Every finding on record at Magnolia Manor of Midway

Based on record review, interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure three of five residents (R) (R2, R6, and R69) reviewed for pneumococcal/flu vaccines was offered a pneumococcal and flu vaccine and were provided the risks and benefits for pneumococcal and flu vaccines. The facility failed to ensure that two of five residents (R3 and R75) were provided with the risks and benefits prior to receiving the pneumococcal vaccine. This had the potential for the residents to have an increased risk of contracting pneumonia and flu, and for those who received the pneumococcal and flu vaccines without consent, and providing the risks and benefits did not provide the residents and or representatives the right to make an informed decision before being given the pneumococcal vaccine. Findings included:1.Review of R2's Face Sheet located in the electronic medical record (EMR) under the Resident tab revealed the resident was admitted to the facility on [DATE] and was [AGE] years old.Review of the [name of facility] Vaccination Authorization form, dated 09/19/23 and provided by the facility, revealed R2's responsible party declined for R2 receive the pneumococcal and flu vaccine. There was no evidence in the medical record the responsible party received the risks and benefits prior to refusing the vaccines. Review of R2's Immunization Records located in the EMR under the Preventative Health Care tab, revealed the resident received the pneumococcal conjugate vaccine (PCV) 13 outside of the facility on 05/26/21 prior to her admission to the facility. There was no evidence that the resident was offered the PCV20 or PCV21 per recommendations of the CDC in order to be complete for the pneumococcal vaccine.Review of R2's EMR revealed there was no further documentation to show the resident/resident representative was given the opportunity besides at admission two years ago to receive the pneumococcal and/or flu vaccine.2. Review of R6's Face Sheet located in the EMR under the Resident tab revealed the resident was most recently admitted to the facility on [DATE] and was [AGE] years old. Review of the [name of facility] Vaccination Authorization form, dated 11/10/22 and provided by the facility, revealed R6's responsible party consented verbally via telephone for R6 to receive the pneumococcal and flu vaccine. There was no evidence in the medical record the responsible party received the risks and benefits prior to receiving the vaccines. Review of R6's immunization records located in the EMR under the Preventative Health Care tab, revealed the resident received the pneumococcal polysaccharide vaccine (PPSV) 23 outside of the facility on 06/22/22 prior to her admission to the facility. There was no evidence that the resident was offered the PCV15, PCV20, or PCV21 per recommendations of the CDC in order to be complete for the pneumococcal vaccine. The Immunization Records further revealed the resident received the flu vaccine on 10/03/25. The area of risks and benefits being provided was blank.3. Review of R69's Face Sheet located in the EMR under the Resident tab revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Review of the undated [name of facility] Vaccination Authorization form, provided by the facility, revealed R69's responsible party consented for R69 to receive the pneumococcal and flu vaccine and received the risks and benefits. Review of R69's Preventative Health Care document located in the EMR under the Preventative Health Care tab, revealed the resident received the PPSV23 at the facility on 11/11/21. There was no evidence that the resident was offered the PCV15, PCV20, or PCV21 per recommendations of the CDC in order to be complete for the pneumococcal vaccine. The immunization record further revealed the resident received the flu vaccine on 10/03/25.Review of R69's Preventative Health Care document located in the EMR under the Preventative Health Care tab, revealed the resident received the flu vaccine on 10/03/25. The area of risks and benefits being provided was blank.4. Review of R3's Face Sheet located in the EMR under the Resident tab revealed the resident was admitted to the facility on [DATE] and was [AGE] years old.Review of the undated [name of facility] Vaccination Authorization form, provided by the facility, revealed R3's responsible party consented for R3 to receive the pneumococcal and flu vaccine and received the risks and benefits. Review of R3's Preventative Health Care document located in the EMR under the Preventative Health Care tab, revealed the resident received the flu vaccine on 10/03/25 and the PCV20 on 09/19/25. The area of risks and benefits being provided was blank.5. Review of R75's Face Sheet located in the EMR under the Resident tab revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Review of the [name of facility] Vaccination Authorization form, dated 02/10/23 and provided by the facility, revealed R75's responsible party consented for R75 to receive the pneumococcal and flu vaccine. There was no evidence the responsible party received the risks and benefits prior to the administration of the vaccines. Review of R75's Preventative Health Care document located in the EMR under the Preventative Health Care tab, revealed the resident received the flu vaccine on 10/03/25 and the PCV20 on 09/19/25. The area of risks and benefits being provided was blank.During an interview on 12/04/25 at 10:45 AM, the Infection Preventionist (IP) confirmed the above findings. She revealed all of the resident's consents were obtained at the time of admission and no further up to date consents were obtained prior to the administration of the flu and pneumococcal vaccines. She further confirmed R2, R6, and R69 were not up to date with their pneumococcal vaccines and the residents' responsible parties were not contacted to obtain consents or refusals for the pneumococcal vaccines recommended by CDC.Review of the facility's policy titled, Infection Prevention and Control Program, revised February 2020, under Influenza and Pneumococcal Immunizations, revealed 1. Each resident or their resident representative must receive education regarding the benefits and potential side effects from Influenza or Pneumococcal Immunization.3. Each resident will be offered the Pneumococcal Vaccine on admission. 4. The resident or their representative have the right to refuse the immunization. 5. Documentation of immunization must include but not be limited to: A. Resident or resident representative was provided education regarding benefits and potential side effects of the immunization. B. If the resident received the immunization or did not receive it due to medical contraindications or refusal. Review of CDC guidelines, located at https://cdc.gov/acip-recs/hcp/vaccine-specific/pneumococcal.html and dated 01/08/25, revealed .Administer PCV15, PCV20, or PCV21 for all adults 50 years or older who have never received any pneumococcal conjugate vaccine, or whose previous vaccination history is unknown. Adults aged 50 years and older if a PPSV23 only was given, give a single dose of PCV21, PCV20, or PCV15 after one year after the last PPSV23 dose. If a PCV13 was only given, give a single dose of PCV21 or PCV20 one year after the PCV13 dose. If a PCV13 was given at any age and a PPSV23 at age [AGE] or older, it is recommended through shared clinical decision-making of either giving a single dose of PC21 or PCV20 for any adult aged 65 years or older who has completed the recommended vaccination series with both PCV13 and PPSV23. If decision to administer PCV21 or PCV20 is made, a single dose is recommended after five years after the last pneumococcal vaccine dose.

Based on record review, interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure one of five residents (R) (R2) responsible party had received the risks and benefits explained before they declined for the resident to receive the COVID-19 vaccine/ booster. The facility failed to ensure that two of five residents (R6 and R75) responsible parties, received the risks and benefits before receiving the COVID-19 vaccine/booster. Additionally, the facility failed to ensure two of five residents (R69 and R3) responsible party were given the opportunity to make a decision if they wanted their residents to receive a COVID-19 vaccine/ booster. This had the potential for an increase in contracting COVID-19 and for the responsible parties not being provided with the risks and benefits in order to make an informed decision. Findings included:1.Review of R2's Face Sheet located in the electronic medical record (EMR) under the Resident tab revealed the resident was admitted to the facility on [DATE].Review of the [name of facility] Vaccination Authorization form, dated 09/19/23 and provided by the facility, revealed R2's responsible party declined for R2 to receive the COVID-19 vaccine/booster. There was no evidence in the medical record the responsible party received the risks and benefits prior to refusing the COVID-19 vaccine/booster. 2. Review of R6's Face Sheet located in the EMR under the Resident tab revealed the resident was most recently admitted to the facility on [DATE]. Review of the [name of facility] Vaccination Authorization form, dated 11/10/22 and provided by the facility, revealed R6's responsible party consented verbally via telephone for R6 to receive the COVID-19 vaccine/booster. There was no evidence in the medical record the responsible party received the risks and benefits prior to receiving the vaccine. R6 received the COVID-19 vaccine/booster on 11/17/25. The area of risks and benefits being provided was blank.3. Review of R75's Face Sheet located in the EMR under the Resident tab revealed the resident was admitted to the facility on [DATE]. Review of the [name of facility] Vaccination Authorization form, dated 02/10/23 and provided by the facility, revealed R75's responsible party consented for R75 to receive the COVID-19 vaccine/booster. Review of R75's Preventative Health Care document located in the EMR under the Preventative Health Care tab, revealed the resident received the COVID-19 vaccine/booster on 11/17/25. The area of risks and benefits being provided was blank.4. Review of R69's Face Sheet located in the EMR under the Resident tab revealed the resident was admitted to the facility on [DATE]. Review of the undated [name of facility] Vaccination Authorization form, provided by the facility, revealed no documented evidence the residents responsible party was given the opportunity or provided the risks and benefits so an informed decision could be made for obtaining the COVID-19 vaccine/booster for the resident. 5. Review of R3's Face Sheet located in the EMR under the Resident tab revealed the resident was admitted to the facility on [DATE]. Review of the undated [name of facility] Vaccination Authorization form, provided by the facility, revealed no documented evidence the resident's responsible party was given the opportunity or provided the risks and benefits so an informed decision could be made for obtaining the COVID-19 vaccine/booster. During an interview on 12/04/25 at 10:45 AM, the Infection Preventionist (IP) confirmed the above findings. She further revealed of the consents obtained for R2, R6, and R69 for the COVID-19 vaccine/booster, were obtained at the time of admission and no further up to date consents were obtained prior to the administration of the COVID-19 vaccine/booster. She confirmed the resident's responsible parties had the right to change their minds and should be asked again, as well as provided the education and risks as those change. Review of the CDC guidelines for COVID-19 boosters located at https://www.cdc.gov/covid/vaccines/long-term-care-residents.html, dated 06/11/25, revealed.CDC recommends everyone ages 65 years and older, including people who live and work in long term care (LTC) settings, get two doses of an updated COVID-19 vaccine six months apart.People who live in LTC setting must give consent or agree to getting a COVID-19 vaccine.Consent or assent for a COVID-19 vaccine is given by LTC residents (or people appointed to make medical decisions on their behalf, called a medical (proxy) and documented in their charts per the provider's standard practice. Residents who receive a COVID-19 vaccine (or their medical proxy) also receive a fact sheet before vaccination. The fact sheet explains the risks and benefits of COVID-19 vaccination.Review of the facility's policy titled, Infection Prevention and Control, revised February 2020, revealed Intent, it is the intent of [name of facility] to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment, and to prevent the development and transmission of disease and infection. The policy did not address COVID-19 vaccine boosters.

