDS assessment documented that Resident 28 received insulin on one of seven days of the seven-day lookback period. Resident 28's order history for the last year was reviewed. Resident 28 did not have any orders or previous orders for insulin. Resident 28's Medication Administration Record (MAR) for the last year was reviewed. There was no documentation that Resident 28 had received any insulin. On 10/8/25 at 7:47 AM, an interview with Licensed Practical Nurse (LPN) 1 was conducted. LPN 1 stated that currently there are no residents in the facility on insulin.

Based on interview, record review, and observation, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, cross contamination was observed in the kitchen during the dish cleaning process, the dishmachine did not reach the appropriate temperature, meals were not served appropriately, and multiple areas of the kitchen were observed to be soiled or in disrepair. Resident identifiers: 4 and 11. Findings include: 1. On 9/26/22 at 7:00 AM, Dietary Staff Member (DSM) 1 was observed in the kitchen next to the steam table area containing food. DSM 1 did not have a mask on. On 9/26/22 at 7:15 AM, an interview was conducted with DSM 1. DSM 1 stated that he did not like to wear masks because they were itchy. 2. On 9/26/22 at 7:05 AM, the dining area was observed. Multiple residents were observed to have been served a portion of bread crumbs, including residents 4 and 11. On 9/26/22 at approximately 7:20 AM, an interview was conducted with DSM 1. DSM 1 stated that if residents were on a mechanical soft diet, and there was bread on the menu, he would toast the bread and then blend it up to make bread crumbs to serve the residents. DSM 1 then stated that he had a list of the therapeutic menus, and how to adjust the menu for residents on a mechanical diet. The list was subsequently reviewed, and indicated that if a resident was on a mechanical soft diet, no adjustments were required to the bread. 3. On 9/26/22 at approximately 7:10 AM, an observation was made of the facility kitchen. The following observations were made: a. A large gouge on the counter in the dry storage area rendered the counter unsanitizable. The gouge was approximately 2 inches long and 1 inch high. b. The freezer in the dry storage area had a stack of approximately 6 small tortillas on the shelf. The tortillas were not in any container, but were completely open to air. c. The freezer in the dry storage area had a pie crust on the shelf that was open to air. d. The refrigerator in the dry storage area had 8 containers of an unknown substance that appeared to be pudding. The containers were not labeled or dated. e. The container of powdered milk had a scoop hung on the outside of it. The scoop was touching the shelving below it. The shelving was observed to have dust and grime on it. f. The microwave was observed to have spills and debris on it, both inside and out. g. The conduits next to the ice machine were observed to have dust and grime on them. 4. On 9/26/22 at approximately 7:15 AM, the dishmachine was observed. The dishmachine had instructions on the top portion of it, indicating that both the wash and rinse cycle needed to reach 120 degrees Fahrenheit (F). At 7:15 AM, the dishmachine was observed to reach a temperature of 80 degrees Fahrenheit (F) for the wash cycle, and 85 degrees F for the rinse cycle. After the wash and rinse cycles were complete, Dietary Staff Member (DSM) 1 was observed to open the machine, and pull the tray of clean dishes out of the machine. DSM 1 then went to the other side of the dishmachine and loaded dirty dishes into a tray. DSM 1 then walked to the three compartment sink and put the tips of his contaminated fingers under a stream of water that was going down into a container of thawing meat. DSM 1 was then observed to walk to the tray cart, and move it into the dry storage area, without appropriately washing his hands. DSM 1 then began loading soiled dishes into a tray and placed them in the dishmachine. After loading soiled dishes in the tray and starting the dishmachine, DSM 1 was observed to move to the other side of the dishmachine, and pick up clean trays with his contaminated hands, and put the trays away. At this time, the dishmachine was observed to reach a temperature of 89 degrees F for the wash cycle, and 90 degrees F for the rinse cycle. DSM 1 was then observed to open the garbage can lid to throw something away, and then proceed to put away a clean pot and several bowls without first washing his hands. At this time, the dishmachine was observed to reach a temperature of 98 degrees F for both the wash and rinse cycles. The next cycle of dishes was then observed. The dishmachine was observed to reach a temperature of 105 degrees F for the wash cycle, and 110 degrees for the rinse cycle. DSM 1 was observed to load the next load of soiled dishes into the machine, and was then asked what the temperature the dishmachine was supposed to reach. DSM 1 looked at the dishmachine, and stated that the temperature was currently 118 degrees on the wash cycle but that it was supposed to be 120 degrees. When asked what the protocol was for the dishmachine not reaching the correct temperature, DSM 1 stated that I just wash everything twice. The next cycle of dishes was then observed. The dishmachine was observed to reach a temperature of 110 degrees Fahrenheit for both the wash and rinse cycle. On 9/28/22 at 11:00 AM, an interview was conducted with the facility Registered Dietitian (RD). The RD stated that all DSMs are supposed to run the dishmachine until it reaches 120 degrees before processing dishes. The RD also confirmed that the DSMs are supposed to wash their hands between handling soiled dishes, and handling clean dishes. The RD confirmed that bread is not supposed to be placed in the blender to make bread crumbs for residents on a mechanical soft diet. The RD also confirmed that she had seen the uncovered tortillas and uncovered pie on 9/26/22, after the surveyor had entered the kitchen. The RD stated that she had subsequently educated DSM 1 about dishmachine temperatures and appropriate covering of food.

Based on observation and interview it was determined that the facility did not store and distribute food in accordance with professional standards for food service safety. Specifically, there were condiments in a metal baskets on the dining room tables that were not sanitized between meal service. In addition, there was peeling paint in the kitchen. Resident identifiers: 2, 10, 18 and 35. Findings include: 1. On 4/12/21 at 11:53 AM, an observation was made of the dining room. There was a meal schedule hanging in the dining room that revealed there were two meal services in the dining room. Tables were observed with one chair per table, with a caddy container of condiments located in the center of the table. The container included salt, pepper, butter packets, mayonnaise, ketchup and hot sauce. The first dining service began at 11:53 AM. On 4/12/21 at 11:53 AM, an observation was made of residents eating lunch in the dining room. Resident 2 was observed to be sitting at a table with a condiment caddy. Resident 2 was observed to cough toward the condiment caddy. Resident 2 was eating and did not have a mask on. At 12:10 PM, an observation was made of the housekeeping staff wiping the tables. At 12:15 PM, an observation was made of resident 10 sitting at the same table with the same condiment caddy. The condiment caddy had not been sanitized between meal services. On 4/12/21 at 11:53 AM, an observation was made of resident 18. Resident 18 was observed to be eating alone at a table that was set with a condiment caddy. At 12:11 PM, an observation was made of the house keeping staff wiped down the table. At 12:16 PM, resident 35 was observed sitting at a table which had been previously used by resident 18. Resident 35 was observed using the mayonnaise from the condiment caddy. On 4/13/21 at 12:24 PM, Licensed Practical Nurse (LPN) 1 was observed removing condiment caddies from the tables and placing them onto a storage cart without sanitizing condiment containers. On 4/13/21 at 12:33 PM, the cart containing the condiment caddies was observed to be stored within the kitchen. On 4/13/21 at 12:33 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that the condiments and metal baskets were sanitized every night. The DM stated they were not sanitized between meals. 2. On 4/13/21 at 12:25 PM, an observation was made of the facility kitchen. There was paint peeling in the cabinet with the domes that were used to cover the food. The DM was interviewed immediately. The DM stated he had tried to fix the peeling paint in the cabinet a few months ago and it was peeling again.

Based on observation and interview it was determined that the facility did not follow menus that met the nutritional needs of residents in accordance with established national guidelines; were prepared in advance; and reflected the religious, cultural and ethnic needs of the resident population. Specifically, menus were not followed for puree diets. Resident identifiers: 12. Findings include: The facility's puree menu for 4/24/19 at lunch stated the following meal: Pureed Herbed Meatloaf Pureed Au Gratin Potatoes Pureed Winter Mix Vegetables Pureed Roll/margarine Pureed Lemon Bars Beverage 2% Milk On 4/23/19 at 12:03 AM, an observation was made of lunch tray line. Dietary Staff Member (DSM) was observed to plate a scoop of a light tan puree and an off white puree on a plate. DSM placed a dessert on the plate and another dessert on the tray along with drinks. DSM passed the tray to Licensed Practical Nurse (LPN) 1 to serve to the resident. DSM was interviewed. DSM stated that the light tan and off white purees where bread and potatoes. DSM was asked why resident 12 did not have meat on his tray. DSM grabbed the plate, added meat, and stated he had forgotten to serve the puree meat. On 4/24/19 at 7:15 AM, DSM was re-interviewed. DSM was asked why the puree tray observed on 4/23/19 did not have the winter vegetable mix. DSM stated that he forgot the puree vegetable mix for puree meals on 4/23/19. DSM stated that two residents in the facility received puree meals. On 4/24/19 at 7:20 AM, the Registered Dietitian (RD) was interviewed. The RD stated that two her knowledge the residents on puree meals have not lost any weight, however it was still concerning that one tray was sent without meat, and neither was served the vegetables.