Based on interviews, record review, and facility policy review, the facility failed to prevent abuse for three of 26 sampled residents (R) (R1, R23, and R8).Findings included:1.Review of R1's Face Sheet located under the Resident tab of the electronic medical record (EMR), revealed R1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, major depressive disorder, dementia, and anxiety disorder.Review of R1's Care Plan located under the RAI [Resident Assessment Instrument] tab of the EMR, dated 02/28/23, contained the following Problem area, [R1] has been making false accusations to any and all staff that are caring for him. The care plan's goal specified, [R1] will not make accusations against staff by next review. The care plan's approach for staff included, Family informed of behaviors.Behavioral health group to follow [R1] for his psychological care. Staff educated to only give care in pairs to be witness to his accusations. Staff to investigate his accusations when necessary. Staff to ensure he is given adequate care.Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/22/25, located in the RAI tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 which indicated severe cognitive impairment. Review of R1's Progress Notes located under the Resident tab of the EMR for 10/10/25 through 10/24/25 revealed no notes regarding the alleged incidents.2. Review of R23's Face Sheet located under the Resident tab of the EMR, revealed R23 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, Alzheimer's disease, dementia, and cognitive communication deficit.Review of R23's Care plan, located under the RAI tab of the EMR, dated 07/12/23, contained the following Problem area, Resident has alteration in thought processrelated to diagnosis of dementia as seen by short/long term memory, impaired decisionmaking skill, difficulty expressing and understanding information. The care plan's goal specified, [R23] will be out of room for socialization as desired over the next review period. The care plan's approach for staff included, Assist resident to activities to socialize as shedesires/allows.Review of R23's quarterly MDS with an ARD of 08/22/25, located in the RAI tab of the EMR, revealed a BIMS score of three out of 15 which indicated severe cognitive impairment. Review of R23's Progress Notes located under the Resident tab of the EMR for 11/26/25 revealed no notes regarding the observed incidents.3. Review of R8's Face Sheet located under the Resident tab of the EMR, revealed R8 was admitted to the facility on [DATE] with diagnoses which included parkinsonism, schizoaffective disorder, bipolar disorder, anxiety disorder, history of traumatic brain injury, altered mental status, and schizophreniform disorder. R8 was discharged from the facility on 11/26/25.Review of R8's quarterly MDS with an ARD of 08/20/25, located in the RAI tab of the EMR, revealed a BIMS score of 15 out of 15 which indicated he was cognitively intact and had not exhibited any physical, verbal, or other behavioral symptoms towards others.Review of R8's Care plan located under the RAI tab of the EMR, dated 09/16/25, contained the following Problem area, Resident has verbal behavioral symptoms directed toward others (impulsive, whispers in residents' ears, unwanted interactions). The care plan's goal specified, Resident will not threaten other residents, visitors, and/or staff. The care plan's approach for staff included, Allow distance in seating other residents around resident. Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Avoid power struggles with resident. Maintain a calm environment and approach to the resident. Maintain a calm, slow, understandable approach. Praise resident when behavior is appropriate. Remove resident from group activities when behavior is unacceptable.Review of R8's Progress Notes located under the Resident tab of the EMR, revealed the following entries:-On 10/18/25 at 5:17 PM, Licensed Practical Nurse (LPN) 5 wrote Two CNAs [Certified Nursing Assistants] told writer about a conversation they overheard between this resident (R8) and his roommate [R1]. Both CNAs wrote a statement. The first CNA statement as follows: Roommate [R1] saying roommate [R8] takes his wheelchair and hits the bed. Walked in on him [R8] saying he will slap the roommate [R1]. Also says the roommate [R8] threatens him [R1]. [R8]: told roommate [R1] he [R8] will kill the whole family. Also said roommate [R1] and roommate [R1's] family will die from [.]. [R8] Told roommate he was going to steal roommates [R1's] belongings. Other CNA's statement: Mr (roommate) [R1] and Mr [R8] was [sic] threaten [sic] each on how they was [sic] going to killed each other family. Mr (roommate) [R8] said he was going to spread all Mr (roommate's) [R1's] [.] blood all his family. So they can die like him. The negative talking and threatening lasts for about 10 minutes. Unit manager [UM] was informed immediately and UM notified DON [Director of Nursing]. Unit manager also notified the state representative as this resident is a ward of the state. Writer informed [physician] at 1521 of room change. All of resident's items were transferred from that room to new room in [.].-On 10/19/25 at 11:32 AM, the DON wrote Spoke with resident [R8] regarding events of yesterday. He stated that he might have done it. He began rabbling about other residents and stated he hates it here and wants to leave because everyone is against him. When asked the specifics of the incident he said that the roommate [R1] is a nasty person with his infected self but would not clarify. When asked about his intent to harm self or others, he stated that he could if he (roommate) [R1] keeps on pushing me. I also questioned him about kicking another residents [unknown] chair, he admitted to the act but with no provocation. Resident will remain separated from other resident. Contacted his legal guardian.Requested placement at [inpatient behavioral health].-On 10/20/25 at 1:23 PM, Resident [R8] left for [inpatient psych facility] via stretcher with two EMS [emergency medical services] techs @1:10pm. No s/s [signs/ symptoms] of distress or discomfort noted at that time.-On 11/26/25 at 9:27 AM, Resident [R8] observed by [LPN1] hitting a female resident [R23] on her right elbow. Resident became aggressive with writer as he is being separated. He denied hitting anyone when I asked him. New order received to give Haldol 5mg [milligram] IM [intramuscular] Now per [physician] and obtain a bed for resident at inpatient psych facility. Resident is informed that [physician] wants him seen by inpatient behavioral services. Resident is now refusing ADL [activities of daily living] care.-On 11/26/25 at 5:24 PM, LPN1 wrote Resident [R8] transfer out [inpatient psych facility] via medical transport at 1730 for aggressive behavior and medication management.Review of the facility's investigation of the 10/18/25 incident between R1 and R8, provided by the facility, revealed the facility substantiated resident to resident abuse. Included in the facility's investigation was a witness statement from the staff who witnessed the incident. A witness statement written by CNA1, who was still employed at the facility at the time of the survey, indicated, 10/18/25 1:30pm [R1] and [R8] was [sic] threaten [sic] each other on how they was [sic] going to killed each other family. [unknown] said he was going to spread all [R1]'s.blood all his family. So they can die like him.Review of the facility's investigation of the 11/26/25 incident between R23 and R8, provided by the facility, revealed the facility substantiated resident to resident abuse. Included in the facility's investigation was a witness statement from the staff who witnessed the incident. A witness statement written by LPN1, who was still employed at the facility at the time of the survey, indicated, 11/26/25 1600pm [4:00 PM] Resident [R8] was in 300 B hallway passing by another resident [R23] waiting to use the restroom when he [R8] swung his left arm hitting second resident [R23] in right arm. This nurse witnessed the incident and intervened before altercation could escalate. Resident denied hitting the second resident even when told it was visually seen. Resident was escorted to his room and incident was reported to unit manager.During an interview on 12/03/25 at 3:02 PM, CNA1 stated [R8] and [R1] didn't know she was sitting behind curtain. She stated [R8] came into the room in his wheelchair. She stated [R8] bumped his wheelchair into [R1]'s bed. CNA1 stated [R8] told [R1] that he had killed one of [R1's] family. She stated, then [R8] told [R1] that he was going to slit [R1]'s throat and spread his disease through his family. She stated she then moved [R8] out of room and notified her supervisor [LPN5]. She stated [R8] was then moved to another room. She stated it sounded like they were just talking to each other. She stated there was no yelling or raised voices.During an interview on 12/03/25 at 3:23 PM, R1 stated Roommate [R8] bumped my bed with his wheelchair. I told him to stop. He told me he killed my parents.During an interview on 12/03/25 at 4:10 PM, when asked about incident between R8 and R1, License Practical Nurse Unit Manager (LPNUM) stated I wasn't involved, I was off. When I came in, I found out the same day. Was told [R8] was over him, threatening him. Prior to being notified, the nurse was writing a statement. Nurse had CNA stay in room. [R8] was supervised until he was moved.I consider this an altercation between residents. [R1] is incapable of moving and defending himself. This was verbal abuse. I was told [R8] said he going to cut [R1]. [R8] was going to smear his blood over on his [R1]'s family member so they could all die from [his blood].During an interview on 12/03/25 at 3:34 PM, when asked about the incident between R8 and R1, the DON stated I was not present, it happened over weekend. They shared a room. [R8] threatened [R1] to do harm to him. Residents were separated until [R8] could be placed in behavioral health for the threats to harm to self or others. [R8] kept bumping [R1]'s bed with his chair.I substantiated the verbal abuse.During an interview on 12/04/25 at 3:33 PM, when asked about the incident between R8 and R1, LPN5, who was no longer employed by the facility, stated, I was told. I don't remember who told me.Someone told me [R8] said something about roommate having [diagnosis]. And that there was talk about [R8] doing something with his blood.I told supervisor and kept [R8] out of room.During an interview on 12/04/25 at 3:47 PM, when asked about the incident between R8 and R23, LPN1 stated I observed [R8] going down 300 hall and [R23] was waiting for the restroom when he swung his arm and hit her arm. It was a backhanded slap intentionally. She attempted to hit him back but missed. Before further escalation, I was able to remove him from the area. They were both in their wheelchairs. They had been arguing throughout the morning. She said [R8] was giving her the middle finger. This was not witnessed. I asked him to go away from her. We took him to his room, talked with him. He denied hitting her.He was sent to psych facility. I believe he went out the next day. After he got Haldol injection, he slept the rest of the day. He did not have a 1 on 1. We just rounded on him regularly every 2 hours.Review of the facility's policy titled, Abuse Prohibition / Reporting and Investigation, updated January 2017, indicated It is the intent of [Name] facilities to actively preserve each resident's right to be free from mistreatment, neglect, abuse or misappropriation of resident property. We believe that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. The purpose of these identified procedural guidelines is to create a standard of intolerance and to prevent the occurrence of any form of mistreatment, neglect, abuse, or misappropriation of any resident and/or their property.

Based on interviews, record review, and facility policy review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime and reporting of all alleged abuse violations to the State Agency (SA) for three of 26 sampled residents (R) (R1, R23, and R8). Findings included:1. Review of R1's Face Sheet located under the Resident tab of the electronic medical record (EMR), revealed R1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, Major depressive disorder, dementia, and anxiety disorder.Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/22/25, located in the RAI tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 which indicated severe cognitive impairment. 2. Review of R23's Face Sheet located under the Resident tab of the EMR, revealed R23 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, Alzheimer's disease, dementia, and cognitive communication deficit.Review of R23's quarterly MDS with an ARD of 08/22/25, located in the RAI tab of the EMR, revealed a BIMS score of three out of 15 which indicated severe cognitive impairment. 3. Review of R8's Face Sheet located under the Resident tab of the EMR, revealed R8 was admitted to the facility on [DATE] with diagnoses which included parkinsonism, schizoaffective disorder, bipolar disorder, anxiety disorder, history of traumatic brain injury, altered mental status, and schizophreniform disorder. R8 was discharged from the facility on 11/26/25.Review of R8's quarterly MDS with an ARD of 08/20/25, located in the RAI tab of the EMR, revealed a BIMS score of 15 out of 15 which indicated he was cognitively intact and had not exhibited any physical, verbal, or other behavioral symptoms towards others.Review of the intake form received from the SA and the facility's provided documentation of electronic submission to the SA regarding an allegation of witnessed verbal abuse between R1 and R8 on 10/18/25 at 3:21 PM, revealed the SA received the report of the allegation of verbal abuse on 10/19/25 at 4:04 PM.Review of the facility provided undated investigative documentation, revealed a staff member witnessed verbal threats that R8 threatened to slap R1 and kill him and his family on 10/18/25 at 3:21 PM. During an interview on 12/03/25 at 3:02 PM, Certified Nursing Assistant (CNA) 1 stated she reported the incident immediately to Licensed Practical Nurse (LPN) 5.During an interview on 12/05/25 at 2:10 PM, LPN5 stated she was told about the incident between R1 and R8. LPN5 stated she would have told her supervisor immediately but didn't remember who she reported the incident to.During an interview on 12/03/25 at 4:10 PM, Licensed Practical Nurse Unit Manager (LPNUM) stated I was off. When I came in, I found out. The CNA who witnessed, reported the incident to me. I believe I was told just before dinner. I notified the DON [Director of Nursing] at the time I was notified. I called her. She came down and assessed the situation and determined that he [R8] needed to go to behavior health and notified social services.During an interview on 12/03/25 at 3:34 PM, the Director of Nursing (DON) stated I was not present, it happened over weekend. It was reported to me on 10/19. I believe the staff told me. The required reporting time frame is 2 hours. But I reported it as soon as I found out about it.3. Review of the intake form received from the SA and the facility's provided documentation of electronic submission to the SA regarding an allegation of witnessed physical abuse between R23 and R8 on 11/26/25 at 9:27 AM, revealed the SA received the report of the allegation of physical abuse on 11/26/25 at 1:52 PM.Review of the facility provided investigative documentation, dated 12/01/25, revealed a staff member witnessing R8 hit R23 on the arm intentionally on 11/26/25 at 9:27 AM.During an interview on 12/04/25 at 3:31 PM, LPN1 stated he informed the DON immediately of the incident.During an interview on 12/03/25 at 3:34 PM, the DON stated The required reporting time frame is 2 hours. But I reported it as soon as I found out about it.Review of the facility's policy titled, Abuse Prohibition / Reporting and Investigation updated April 2017, revealed The initial report of the incident will be faxed or emailed immediately but no more than 2 hours of abuse or an incident that results in serious injury or within 24 hourswhen there is no abuse or serious injury.

Based on interviews, record review, and policy review, the facility failed to develop a comprehensive care plan following victimization of abuse for two of 26 sampled residents (R) (R1 and R23).Findings included:1. Review of R1's Face Sheet located under the Resident tab of the electronic medical record (EMR), revealed R1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, major depressive disorder, dementia, and anxiety disorder.Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/22/25, located in the RAI [Resident Assessment Instrument] tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 which indicated severe cognitive impairment.Review of the facility provided undated investigative documentation, revealed a staff member witnessed R8 threatened to slap R1 and kill him and his family on 10/18/25 at 3:21 PM.Review of R1's Care plan located under the RAI tab of the EMR, revealed victimization of abuse was not addressed or the potential for psychosocial harm.2. Review of R23's Face Sheet located under the Resident tab of the EMR, revealed R23 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, Alzheimer's disease, dementia, and cognitive communication deficit.Review of R23's quarterly MDS with an ARD of 08/22/25, located in the RAI tab of the EMR, revealed a BIMS score of three out of 15 which indicated severe cognitive impairment. Review of R23's Care plan located under the RAI tab of the EMR, revealed victimization of abuse was not addressed or the potential for psychosocial harm.During an interview on 12/04/25 at 2:03 PM, the Director of Nurses (DON) confirmed that victimization of abuse was not addressed in R1's or R23's care plans. The DON stated that she would expect to see a care plan and interventions related to being at risk for further abuse.Review of the facility's policy titled, Care Plans - Comprehensive Person-Centered, dated September 2017, indicated It is the intent of [Company Name] facilities to develop and implement a person-centered plan of care for each resident that includes goals for admission, discharge and desired outcomes.

Based on interviews, record review, and policy review, the facility failed to revise a comprehensive care plan following aggressions of abuse for one of 26 sampled residents (R) (R8). Findings included:Review of R8's Face Sheet located under the Resident tab of the electronic medical record (EMR), revealed R8 was admitted to the facility on [DATE] with diagnoses which included parkinsonism, schizoaffective disorder, bipolar disorder, anxiety disorder, history of traumatic brain injury, altered mental status, and schizophreniform disorder. R8 was discharged from the facility on 11/26/25.Review of R8's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/20/25, located in the RAI [Resident Assessment Instrument] tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated he was cognitively intact and had not exhibited any physical, verbal, or other behavioral symptoms towards others.Review of R8's Care plan located under the RAI tab of the EMR, dated 09/16/25, contained the following Problem area, Resident has verbal behavioral symptoms directed toward others (impulsive, whispers in residents' ears, unwanted interactions. The care plan's goal specified, Resident will not threaten, other residents, visitors, and/or staff. The care plan's approach for staff, dated 09/16/25, included, Allow distance in seating other residents around resident. Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Avoid power struggles with resident. Maintain a calm environment and approach to the resident. Maintain a calm, slow, understandable approach. Praise resident when behavior is appropriate. Remove resident from group activities when behavior is unacceptable.Review of the facility provided undated investigative documentation, revealed a staff member witnessed verbal threats that R8 threatened to slap R1 and kill him and his family on 10/18/25 at 3:21 PM.Review of the facility provided investigative documentation, dated 12/01/25, revealed a staff member witnessing R8 hit R23 on the arm intentionally on 11/26/25 at 9:27 AM.Review of R8's Care plan, located under the RAI tab of the EMR, revealed no updated interventions to prevent R8 from abusing other residents.During an interview on 12/04/25 at 2:03 PM, the Director of Nursing (DON) stated direct care nurses or nurse managers were responsible for day-to-day care plan updates. DON confirmed R8's care plan had not been revised since the 10/18/25 and 11/26/25 incidents with interventions to prevent further abuse to other residents. The DON also stated that she would expect to see the current interventions on the care plan.Review of the facility's policy titled, Care Plans - Comprehensive Person-Centered, updated September 2017, indicated Care plans are revised as changes in the resident's condition dictates.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure assistive devices and treatment were attempted for one of seven residents (R) (R69) reviewed for positioning/mobility. This had the potential for the residents to experience a further decline in range of motion (ROM). Findings included:Review of R69's Face Sheet located in the electronic medical record (EMR) under the Resident tab, revealed the resident was admitted to the facility on [DATE] with diagnosis of hemiplegia and hemiparesis (paralysis/loss of strength) following a cerebral infarction (stroke) affecting his right dominant side. Review of R69's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/25 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) was unable to be completed. The resident was noted to be severely impaired for daily decision making. The MDS further revealed the resident had impaired ROM of the upper extremity and was not receiving specialized rehabilitation services. Review of R69's Care Plan with a start date of 02/10/22, located in the EMR under the Care Plan tab, revealed the resident had potential for pain/discomfort related to impaired mobility and contractures. The goal was the resident would demonstrate relief or reduction in pain intensity after receiving interventions through the review period. Interventions included administering pain medication and repositioning. Review of R69's Occupational Therapy Daily Note, dated 06/04/20 and provided by the facility, revealed the resident received passive stretching and was able to open his right hand for hand hygiene. R69 was participating without any complaints with moving his right upper extremity initially. With progression he withdrew his limb. The evaluation revealed that without Occupational Therapy (OT) the resident was at risk of further progression of contracture. Review of R69's Occupational Therapy Daily Note, dated 06/05/20 and provided by the facility, revealed the resident tolerated gentle passive movements and was agreeable for trialing a temporary splint (rolled wash cloth shaped as a carrot). The resident was able to hold on to the splint for five minutes, then after 30 minutes he took off the splint. On 06/08/20 and 06/10/20, R69 refused therapy services and was discharged from OT services. There were no documented recommendations made in order to potentially prevent the resident from a decline in ROM for his right wrist or any other device be attempted. Review of the [Name] Rehab Physician Order Request, dated 09/16/25 and located in the EMR under the Documents tab, revealed a request was made from OT for the resident to receive OT therapy three times a week for eight weeks for therapeutic activities and orthotic management and training. The order was approved on 09/17/25. During observations of R69 on 12/02/25 at 11:00 AM and 12/04/25 at 8:51 AM, it was revealed that the resident was in the common/dining area in his wheelchair. His right wrist was contracted, and his hand was closed. There was no splint or device in place. During an interview on 12/04/25 at 8:30 AM, the Occupational Therapy Assistant (OTA) revealed R69 was only seen for wheelchair positioning 09/16/25 and was discharged from OT therapy on 10/23/25. She confirmed the resident was not seen for any orthotic management for his right wrist contracture. She further confirmed there were no orders in place for a splint, brace, or any device for his wrist contracture. During an interview on 12/04/25 at 9:00 AM, Certified Nursing Assistant (CNA) 1 revealed she was often assigned to the care of R69. She confirmed she wasn't aware of any device to be used for his contracted right wrist. During an interview on 12/04/25 at 3:30 PM, the Director of Rehab (DOR) confirmed R69 was seen five years ago (June 2020) for his right wrist contracture and it was recommended the resident use a splint/device to help prevent worsening of the contracture. The DOR confirmed the resident was discharged from OT on 06/12/20. She revealed the goal was for the resident to tolerate the splint for two to three hours per day. She confirmed he was discharged from OT therapy due to multiple refusals on 06/12/20. The DOR confirmed the last documentation regarding R69's right wrist contracture was five years, and nothing had been attempted since then. She confirmed there was an order dated 09/16/25 for orthotic management, however he was only seen for positioning in his wheelchair. Review of the facility's policy titled, Specialized Rehabilitative Services, revised November 2016, revealed Intent, it is the intent of [name of facility] to provide specialized rehabilitative services to meet the resident's needs and support the resident in attaining or maintaining their highest practicable physical, mental and psychosocial well-being.

Based on observation, record review, interviews, and review of policies and procedures, the facility failed to assess the entrapment risk of bedrails used for mobility assistance and obtain consent for one of three residents (R) (R47) reviewed for accident hazards.Findings included:Review of R47's Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R47 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and depression. Review of R47's quarterly Minimum Data Set (MDS) located under the RAI [Resident Assessment Instrument] tab of the EMR with an Assessment Reference Date (ARD) of 10/01/25, revealed R47 had Alzheimer's disease, no upper and lower extremity impairments, and was dependent on staff to help with rolling from side to side. It was recorded that R47 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Review of R47's Care plan located under the RAI tab of the EMR, dated 02/14/24, revealed focuses related to activities of daily living (ADLs) Functional Status/Rehabilitation Potential of impaired functional mobility. Goals included functional mobility, positioning and transfers will be achieved daily with use of appropriate devices with interventions that included bed mobility assist handles to bed bilaterally, dated 08/20/24.During an observation and interview on 12/02/25 at 11:46 AM, bilateral 1/8 side rails were on R47's bed. R47 stated she used the side rails to help herself reposition in bed. R47 demonstrated how she used the side rails to reposition.Review of R47's Physician's Orders located under the Resident tab of the EMR, revealed an order, dated 03/25/25, for Resident uses bilateral Grab Bars for bed mobility.Review of R47's side rail assessment, dated 12/28/23, provided by the facility, revealed Bed rails are not indicated at this time.Review of R47's Progress notes located under the Resident tab of the EMR, revealed a progress note, dated 12/01/25 at 9:48 AM, that included Bilateral upper and lower body weakness. Resident is able to grab bars and turn self without any injury.During an interview on 12/05/2025 at 12:07 PM, the Director of Nursing (DON) stated documentation regarding risks and benefits of bedrails discussed and a consent form were unable to be located.Review of the facility's policy titled, Restraints/Bed Rails, updated August 2018, indicated Prior to the use of bed rails the facility must: Attempt to use alternatives, Assess the resident for the risk of entrapment, Review the risks and benefits with the resident and resident representativeObtain consent.

Based on observation, interviews, record review, and a review of the facility policies titled Admissions and Medication Orders, the facility failed to protect one of 33 sampled residents (R) (R4) with allergies. Harm was identified to have occurred on 9/24/2025 when R4 was administered Bactrim DS (an antibiotic medication) that was listed as a known allergy for the resident, resulting in an allergic reaction to the medication (flushing (feeling hot), redness, and rash).Findings included:A review of the facility's policy titled Admissions, reviewed and updated in October 2016, revealed that it is the intent of the facility for the charge nurse to record information, including but not limited to the following, in the designated place (nurses' notes, admission nurse assessment, etc) . any known allergies.A review of the facility's policy titled Medication Orders, reviewed and updated in October 2017, revealed that medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders are received by a licensed nurse, pharmacist, or other authorized by state law to do so. under section of new verbal orders, the nurse will transcribe the order.verbally repeat the order back to the prescriber for verification and clarity, and then note the read back and verified on the order.A review of medical records revealed that R4 was admitted to the facility on [DATE] from an acute care facility. R4's diagnoses included but were not limited to spinal stenosis, cervical region, diabetes mellitus, essential hypertension, peripheral vascular disease, constipation, urinary retention, arthrodesis, and neuromuscular dysfunction of the bladder. R4's allergies on admission included naproxen, acetaminophen, sulfamethoxazole, metoprolol, penicillins, and Symbicort.A review of R4's medication administration records revealed that R4 received the first dose of Bactrim was 9/24/2025 at 9:00 pm and the second dose of Bactrim was 9/25/2025 at 9 am.A review of medical records revealed that Licensed Practical Nurse (LPN) Unit Manager AA contacted the provider at 9/24/2025 at 3:23 pm, related to R4 was experiencing right flank pain and foul-smelling urine. LPN FF entered a telephone order and bypassed the safety alert for Bactrim DS at 9/24/2025 at 4:44 pm.During an interview on 10/7/2025 at 3:30 pm, LPN Unit Manager AA revealed that she put in the order (Bactrim DS) late that evening. She stated that in the EMR that the order form asks for drug name, route, time, and provider name. She stated there were safety alerts and denied seeing a safety alert. She was unsure if the evening nurse pulled out of the emergency kit or received it during the pharmacy midnight distribution. She confirmed that she did not notify the provider that the resident had an allergy to sulfamethoxazole (Bactrim DS). LPN Unit Manager AA revealed that the pharmacy receives orders through the electronic record and a faxed copy as well, then the pharmacy sends a note out to alert the facility, and a fax would come across when a medication may be contraindicated. She stated that she received education from the Director of Nursing (DON) covering medication errors with handouts. She was unsure of the reasons to bypass an alert and was unsure if the resident had received the medication before. She was later told by the DON that the resident had an allergy. She believed that the medical doctor had reviewed the chart and prescribed medication. She stated that she did not review the resident's allergies with the medical doctor. She presumed the doctor knew because that was his patient. On 10/7/2025 at 3:35, LPN Unit Manager AA returned, stating that she reviewed her notes and that she did not input the order but had received the order from the provider later that evening when she was at home and called the nurse to inform her of the order from the provider.An observation and interview with LPN CC on 10/7/2025 at 3:50 pm revealed that he found the error and contacted the Director of Nursing (DON) immediately. The Surveyor observed the computer with LPN CC and was shown the ribbon where allergies were found in the electronic medical records. LPN CC reported R4 experienced redness of the cheek and face, and was feeling hot. He stated he administered the Bactrim DS; however, he did not receive a safety alert. He revealed that when you enter a medication that a safety alert appears, and the nurse would have to notify the provider to verify that the resident needs the medication. Once the medication is overridden, the alert does not continue to appear. He reported that they treated the resident with intravenous fluids and gave her Benadryl (an antihistamine) to treat the allergic reaction. The Bactrim DS (antibiotic) was discontinued and removed from the medication cart. He did not notify the physician but did notify the DON of the allergic reaction, who obtained the orders for IV fluids and Benadryl (antihistamine).An interview with Staff Pharmacist DD on 10/7/2025 at 4:40 pm revealed that electronic records were integrated into their electronic record. Staff Pharmacist DD revealed that they receive both electronic and faxed orders from the facility. The nurses key the orders into the electronic medical record at the direction of the Physician or Nurse Practitioner (NP), then the pharmacy receives the orders, and the checks and balances are put into place at that point to process an order. Orders were then sent out in the evening to the facility. He states that one of the checks of balances was to confirm that the resident was not allergic or had an interaction with medications. If a resident was found to have an allergy or contraindication to a medication, the pharmacist would call the nurse and fax a form to the facility verifying the need to fill a medication. Medications were not sent if a medication had an allergy without confirmation that the medical provider would like to continue the medication. When a medication was ordered, the pharmacy would ask if the provider would like to continue, and then a form would still need to be sent with the medication again, making the facility aware. Staff Pharmacist DD revealed that the pharmacy receives residents' allergies on admission when the facility provides the resident census information that includes their date of birth , address, contact, and allergies.An interview with the Director of Pharmacy Services on 10/8/2025 at 10:50 am revealed that after the review of the R4 medical records revealed the resident's allergies on 9/4/2025 were initially transmitted and entered as no known allergies in the pharmacy system. The Director of Pharmacy Services confirmed that the allergies were updated, but that (Bactrim DS) was missing and was not updated in R4 pharmacy profile. The allergy did not flag in the pharmacy system because the allergies were not updated on the resident's profile. She proceeded to state that when the Bactrim DS order was transmitted, R4's allergies were not listed on the order. She revealed that allergies were found in the census system segment, which was separate from the orders. She revealed that the pharmacy did not receive the alert bypass reason when entered by a nurse. She revealed that they were going through all the residents' records at the facility to make sure no one else was missing. An interview with LPN FF on 10/8/2025 at 10:53 am revealed she received a telephone order from the LPN AA for Bactrim DS (antibiotic) for R4. She revealed that she obtained the first dose from the emergency kit. She revealed that she received a safety alert and made the selection that the provider was aware of the contraindication. She reported that she believed the doctor was aware because the unit manager had received the order. She admits that she should have checked with the doctor. She reported she thought both the unit manager and doctor looked at the resident's allergies. LPN AA revealed that she did not believe an alert would come up again after the first alert was overridden. She revealed she had received education on the six rights of medication administration to always double-check allergies. She revealed that she did not recall any symptoms with the first dose.An interview with the DON on 10/8/2025 at 11:15 am revealed that the nurse should have identified the resident's allergies. The DON revealed that R4 had received three doses of the antibiotic, and she turned red and had a rash. The floor nurse that morning notified her that R4 was experiencing symptoms, and a call was placed to the provider. Orders were given to treat with intravenous (IV)fluids and Benadryl (antihistamine). The resident was monitored, and vitals were monitored. The DON revealed that all nurses should put the telephone orders into the system that they receive. A nurse should not provide telephone orders to another nurse. Telephone orders should be read back. Orders after hours should only be received by me, but since the provider calls the unit manager directly, that manager should have entered them from home. The DON revealed that she was not aware of ever receiving a call from the pharmacy alerting them of an allergy contraindication for a resident. She stated that allergies were found in the ribbon of the electronic record and entered upon admission and during medication reconciliation. She confirmed that she had not called the pharmacy to send a form identifying an interaction and was not aware that the resident had received the medication (Bactrim DS) until R4 had a reaction to the medication.An interview with the Administrator on 10/8/2025 at 1:15 pm revealed that Nurses were educated on how to verify with the provider before completing an override. The Administrator revealed that the electronic medical record has added alerts and that all the precautions were in the ribbon of the chart to include diet. The Administrator revealed, she was unsure if the update was before the incident or after the incident; however, there was a new communication tool form to be completed to communicate with the provider. She revealed that the pharmacy would send out alerts through the electronic medical record and through the fax. Also, when the nightly courier delivered medications, alerts were provided during that time that required signatures. The Administrator revealed that the education should be completed by now, with the expectation that the night shift should also receive the education.