Based on interview and record review it was determined that the facility did not establish an infection prevention and control program (IPCP) that included an Antibiotic Stewardship Program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, one resident received an antibiotic without a culture and sensitivity completed and another resident received an antibiotic without visible signs or symptoms (s/s) of infection. Resident identifiers 15 and 24. Findings include: 1. Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/24/19 at 10:21 AM, the facility's infection control tracking was reviewed. Documents revealed that resident 15 on (MONTH) 5 started receiving antibiotic [MEDICATION NAME] 250 milligrams (mg) for Shortness of Breath (SOB). On 4/24/19, resident 15's medical records were reviewed. Medical records revealed that resident 15 was a smoker. Records revealed that resident was assessed to have confusion. A nursing progress note dated 3/4/19 at 2:52 PM revealed the following: (Resident 15) not happy today, w (with) outburst. (Resident 15) denies pain, but co (complained of) being sob. assessment done. (Resident 15) breathing/ resp (respirations) wnl (within normal limits). No sob, no cough. Amb (ambulated) without assisted device without sob. Lungs clear. vital signs (vs) 121/75,hr (heart rate) 70, respiration (r) 18, temp 97.6, RA O2 (oxygen) sats (saturation) of 95%, reassured (resident 15), resp wnl, sats wnl. Bit (sic) res (resident 15) getting anxious et more fixated. MD (Medical Director) notified et (and) ordered CXR (chest x ray). Note from 3/4/19 at 5:24 PM revealed: CXR results back, no abnormality, (Resident 15) et MD notified of results. Taught at (sic) enc (encouraged) res to relax, reassuring breathing/ resp. wnl. Lungs clear, no cough, vs 120/ 74, hr 71, rr 18, temp 97.6, RA O2 sats of 94%. Res stated feeling better. Nursing progress note from 3/5/19 at 11:43 AM revealed following:Resident getting anxious et fixated w (with) her breathing. (Resident 15) no cough. no sob after exertion. RA O@94%. Lungs clear, other vs hr 72, rr18, temp 97.6, bp 118/78. CXR done yesterday came back no abnormality. MD notified of above et ordered [MEDICATION NAME] 250 mg po(per mouth) qd (every day) x 5 days to start at noon today. Resident notified of order et happy w it, more calm. Physician medical visit note from 3/5/19 revealed that resident 15 had : Ongoing complaint of cough. Asking for oxygen although her sats are > (greater than) 90%. CXR negative. Started on empiric treatment with [MEDICATION NAME]. Nonproductive cough, no fever. Denies nasal congestion. Behavior stable. Denies pain, N (nausea)/V(vomiting)/D(diarrhea). Appetite and sleep OK. Denies problems with meds. Per this assessment, resident 15's lungs were expanding symmetrically and they sounded clear. Medication Administration Records (MAR) revealed that the first dose of [MEDICATION NAME] was given on 3/5/19 and the last dose was given on 3/9/19. On 04/24/19 at 10:43 AM, the Director of Nursing (DON) was interviewed. The DON stated that if their residents complained of things such as SOB, burning during urination or started acting differently from their baseline, they would notify physician immediately. The DON stated that very often the facility would make decision about antibiotic usage when they would see that the resident behavior changed. The DON stated that resident 15 had fixations about having SOB. The DON stated that in March, resident 15 complained of SOB, so the nurse did an assessments and notified physician. The DON stated that in (MONTH) staff were unable to redirect resident 15 and she fixated on her SOB, the MD ordered chest X-ray which came negative for any sign of lung infection. The DON stated that resident 15 was very fixated on her SOB so the MD ordered [MEDICATION NAME] to put resident 15's mind at easy. The DON stated that few months ago resident 15 had [MEDICAL CONDITION] and that they gave her an antibiotics, so resident 15 probably thought that she had [MEDICAL CONDITION] again and had to be treated with antibiotics. She stated that as soon as resident 15 was notified about [MEDICATION NAME] order, she stopped talking about SOB and became happier. 2. Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/24/19 at 10:30 AM, resident 24's medical records were reviewed. Medical records revealed that on 1/24/19 resident 24's physician [MEDICATION NAME] mg tablet to be given two times a day (BID) as a [MEDICATION NAME] and until 1/27/19. Nursing progress note dated 1/23/19 revealed that resident 24 was : alert et oriented x2, w confusion, but able to express self. (Resident 24) w increasing behavior, been more withdrawn, refusing cares, refusing to attend activities et wanting to stay in his room, behavior changed from resident usual behavior .MD ordered labs yesterday, MD been notified of results. MD seen resident this am. Per MD labs indicated [MEDICAL CONDITION], et (resident 15) Dementia progressing. No new order at this time. Physician visit note from 1/23/19 revealed that patient has been isolating in his room. Gets his coffee in the morning and then goes back to room. Denies depression, anxiety, pain or physical symptoms. No falls, Labs drawn yesterday show Hct (hematocrit)=39.9, GFR (glomerular filtration rate)=48, but other wise unchanged from admission. (Note: There was no other note found about resident 24's behaviors or S/S for possible infection.) Nursing progress note from 1/23/19 at 3:23 PM revealed that res (resident 24) alert et oriented, w confusion, but been able to express self. Res (resident 24) with increasing behavior, been more withdrawn, refusing cares, refusing to attend activities et wanting to stay in his room, wc behavior changed from resident usual behavior. Res (resident 24) w more (-) comments, stating he doesn't care. MD ordered labs yesterday wc MD been notified of results. MD seen resident this am. Per MD labs indicated CKD, et res (resident 24) dementia progressing. No new order at this time. Nursing progress note from 1/24/19 revealed that: (Resident 24) alert et oriented x2. (resident 24) behavior continue. MD notified et ordered to obtain urine sample, but resident refusing. MD notified et [MEDICATION NAME] mg po bid x 3 days to start this pm until 1/27/19 0800 dose. Ordered [MEDICATION NAME] 100 mg po qd (daily) et track behavior et side effect. Res notified of order, but no reply, then stated ok. Note from 1/25/19 revealed that resident 24 was alert and oriented X 2, appears more agitated with cares this morning. Note from 1/30/19 revealed that resident 24 had occ (occasional confusion, outburst, fixated on things, restlessness, agitated and wandering. Note from 2/9/19 revealed that resident 24 was A/O X2, with confusion, episodes of outburst delusion, hallucination, anxiousness, fixated on things, but behaviors can be redirected with current meds. Treatment Administration Report (TAR) revealed that resident 24's behavior was monitored and that he made negative statements, verbalized sadness and refused to leave room [ROOM NUMBER] to 3 times per shift in January, 2019. TAR for (MONTH) 2019 revealed that resident 24 did not have any episodes of verbalizing sadness, negative statements and isolating self into a room. In their attachment provided on 4/29/19 at 2:59 PM, the facility included bowel and bladder program screener for resident 24 done on 12/3/18. Per this screener, resident 24 voids appropriately without incontinence-not always, but at least daily, was confused, needs prompting. The continence evaluation done on 12/3/18 revealed that one of the [DIAGNOSES REDACTED]. On 04/24/19 at 10:43 AM, the DON was interviewed. The DON stated that if residents complained of things such as SOB, burning during urination or started acting differently from their baseline, they would notify physician immediately. The DON stated that majority of residents were residents with mental disturbances and that they could refuse urine, blood samples or other means of testing's required to rule out or confirm an infections. The DON stated that very often the facility would make decision about antibiotic usage when they would see that the resident behavior changed. The DON stated that regarding resident 24's antibiotic usage, on (MONTH) 24 his behavior changed. The DON stated that he was more agitated and restless. She stated that at the same day they [MEDICATION NAME] to address his behaviors such as negative comments, sadness, refusal to leave his room. The DON stated that this kind of behavior was not normal for resident 24 so they thought that he could have an UTI. The DON stated that resident 24 refused to give urine for Urinary Analysis (UA), so the MD [MEDICATION NAME] a [MEDICATION NAME]. The DON stated their [MEDICATION NAME] regimen consisted of shorter dosages and if symptoms did not resolve, then they would do a follow up with the doctor who would usually or change medications or would prescribe longer usage of antibiotics. She stated that they did not want to order only [MEDICATION NAME] for resident 24's behavior because that could mask his possible UTI infection. The DON stated that after resident 24 started taking [MEDICATION NAME] and Cipro, staff noticed that resident 24's depressive statements resolved, so the infection was ruled out [MEDICATION NAME] given only till 1/27/19. The DON stated that the facility tried not to use [MEDICAL CONDITION] medications to manage residents behaviors so would start antibiotic treatments first and per the MD's orders. On 4/24/19 at 11:00 AM, an Antibiotic Stewardship Policy was reviewed. Section 4 on the policy stated that: If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the elements such as drug name, dose, frequency of administration (start and stop date, number of days of therapy), route of administration and indication of use. Section 8 of the policy revealed that: When a culture and sensitivity (C&S) or other diagnostic tests are ordered, test results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified or discontinued.