Based on observation, interview, record review, and review of facility policy titled Medication Orders and Admissions revealed the facility failed to order an anticonvulsant for one of 17 sampled residents (R) (R1) who received an anticonvulsant for seizures and an antibiotic. Harm was identified to have occurred on 2/15/2025, when R1 was rehospitalized for seizure activities due to not receiving the required anticonvulsant medication.Findings included:A review of the facility policies titled Admissions, reviewed and updated in October 2016, revealed that it is the intent of the facility to gather necessary information upon a resident's admission to the facility. The procedural guidelines reflect that residents' readmission and new admission data must be recorded. A review of the policy titled Medication Orders, reviewed and updated in October 2017, revealed that medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders are received by a licensed nurse, pharmacist, or other authorized by state law to do so . under the section of new verbal orders, the nurse will transcribe the order . verbally repeat the order back to the prescriber for verification and clarity, and then note the read back and verified on the order.A review of the electronic Medical Record (EMR) revealed that R1 was re-admitted to the facility on [DATE] from an acute care facility (hospital). R1's diagnoses included, but were not limited to, cerebral infarction due to thrombosis of the left middle cerebral artery, dysphagia following cerebral infarction, unspecified atrial fibrillation, unspecified convulsions, and a history of urinary (tract) infections.A review of the hospital Medication Reconciliation Report printed 12/19/2024 revealed a new order to start Keppra 500 milligrams (MG) tablets two times a day (BID) by mouth (PO) in addition to cephalexin 500 MG tablets every (Q) 12 hours PO for seven days.A review of the hospital Patient Summary dated 12/19/2024 revealed a discharge diagnosis of seizure and pending labs for urine culture.A review of the Physician orders for R1 revealed the new order for Keppra and cephalexin was not ordered and put into the EMR when she returned from the hospital on [DATE] through 2/15/2025 when she was sent back to the hospital for seizure activity.A review of the R1 Medication Administration Report (MAR) dated 12/19/2024 through 2/15/2025 revealed that it did not include an order for Keppra or cephalexin.A review of R1 facility Progress Notes revealed on 12/17/2024, the resident was sent to the hospital for seizure activity. On 12/19/2024, the Licensed Practical Nurse (LPN) FF documented that the resident returned to the facility at 3:00 PM. The documentation did not include verifying new orders with the physician. On 12/20/202,4 an antibiotic was ordered for a UTI (urinary tract infection). On 2/15/2025, R1 had seizure activity and was sent to the hospital.An interview with Staff Pharmacist HH on 10/8/2025 at 10:17 am revealed that electronic records were integrated into their EMR. The Staff Pharmacist HH revealed that they receive both electronic and faxed orders from the facility. The nurses key the orders into the electronic medical record at the direction of the Physician or Nurse Practitioner (NP), then the pharmacy receives the orders, and the checks and balances are put into place at that point to process an order. Orders were then sent out in the evening to the facility.An interview with the facility Pharmacy Consultant on 10/8/2025 at 10:30 am revealed that she was responsible for reviewing the orders that were in the medical records and making recommendations according to any concerns identified.An interview with LPN FF on 10/8/2025 at 10:53 am revealed that she had been at the facility for two years. She stated she received R1 from the hospital on [DATE] around 3:00 pm. She indicated she thought the orders were received earlier and had already been put into the EMR. She indicated she had received education on how to receive a resident back from the hospital.An interview with the Assistant Director of Nursing (ADON) on 10/8/2025 at 1:49 pm revealed that the facility usually received the orders from the hospital before the resident arrived. She indicated the orders are entered into the EMR by the receiving nurse, and a copy is then placed into the Unit Manager Box. She indicated she does a review of the orders within 24 hours after admission.An interview with the Director of Nursing (DON) on 10/8/2025 at 2:30 pm revealed that when a resident comes back from the hospital, any new orders are verified by the Physician and put into the EMR. It was stated by the DON that the orders are to be double-checked by the unit manager and the ADON. She stated that she expects the nurses to follow the policy on ordering medications. She indicated that R1 did not return to the facility but was admitted to another facility upon discharge from the hospital.

Based on observations and staff interviews, the facility failed to properly label opened food items in the walk-in refrigerator and walk-in freezer, discard expired foods in the walk-in refrigerator, clean the ice machine, and ensure that kitchen staff wore beard guards while in the food preparation area. These deficient practices had the potential to adversely affect the 72 residents receiving an oral diet. Findings include: During a tour of the kitchen on [DATE] from 11:00 am to 12:00 pm, observation of the ice machine, located next to the handwashing station, revealed dust and dirt around the inside of the ice machine in the top corners and the bottom interior of the lid. Observation of the walk-in cooler on [DATE] at 11:09 am revealed two bags of romaine salad mix and one bag of [NAME] slaw mix with a use-by date of [DATE]. Continued observation of the walk-in cooler revealed three half-stacks of cheese not in the original packaging and undated and unlabeled, and one undated and unlabeled open box of liquid eggs. Observation of the walk-in freezer on [DATE] at 11:18 am revealed three packs of waffles removed from the original package which were unlabeled and undated, and two packs of pancakes not in the original packaging unlabeled and undated. Observation on [DATE] from 11:00 am to 12:00 pm, during the tour of the kitchen, revealed Dietary Cooks CC and EE were not wearing beard guards while in the kitchen. In an interview on [DATE] at 11:30 am, Dietary [NAME] CC stated he was the acting Dietary Manager. Dietary [NAME] CC revealed the ice machine was cleaned weekly by the kitchen aides and the last cleaning was completed on [DATE]. During further interview, Dietary [NAME] CC revealed food items should be labeled and dated when opened and removed from the original packaging, and expired foods should be discarded. He confirmed staff with beards should always wear beard guards while in the kitchen. An interview on [DATE] at 2:18 pm with the Administrator revealed her expectation was for the male dietary aides with facial hair to always wear a beard guard while in the kitchen. The Administrator revealed she expected the dietary staff to label and date food items out of the original package and opened food items, and the scheduled cleaning for the ice machine should be followed.

Based on observations, staff interviews, record review, and a review of the facility policy titled Treatment of Residents, the facility failed to ensure privacy was provide during Activity of Daily Living (ADL) care for one of nine residents (R) (R23), the facility also failed to ensure a privacy bag was provided for one of three residents R7 that utilized a urinary catheter. Findings include: Review of the undated facility policy titled, Treatment of Residents under Intent: It is the intent of facility that all residents should be treated fairly and with kindness, respect, and dignity. Under Procedural Guidelines number (3). Residents should be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the resident from passers-by. (4). Privacy of a resident body should be maintained during toileting, bathing and other activities of personal hygiene. 1.Record review for R23 revealed the following diagnoses but not limited to atrial fibrillation, malignant neoplasm of right breast, and rheumatoid arthritis. Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed a Brief Interview for Mental Status Score (BIMS) of six indicating severe cognitive impairment. Continued review of the assessment revealed that R23 was dependent for all ADL's and always incontinent for bladder and bowel. During an observation on 6/11/2024 at 12:07 pm revealed certified nursing assistant (CNA), CNA AA and CNA BB providing peri care services to the resident. Continued observation of the care services being provided to R23 revealed that privacy curtains were not pulled to provide full privacy (curtains were pulled to end of the bed board and did not enclose the bed) allowing view of the resident to anyone entering the room. In addition, the window blinds were open allowing outside view of the resident. During an interview at the time of the observation on 6/11/2024 at 12:08 pm with Assistant Director of Nursing (ADON) and CNA BB, both staff confirmed that resident was not provided full privacy while care was being rendered. The ADON reminded CNA BB to close the window blinds and ensure privacy curtains enclosed the residents' bed. Interview on 6/13/2024 at 11:52 am, CNA AA confirmed that she failed to provide full visual privacy by not pulling the privacy curtains and closing the window blinds while providing peri care/incontinent care for R23. 37650 2.Review of the Electronic Medical Record (EMR) revealed R7 was admitted with diagnoses of but not limited to type 2 diabetes mellitus with diabetic chronic kidney disease, end stage renal disease, and chronic diastolic (congestive) heart failure. Review of the Physician Orders revealed an order for suprapubic catheter care every shift. Observation on 6/11/2024 at 1:53 pm revealed R7 suprapubic catheter in place; catheter drainage bag was hanging on the side of the bed with a large amount of urine inside; there was no dignity bag observed covering the drainage bag. Observation on 6/12/2024 at 3:00 pm R7 suprapubic catheter in place catheter drainage bag hanging on side of bed there was no dignity cover observed covering the drainage bag. Observation on 6/13/2024 at 2:33 pm revealed R7 suprapubic catheter in place with drainage bag hanging on side of bed; drainage bag was not placed in a dignity bag. Interview on 6/13/2024 at 2:39 pm with CNA GG revealed she cleans around R7's catheter site to ensure it does not move, and empty's the drainage bag. CNA GG revealed R7's drainage bag should have been covered and placed inside a dignity bag. Interview on 6/13/2024 at 2:43 pm with Licensed Practical Nurse (LPN FF) revealed R7's drainage bag should be in a privacy bag when visible to the public but may have been left on his wheelchair. Interview on 6/13/2024 at 3:08 pm the Unit Manager revealed R7's drainage bag should always be covered. The CNAs and Nurses are responsible for making sure the dignity bag is always in place to promote dignity of residents that are utilizing catheters.

Based on observations, staff interviews, record review, review of facility documents, and review of the facility policy titled, Residents' Rights Protection, the facility failed to ensure one of nine residents (R) R18 was provided with a chair that accommodated his height and ensured body alignment. The facility also failed to ensure two of 28 residents, R16 and R51 were assessed for placement on the Secured Unit (Unit 3). The deficient practice had the potential to prevent R16, R18, and R51 from receiving care that accommodated their individual care needs. Findings include: Review of the undated facility policy titled, Residents' Rights Protection under Specific Rights: 1. Rights to Self-Determination the resident has the right: 1C.) to reside and receive services with reasonable accommodation by the facility of individual needs and preferences. A.Record review for R18 revealed diagnoses included but not limited to, dementia, benign prostatic hyperplasia, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. The Quarterly Minimum Data Set Assessment (MDS) dated [DATE] assessed a Brief Interview for Mental Status (BIMS) score of five indicating severe cognitive impairment, non-ambulatory, dependent for mobility and transfer. Resident was assessed for height of 73 inches (6 ft 1 inches) and weight of 266 lbs. (pounds). Observation on 6/11/2024 starting at 11:00 am to 2:07 pm, R18 was observed in the activity/common area sitting in a Geri-chair in a semi-reclining position. Ongoing observation revealed residents' upper torso and lower torso (buttock, thigh, leg) was positioned slouched and downward in the chair. Residents' arms and hands were observed hanging off the arm rest and draped down over the chair. Interview and observation on 6/12/2024 at 2:10 pm with the Activity Director (AD) confirmed R18 was slumped down and sliding downward in the chair during activities. Interview on 6/12/2024 at 2:11 pm, Certified Nursing Assistant (CNA) JJ, who served as an activity assistant, confirmed that R18 had been up in the activity area since 10 am and he was not in his regular chair. Interview on 6/12/2024 at 2:12 pm, CNA KK confirmed that R18 was not sitting in his assigned Geri-chair. Further interview also revealed resident was already up and dressed, by the night shift, and placed in the chair when she arrived to work today at 6:57 am. Interview on 6/12/2024 at 2:23 pm the Director of Nursing (DON) confirmed that R18 was not sitting in his assigned Geri-chair that was provided by Hospice. The DON also confirmed that the chair did not fit the height and body alignment for R18, and the residents Geri-chair was in the bathroom. Further interview also revealed residents chair was cleaned the night before and there was not an attempt by staff to put resident in the chair he was assigned. Observation and interview on 6/14/2024 at 11:13 am, R18 was observed receiving services from the Certified Occupation Therapy Assistant (COTA) the resident was noted not to be sitting upright and his body not aligned. During the observation the COTA revealed that based on her assessment of the resident, the chair provided by Hospice services did not accommodate the residents' needs and she would reach out to the nursing staff with her findings. B. Review of the facility document titled, Special Care Unit Criteria Review revealed a checklist used to determine placement in the Special Care Unit. The document questions included under number 1. Resident has Alzheimer's or related dementia diagnosis. 2. Resident habitually wanders or would wander out of the building and would not be able to find way back. 4. Resident is a serious danger to self or others. 5. Less restrictive alternatives have been unsuccessful. 6. Resident is able to ambulate independently. Review of the facility document titled,Resident Rights -Room Change revealed a section titled Room changes for medical or safety reasons: 1. A move for medical, or safety reasons will be determined by the physician, nursing staff, and the Social Service department. Record review for R16 revealed diagnoses including, but not limited to, schizoaffective disorder, bipolar type, mood disorder, and vascular dementia. Review of the Annual MDS assessment dated [DATE] and the Quarterly MDS assessment dated [DATE] documented the resident had no behaviors, was not ambulatory and was dependent on staff for Activities of Daily Living (ADL) care. Review of R16 's nursing progress note dated 7/4/2023 and a Facility Reported Incident dated 7/4/2023 documented that R16 would be evaluated to be taken off the Secured Unit. Review of a psychiatric consult dated 7/7/2023 by a Nurse Practitioner documented the resident has no wandering behaviors. Record review for R51 revealed diagnoses including, but not limited to Alzheimer's Disease. Further review revealed that R51 received hospice services. Review of the Annual MDS assessment dated [DATE] and the Quarterly MDS assessment dated [DATE] documented a BIMS score of 00 indicating severe cognitive impairment and was dependent on staff for care. Review of R51's care plan documented care areas of receiving hospice care and required assistance for all ADLs. Review of a form titled, Functional Abilities - During Stay dated 5/21/2024 documented R51 was dependent on staff for care, unable to transfer, was not ambulatory, and dependent for mobility with wheelchair. In an interview on 6/12/2024 at 2:48 pm, the Assistant Director of Nursing (ADON) reported that both R16 and R51 were non-ambulatory and had not exhibited behaviors and that R16 and R51 were dependent on staff for care. She further stated that residents with behaviors should not be placed with residents who have dementia and that she was unaware that R16 was supposed to be assessed to move off the Secured Unit. In an interview on 6/12/2024 at 3:48 pm, the DON reported that the Secure Unit is not a memory care unit, and it was for residents who have elopement tendencies. She could not explain why R16 remained in the Secure Unit and was unaware that the resident was supposed to be assessed to be moved. She also confirmed that R51 received hospice services and resided in the Secured Unit and did not have any wandering tendencies and was non ambulatory. In an interview on 6/13/2024 at 4:47 pm, the Administrator and DON reported that residents are placed in the Secure Unit for safety precautions, such as elopement risks. She reported she was unaware that R51 was dependent on staff for ADL care. The DON stated that the criteria or intent for placing the resident in the unit was to keep the resident safe. The DON stated that R16 displayed no behavior problems or had exit seeking tendencies.

Based on observations and staff interview, the facility failed to maintain a clean sanitary environment free of odor, replacing missing floor tiles, and ensure resident's equipment was free from rust on two of three halls. Finding include: A policy for this specific issue was requested but not provided. 1. Observations on 6/11/2024 at 11:50 am, 6/12/2024 at 2:00 pm., and 6/13/2024 at 12:49 pm, in bathroom [ROOM NUMBER]-306 on Hall 3, a strong urine odor and missing floor tiles were noted. 2. Observation on 6/11/2024 at 12:02 pm and 6/13/2024 at 12:52 pm, in bathroom [ROOM NUMBER]-219 on Hall 2 revealed a raised toilet seat was positioned over the toilet. A closer observation revealed dark brown substances coating the frame of the raised toilet seat. 3. Observation on 6/11/2024 at 12:03 pm and 6/13/2024 at 12:23 pm, in bathroom [ROOM NUMBER]-223 on Hall 2 revealed a raised toilet seat positioned over the toilet. A closer observation revealed dark brown substances coating the frame of the raised toilet seat. During a tour of the bathrooms on 6/13/2024 between 12:49 pm and 12:53 pm, with the Maintenance Director and Director of Nursing (DON), both confirmed the urine odor, missing floor tiles, and they identified the brown substance on the toilet chairs as rust. They revealed that replacing the floor tiles and the raised toilet seat would eliminate the odor in bathroom. The Maintenance Director reported being unaware of the problem and reported staff are required to submit a work order for any repairs. Interview on 6/13/2024 at 1:09 pm, the Housekeeping Supervisor reported being unaware of strong urine odor in room [ROOM NUMBER]-306 and stated that staff had a log to address any issues.

Based on staff interview ,record review, and review of the facility policy titled, Care Planning Policy, the facility failed to develop a plan of care for two of 14 residents (R) (R16 and R40). Specifically, the facility failed to create a plan of care to monitor and prevent future occurrences of abuse for R16 and failed to develope a care plan for restorative services for R40. Findings include: Review of the facility policy titled, Care Planning Policy dated October 2016 under Procedural Guidelines number 1. A comprehensive person-centered care plan shall be developed and implemented for each resident that includes measurable objectives and time frames that meet a resident 's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessments. Record review of R16's medical record revealed the following diagnoses but not limited to cerebral infarction, vascular dementia moderate behavior disturbances, epilepsy, intermittent explosive disorder, and schizoaffective bipolar disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] assessed a Brief Interview for Mental Status score (BIMS) of 99 indicating severe cognitive impairment. Record review of nurse progress note dated 7/4/2023 at 2:11 pm documented that R16 had a resident-to-resident altercation with another resident on his hall. R16 was assessed and noted to have an injured upper lip. Review of the Facility Reported Incident (FRI) dated 7/4/2023 documented the incident and included no care plan attached. Record review for R16 revealed no care plan was developed for abuse. Interview on 6/12/2024 at 4:06 pm, Unit Manager LL printed out and reviewed the resident care plan and confirmed no plan of care for abuse. During an interview with the MDS Coordinator on 6/13/2024 at 11:21 am, the MDS Coordinator reviewed the resident 's care plan with the surveyor and confirmed that R16's record did not contain a plan of care for abuse. She reported that she was unaware that the abuse care plan needed to be done on the victim and the abuser. The Director of Nursing (DON) entered the office during the time that the MDS was looking for the record. She was informed that the abuse care plan was missing. The DON explained to the MDS Coordinator that abuse care plan should have been completed for R16. 37650 2.Review of the Electronic Medical Record (EMR) revealed that R40 was admitted to the facility with diagnoses of but not limited to, hemiplegia/hemiparesis following cerebral infarction affecting left non-dominant side, unspecified dementia without behavioral disturbance, personal history of Transient Ischemic Attack (TIA), and cerebral infarction without residual deficits. Review of the Quarterly MDS dated [DATE] revealed that R40 had a BIMS score of nine (9), indicating moderate cognitive impairment. Further review of the Quarterly MDS revealed R40 required total assistance with bed mobility, transfer, bathing, dressing, and toileting. Precautions for contractures were noted on the Quarterly MDS. Review of the Plan of Care for R40 revealed no documentation of a plan of care for Restorative Nursing Services. Interview on 6/13/2024 at 3:33 pm the Restorative Care/Registered Nurse (RN) revealed she did not complete an assessment on R40 to receive Restorative Nursing Services for mobility.

Based on observations, staff interviews, record review, and review of the facility policy titled, Restorative Nursing, the facility failed to ensure three of 18 residents (R), (R18, R26, and R40) received services required to maintain or improve their functional abilities. Specifically, the facility failed to ensure R18 was provided with a Geri-chair that was properly fitted to ensure adequate body alignment, failed to provide equipment (footrest) for R26 to prevent potential for foot drop, and failed to provide Range of Motion (ROM) for left hand contracture for R40. Findings include: Review of the undated facility policy titled, Restorative Nursing revealed It is the Intent of the facility to provide nursing interventions that promote the resident's ability to attain or maintain the highest level of functioning as possible. Procedural guidelines: number 2. The facility's rehabilitative/restorative nursing care program is designed to assist each resident to maintain their highest level of functioning. Number 3. The Interdisciplinary team determines restorative need of the resident through assessment, planning, implementation, and evaluation. 4. All personnel may identify a resident with a functional decline/deficit that may be referred to Restorative Nursing. 1. Record review for R18 revealed the following diagnoses but not limited to unspecified dementia, chronic obstructive pulmonary disease, cerebrovascular disease, and heart failure. The Annual Minimum Data Set (MDS) dated [DATE] assessed a Brief Interview for Mental Status (BIMS) score of five indicating severe cognitive impairment and extensive assistance with all Activities of Daily Living Skills (ADL) except eating. Observation on 6/11/2024 starting at 11:00 am to 2:07 pm, R18 was observed in the activity/common area sitting in a Geri-chair in a semi-reclining position. Ongoing observation revealed residents' upper torso and lower torso (buttock, thigh, leg) was positioned slouched and downward in the wheelchair. Residents' arms and hands were observed hanging off the arm rest and draped down over the chair. Interview on 6/12/2024 at 2:23 pm the Director of Nursing (DON) confirmed that R18 was not sitting in his assigned Geri-chair that was provided by Hospice. The DON also confirmed that the chair did not fit the height and body alignment for R18, and the residents Geri-chair was in the bathroom. A further interview also revealed the residents' chair was cleaned the night before and there was not an attempt by staff to put the resident in the chair he was assigned. 2. Record review for R26 revealed the following diagnoses but not limited to intellectual disabilities. The Quarterly MDS assessment dated [DATE] assessed the resident as having severe cognitive impairment and dependent for all ADLs. Observation on 6/12/2024 at 10:27 am until 2:27 pm revealed R26 sitting in his wheelchair in the activity/common area. R26 was observed sitting in a wheelchair with his feet dangling in the air and not touching the floor. Further observation revealed there was not a footrest attached to the wheelchair. Interview on 6/12/2024 at 2:48 pm with Unit Nurse Supervisor Licensed Practical Nurse (LPN) MM confirmed that R26 should have had a footrest attached to his chair. She reported that R26 is at risk for edema and foot drop. She stated the certified nursing assistants (CNAs) were responsible for ensuring that the footrests are attached to the residents' wheelchairs during ADL care. Interview on 6/14/2024 at 11:33 am with Occupational Therapist (OT) revealed that the residents' footrest and wheelchair can be lowered to prevent the resident foot from dangling in the air. She further stated that if the resident decides to remove his foot from the footrest the wheelchair being lowered will allow the resident to rest his foot on the floor. 37650 3.Review of the Electronic Medical Record (EMR) revealed that R40 was admitted to the facility with diagnoses of but not limited to, hemiplegia/hemiparesis following cerebral infarction affecting left non-dominant side, unspecified dementia without behavioral disturbance, personal history of Transient Ischemic Attack (TIA), and cerebral infarction without residual deficits. Review of the Quarterly MDS dated [DATE] revealed that R40 had a BIMS of nine (9), indicating moderate cognitive impairment. Further review of the Quarterly MDS revealed R40 required total assistance with bed mobility, transfer, bathing, dressing, and toileting. Precautions for contractures were noted on the Quarterly MDS. Review of the Physician Orders showed no documentation for Restorative Services. Observation on 6/12/2024 at 3:06 pm revealed R40 lying in bed alert with eyes open unable to move left hand or arm; no splint noted. Observation on 6/13/2024 at 2:28 pm revealed R40 sitting up in bed talking with roommate using one hand (right) to pull the covers back and attempt to move the bedside table; R40 was unable to move his left hand or arm to pull the covers back. Interview on 6/13/2024 at 3:24 pm the Director of Nursing (DON) revealed R40 was not receiving Restorative Care Services secondary to being on hospice care. The DON revealed a consultation for Restorative Care Services had not been completed. Interview on 6/13/2024 at 3:33 pm the Restorative Care Nurse/RN revealed she did not complete an assessment on R40 to receive Restorative Care Services for mobility or range of motion. The RN revealed that she was told if a resident was on hospice services they did not get restorative services, but later found that to be untrue. Interview on 6/13/2024 at 3:33 pm the Restorative Care Nurse/RN revealed she did not complete an assessment on R40 to receive Restorative Care Services for mobility or range of motion. The RN revealed that she was told if a resident was on hospice services they did not get restorative services, but later found that to be untrue.

Based on observations, staff interviews, record review, and review of the facility policy titled Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE) for one of five residents (R) (R23) reviewed for Enhanced Barrier Precautions. This deficient practice had the potential to place R23 and other residents at risk for avoidable infections. Findings include: A review of the facility policy titled, Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated June 2021, under Executive Summary number 2. Enhanced Barrier Precautions (EBP) is an approach of target gown and glove use during high-contact resident care activities, designed to reduce transmission of S. aureus and MDRO (multidrug -resistant organism). 3. EBP may be applied when contact precautions do not otherwise apply to residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. Infection or colonization with an MDRO. 4. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE with hand hygiene products at the point of care. Record review of R23 's medical record revealed the following diagnoses, but not limited to, malignant neoplasm of unspecified site of right female breast (wound). Record review of the Physician Order Form, dated June 2024, documented an order for Enhanced Barrier Precautions related to a wound. Observation on 6/11/2024 at 12:07 pm revealed Certified Nursing Assistants (CNA) KK and CNA BB providing incontinent care to R23. Continued observation revealed that CNA BB did not wear PPE while providing incontinent care. Further observation revealed there was no PPE readily available for staff use in the hallway or inside R23's room, nor a container for discarding PPE. Observation revealed there was Enhanced Barrier Precautions signage on R23's door. The sign did not provide private specific instructions about donning and doffing (putting on and removing) PPE. Observation on 6/11/2024 at 12:07 pm, revealed the Assistant Director of Nursing (ADON) provided instruction to the CNAs about providing privacy during care by using privacy curtains but did not mention the failure to wear PPE during high-contact resident care. In an interview on 6/13/2024 at 3:30 pm, the ADON stated that her focus was on the CNAs not pulling the privacy curtains and not the PPE. She reported that PPE is kept at the nurse station for CNAs to use during patient care. She confirmed that CNA KK and CNA BB did not wear PPE during high-contact resident care. In an interview on 6/14/2024 at 9:20 am, the Administrator reported being unaware of the issues regarding staff not wearing PPE while providing high-contact resident care. She reported that her expectations were that staff should wear PPE and that in-services would be provided to staff. In an interview with the Infection Control Preventionist (IPC) on 6/14/2024 at 11:00 am, she reported that her expectation is that staff wears PPE while providing high-contact resident care. She confirmed providing in-service to staff about PPE use. She stated that PPE was kept at the front desk and not at the resident rooms. She reported that her plans were to make changes and provide more specific instructions about PPE use. The IPC placed a second EBP sign on R23's door with instructions on donning and doffing PPE. In an interview on 6/14/2024 at 11:35 am, CNA BB confirmed not wearing PPE while providing incontinent care to R23. She reported that she just forgot to wear PPE and was more focused on resident care.

Based on observation, record review and interviews of staff, residents and residents family members, the facility failed to notify one of the three residents family members of a change in resident condition until after sent out for evaluation to ER and after residents death. Findings include: Review of Policy titled, Change in a Residents condition or status (Page 1; section 2) states, Unless otherwise instructed by the resident, the nurse supervisor should notify the resident's representative when: a. The resident is involved in any accident/incident which results in an injury including injuries of an unknown source; b. There is a significant change in the resident treatment significantly; c. There is a need to alter the resident's treatment significantly; d. A decision has been made to discharge the resident from the facility; and/or e. It is necessary to transfer the resident to a hospital. Review of Nursing Note dated [DATE] at 3:38 p.m., R#2 was found on the floor with temperature 103.0 and SAT 88%. Order to send to ER was obtained. Review of Nursing Note dated [DATE] at 11:42 p.m., R#2 out of institution at hospital Review of Nursing Note dated [DATE] at 6:42 p.m., hospital called on [DATE] to obtain phone number to notify next of kin that he is deceased . Review of Nursing Note dated [DATE] at 11:18 p.m., SW called hospital to confirm when resident had passed. Family of R#2 called Magnolia Manor and asked when R#2 was sent out to hospital. SSD informed R#2 was sent out on [DATE]. Family of R#2 reported she had a missed a call on her caller I.D. from facility and tried to call back without being able to reach anyone. Interview on [DATE] at 12:24 p.m., Family of R#2 reported she was never notified by the facility of R#2 going out to the hospital, having a change in condition, that he had fallen in the facility or that he had passed. Family of R#2 reported she was contacted by the hospital on [DATE] late in the evening, after 6 p.m., that R#2 had deceased at the hospital. Family of R#2 reported she began to call Magnolia Manor and an unknown person told her no one was there at that time to talk with her regarding what happened to R#2. Family of R#2 stated she started calling around p.m. on [DATE] (the next day) to Magnolia Manor for answers. She reported she called from p.m. until dark and finally spoke with someone that told her she would need to call back to speak with someone else. Family of R#2 reported she finally spoke with someone on [DATE], who told her R#2 went to the hospital on [DATE]. She reported no one from the facility ever called her about her brothers' condition or death.