Based on observation, interview, and record review, it was determined that the facility did not store, prepare, distribute, and serve food under sanitary conditions. Specifically, items stored in the kitchen refrigerator were uncovered and open items were lacking open dates. Findings Include: On 4/22/19 at 7:20 AM, the following observations were made during an initial tour of the kitchen. a. A 8 pound open container of salsa was lacking an open date in the refrigerator. b. A 5 pound container of sour cream was lacking an open date in the refrigerator. c. A large bowl of a pink mixture was uncovered on the bottom of the refigerator. d. A small plastic cup containing two peeled hard boiled eggs was uncovered in the small black refrigerator. Dietary Staff Member (DSM) was immediatley interviewed and confirmed that there were no open dates on the salsa or sour cream. DSM stated that they were likely opened last week. On 4/24/19 at 7:20 AM, the Registered Dietitian (RD) was interviewed. The RD stated that the sour cream and salsa should have had open dates and that both items were disposed of. The RD stated that the dessert and hard boiled eggs should have been covered.

Based on observation, interview and record review, it was determined the facility did not implement the comprehensive person-centered care plan for 3 of 15 sample residents. Specifically, pain assessments were not completed as care planned. Resident identifiers: 9, 11 and 21. Findings include: 1. Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/19/17 at 9:36 AM, an interview was conducted with resident 21. Resident 21 was laying in bed on his right side. Resident 21 stated that he had chronic pain from his low back down to his toes. Resident 21 stated that his pain was from an old injury but had no fractures. Resident 21 stated that his pain was rated at an 8 but that his pain did not prevent him from going out with his family or participating in activities of his choosing. Resident 21's medical record was reviewed on 12/19/17. A quarterly Minimum Data Set (MDS) assessment was completed by the facility staff on 11/7/17. The facility staff assessed resident 21 as having moderate cognitive impairment and having occasional pain. The facility staff did not document a pain score. An Alteration in comfort level care plan was developed on 8/7/17 related to resident 21's general weakness, limited mobility and complaints of lower extremity pain. The goal developed was that resident 21 would have no unrelieved signs or symptoms of pain or discomfort. The interventions developed to achieve the goals included: (1) Assess resident for s/s (signs of symptoms) of pain ? verbalizing pain/moaning/facial grimace/affecting residents function/affecting participation in cares; (2) Assess situation/contributing factors and implement interventions and evaluate effectiveness; (3) Anticipate cause of pain if care being provided ? administer medications prior to care as ordered; . (4) Meds (medications) as ordered. Review of the physician's orders [REDACTED]. The Medication Administration Records (MARs) from 10/1/17 through 12/19/17 were reviewed. There was no documentation that the licensed nursing staff assessed resident 21's pain as care planned. Review of the electronic progress notes revealed no documentation that the licensed nursing staff documented resident 21's level of pain, location, or severity. On 12/19/17 at 9:42 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 21 had chronic low back pain which resident 21 rated between 7-8 on a scale of 1-10 LPN 1 stated that she did not assess or document resident 21's level of pain. On 12/19/17 at 9:57 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that pain assessments were completed quarterly. The DON further stated that all other pain assessments would have been documented in a progress note. 2. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/18/17 at 10:41 AM, an interview was conducted with resident 9. Resident 9 stated that stated that she had [MEDICAL CONDITION] arthritis and was in a lot of pain in the mornings. Resident 9 stated that the Tylenol ordered for her pain did not alleviate the pain. Resident 9 stated she was in pain currently and that it hurt to move around. Resident 9's medical record was reviewed on 12/19/17. An Admission MDS dated [DATE] revealed that resident 9 complained of occasional pain. The MDS revealed that resident 9's pain did not prevent her from sleeping or day to day activities. There was no pain score documented on the MDS. A care plan dated 10/3/17 revealed Alteration in comfort. CO (complaints of) pain/moaning/facial grimacing/groaning/restlessness/agitations. The goal developed was, No ss (signs or symptoms) unrelieved pain/discomfort TNR (through next review). Some interventions developed were, Assess resident for s/s of pain ? (sic) verbalizing pain/moaning/facial grimace/affecting residents function/affecting participation in care and report to MD of any unrelieved ss pain, difficulty, discomfort. A physician's orders [REDACTED]. There were no other current orders for pain medication. A review of resident 9's MAR for November and December 2017 revealed that resident 9 was administered Tylenol according to physician's orders [REDACTED]. A review of resident 9's progress notes revealed no pain assessments. A Medical Visit dated 11/29/17, . Pain is well-managed and .Peripheral [MEDICAL CONDITION]/Chronic pain: Continue [MEDICATION NAME]. (Note: Resident 9 had [MEDICATION NAME] and [MEDICATION NAME] discontinued on 11/1/17 according to physician's orders [REDACTED]. On 12/19/17 at approximately 12:30 PM, an interview was conducted with LPN 1. LPN 1 stated that resident 9 had not complained of pain. LPN 1 stated that she did not document pain scores or assessments unless a resident complained of pain. On 12/19/17 at approximately 12:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 9 was admitted to the facility with physician orders [REDACTED]. The DON stated that the pain medications were discontinued and resident 9's physician ordered Tylenol. The DON stated that pain scores and assessments were not documented according to resident 11's care plan. 3. Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/18/17 at 9:57 AM, an interview was conducted with resident 11. Resident 11 was observed to rub her shoulder and stated that her shoulder hurt. Resident 11 stated that she was given Tylenol for her pain and the Tylenol did not relieve her pain. Resident 11 stated that she was sick with a sore throat and cough. Resident 11 was observed to be coughing. On 12/19/17 at approximately 8:30 AM, a follow up interview was conducted with resident 11. Resident 11 stated that she had been coughing and had a sore throat with ear pain throughout the previous night. Resident 11 stated that her shoulder was hurting and that anytime she moved her shoulder she experienced pain. Resident 11 stated her shoulder pain was from a 4 to a 10 at times using a pain scale of 1 for no pain and 10 for severe pain. Resident 11's medical record was reviewed on 12/19/17. An Admission MDS dated [DATE] revealed that resident 11 complained of pain in the last 5 days. The MDS revealed that she was not administered pain medication as needed. The MDS revealed that non-pharmalogical interventions were not used. The MDS further revealed no pain scale number. A care plan dated 9/26/17 revealed resident 11 had Alteration in comfort level related to confusion, behavior problems, drug seeking behavior, poor safety judgement, general weakness, high fall risk, and limited mobility. The goal developed was No unrelieved ss pain/discomfort TNR. An intervention developed was Assess resident for s/s pain ? (sic) verbalizing pain/moaning/facial grimace/affecting residents function/affecting participation in cares. A physician's orders [REDACTED]. A review of resident 11's October, November and December 2017 MAR indicated [REDACTED]. A review of resident 11's nursing progress notes revealed no information regarding a pain assessment. A Medical Visit dated 11/22/17 revealed, . C/o right shoulder pain and leg pain, no recent injury, chronic complaint. Asking for narcotics. and .Chronic pain: Continue [MEDICATION NAME], off [MEDICATION NAME]. Patient with med-seeking behavior. On 12/19/17 at 8:53 AM, an interview was conducted with LPN 1. LPN 1 stated that resident 11's night nurse stated to LPN 1 in report on 12/18/17 that resident 11 did not feel well. LPN 1 stated that resident 11 was receiving Tylenol 1000 milligrams twice daily. LPN 1 stated that resident 11 had not complained of pain. LPN 1 stated that resident 11 had not been feeling well on 12/19/17 because she had a cold. LPN 1 stated that resident 11 complained of minimal pain to her shoulder. LPN 1 stated that she did not document resident 11's pain scores. On 12/19/17 at approximately 12:30 PM, an interview was conducted the DON. The DON stated that resident 11 complained of back pain after admission to the facility but had not complained about other pain. The DON stated that resident 11's pain levels were not tracked or assessed per the care plan. (Cross refer to F697)