Based on observation, record review, staff, resident and resident representatives, the facility failed to meet the need of the residents with regard to the quality and/pr timeliness of providing laboratory serviced and reporting laboratory results. Findings Include: Review of Progress note dated [DATE] at 10:27 p.m.- daughter called facility and spoke with SW upset with COVID-19 in facility and another resident died without her being notified. It also revealed, MD provided order for cough syrup for dry cough R#3 had. [DATE] at 10:40 p.m.- revealed SW tried to explain to family R#3 did not have COVID test results back. [DATE] at 5:43 p.m.- R#3 confused with Temp. 97, SAT 95%. MD notified, order to retest for COVID-19 and urinalysis. Daughter notified. Record review for R#3 revealed that on [DATE] at 8:35 a.m.- R#3 noted with increased labored breathing at 4 a.m., O2 SAT ,[DATE]%. MD notified, order to send to ER, 911 called, resident respirations ceased, code blue called at 4:15 a.m., EMS notified of resident coding, EMS arrived at 4:25 a.m., code was called at 4:35 a.m., daughter called at 5 a.m. and left message to call facility ASAP, sister was called at 6:30 a.m. as daughter had not responded, sister of R#3 was told of R#3 demise, daughter called and was told details, weekend supervisor arrived at 8:05 a.m. and pronounced R#3, funeral home picked up R#3. Review of record provided by facility lab revealed the following dates of COVID-19 testing: R#3- collected [DATE], received [DATE]. Resident specimen received without a name and without a birthdate on the tube hence we had to reject it. Rejection report loaded to facility portal on [DATE] at 1:10 p.m. Interview on [DATE] at 2:10 p.m., Interim Administrator/ Vice President (VP) of Operations for Magnolia Manor reported the nurse who obtains the lab sample is the person responsible for labeling the tube and packaging. She reported after review of the medical record of R#3 there was no documentation found to confirm which nurse obtained the sample to be sent to the lab for the COVID-19 test. She stated the medical record did indicate that R#3 was testing on [DATE], and the results were negative. She stated the medical record revealed R#3 refused to be tested on [DATE]. She reported they had an order to retest R#3 on [DATE], and that sample was sent to the lab. She reported on [DATE], they were notified by the lab that when the specimen was received there was no name or date of birth on the tube and the specimen was rejected. Further interview with Interim Administrator/ Vice President (VP) of Operations for Magnolia Manor reported during the time when the physician order [REDACTED].#3, they had multiple tests for residents for COVID-19 ordered by the physician. She stated they stored the sample tubes in the refrigerator after labeled and placed in packaging until they were picked up for transport. She stated she felt due to removing the specimens from cold storage and putting into a hot environment of a vehicle caused condensation which could have caused the labels to fall off the tubes. She reported the labels placed on the outside of the package had to been present when arrived at the lab or they would not have known R#3's labels on her tubes had fallen off. She reported when the lab receives specimens there has to be two identifiers for them to accept the specimen.

Based on record review, staff interview and review of the facility policy titled, Care Plans-Comprehensive Person-Centered the facility failed to follow the care plans for one of five residents (R) (R#33) and the facility failed to develop a care plan for dysphagia for one of five residents (R#44). Findings include: 1. Review of facility policy titled 'Care Plans-Comprehensive Person Centered' (not dated), revealed: 'The care plan will be reviewed and updated with the participation resident and resident representative(s) and all personnel involved in the care of the resident as needed and no less than quarterly. 3. The care plan is available for use by all personnel providing care/services to/for the resident. It includes but is not limited to: A. Incorporate identified problem areas; B. Incorporate risk factor(s) associated with identified problems; F. Prevent declines in functional status and/or functional levels. 5. Care plans are revised as changes in resident condition dictates. Reviews are made at least quarterly.' Record review revealed that R#33 was readmitted to the facility from a psychiatric hospital on [DATE] with [DIAGNOSES REDACTED]. Review of R#33 care plans revealed: Hypertension; give anti-hypertensive medications as ordered. [MEDICAL CONDITION] medications for behavior management; administer [MEDICAL CONDITION] medications as ordered by Physician. Review of the Physicians Orders for October 2019 for R#33 revealed an order for [REDACTED].#33 was administered his medication as ordered. 2. Review of the medical record for R#44 revealed he was admitted to the facility 8/26/2019 with the [DIAGNOSES REDACTED]. Quarterly Minimum Data Set ((MDS) dated [DATE] reveals a Brief Interview of Mental Status (BIMS) assessment score of zero out of 15, indicating severe cognitive impairment. Review of R #44 medical record revealed an order on admission from assisted living facility for nectar thick liquids. Review of care plan provided to facility from assisted living facility revealed resident had an issue with choking on certain foods. Review of care plans for R #44 revealed there was no evidence that the facility developed a care plan to address the resident's dysphagia. Interview with the Director of Nursing (DON) on 3/11/2020 at 12:23 p.m. revealed she expected medications to be given as ordered.

Based on observations, record review and staff interview, the facility failed to accurately reflect the fall status on the Minimum Data Sets (MDS) for one (1) resident (R) (R#29). This failure to accurately reflect the fall status so that the root cause of the falls could be identified and appropriate interventions developed to prevent future falls resulted in actual harm when Resident # 29 fell on [DATE] and suffered a two inch laceration to the back of his head requiring staples. The sample size was 27 residents. Findings include: R#29 had [DIAGNOSES REDACTED]. The resident received Hospice services since February 2017. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) of 3, indicating that he was cognitively impaired; required limited assistance from one staff person for transfer; was non-ambulatory; and had no falls since the last assessment (Quarterly MDS dated [DATE]). Review of the Quarterly MDS dated [DATE] revealed that the resident had a BIMS of 9, indicating that he had some confusion; required extensive assistance of two staff for transfer; and had no falls since the prior assessment (Quarterly MDS dated [DATE]). Review of the Nurses' Notes dated 5/29/17 at 6:38 p.m. revealed that the resident was found on the floor in his room. He stated at that time that he was attempting to get a brief out of his closet and his leg gave out. Review of the Nurses' Notes dated 6/17/17 at 6:16 p.m. revealed that the resident was found on the floor in front of his wheelchair. Another resident told staff that R#29 had intentionally slid out of his wheelchair. Although staff had documented that the resident had falls on 5/29/17 and 6/17/17, staff failed to capture those falls on the Quarterly MDS dated [DATE] so that the root cause of each fall could be determined and appropriate interventions developed and implemented to prevent further falls. Review of the Nurses' Notes dated 9/19/17 at 3:45 p.m. revealed that the resident was found on the bathroom floor in front of the toilet holding onto the grab bar. The resident stated at that time that he was going to the bathroom, lost his balance and slid to the floor. Review of the Risk Management Note dated 9/19/17 revealed that staff also placed the resident in the common area for closer monitoring. Review of the Risk Management Note dated 10/5/17 at 2:20 p.m. revealed that the resident was found laying on the floor next to his bed with his lower body on the fall mat. Review of the Risk Assessment Note dated 10/15/17 at 7:22 p.m. revealed that the resident was found sitting on the floor of his bathroom. The resident stated at that time that he needed to have a bowel movement. The resident did not have any injuries. Review of the Risk Management Note dated 1/6/18 at 4:43 p.m. revealed that the resident attempted to transfer himself from the wheelchair to the bed, fell and hit his head on the leg of the bedside table. The resident sustained [REDACTED]. The resident was sent to the emergency room (ER) where he received staples. Although staff had documented that the resident had three falls on 9/19/17, 10/5/17 and 10/15/17, staff failed to capture those falls on the Quarterly MDS dated [DATE] so that the root cause of each fall could be determined and appropriate interventions developed and implemented to prevent further falls with injury. Interview with Licensed Practical Nurse NN, who was also the Restorative Nurse and MDS Coordinator, on 2/1/18 at 2:15 p.m. revealed that she was responsible for coding falls on the residents' MDS and that she obtained her information by talking with the nurses and by reading the Risk Management and Nurses' Notes in the resident's chart. After reviewing the MDS dated [DATE] for R#29, LPN NN confirmed that she failed to accurately capture the resident's falls. Cross refer to F689.

Based on observations, record review and staff interviews, the facility failed to revise the care plan after each fall with a new intervention and/or with an appropriate intervention to prevent further falls for one (1) resident (R#29). Actual harm was identified when Resident # 29 fell on [DATE] and suffered a two inch laceration to the back of his head requiring staples. The sample size was 27 residents. Findings include: R#29 had [DIAGNOSES REDACTED]. Review of the resident's care plan initiated 2/21/17 revealed that the resident had an Activities of Daily Living (ADL) self care deficit related to Alzheimer's dementia with an intervention that he was totally dependent on one staff person for toilet use. Continued review revealed that the resident had bladder incontinence with interventions for staff to clean the resident with each incontinent episode. Further review revealed that the resident was at moderate risk for falls related to psychoactive drug use and gait/balance problems with interventions for staff to anticipate and meet his needs, be sure the resident's call light is in reach and encourage him to use it, ensure that he is wearing appropriate footwear when ambulating and mobilizing in wheelchair, fall mat at bedside, follow facility fall protocol, Physical Therapy (PT) screen, and review information on past falls and attempt to determine cause of falls; record possible root cause of falls and alter/remove any potential causes if possible; and educate resident/family/caregivers as to causes. Review of the Nurses' Notes dated 5/29/17 at 6:38 p.m. revealed that the resident was found on the floor in his room. He stated at that time that he was attempting to get a brief out of his closet and his leg gave out. Review of the resident's care plan revealed that staff did not revise it to include a new intervention to prevent further falls. Review of the Nurses' Notes dated 6/17/17 at 6:16 p.m. revealed that the resident was found on the floor in front of his wheelchair. Another resident told staff that R#29 had intentionally slid out of his wheelchair. Review of the care plan revealed that staff did not revise it to include a new intervention to address the fall and/or the resident's behavior of intentionally sliding out of the wheelchair to prevent futher falls. Review of the Risk Management Note dated 10/5/17 at 2:20 p.m. revealed that the resident was found laying on the floor next to his bed with his lower body on the fall mat. The resident stated at that time that he fell . The resident did not have any injuries. Review of the care plan revealed that staff did not revise it to include a new intervention to prevent further falls. Review of the Risk Assessment Note dated 10/15/17 at 7:22 p.m. revealed that the resident was found sitting on the floor of his bathroom. The resident stated at that time that he needed to have a bowel movement. Continued review revealed that the resident was instructed to use his call light for assistance. Review of the care plan revealed that staff did not revise it to include a new intervention to prevent further falls. Review of the Risk Management Note dated 1/6/18 at 4:43 p.m. revealed that the resident attempted to transfer himself from the wheelchair to the bed, fell and hit his head on the leg of the bedside table. The resident sustained [REDACTED]. Although the resident sustained [REDACTED]. Review of the Risk Management Note dated 1/14/18 at 2:47 p.m. revealed that the resident was found lying on the bathroom floor. The resident stated that he was going to the bathroom. The resident did not have any injuries. Continued review revealed that the resident was instructed to call for assistance. Review of the care plan revealed that staff did not revise it to include a new intervention to prevent further falls. Interview with Licensed Practical Nurse/MDS Coordinator DD on 2/1/18 at 2:20 p.m. revealed that any resident who had a fall the previous night was discussed during the morning Interdisciplinary Team meeting to ensure that interventions to prevent falls were in place. Continued interview revealed that the nurses and MDS Coordinators were responsible for documenting new interventions on the residents' care plans. Cross Refer to F689.