Based on observation, interview and record review, it was determined the facility did not ensure that pain management was provided consistent with the care plan of 3 of 15 sample residents. Specifically, pain assessments were not completed as care planned. Resident identifiers: 9, 11 and 21. Findings include: 1. Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/19/17 at 9:36 AM, an interview was conducted with resident 21. Resident 21 was laying in bed on his right side. Resident 21 stated that he had chronic pain from his low back down to his toes. Resident 21 stated that his pain was from an old injury but had no fractures. Resident 21 stated that his pain was rated at an 8 but that his pain did not prevent him from going out with his family or participating in activities of his choosing. Resident 21's medical record was reviewed on 12/19/17. A quarterly Minimum Data Set (MDS) assessment was completed by the facility staff on 11/7/17. The facility staff assessed resident 21 as having moderate cognitive impairment and having occasional pain. The facility staff did not document a pain score. An Alteration in comfort level care plan was developed on 8/7/17 related to resident 21's general weakness, limited mobility and complaints of lower extremity pain. The goal developed was that resident 21 would have no unrelieved signs or symptoms of pain or discomfort. The interventions developed to achieve the goals included: (1) Assess resident for s/s (signs of symptoms) of pain ? verbalizing pain/moaning/facial grimace/affecting residents function/affecting participation in cares; (2) Assess situation/contributing factors and implement interventions and evaluate effectiveness; (3) Anticipate cause of pain if care being provided ? administer medications prior to care as ordered; . (4) Meds (medications) as ordered. Review of the physician's orders [REDACTED]. The Medication Administration Records (MARs) from 10/1/17 through 12/19/17 were reviewed. There was no documentation that the licensed nursing staff assessed resident 21's pain as care planned. Review of the electronic progress notes revealed no documentation that the licensed nursing staff documented resident 21's level of pain, location, or severity. On 12/19/17 at 9:42 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 21 had chronic low back pain which resident 21 rated between 7-8 on a scale of 1-10. LPN 1 stated that she did not assess or document resident 21's level of pain. On 12/19/17 at 9:57 AM. an interview was conducted with the Director of Nursing (DON). The DON stated that pain assessments were completed quarterly. The DON further stated that all other pain assessments would have been documented in a progress note. 2. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/18/17 at 10:41 AM, an interview was conducted with resident 9. Resident 9 stated that she had [MEDICAL CONDITION] arthritis and was in a lot of pain in the mornings. Resident 9 stated that the Tylenol ordered for her pain did not alleviate the pain. Resident 9 stated she was in pain currently and that it hurt to move around. Resident 9's medical record was reviewed on 12/19/17. An Admission MDS dated [DATE] revealed that resident 9 complained of occasional pain. The MDS revealed that resident 9's pain did not prevent her from sleeping or day to day activities. There was no pain score documented on the MDS. A care plan dated 10/3/17 revealed Alteration in comfort. CO (complains of) pain/moaning/facial grimacing/groaning/restlessness/agitations. The goal developed was, No ss (signs or symptoms) unrelieved pain/discomfort TNR (through next review). Some interventions developed were, Assess resident for s/s of pain ? (sic) verbalizing pain/moaning/facial grimace/affecting residents function/affecting participation in care and report to MD of any unrelieved ss pain, difficulty, discomfort. A physicians order dated 11/1/17 revealed to administer Tylenol 500 mg 2 tablets twice daily. There were no other current orders for pain medication. A review of resident 9's MAR for November and December 2017 revealed that resident 9 was administered Tylenol according to physician's orders [REDACTED]. A review of resident 9's progress notes revealed no pain assessments. A Medical Visit dated 11/29/17, . Pain is well-managed and . Peripheral [MEDICAL CONDITION]/Chronic pain: Continue [MEDICATION NAME]. (Note: Resident 9 had [MEDICATION NAME] and [MEDICATION NAME] discontinued on 11/1/17 according to physician's orders [REDACTED]. On 12/19/17 at approximately 12:30 PM, an interview was conducted with LPN 1. LPN 1 stated that resident 9 had not complained of pain. LPN 1 stated that she did not document pain scores or assessments unless a resident complained of pain. On 12/19/17 at approximately 12:30 PM, an interview was conducted with the DON. The DON stated that resident 9 was admitted to the facility with physician orders [REDACTED]. The DON stated that the pain medications were discontinued and resident 9's physician ordered Tylenol. The DON stated that pain scores and assessments were not documented daily. The DON stated that she performed rounds with each residents weekly and resident 9 had not complained of pain on 12/15/17 when her rounds were done. The DON stated that she did not document the discussion with resident 9. 3. Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/18/17 at 9:57 AM, an interview was conducted with resident 11. Resident 11 was observed to rub her shoulder and stated that her shoulder hurt. Resident 11 stated that she was given Tylenol for her pain and the Tylenol did not relieve her pain. Resident 11 stated that she was sick with a sore throat and cough. Resident 11 was observed to be coughing. On 12/19/17 at approximately 8:30 AM, a follow up interview was conducted with resident 11. Resident 11 stated that she had been coughing and had a sore throat with ear pain throughout the previous night. Resident 11 stated that her shoulder was hurting and that anytime she moved her shoulder she experienced pain. Resident 11 stated her shoulder pain was from a 4 to a 10 at times using a pain scale of 1 for no pain and 10 for severe pain. Resident 11's medical record was reviewed on 12/19/17. An Admission MDS dated [DATE] revealed that resident 11 complained of pain in the last 5 days. The MDS revealed that she was not administered pain medication as needed. The MDS revealed that non-pharmacological interventions were not used. The MDS further revealed no pain scale number. A care plan dated 9/26/17 revealed resident 11 had Alteration in comfort level related to confusion, behavior problems, drug seeking behavior, poor safety judgement, general weakness, high fall risk, and limited mobility. The goal developed was No unrelieved ss pain/discomfort TNR. An intervention developed was Assess resident for s/s pain ? (sic) verbalizing pain/moaning/facial grimace/affecting residents function/affecting participation in cares. A physicians order dated 9/26/17 revealed APAP ([MEDICATION NAME]) extra strength tablet 500 mg give 2 tablets twice daily. A review of resident 11's October, November and December 2017 MAR indicated [REDACTED]. A review of resident 11's nursing progress notes revealed no information regarding a pain assessment. A Medical Visit dated 11/22/17 revealed, . C/o right shoulder pain and leg pain, no recent injury, chronic complaint. Asking for narcotics. and . Chronic pain: Continue [MEDICATION NAME], off [MEDICATION NAME]. Patient with med-seeking behavior. On 12/19/17 at 8:53 AM, an interview was conducted with LPN 1. LPN 1 stated that resident 11's night nurse stated to LPN 1 in report on 12/18/17 that resident 11 did not feel well. LPN 1 stated that resident 11 was receiving Tylenol 1000 mg twice daily. LPN 1 stated that resident 11 had not complained of pain. LPN 1 stated that resident 11 had not been feeling well on 12/19/17 because she had a cold. LPN 1 stated that resident 11 complained of minimal pain to her shoulder. LPN 1 stated that she did not document resident 11's pain scores. On 12/19/17 at approximately 12:30 PM, an interview was conducted the DON. The DON stated that resident 11 complained of back pain after admission to the facility but had not complained about other pain. The DON stated that resident 11 was on [MEDICATION NAME] and had problems with cognition. The DON stated that the resident's family wanted the resident to discontinue from [MEDICATION NAME] and use another pain medication. The DON stated that the physician ordered Tylenol for resident 11. The DON stated that she was not aware that resident 11 had a cough and complained of pain in her shoulder. The DON stated she did not know about the pain in her shoulder that the physician documented in his visit notes on 11/22/17. The DON stated that resident 11's pain levels were not tracked regularly. The facility Policy and Procedure for Pain was reviewed and revealed the following: Pain - Clinical Protocol Assessment and Recognition 1. The physician and staff will identify individuals who have pain or who are at risk for having pain. a. This includes a review of each person's known [DIAGNOSES REDACTED]. b. It also includes a review for any treatments that the resident currently is receiving for pain, including complementary (non-pharmacological) treatments. 2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. 3. The staff and physician will identify the nature (characteristics such as location, intensity, frequency, pattern, etc) and severity of pain. a. Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. b. The staff will observe the resident (during rest and movement) for evidence of pain; for example, grimacing while being repositioned or having a wound dressing changed. 4. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example, wound care, ambulation, or repositioning. 5. The staff and physician will also evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, including complications such as gait disturbances, social isolation, and falls. Cause Identification 1. The physician will help identify causes of pain; for example, by example, by examining the resident directly, reviewing the resident's history, and via discussion with the resident and staff. a. 2. As part of the medical assessment, the physician will help identify the extent to which underlying causes of pain can be addressed or reversed. 3. The physician will perform or order appropriate tests as needed to help clarify sources pain. For example, an x-ray may help to identify the cause of joint pain. Treatment/Management 1. With input from the resident and/or advocate, the physician and staff will establish goals of pain treatment; for example, freedom from pain with minimal medication side effects, less frequent headaches, or improved functioning, mood, and sleep. 2. The physician will order appropriate non-pharmacological and medication interventions to address the individual's pain. a. Pain medication should be selected based on pertinent treatment guidelines. 3. The staff will evaluate and report how much and how often the individual asks for PRN pain medication. a. Depending on the severity and location of the pain, the physician may start with PRN pain doses or supplements standing doses with PRN doses for breakthrough pain. b. If there are more than occasional [MEDICATION NAME] requests, and depending on the success of non-pharmacological interventions, the physician will consider changing to regular administration of at least one [MEDICATION NAME] with another medication for PRN use, increasing the standing dose of an existing [MEDICATION NAME], or switching to another [MEDICATION NAME]. 4. Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions;. 5. Monitoring 1. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. a. For example, review frequency and intensity of pain, ability to perform activities of daily living (ADLs), sleep pattern, mood, behavior, and participation in activities. 2. Periodically the physician will evaluate and summarize the status of an individual with chronic or fluctuating pain including the status of any active conditions what exacerbate pain, consequences or complications for pain, and effectiveness of current interventions for pain. 3. The staff will discuss significant changes in levels of comfort with the Attending Physician who will consider adjusting interventions accordingly. a. This may include non-pharmacological measure and adjustments of regular and PRN [MEDICATION NAME] doses to fine the best combination of effectiveness and tolerable side effects. 4. The staff and physician will monitor for adverse effects of pain medications such as [MEDICAL CONDITION] from nonsteroidal anti-[MEDICAL CONDITION] drugs. a. 5. If the resident's pain is complex or not responding to standard interventions, the Attending Physician may consider a psychiatric evaluation or referral to a pain clinic or specialist. a. 6. If pain is stable and the underlying cause is resolved or it is unclear whether a source of pain remains, the physician will consider a trail reduction or elimination of [MEDICATION NAME] medication; for example, reduce the standing dose of an [MEDICATION NAME] and see if there is any change in pain-related symptoms or use of PRN [MEDICATION NAME]. a. The physician should document periodically why reduction of [MEDICATION NAME] is not feasible. It should be more explicit than just assuming that the absence of pain symptoms implies the need for indefinite [MEDICATION NAME] administration. Sometimes a trial tapering or discontinuation of [MEDICATION NAME] is indicated to determine if current medications or doses are still needed. (Cross refer to F656)