Based on observation, record review, review of the facility's Falls Management policy, and staff interview, the facility failed to determine the root cause after each fall for one (1) resident (R#29) from a sample of 27 residents. Actual harm was identified when Resident # 29 fell on [DATE] and suffered a two inch laceration to the back of his head requiring staples. Sample size was 27 residents. Findings include: Review of the facility Falls Management policy revealed that all residents would be assessed for fall risks a resident with falls in the past 24 hours would be presented in the morning interdisciplinary meeting, trends identified and potential new risk factors discussed the resident's care plan would be reviewed and revised the resident would be referred to therapy for a screen and revised interventions communicated to staff. R#29 had [DIAGNOSES REDACTED]. The resident received Hospice services since at least 2/2017. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) of 3, indicating that he was cognitively impaired; required limited assistance from one staff person for transfer; was non-ambulatory; was totally dependent on one staff person for toilet use; was always incontinent of bladder and occasionally incontinent of bowel; was not on a toileting program; and had no falls since the last assessment (Quarterly MDS dated [DATE]). Review of the Quarterly MDS dated [DATE] revealed that the resident had a BIMS of 9, indicating that he had some confusion; required extensive assistance of two staff for transfer; was non-ambulatory; was totally dependent on one staff person for toilet use; was always incontinent of bladder and bowel; was not on a toileting program; and had no falls since the prior assessment (Quarterly MDS dated [DATE]). Review of the resident's care plan initiated 2/21/17 revealed that the resident had an Activities of Daily Living (ADL) selfcare deficit related to Alzheimer's dementia with an intervention that he was totally dependent on one staff person for toilet use. Continued review revealed that the resident had bladder incontinence with interventions for staff to clean the resident with each incontinent episode. Further review revealed that the resident was at moderate risk for falls related to psychoactive drug use and gait/balance problems with interventions for staff to anticipate and meet his needs, be sure the resident's call light is in reach and encourage him to use it, ensure that he is wearing appropriate footwear when ambulating and mobilizing in wheelchair, fall mat at bedside, follow facility fall protocol, Physical Therapy (PT) screen, and review information on past falls and attempt to determine cause of falls; record possible root cause of falls and alter/remove any potential causes if possible; and educate resident/family/caregivers as to causes. Review of the Nurses' Notes dated 5/29/17 at 6:38 p.m. revealed that the resident was found on the floor in his room. He stated at that time that he was attempting to get a brief out of his closet and his leg gave out. Continued review revealed that the resident had no injuries and staff instructed him to call for assistance. Review of the resident's care plan revealed that staff did not revise it to include a new intervention to address the fall to prevent further falls. There was no indication that staff obtained a Physical Therapy (PT) screen for the resident after the fall. Review of the Nurses' Notes dated 6/22/17 at 6:16 p.m. revealed that the resident was found on the floor in front of his wheelchair. Another resident told staff that R#29 had gotten out of his wheelchair, sat on the floor and then turn over like he had fallen to the floor. The resident then proceeded to call for help. The resident had no injuries. Further review of the Nurses' Note revealed that staff did not consider this incident a fall because the resident intentionally placed himself on the floor. Review of the care plan revealed that staff did not revise it to include a new intervention to address the fall and/or the resident's behavior of intentionally placing himself on the floor. There was no indication that staff obtained a PT screen for the resident after the fall. Although staff had documented that the resident had falls on 5/29/17 and 6/17/17, staff failed to capture those falls on the Quarterly MDS dated [DATE] so that the root cause of each fall could be determined and appropriate interventions developed and implemented to prevent further falls. Review of the Nurses' Notes dated 9/19/17 at 3:45 p.m. revealed that the resident was found on the bathroom floor in front of the toilet holding onto the grab bar. The resident stated at that time that he was going to the bathroom, lost his balance and slid to the floor. The resident did not have any injuries. Continued review revealed that the resident was instructed to use his call light for assistance. Review of the Risk Management Note dated 9/19/17 revealed that staff placed him in the common area for closer monitoring. Review of the care plan revealed that staff revised the resident's care plan on 9/26/17 with an intervention for staff to educate the resident to wait for assistance before toileting and for staff to stay in the room while the resident was on the toilet as he was known to not use the call light for assistance. Review of the therapy note dated 9/21/17 at 1:11 p.m. revealed that PT screened the resident and determined that skilled therapy was not indicated. Continued review revealed that PT educated R#29 about safety and to wait for staff assistance for transfers. Review of the Risk Management Note dated 10/5/17 at 2:20 p.m. revealed that the resident was found lying on the floor next to his bed with his lower body on the fall mat. The resident stated at that time that he fell . The resident did not have any injuries. There was no indication that staff determined the root cause of the fall i.e., attempting to go to bathroom. Review of the care plan revealed that staff did not revise it to include a new intervention to address the fall to prevent further falls. There was no indication that PT screened the resident after this fall. Review of the Risk Assessment Note dated 10/15/17 at 7:22 p.m. revealed that the resident was found sitting on the floor of his bathroom. The resident stated at that time that he needed to have a bowel movement. The resident did not have any injuries. Continued review revealed that the resident was instructed to use his call light for assistance. Review of the care plan revealed that staff did not revise it to include a new intervention to address the fall to prevent further falls. There was no indication that PT screened the resident after this fall. Although staff had documented that the resident had three falls on 9/19/17, 10/5/17 and 10/15/17, staff failed to capture those falls on the Quarterly MDS dated [DATE] so that the root cause of each fall could be determined and appropriate interventions developed and implemented to prevent further falls with injury. Review of the Nurses' Note dated 12/26/17 at 10:30 p.m. revealed that the resident was found on the floor of his bathroom. The resident stated that he was trying to go to the bathroom. The resident had no injuries. Review of the 1/16/18 Late Entry Therapy Note revealed that the resident was screened by PT after the 12/26/17 fall and PT educated him to call staff for assistance prior to transfer. Review of the Risk Management Note dated 1/6/18 at 4:43 p.m. revealed that the resident attempted to transfer himself from the wheelchair to the bed, fell and hit his head on the leg of the bedside table. The resident sustained [REDACTED]. The resident was sent to the emergency room (ER) where he received staples. Continued review revealed that the resident was instructed again to call staff for assistance. Although the resident sustained [REDACTED]. There was no indication that PT screened the resident after this fall with injury. Review of the Risk Management Note dated 1/14/18 at 2:47 p.m. revealed that the resident was found lying on the bathroom floor. The resident stated that he was going to the bathroom. The resident did not have any injuries. Continued review revealed that the resident was instructed to call for assistance. Review of the care plan revealed that staff did not revise it to include a new intervention to address the fall to prevent further falls. Review 1/19/18 Late Entry Therapy Note revealed that PT screened the resident after the fall and determined that skilled therapy was not indicated. Continued review revealed that PT educated the resident to use the call light to call staff for assistance with transfers. Interview with Certified Nursing Assistant (CNA) OO revealed that the resident could ambulate but, had an unsteady gait and was at risk for falls. Continued interview revealed that the resident knew when he needed to toilet and that most of his falls occurred when he tried to go to the bathroom unassisted. Further interview revealed that she would assist the resident to the bathroom if he used his call light. She stated that she also offers to take him to the toilet every two hours. CNA OO stated that staff bribe R#29 with cookies to get him to use his call light. Interview with CNA RR on 1/31/18 at 4:15 p.m. revealed that she offered to take the resident to the bathroom every two hours and that sometimes the resident was already incontinent of urine. Interview with CNA PP on 2/1/18 at 11:08 a.m. revealed that the resident knew when he was wet, would yell for staff and staff would change his brief. She stated that the resident knew when he needed to have a bowel movement, would yell for staff and staff would take him to the bathroom in his wheelchair for the bowel movement. Continued interview with CNA PP revealed that the resident would not use his call light. Further interview revealed that the resident did not refuse care but, would sometimes hit staff during care. CNA PP stated that she was not aware that the resident had any recent falls. Interview with Hospice CNA QQ on 2/1/18 at 11:15 a.m. revealed that she provided care for the resident for 1 to 1 ½ hours five days per week. Continued interview revealed that the resident would tell her when he needed to use the bathroom and she would place him in his wheelchair and assist him to the bathroom. Interview with Licensed Practical Nurse (LPN) HH on 2/1/18 at 11:25 a.m. revealed that R#29 did not have any recent falls to her knowledge. Continued interview revealed that the resident knew when he needed to toilet and would attempt to walk to the bathroom unassisted even though staff have educated him to use his call light. Further interview revealed that staff told R#29 that he would receive a cookie if he called staff for assistance and waited on them to assist him to the toilet. LPN HH stated at that time that staff communicated a resident's falls to staff on subsequent shifts via the 24 Hour Report. She stated that the nurses tell the CNAs so that those residents were more closely monitored. Continued interview with LPN HH revealed that the MDS Coordinators communicated any new interventions to the nurses who communicated to the CNAs. Further interview revealed that she ensures fall prevention interventions were in place by walking my hall. Interview with Licensed Practical Nurse NN, who was also the Restorative Nurse and MDS Coordinator, on 2/1/18 at 2:15 p.m. revealed that she was responsible for coding falls on the residents' MDS and that she obtained her information by talking with the nurses and by reading the Risk Management and Nurses' Notes in the resident's chart. After reviewing the Quarterly MDS dated [DATE], LPN NN confirmed that she failed to accurately capture the resident's falls on 9/19/17, 10/5/17 and 10/15/17. Continued interview with LPN NN revealed that the root cause of each fall was documented in the Weekly Summary note, Nurses' Notes or Interdisciplinary Notes. When asked if staff had identified any trends or patterns to R#29's falls, LPN NN stated that the resident had behaviors that included getting out of the bed/wheelchair and purposefully sitting on the floor. However, review of the resident's care plan with LPN NN at that time revealed that there was no documented behavior related to purposefully sitting on the floor or interventions to address that behavior. When asked if a scheduled toileting program was attempted for R#29, LPN NN stated No .I do not think he would be a candidate since he will not tell you when he needs to toilet. When asked if staff had obtained a Physical Therapy (PT) screen as care planned, LPN NN stated that all residents were screened by therapy after a fall. When asked if the appropriateness of the intervention to educate the resident to use the call light was evaluated, LPN NN stated that she believed it was still appropriate because he had used the call light in the past. LPN NN stated I do not know what else we can do for him. Interview with Licensed Practical Nurse/MDS Coordinator DD on 2/1/18 at 2:20 p.m. revealed that any resident who had a fall the previous night was discussed in the morning meetings to ensure that interventions to prevent falls were in place. Continued interview revealed that the nurses and MDS Coordinators were responsible for documenting new interventions on the residents' care plans. Interview with Physical Therapist Assistant (PTA) SS on 2/2/18 at 9:15 a.m. revealed that R#29 had not received skilled therapy because Hospice would have to pay for the therapy. Continued interview with PTA SS revealed that the nurses were responsible for contacting Hospice to see if Hospice would agree to pay for skilled therapy. Interview with the Director of Nursing (DON) on 2/2/18 at 11:10 a.m. revealed that residents who had falls the previous night were discussed in the morning meeting the following day, this meeting included therapy, MDS and the Restorative Nurse. Continued interview revealed that the facility has not has a weekly At Risk meeting since she started working as DON but, the plan was to discuss residents with falls at the At Risk meetings as well. Further interview revealed that staff reviewed the circumstances of each fall and current interventions and evaluate and revise interventions if needed. The DON stated that therapy would assess the resident after each fall. Continued interview revealed that she and other supervisory nursing staff ensured that direct care staff were implementing interventions to prevent falls by walking the halls every thirty minutes. When asked about R#29 the DON stated that he knew when he needed to toilet but, would not wait on the CNAs to assist him to the bathroom. The DON stated that R#29 would attempt to toilet himself even after the CNAs have taken him to the bathroom. Although staff documented each of the resident's eight falls since 5/29/17, staff failed to identify that six of the eight falls occurred during the 3:00 p.m. to 11:00 p.m. shift. There was no indication that staff determined that the possible root cause of those falls may have been related to the resident's Alzheimer's dementia with increased restlessness/confusion in the afternoon and evening and the need for more frequent monitoring/supervision at that time. Although staff were aware that the resident knew when he needed to toilet and that four of the eight falls occurred when the resident went to the bathroom unassisted, there was no indication that staff attempted a trial toileting program for the resident. Although staff were aware that the resident would not use his call light to call for assistance, staff continued to use the same intervention, i.e., educate resident to use call light, for six of the eight falls. There was no indication that staff evaluated the appropriateness of that intervention for R#29.