Based on interview and record review it was determined that the facility did not maintain medical records on each resident that were accurately documented. Specifically, there were two residents that were not receiving medications that the physician documented in the medical visit that were discontinued. Resident identifiers: 9 and 11. Findings include: 1. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9's medical record was reviewed on 12/19/17. A Medical Visit dated 11/29/17, .Pain is well-managed and .Peripheral [MEDICAL CONDITION]/Chronic pain: Continue [MEDICATION NAME]. (Note: Resident 9's [MEDICATION NAME] and [MEDICATION NAME] were discontinued on 11/1/17 according to physician's orders.) On 12/9/17 at approximately 12:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she did not know why resident 9's physician documented that resident 9 was receiving the pain medications that had been discontinued. 2. Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/19/17 at approximately 1:00 PM, an interview was conducted with resident 11. Resident 11 stated that she had pain in her shoulder when she moved it. Resident 11 stated that she had not had patches or creams for her shoulder since admission to the facility. Resident 11's medical record was reviewed on 12/19/17. A Medical Visit dated 10/25/17 revealed, .Chronic pain. C/O (complains of) right shoulder pain. and the summary of findings were .Chronic pain: Continue [MEDICATION NAME]. (Note: There were no physician's orders for the patches in resident 11's medical record.) On 12/9/17 at approximately 12:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 11 did not have patches for shoulder pain. The DON stated that resident 11 did not complain of shoulder pain. The DON stated that she did not know why resident 11's physician documented to continue the [MEDICATION NAME].

Based on observation, interview, and record review, it was determined that the facility did not maintain an effective pest control program so that the facility was free of pests and rodents. Specifically, multiple observations were made of various types of pests in the facility. Findings included: 1. On 8/1/16 at approximately 7:05 AM, an initial facility tour was conducted. An observation was made of multiple flies inside the facility, next to the patio door. Another observation was made of a Box Elder Beetle on the ceiling in the hallway between rooms 9 and 10. 2. On 8/2/16 at 8:11 AM, a black spider was observed in the staff bathroom. At 3:00 PM, an observation was made of the stairs located off of the main dining room to the basement. There was a spider web with a spider and an egg sac. 3. On 8/3/16 at 7:00 AM, an observation was made of the window sills in rooms 10, 11, and 12. There were multiple small, black beetle-like insects on the window sills of all three rooms. At 7:05 AM, an earwig was observed in the hallway near the facility entrance. At 7:28 AM, observations were made of multiple dead insects on the east window of the supply storage room. At this time observations were also made of multiple spider webs on the emergency water barrels in the supply storage room. At 8:51 AM, two black spiders were observed in the staff bathroom, one approximately the size of a dime and one approximately the size of a quarter. At 10:40 AM, an observation was made of a fly in the Director of Nursing's (DON) office. At 11:00 AM, an observation was made of a brown spider, approximately the size of a dime, on the floor of the supply storage room. 4. On 8/3/16 at approximately 10:30 AM, the Corporate Resource Nurse (CRN) furnished three receipts for a local pest extermination company. The dates of service for extermination were 6/30/15, 8/5/15, and 9/8/15. 5. On 8/3/16 at approximately 10:45 AM, the Maintenance Resource (MR) and Maintenance Technician (MT) were interviewed. The MT stated that there is not a regular schedule for the exterminator services, but that if he received complaints of pests, then he called the company to come treat the building. The MT stated that the last time the exterminator treated the building was in September 2015. The MR and the MT did not believe that there was a facility policy regarding pest control and deferred that question to the DON. 6. On 8/3/16 at approximately 11:30 AM, the DON furnished a Policy Statement which revealed that the facility, .shall maintain an effective pest control program 1. This facility maintain (sic) an ongoing pest control program to ensure that the building is kept free of insects and rodents .

Based on interview, observation, and record review it was determined, for 10 of 26 sample residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, residents assessed by facility staff as requiring supervision while smoking cigarettes were observed to be without supervision, for approximately four minutes, during the smoking breaks. Multiple residents, who were assessed as requiring supervision with smoking, were observed to have cigarette burns in their clothing and one resident was observed to have a yellow nicotine stain and possible burn on the two fingers that held his cigarette. Additionally, chemicals were observed to be left unattended and unsecured on the house keeping cart. The deficient practice identified, in regards to the chemicals, was found to have occurred at a potential for harm and will not be included in the Immediate Jeopardy. Resident identifiers: 12, 17, 18, 23, 25, 27, 29, 43, 45, and 49. NOTICE: Notice of Immediate Jeopardy was given verbally to the Administrator on 5/27/15 at approximately 2:00 PM. The Administrator was asked to develop an immediate plan to ensure resident safety related to smoking cigarettes. PLAN: On 5/28/15 at approximately 1:00 PM, the Administrator provided surveyors with a written plan of action to remove the Immediate Jeopardy to the residents in the facility. The written plan dated 5/28/15 stated the following: Dear (name of Long term Care Survey Section Manager), This is our credible allegation of removal of Immediate Jeopardy. We were notified of Immediate Jeopardy in the area of F323 smoking policy violation at 2 PM on 5/27/15. We reviewed with our QA (Quality Assurance) committee and we have implemented the following: F323 Corrective action for residents found to have been affected by this deficiency: All residents who smoke will have an updated smoking assessment evaluation completed 5/27/15. All residents who smoke will have clothing evaluated for burn holes. Clothes will be replaced and plan of care will be updated with appropriate intervention for safe smoking 5/27/15. Supervised smoking assignment will be reassigned and implemented. Corrective action for residents that may be affected by this deficiency: All residents have the potential to be affected by this deficiency. New admissions will have smoking policy educated to them upon admit. Additional activity employee will be hired to increase supervision of the smoking area. Resident council meeting will take place with smoking residents and smoking policy education will occur 5/27/15. Measures that will be put into place to ensure that this deficiency does not recur: Incidents of unsafe smoking will be reported with an incident report and reviewed in stand up meeting with Administrator signature verifying notification. Alert documentation will occur for 72 hours post incident for monitoring. New smoking assessment will be completed and plan of care updated with new interventions. Incidents will be tracked. Continued noncompliance with unsafe smoking by a resident puts others at risk and will be issued with 30 day notice. All staff will be in-serviced on supervised smoking, burn hole reporting with incident report and smoking policy. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: DNS (Director of Nursing Services) or designee will conduct daily audits x (times) 6 weeks on supervised smoking safety, incident reporting, care plan updating and alert charting and report results to the QA (Quality Assurance) Committee. The QA Committee will review each finding and determine the frequency of continued audits and monitoring. We believe that by 5/28/15 at 2 PM we will be able to remove the Immediate Jeopardy on our smoking policy. Prior to leaving the facility on 5/28/15, the surveyors confirmed the components outlined above in the written plan of action had been implemented. During the survey on 5/28/15 the surveyors confirmed removal of the Immediate Jeopardy situation as of 5/28/15. Deficient practice with the potential for more than minimal harm remained for the risk of injury. Findings include: Immediate Jeopardy: A. On 5/26/15 at 10:00 AM, the resident smoke break was observed. Seven facility residents were observed to be outside in the smoking area smoking cigarettes. Residents 17, 23, and 43 were observed to be smoking. Laundry Worker (LW) 1 was observed to pass out cigarettes to the residents and assist the residents with lighting the cigarettes. LW 1 was then observed to go back into the facility and leave the residents unattended for approximately four minutes. LW 1 was observed to come back out to the smoking area and monitor the residents for the remaining time of the smoke break. While LW 1 was supervising the residents, resident 29 was observed to pass the remainder of his cigarette to resident 25. Resident 25 was then observed to finish smoking resident 29's cigarette. No observations were made of facility staff intervening and taking resident 29's cigarette from resident 25 before he finished smoking resident 29's cigarette. On 5/26/15 at 12:30 PM, the resident smoke break was observed. Residents 12, 17, 18, 23, 25, 43, 45, and 49 were observed to be smoking. Housekeeper (Hsk) 1 was observed to assist the residents with lighting the cigarettes. Hsk 1 was observed to go back into the facility and leave the residents unsupervised for approximately four minutes. Hsk 1 was observed to leave the residents unsupervised on multiple occasions during the smoke break. On 5/26/15 at approximately 12:30 PM, residents 17 and 49 were interviewed. Both residents stated that the facility staff were supposed to stay outside and monitor residents during the smoke break. Both residents stated that none of the residents within the facility were to smoke independently. Resident 17 confirmed that he had a cigarette burn in his sweatshirt. Resident 17 was observed to have difficulty holding his cigarette due to tremors in his upper extremities. During the smoke break, resident 43 was observed to pass his partially smoked cigarette to resident 25. Resident 25 was then observed to finish smoking resident 43's cigarette. Resident 49 was then observed to give resident 25 a cigarette to smoke. No observations were made of facility staff assisting resident 25 to light the cigarette. No observations were made of facility staff intervening and taking resident 43's cigarette from resident 25 before he finished smoking resident 43's cigarette. On 5/27/15 at 8:00 AM, the resident smoke break was observed. Residents 12, 18, 23, 25, 43, 45, and 49 were observed to be smoking. Hsk 1 was observed to assist residents with lighting their cigarettes. Hsk 1 was then observed to go back into the facility and leave residents unsupervised for up to two minutes. Resident 49 was observed to give resident 25 a cigarette. Facility staff were not observed to assist resident 25 with lighting the cigarette. Resident 25 was observed to have a yellow nicotine stain on the two fingers that he used to hold the cigarette. Additionally, resident 25 was observed to have a possible burn on one of his fingers that he used to hold the cigarette. On 5/27/15 at approximately 8:00 AM, Hsk 1 was interviewed. Hsk 1 stated that he was supposed to be monitoring residents during the smoke break. Hsk 1 stated that residents should not be left unattended during the smoke break. Hsk 1 further stated that he sometimes left the residents unattended while he took residents back into the building after smoking. On 5/27/15 at 8:20 AM, resident 49 was interviewed. Resident 49 stated that Hsk 1 did not always monitor the residents during the smoke break. Resident 49 stated that Hsk 1 would sometimes go back into the building and monitor residents from the facility Laundry window. On 5/27/15 at 10:00 AM, the resident smoke break was observed. Residents 12, 17, 18, 23, 25, 43, 45, and 49 were observed to be smoking. Hsk 1 was observed to assist residents with lighting their cigarettes. Hsk 1 was observed to go back into the facility on multiple occasions thus leaving the residents unsupervised for up to two minutes. On 5/27/15 the facility SMOKING POLICY was reviewed and revealed the following information: All resident (s) wishing to smoke WILL have a smoking evaluation completed upon admission. Due to the safety of the building and the residents, each resident is to be supervised for smoking to prevent injury. ALL RESIDENT (S) WHO SMOKE: 1. Remember, THIS IS YOUR HOME. 2. Throwing ash and used cigarette butts on the ground WILL NOT BE TOLERATED!!! This creates a fire hazard and safety hazard for other residents in the facility. 3. Use the appropriate ash tray SUPPLIED. 4. SMOKING IS ALLOWED IN DESIGNATED AREAS ONLY!!!! 5. Remember, you have the right to smoke, BUT you need to take responsibility for your smoking and other resident's safety. 6. All lighters/matches and cigarettes must be kept at the nursing station. *This includes e-cigarettes and ALL smoking paraphernalia. 7. State law requires you to smoke outside and 25 ft. (feet) away from any door or window. 8. If I don't have cigarettes to smoke I understand that it is against the smoking policy to ask other residents for their cigarettes. If I am found to be doing this, I will be given the consequence below. 9. If I do not have my own cigarettes, I understand that I am not to disrupt the smoking area/time by asking other residents and/or staff members for a cigarette as it is not anyone else's responsibility to supply me with cigarettes, but mine alone. 10. I understand that I cannot give my cigarettes to any resident. Doing so is against the smoking policy and if I am found to be doing this, I will be given the consequence below. 11. If a staff member suspects that I have smoking paraphernalia in my room, I agree to allow staff to search for the related materials and confiscate them in order to keep the building safe from fire related accidents. The smoking times are as follows: 8:00 AM, 10:00 AM, 12:30 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM The Charge Nurse will pass out the cigarettes at the appropriate times for all smokers and assign a staff member to be with any unsafe smokers. The Staff member will light the cigarettes and monitor from a smoke free distance, and in a designated smoking area. The staff member will return the lighter and cigarettes to the nurses' station when smokers are done. Lighters/matches and cigarettes brought into the facility by family, friends, etc (et cetera). will be turned over to the Nurse to hold for me. 1. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. (Note: An EVALUATION FOR SMOKING form could not be found for resident 12.) Resident 12's Care Plan (CP) initiated on 12/9/14 revealed the following focus, SMOKING UNSAFELY: LOVE TO SMOKE BUT I CANNOT SMOKE SAFELY ALL BY MYSELF. I HAVE BURNED MY CLOTHES. I HAVE BURNED MYSELF. I HAVE DROPPED MY CIGARETTE. I HAVE GIVEN CIGARETTES TO PEOPLE I SHOULDN'T. I HAVE ASKED/BEGGED OTHERS FOR CIGARETTES. I CANNOT LIGHT MY OWN CIGARETTE. I HAVE SMOKED IN MY ROOM. I NEED HELP MANAGING MY CIGARETTES TO LAST ME AN ENTIRE MONTH. 2. Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident 17's medical record revealed the following Evaluation for Smoking form: This is a NO smoking facility, in that there is no smoking allowed within the building. Little Cottonwood Rehabilitation and Nursing has a strong commitment to protect the residents by providing a safe environment. Matches, lighters, cigarettes will be kept at the nurse's station. Smokers will be offered smoking breaks per the attached schedule If the resident does not meet the following criteria, the IDT (Interdisciplinary Team) team will recommend that the resident be on a SUPERVISED SMOKING PROGRAM. This means that the resident will be accompanied by a staff member on smoking breaks. The staff member will light the resident's cigarette and closely supervise resident while smoking to ensure safety, and make sure the resident's cigarette is properly extinguished and disposed of in authorized receptacles. The need for supervised smoking will be re-evaluated at least quarterly at the resident care planning meeting (IDT). Resident 17 was assessed by facility staff as not being able to smoke independently without posing a fire hazard. Facility staff further assessed resident 17 as not being able to smoke safely without burning self, clothing or property. Resident 17's Care Plan (CP) initiated on 10/3/14 and revised on 2/27/15 revealed the following Focus,I LOVE TO SMOKE BUT CANNOT SMOKE SAFELY ALL BY MYSELF. I HAVE BURNED MY CLOTHES. I HAVE DROPPED MY CIGARETTE. I HAVE DISPOSED OF MY CIGARETTE BUTTS INAPPROPRIATELY BY THROWING THEM ON THE GROUND, ACROSS THE FENCE, UNDER THE AC (air conditioning) UNIT, ETC. I DO NOT FOLLOW THE SMOKING TIMES WRITTEN IN THE SMOKING POLICY. I HAVE BEEN FOUND TO KEEP LIGHTER (S) AND CIGARETTES ON MY PERSON; WHICH IS AGAINST THE SMOKING POLICY. I DO NOT FOLLOW THE SMOKING POLICY TO SMOKE 25 FT AWAY FROM THE BUILDING AND HAVE BEEN FOUND SMOKING LESS THAN 25 FT AWAY. The interventions listed were, STAFF WILL MONITOR CIGARETTE FROM TIME LIT UNTIL EXTINGUISHED. GIVE ME A COPY OF THE SUPERVISED SMOKING SCHEDULE. DON'T LET ME KEEP CIGARETTES, MATCHES, OR LIGHTER ON MY PERSON OR IN MY ROOM. IF STAFF CANNOT HELP ME SMOKE, I?D (sic) LIKE THEM TO TELL ME A SPECIFIC TIME THEY CAN GO OUT WITH ME TO SMOKE. REMIND ME OF THE DESIGNATED SMOKING TIMES AND THE SMOKING POLICY. OFFER TO RE-EDUCATED ME IF I FORGET. 3. Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 18 was observed during the survey to be outside smoking. No Evaluation for Smoking form could be located in resident 18's medical record. 4. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An EVALUATION FOR SMOKING form dated 1/26/15 revealed the following: Resident 23 was assessed by facility staff as not being able to smoke independently without posing a fire hazard. Facility staff further assessed resident 23 as not being able to smoke safely without burning self, clothing or property. Resident 23's CP initiated on 10/20/14 and revised on 10/23/14 revealed the following focus, I LOVE TO SMOKE BUT CAN'T SMOKE SAFELY ALL BY MYSELF. I HAVE BURNED MY CLOTHES. I HAVE DROPPED MY CIGARETTE. I CANNOT LIGHT MY OWN CIGARETTE. The interventions listed were, STAFF WILL MONITOR CIGARETTE FROM THE TIME LIT UNTIL EXTINGUISHED. GIVE ME A COPY OF THE SUPERVISED SMOKING SCHEDULE. DON?T (sic) LET ME KEEP CIGARETTES, MATCHES OR LIGHTER ON MY PERSON OR IN MY ROOM. 5. Resident 25 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. An EVALUATION FOR SMOKING form dated 4/16/15 revealed the following: Resident 25 was assessed by facility staff as not being able to smoke independently without posing a fire hazard. Facility staff further assessed resident 25 as not being able to smoke safely without burning self, clothing or property. Resident 25's CP initiated on 10/10/14, and revised on 2/25/15 revealed the following focus, SMOKING UNSAFELY: I LOVE TO SMOKE BUT I CANNOT SMOKE SAFE INDEPENDENTLY: I HAVE ASKED/BEGGED OTHERS FOR CIGARETTES. I SMOKE THE BUTTS FOUND ON THE GROUND OR I TAKE BUTTS FROM THE ASHTRAYS AND TRY TO SMOKE THEM. I CANNOT MANAGE MY CIGARETTES TO LAST ME AN ENTIRE MONTH AND REQUIRE ASSISTANCE WITH THIS. I HAVE BEEN FOUND TO HAVE CIGARETTES AND LIGHTERS ON MY PERSON AND IN MY ROOM, WHICH IS AGAINST THE FACILITIES SMOKING POLICY. The interventions listed on resident 25's CP were, STAFF WILL MONITOR MY CIGARETTE FROM THE TIME LIT UNTIL THE TIME EXTINGUISHED. GIVE ME A COPY OF THE SUPERVISED SMOKING SCHEDULE. DON'T LET ME KEEP CIGARETTES, MATCHES, OR LIGHTERS ON MY PERSON OR IN MY ROOM. 6. Resident 27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An EVALUATION FOR SMOKING form dated 1/26/15 revealed the following: Resident 27 was assessed by facility staff as not being able to smoke independently without posing a fire hazard. Facility staff further assessed resident 27 as not being able to smoke safely without burning self, clothing or property. Resident 27's Care Plan (CP) initiated on 10/31/14 and revised on 2/10/15 revealed the following Focus,I LOVE TO SMOKE BUT CANNOT SMOKE SAFELY ALL BY MYSELF. I HAVE BURNED MY CLOTHES. I HAVE GIVEN CIGARETTES TO PEOPLE I SHOULDN'T.I HAVE ASKED/BEGGED OTHERS FOR CIGARETTES.I HAVE BEEN FOUND TO CARRY A LIGHTER ON MY PERSON.I DO NOT FOLLOW THE SMOKING TIMES WRITTEN IN THE SMOKING POLICY. The interventions listed were, STAFF WILL MONITOR CIGARETTE FROM TIME LIT UNTIL EXTINGUISHED. GIVE ME A COPY OF THE SUPERVISED SMOKING SCHEDULE. DON'T LET ME KEEP CIGARETTES, MATCHES, OR LIGHTER ON MY PERSON OR IN MY ROOM. IF STAFF CANNOT HELP ME SMOKE, I WOULD LIKE THEM TO TELL ME A SPECIFIC TIME THEY CAN GO OUT WITH ME TO SMOKE. REMIND ME OF THE SMOKING TIMES AND THE SMOKING POLICY. 7. Resident 43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An EVALUATION FOR SMOKING form dated 1/26/15 revealed the following: Resident 43 was assessed by facility staff as not being able to smoke independently without posing a fire hazard. Facility staff further assessed resident 43 as not being able to smoke safely without burning self, clothing or property. Resident 43's CP initiated on 1/16/15, and revised on 2/6/15 revealed the following focus, SMOKING: I LOVE TO SMOKE BUT I CANNOT SMOKE SAFELY ALL BY MYSELF: I HAVE SMOKED IN MY ROOM UNATTENDED. I GATHER CIGARETTE BUTTS FROM THE SMOKING AREA AND TRY TO SMOKE FROM THEM. I HAVE ASKED/BEGGED OTHERS FOR CIGARETTES. I NEED HELP MANAGING MY CIGARETTES TO LAST ME AN ENTIRE MONTH. I HAVE BURNED MY CLOTHES. I HAVE BEEN FOUND TO HAVE A LIGHTER IN MY ROOM AND ON MY PERSON. I DO NOT COMPLY WITH THE SMOKING POLICY. The interventions listed on resident 43's CP were, STAFF WILL MONITOR CIGARETTE FROM TIME LIT UNTIL EXTINGUISHED. I WAS GIVEN A COPY OF THE SUPERVISED SMOKING SCHEDULE; I SIGNED THIS POLICY AND AGREE TO ABIDE BY IT. DO NOT LET ME KEEP CIGARETTES, MATCHES OR LIGHTER ON MY PERSON OR IN MY ROOM. IF IT IS SUSPECTED THAT I HAVE SMOKING MATERIALS IN MY ROOM OR ON MY PERSON PLEASE ASK TO SEARCH MY ROOM FOR THESE MATERIALS; TO KEEP ME SAFE AND TO KEEP THE RESIDENTS AND BUILDING SAFE. 8. Resident 45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An EVALUATION FOR SMOKING form dated 2/6/15 revealed the following: Resident 45 was assessed by facility staff as not being able to smoke independently without posing a fire hazard. Facility staff further assessed resident 45 as not being able to smoke safely without burning self, clothing or property. 9. Resident 49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An EVALUATION FOR SMOKING form dated 3/9/15 revealed the following: Resident 49 was assessed by facility staff as providing and lighting other cigarettes for residents. Facility staff further assessed resident 49 as providing lighters and matches to other residents. At the bottom of resident 49's Evaluation for Smoking facility staff indicated that resident 49 needed supervision while smoking. (Note: CP for resident 49 did not address smoking.) On 5/28/15 at 8:50 AM, the facility Director of Nursing (DON) was interviewed. The DON stated that facility staff members were assigned to supervise the residents on the smoke breaks. The DON stated that the staff member would retrieve the cigarettes from the nurse's station, hand the smokes out to the residents, light the cigarettes, and then stay and monitor the residents and pick up the cigarette butts after residents were finished smoking. The DON stated that resident 25 would pick up other resident's cigarette butts and smoke them. The DON stated that resident 25's family did not want him to smoke but it was his right to smoke. The DON stated that resident 25 would flick his cigarette butts onto the ground which posed a fire hazard. The DON stated that all residents were supervised while smoking due to behaviors and cigarettes hole burns in clothing. The DON confirmed that resident 25 did have cigarette burn holes in his clothing. The DON further confirmed that smoking and monitoring of the smoking were the facility's biggest problem. The DON stated that facility staff were supposed to stay with the resident during the entire smoke break but, That doesn't always happen. The DON further stated that the facility did have smoking aprons but currently no residents required a smoking apron. The DON stated that currently she had no residents that had been recently burned or had any burns on their hands. The DON stated that all residents within the facility were on supervised smoking. On 5/27/15 at 9:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that all residents were supposed to be supervised by a staff member while smoking. LPN 1 further stated that staff were not supposed to go into the building and leave residents unattended. LPN 1 stated there were a few resident's who have had, Ashes hit their shirt but the resident themselves were not burned. LPN 1 stated if a resident was found with a cigarette burn in their clothing she (LPN 1) would talk to the resident to make sure they were okay and then report it to the DON. LPN 1 stated it was up to the DON to determine if an incident report needed to be completed. (Note: LPN 1 did not state that facility staff check resident's skin for burns if cigarette burn holes were found in clothing.) On 5/27/15 at 9:29 AM, the facility DON was re-interviewed. The DON stated that unless A resident was injured or it was A behavior facility staff would not complete an incident report. The DON further stated that if a resident could not be interviewed in regards to a burn or injury, facility staff would, Redirect the resident to the smoking policy. On 5/27/15 at 11:16 AM, an interview was conducted with Hsk 1. Hsk 1 stated, They (all residents who smoke) need supervision Hsk 1 stated the residents need supervision in order to assure the residents did not burn themselves or their clothing. The housekeeper also stated residents needed supervision to ensure they did not share used cigarettes. On 5/27/15 at 11:17 AM, an interview was conducted with the facility Social Worker (SW). The SW stated there were no residents in the facility who could smoke safely unsupervised. The SW stated, All of their (resident's who smoke) evals (evaluations) say they have to be supervised. The SW stated the residents needed to be supervised to ensure they would not share cigarettes. The SW stated the residents were also supervised because the facility did not want residents to have lighters on their persons, So they don't catch themselves on fire. On 5/27/15 at 11:23 AM, LPN 1 was re-interviewed. LPN 1 stated, There are some residents who are safe to smoke unsupervised, but that they are supervised in order to assure their cigarettes last them the entire month. LPN 1 stated resident 43 was one of the residents who needed supervision to ensure his cigarettes lasted him the entire month. LPN 1 stated resident's 12, 18, 25, and 29 would be unsafe to be left unsupervised to smoke. The LPN stated resident 25 was Obviously not safe to smoke unsupervised due to the discoloration and the appearance of burns on his hands. LPN 1 then stated as per the facility policy none of the residents that smoke were safe to smoke unsupervised. On 5/27/15 at 11:26 AM, an interview was conducted with LW 1. LW 1 stated residents 43 and 23 were safe to smoke unsupervised. LW 1 stated resident 17 had burned his clothing a couple of times so he was one resident that was unsafe to smoke unsupervised. LW 1 stated the residents who smoked needed to be supervised to make sure they didn't burn themselves or their clothing. On 5/27/15 at 11:28 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated,Everybody (all residents who smoked) should have supervision. CNA 1 stated the residents who smoked needed supervision in order to ensure they did not share cigarettes, and to ensure they did not burn themselves. CNA 1 confirmed she took the residents who smoked to the 5:45 PM smoke break on 5/26/15 and would again take them out tonight (5/27/15). Review of facility incident reports revealed no incident reports for any residents in regards to burns in clothing or burns on the residents' skin. No documentation could be found in residents' medical records to show facility staff re-evaluated resident safety after cigarette burn holes were found in their clothing. Potential for more than Minimal Harm: B. On 5/26/15 at 7:48 AM, during an initial tour of the building, observations revealed the Housekeeping cart unattended outside a resident room. At the bottom of the housekeeping cart a tile and grout cleaner was left unattended and unsecured. The following cautionary instructions were observed on the tile and grout cleaner: Keep out of reach of children. Irritant causes skin and eye irritation. Avoid contact with skin and eyes. The housekeeping cart was observed to be left unattended for five minutes. Several residents were observed to walk by the unattended cart.

Based on interview and observation, it was determined the facility did not provide maintenance services necessary to maintain a sanitary, orderly and comfortable interior. Resident identifier: 44. Findings include: Upon entrance to the facility, on 5/26/15 just before 7:00 AM, survey staff noticed a heavy odor of feces in the entrance way, the hallways and into the dining room where 17 residents were seated. On 5/28/15, observations revealed there was no water to the hand-washing sinks in rooms 7 and 10. Neither residents nor nursing staff could wash their hands before leaving the rooms. On 5/28/15 at approximately 4:00 PM, resident 44 was interviewed. The resident stated the water to his sink had been off since Friday (5/22/15) but that maintenance was aware. Resident 44 stated maintenance staff was planning to get the water turned back on as soon as possible. Resident 44 stated he had been told the repair had to take place at night when people were sleeping because the water would have to be turned off to the entire building. On 5/28/15, observations of room 7 revealed the white cupboards under the sink and counter had paint chipped from the sides and front of the cupboard doors. It was observed on 5/26/15 through 5/28/15, that baseboards had been pulled off the walls in the residents' rooms. Large spots of glue remained along the bottom of the walls where baseboards had been removed.

Based on observation and interview, it was determined the facility did not store and prepare food under sanitary conditions. Findings include: On 5/26/15 at 7:25 AM, a brief observation of the kitchen and pantry was conducted. The following was observed: a. The linoleum floor was soiled. It had numerous chipped and torn spaces. The linoleum appeared to have been torn away from under the dishwasher and from under the ice machine. The torn edges were coming up. The floor could not be sanitized. b. There was a round, soiled grate in the floor in front of the ice maker and in the walking path around the kitchen. The drain from the ice maker was soiled and pushed down through the grate in the kitchen floor. c. A nearly empty carton of soy milk was in the refrigerator without an open date. d. An open container of yogurt was in the refrigerator without an open date. e. A partially wrapped and undated stack of tortillas was in the refrigerator. f. A dish of chicken was in the refrigerator without a label or date. g. A dish of what appeared to be leftover casserole was not labeled or dated. The clear cover appeared to have numbers 7-2 written on it. h. A partially used gallon jug of syrup was on a shelf in the pantry. There was no lid or cover on the jug. i. The lid to a bin of pancake mix was visibly soiled. A plastic scoop was sitting on top of the soiled lid. j. The lid to a bin of sugar was visibly soiled. The lid was not fastened down and only partially covered the sugar bin. k. The lid to a bin of flour was visibly soiled. The lid was not fastened down and covered approximately half of the flour bin. l. The stove burners were soiled with crusted and loose blackened substances. m. A mop and bucket were in a corner of the kitchen near the dish washer. n. The cupboard doors in the same area were soiled and had areas of dry spills. On 5/28/15 at approximately 2:00 PM, the Dietary Manager was interviewed. The DM stated the facility was planning to replace the floor and she was preparing to get estimates.

Based on observation, interview, and record review it was determined that the facility did not establish and maintain an adequate Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Resident identifiers: 21, 25, 29, 36, 43, and 45. Findings include: 1. On 5/26/15, the following was observed during the breakfast and lunch meal: a. 8:00 AM: Licensed Practical Nurse (LPN) 1 was observed to handle a cup of water by the rim or area that the resident would place their mouth to drink. LPN 1 was observed to give the water to the resident to drink while swallowing medications. LPN 1 was then observed to go back to the medication cart and to prepare medications for another resident without washing or sanitizing her hands. b. 7:15 to 8:00 AM: Resident 43 and 45 were observed to not be wearing shoes or socks. Resident 43 and 45 were observed to touch their feet, their buttocks and incontinence brief. Resident 43 and 45 were then observed to walk over to the self serve coffee and hot chocolate and retrieve a clean cup and proceed to touch the handle of the coffee dispenser to pour themselves a cup of coffee. No observations were made of facility staff encouraging residents 43 or 45 to wash their hands prior to touching a community coffee dispenser. No observations were made of facility staff cleaning the coffee dispenser or disinfecting the areas that the residents touched. c. 7:30 AM: Certified Nursing Assistant (CNA) 1 was observed while assisting residents 21 and 36 with their meal. CNA 1 was observed to touch resident 36's spoon to put food into resident 36's mouth. CNA 1 was then observed to touch resident 36's clothing protector to wipe resident 36's mouth. CNA 1 was observed to then pick up resident 21's spoon to assist resident 21 with a bite. CNA 1 was observed to touch resident 21's clothing and wheel chair and then pick up resident 36's spoon to give resident 36 a bite of food. No observations were made of CNA 1 washing or sanitizing her hands after touching the clothing protectors or wheel chairs of resident 21 or 36. No observations were made of CNA 1 washing or sanitizing her hands after touching the silverware of the resident before assisting the other resident. On 5/26/15 at 9:45 AM, CNA 1 was interviewed. CNA 1 stated that hand hygiene should be done after touching any dirty surface, smoking, eating, and in between resident cares to the residents. CNA 1 further stated that nothing should be touched with bare hands that would be going into a resident's mouth. 2. On 5/26/15, observations were made of the breakfast meal service. Between 7:25 AM and 7:32 AM, CNA 2 was observed to pass beverages to seven residents. While passing the beverages, CNA 2 was observed to touch the rims of the glasses with his thumb, middle, and index fingers when placing the glasses on the table. CNA 2 was not observed to sanitize or wash his hands throughout the time he was passing beverages. On 5/26/15 at 7:33 AM, an observation was made of CNA 3 assisting two residents to eat. CNA 3 was observed to claw one of the resident's beverage glasses, and place the glass to the resident's mouth. On 5/28/15 at 1:35 PM, an interview was conducted with the facility Director of Nursing (DON). The DON stated staff are not supposed to claw residents glasses or touch the rim of the glasses with their hands because that was considered to contaminate the glasses. The DON stated if staff touch a resident or themselves while passing trays she expected the staff member to wash or sanitize their hands. A Service Staff Guidelines sheet provided by the DON revealed the following information regarding the handling of glasses, Hold glasses by the middle, bottom, or stem. 3. On 5/26/15 at approximately 7:15 AM, Housekeeper (Hsk) 1 was observed to be cleaning a community resident bathroom. Hsk 1 was observed to not be wearing gloves while cleaning a facility toilet that appeared to have fecal material on the outside bowl of the toilet. No observations were made of the housekeeping cart containing a box of gloves. 4. On 5/26/15 at 10:00 AM, the resident smoke break was observed. Resident 29 was observed to pass the remainder of his cigarette to resident 25. Resident 25 was then observed to finish smoking resident 29's cigarette. No observations were made of facility staff intervening and taking resident 29's cigarette from resident 25 before he finished smoking resident 29's cigarette. On 5/26/15 at 12:30 PM, the resident smoke break was observed. Resident 43 was observed to pass his partially smoked cigarette to resident 25. Resident 25 was then observed to finish smoking resident 43's cigarette. No observations were made of facility staff intervening and taking resident 43's cigarette from resident 25 before he finished smoking resident 43's cigarette.

Based on interview, observation, and record review it was determined that the facility failed to be administered in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, facility administration were aware that residents were being left unsupervised during cigarette breaks after being identified during assessments as requiring supervision. Additionally, if a resident experienced a burn in their clothing or on their skin, facility staff were not re-evaluating the resident for smoking safety and then implementing additional interventions to keep the resident safe while smoking. The deficient practice identified for residents 12, 17, 18, 23, 25, 27, 43, 45, and 49 was found to have occurred at an Immediate Jeopardy Level. Resident identifiers: 12, 17, 18, 23, 25, 27, 43, 45, and 49. Findings include: 1. The facility Administration failed to provide an environment free of accident hazards. This failure resulted in a finding of Immediate Jeopardy. (Cross refer to F323)

Based on interview, observation and record review it was determined the facility did not identify issues to which quality assessment and assurance (QAA) activities were necessary to develop and implement an appropriate plan of action. Specifically, facility administration were aware that residents were being left unsupervised during cigarette breaks after being identified during assessments as requiring supervision. Additionally, if a resident experienced a burn in their clothing or on their skin, facility staff were not re-evaluating the resident for smoking safety and then implementing additional interventions to keep the resident safe while smoking. The deficient practice identified for residents 12, 17, 18, 23, 25, 27, 43, 45, and 49 was found to have occurred at an Immediate Jeopardy Level. Resident identifiers: 12, 17, 18, 23, 25, 27, 43, 45, and 49. Finding include: 1. The facility Quality Assurance (QA) committee failed to provide an environment free of accident hazards. This failure resulted in a finding of Immediate Jeopardy. (Cross refer to F323)