Based on observations, record review including the facility policy titled, Smoking, Residents and Employees and interviews, it was determined that the facility failed to develop comprehensive care plans to include interventions to ensure safe smoking practices for twenty-three (23) residents (R) (#53, 54, 51, 71, 81, 116, 100, 105, 60, 38, 23, 64, 111, 21, 12, 59, 87, 120, 72, 30, 69, 163 and 152) of thirty-three (33) reviewed for smoking and for one (1) resident (#49) who had a contracture. On 2/2/2017, a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the immediate jeopardy on 2/2/17 at 8:52 a.m. The noncompliance related to the immediate jeopardy (IJ) was identified to have existed on 1/30/17. The facility submitted a Credible Allegation of Compliance (AOC) on 2/2/17 related to the immediate jeopardy. The immediate jeopardy was removed on 2/4/17. A Credible Allegation of Compliance (AOC) was received on 2/2/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AOC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 2/4/17. The facility remained out of compliance at a lower scope and severity at F279 S/S:D, F280 S/S:D, F323 S/S: D, F490 S/S:D, and F520 S/S:D, while the facility continued management level staff oversight of resident smoking assessments and procedures to ensure the safety of residents that smoke. This oversight process also includes analysis of facility staff ' s conformance with the facility ' s Policies and Procedures, and while the facility develops and implements the Plan of Correction (POC); and the facility ' s Quality Assurance (QA) monitors the effectiveness of the systemic changes. In-service materials and records were reviewed. Observation and interviews were conducted with residents and staff to ensure they demonstrated knowledge of facility Policies and Procedures governing residents smoking safely. Resident records were reviewed to ensure that resident assessments were current and accurate. Cross refer to F323 Findings include: Review of the facility's policy titled, Smoking, Residents and Employees revealed in part that all residents who smoke will be assessed upon admission, quarterly, and PRN (as needed) as conditions warrant for safety equipment needs. Examples of equipment include smoking aprons and assistive devices; All residents will be supervised during smoking. Residents will not be permitted to smoke without the direct supervision of a responsible staff member, visitor, or volunteer; Residents will not be permitted to smoke outside of the designated smoking times, and: All smoking equipment will not be retained by the resident at any time. All smoking equipment for residents will be left with the charge nurse and stored in a secured area. 1. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed that R#72 currently used tobacco products. Review of the Annual MDS dated [DATE] revealed that the resident was severely cognitively impaired and did not currently use tobacco products. Review of the care plan dated 1/26/16 and reviewed by staff on 12/2/16 revealed that there were no interventions to address smoking safety. On 1/30/17 at 4:00 p.m., R#72 was sitting on the smoking porch with ten (10) other residents. One (1) staff member passed out cigarettes and lighted the cigarettes for the residents. None of the residents were observed to hold their own smoking materials. R#72 was observed to drop a long ash onto his sweat pants and immediately brush it off. Activity Staff BBB, who was standing next to the resident also brushed off the resident's pants where the ash dropped. The resident was not wearing a smoke apron or any other protective covering at that time. The resident continued to smoke while holding the cigarette over his lap. Slight tremors were noted to the resident's right hand holding the cigarette. Observation of the resident's clothing at that time revealed no burn holes. Interview with Activity Staff BBB on 1/30/17 at 4:29 p.m., revealed that R#72 had smoked since his admission. Interview with the Director of Nursing (DON) on 2/1/17 at 1:02 p.m., revealed that every resident who smoked should have a smoking evaluation and a care plan for smoking. 2. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed that R#53 had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was alert and oriented and that he currently used tobacco. Review of the resident's comprehensive care plan dated 1/12/17 and reviewed by staff on 1/26/17 revealed that there were no interventions to address the resident's ability to smoke safely. On 1/31/17 at 12:25 p.m., R#53 was sitting in his wheelchair in the parking lot past the facility boundaries smoking unsupervised and without wearing a smoking apron. Observation of the resident at that time revealed that he smoked safely and that there were no burn holes in his clothing. R#53 stated at that time that he comes outside whenever he wants to smoke and that he is unsupervised at those times. Continued interview revealed that he did not wear a smoke apron while smoking and that he kept his smoking materials, cigarettes and lighter with him. A pack of cigarettes and a lighter were observed resting in the resident's lap at that time. On 2/1/17 at 8:15 a.m. R#53 was sitting in his wheelchair in the parking lot past the facility boundaries smoking unsupervised and without wearing a smoke apron. Interview with the Director of Nursing (DON) and Social Services Director (SSD) on 2/1/17 at 1:02 p.m., revealed that any resident who smokes should have a care plan to address smoking safety. Further interview with the DON at that time revealed that R#53 signed himself out to smoke off campus. Continued interview with the DON revealed that R#53 should give all his smoking materials to the nurses for storage at the nurses station after smoking. Further interview with the SSD at that time revealed that she did not know if R#53 was care planned for unsupervised smoking. Observation on 2/1/17 at 1:25 p.m., R#53 was in his room. Upon request, he opened his bookbag hanging on the back of his wheelchair and retrieved a pack of cigarettes and a lighter. 3. Review of the Quarterly MDS dated [DATE] revealed that R#87 had a Brief Interview for Mental Status (BIMS) score of 10 indicating that she was alert and oriented with some short-term and long-term memory problems. Review of the Annual MDS dated [DATE] revealed that the resident currently used tobacco products. Review of the care plan dated 12/23/16 and reviewed 12/30/16 revealed that there were no interventions to address the resident's ability to smoke safely. Review of the Smoking Evaluation dated 5/31/16 revealed that the resident currently used tobacco products and needed to wear a smoke apron. On 1/30/17 at 4:00 p.m. and 6:35 p.m., R#87 was smoking on the smoke porch with the supervision of one staff person. However, the resident was not wearing a smoke apron at the times of the observations. Observation of the resident revealed no burn holes in clothing. Interview with R#87 on 2/3/17 1:24 p.m., revealed that about 9 months ago she was attempting to sit in a chair on the smoke porch and the leg of the chair slipped causing her to tilt and causing her cigarette to touch her dress that she was wearing. Continued interview revealed that the lit cigarette burned a hole in her dress but, did not burn her. Further interview with R#87 revealed that she did not notify staff that she had burned her clothing while smoking. review of the resident's medical record revealed [REDACTED]. 4. Review of the Admission MDS dated [DATE] revealed that R#12 currently used tobacco products. Review of the Quarterly MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating that he had some short-term and long-term memory problems. Review of the care plan dated 2/25/16 and reviewed 12/12/16 revealed that there were no interventions to address the resident's ability to smoke safely. Review of the Smoking Evaluation dated 8/17/16 revealed that R#12 currently used tobacco products and needed a smoking apron for safety. On 1/30/17 at 6:27 p.m., R#12 was smoking on the smoke porch with the supervision of one staff member. However, R#12 was not wearing an apron at that time. There were no burn holes observed in the resident's clothing at that time. 5. Record review for R#163 revealed that she was admitted on with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 5 indicating that she was cognitively impaired and that she currently used tobacco products. Review of her comprehensive care plan dated 1/31/17 revealed no interventions to ensure that the resident smoked safely. Review of the Smoking Evaluation dated 1/24/17 revealed that the resident needed a smoke apron. However, R#163 was not on the original list of residents who smoked that was provided by the facility on 1/30/17. Review of her medical record revealed no indication that the resident had burned herself while smoking. R#163 was not observed to smoke on 1/30/17. On 1/31/17, R#163 wore a smoke apron while smoking. 6. Review of the medical record for R#54 revealed he was admitted with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed that the resident currently used tobacco products. Review of the Quarterly MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3 indicating that the resident was severely cognitively impaired. Review of the care plan dated 6/3/16 and reviewed 12/15/16 revealed that there were no interventions to ensure the resident's safety while smoking. Review of the Smoking Evaluation dated 1/19/17 revealed that the resident did not need to wear an apron while smoking. R#54 was not observed to smoke on 1/30/17 and 1/31/17. On 2/1/17 at 7:45 a.m., the resident was wearing a smoke apron while smoking. 7. Review of the medical record for R#59 revealed she was admitted with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9 indicating that she was alert and oriented with some confusion. Review of the Annual MDS dated [DATE] revealed that she currently used tobacco products. Review of the care plan dated 6/13/16 and reviewed 12/15/16 revealed that there were no interventions to ensure the resident's safety while smoking. Review of the Smoking Evaluation dated 8/27/15 revealed that the resident required a smoke apron while smoking. The resident was not observed to smoke all days of the survey. Interview with R#59 on 1/31/17 at 9:55 a.m., revealed that the residents did not wear smoke aprons and that the facility quit with them months ago. Interview with R#59 on 2/1/17 12:10 p.m. revealed that she did not smoke because she did not have any money to buy cigarettes. 8. Review of the medical record for R#120 revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9 indicating that she was alert and oriented with some confusion and that she did not currently use tobacco products. Review of the care plan dated 1/14/16 and reviewed 12/23/16 revealed that there were no interventions to ensure the resident's safety while smoking. Although the resident was not observed to smoke during the survey, she was on the initial list of residents who smoked provided by the facility on 1/30/17 as well as the revised list of smokers provided by the facility on 2/1/17. 9. Review of the medical record for R #30 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 indicating that she was alert and oriented with some confusion and that she currently used tobacco products. Review of the care plan dated 12/15/16 and reviewed 12/30/16 revealed that there were no interventions to ensure the resident's safety while smoking. Review of the Smoking Evaluation dated 12/2/16 revealed that the resident needed a smoke apron. On 1/30/17 at 4:00 p.m. and 6:30 p.m. the resident was smoking on the smoke porch with the supervision of one staff member. The resident was wearing a smoke apron at those times. Interview with CNA QQ on 1/31/17 at 9:20 a.m. revealed that R#30 had dropped ashes on herself while smoking and that staff had been instructed to ensure that she wore a smoke apron each time she smoked. Interview with R#30 on 2/1/17 at 12:20 p.m. revealed that she dropped ashes on her pants while smoking but, the ashes did not burn her or her clothing. Continued interview revealed that staff place a smoke apron on her at every smoke break. 10. Review of clinical record for R#99 revealed the following [DIAGNOSES REDACTED]. Admission Minimum Data Set ((MDS) dated [DATE] for R#99 revealed the following a coding for tobacco use. Quarterly MDS dated [DATE] revealed no coding for tobacco use. Review of Brief Interview Mental Status (BIMS) of six (6).A score of (7-0) indicate severely impaired. The last smoking assessment Smoking Evaluation was completed on 10/12/16. The assessment were checked and coded for the following: a smoking apron required. The plan of care dated 10/18/16 revealed that R#99 was care plan for smoking. However the care plan did not address specific interventions for a smoke apron usage based on R#99's smoking evaluation dated 10/12/16. Nurses Notes for R#99 from 7-1-16 to 2-1-17 revealed no documentation of tobacco or tobacco products in possession of resident outside of supervised smoke area without supervision from staff. Observation of Resident (R)#99 on 1/30/17 at 2:20 p .m. was not wearing a smoke apron. Observation on 1/31/17 at 4:46 p.m. revealed R#99 smoking with no apron and being monitored by Receptionist Central Supply Clerk. This included a total of 18 residents smoking without smoking aprons (R51, R80, R23, R40, R71, R52, R116, R46, R81, R70, R38, R103, R64, R111, R104, R69, R21, R105). Observation 2/1/17 at 2:20 p.m. R#99 revealed smoking with no apron monitored by CNA TT (total 17 residents observed smoking without smoking aprons-R52, R81, R105, R116, R71, R46, R38, R64, R111, R69, R60, R51, R70, R80,R40).Observation on 2/2/17 at 9:30 a.m. revealed R#99 smoking with no apron and being monitored by CNA OO (total 18 residents smoking without aprons- R52, R40, R105, R116, R81, R69, R60, R51, R21,R103,R70, R80, R38,R46, R104,R71,R64 ) Observation on 2/2/17 at 1:56 p.m. revealed R#99 smoking with an apron and being monitored by Director of Nursing, DON', Assistant Director of Nursing, ADON, Social Service Director and CNA WW. This consisted of a smaller group of 12 residents. Observation on 2/3/17 at 1:30 p.m. revealed R#99 smoking with an apron and being monitored by DON. This consisted of a smaller group of 12 residents all wearing apron. Observation on 2/4/17 at 7:30 p.m. revealed R#99 smoking with apron and being monitored by DON, CNA AA, and CNA UU. This consisted of a smaller group of 12 residents all wearing apron. On 2/1/17 at 12:20 p.m. with R#99 reported no incidents of self-hazardous dangerous behaviors of dropping ashes on clothes during cigarette break that may have resulted in a burn. R#99 stated that she was wearing an apron only once which was approximately only 6 months ago and smoking at least 3 three times a day. Interview on 2/3/17 at 2:10 p.m. with R#99 verified receiving education about the smoking requirements, which included wearing an apron, prohibition from keeping smoking supplies cigarettes, lighters, and etc. on personal belongings, and safety hazardous from the Director of Nursing (DON), Social Worker (SW), and Assistant Director of Nursing (ADON) along with other residents. Verified that she signed and received copy of the new smoking policy. 11. Review of clinical record for R#81 revealed the following: [MEDICAL CONDITIONS], failure to thrive. Review of Brief Interview Mental Status revealed a score of 8 eight (moderately impaired). The last smoking Smoking Evaluation was completed on 9/29/15. Smoking assessment was coded for the following: smoking apron needed. The plan of care dated 12/21/16 revealed R#81was not care planed for smoking. Review of Annual Minimum Data Set ((MDS) dated [DATE] for R#81 revealed the following no coding for tobacco use. Quarterly MDS dated [DATE] revealed no coding for tobacco use. Observation on 1/30/17 at 2:20 p.m. R#81 smoking with no apron. Observation on 1/31/17 at 2:25 p.m. R#81 smoking with no apron monitored by CNA EE and CNA TT . Observation on 1/31/17 at 4:46 p.m. revealed R#81 smoking with no apron and being monitored by Receptionist Central Supply Clerk (a total of 18 residents smoking without smoking aprons-R51, R80, R23, R40, R71, R99, R116, R46, R60, R70, R38, R103, R64, R111, R104, R69, R21, R105) Observation 2/1/17 at 2:20 p.m. R#81 revealed smoking with no apron monitored by CNA TT( total 17 residents observed smoking without smoking aprons-R52, R99, R105, R116, R71, R46, R38, R64, R111, R69, R60, R51, R70, R80,R40). Observation on 2/2/17 at 9:30 a.m. revealed R#81 smoking with no apron and being monitored by CNA OO (total 18 residents smoking without aprons- R52, R99, R105, R116, R81, R69, R60, R51, R21,R103,R70, R80, R38,R46, R104,R71,R64 ). Observation of Resident (R)#81 on 1/30/17 at 2:20 p.m. was not wearing a smoke apron On 1/31/17 at 4:40 p.m. revealed R#81 was not wearing a smoke apron and being monitored by Central Supply Clerk. Observation on 2/2/17 at 1:56 p.m. revealed R#81 smoking with an apron and being monitored by Director of Nursing, DON', Assistant Director of Nursing, ADON, Social Service Director and CNA WW. This consisted of a smaller group of 12 residents. Observation on 2/3/17 at 1:30 p.m. revealed R#81 smoking with an apron and being monitored by DON. This consisted of a smaller group of 12 residents all wearing apron. Observation and interview on 2/4/17 at 7:30 p.m. revealed R#81 smoking with apron and being monitored by DON, CNA AA, and CNA UU. This consisted of a smaller group of 12 residents all wearing apron.On 2/1/17 at 12:15 p.m. R#81 reported no incident of self-hazardous dangerous behaviors of dropping ashes on self or clothes during cigarette break resulting in a burn. R#81 reported never witnessing any resident having a burn injury from a cigarette during smoke break and that staff never encouraged him to wear an apron during smoke break. R#81 confirmed smoking at least 5 five times a day. On 2/3/17 at 2:14 p.m. R#81 verified receiving education about the smoking requirements, which included wearing an apron, prohibition from keeping smoking supplies cigarettes, lighters, and etc on personal belongings, and safety hazardous from the Director of Nursing (DON),Social Worker (SW), and Assistant Director of Nursing (ADON) along with other residents. R#81 verified that he signed and received copy of the new smoking policy. 12. Review of clinical record for R#23 revealed the following [DIAGNOSES REDACTED]. A Brief Interview for Mental Status BIMS score of 11 that indicates moderately impaired. The last smoking assessment Smoking Evaluation completed on 6/20/16 . Smoking assessment was coded for the following: does not need a smoking apron, light his own cigarette, and coded for impaired cognition. Plan of care dated 9/19/16 was not care plan for smoking. Review of Nurses Notes for R#23 from 7-1-16 to 2-1-17 revealed no documentation of tobacco or tobacco products in possession of resident outside of supervised smoke area without supervision from staff. Annual Minimum Data Set ((MDS) dated [DATE] for R#23 revealed the following a coding for tobacco use. Quarterly MDS dated [DATE] revealed no coding for tobacco use. Observation on 1/30/17 at 2:20 p.m. revealed R#23 observed smoking with no apron. Observation on 1/31/17 at 2:25 p.m revealed R#23 smoking with no apron and being monitored by CNA EE and CNA TT. Observation on 1/31/17 at 4:46pm revealed R#23 smoking with no apron and being monitored by Central Supply Clerk. A total of 18 residents observed smoking with no smoke apron--R51, R80, R71, R40, R81, R99, R116, R46, R60, R70, R38, R103, R64, R111, R104, R69, R21, R105) Observation on 1/31/17 4:46 p.m. During smoke break observed R#23 enter the smoke designated area on Hall -2, holding one cigarette in his hand. Resident reported that Housekeeper PP (later identified by Central Supply Clerk as the Housekeeper Staff) gave him the cigarette. Interview with Central Supply Clerk during the observation revealed that any cigarette given/donated to a resident should be given to a staff member to place in the cigarette lock box. A resident should never be given a cigarette to hold for himself or herself. She stated that further clarity can be made by upper management and not her. Interview on 1/31/17 at 5:00 p.m. with Central Supply Clerk verified that she never witness R#23 or any other resident having their own lighter or cigarettes during smoke break or in the facility prior to today. Reported this was the first incident with R#23. Reported she rarely monitor smoke breaks. Observation 2/1/17 at 2:20 p.m. R#23 revealed smoking with no apron monitored by CNA TT(total 17 residents observed smoking without smoking aprons-R52, R99, R105, R116, R81, R46, R38, R64, R111, R69, R60, R51, R70, R80,R40, R71). Observation on 2/2/17 at 9:30 a.m. revealed R#23 smoking with no apron and being monitored by CNA OO (total 18 residents smoking without aprons- R52, R99, R105, R116, R81, R69, R60, R51, R21,R103,R70, R80, R38,R46, R71,R81,R64 ). Observation on 2/2/17 at 1:56 p.m. revealed R#23 smoking with an apron and being monitored by Director of Nursing DON', Assistant Director of Nursing, ADON, Social Service Director and CNA WW. This consisted of a smaller group of 12 residents. Observation on 2/3/17 at 1:30 p.m. revealed R#23 smoking with an apron and being monitored by DON. This consisted of a smaller group of 12 residents all wearing apron. Observation on 2/4/17 at 7:30 p.m. revealed R#23 smoking with apron and being monitored by DON, CNA AA, and CNA UU. This consisted of a smaller group of 12 residents all wearing apron. Interview on 2/1/1 at 12:36 p.m. with R#23 revealed no incidents of self-hazardous dangerous behaviors of dropping ashes on clothes during cigarette break resulting in a burn. R#23 reported staff never encouraged him/her to wear an apron during smoke break. R#23 stated he smokes at least 3-4 times a day. Interview on 2/3/17 at 2:19 p.m. with R#23 verified received education about the smoking requirements, which included swearing an apron, prohibition from keeping smoking supplies cigarettes, lighters, and etc on personal belongings, and safety hazardous from the DON, SW, and ADON along with other residents. R#23 verified that he signed and received copy of the new smoking policy. 13. Review of clinical record for R#71 revealed the following Diagnosis: [REDACTED]. Brief Interview Mental Status revealed a score of 11 (moderately impaired). The last smoking assessment Smoking Evaluation completed on 12/14/16 . Noted smoking assessment was coded for the following: need a smoking apron. Plan of care completed on 9/22/16 for R(71) was not care plan for smoking. Review of Nurses Notes or R#71 dated 10/3/16 at 11:07 a. m. stated Note Text: This nurse attempted to check resident skin for bleeding at this time. Resident refused skin assessment by this nurse. Resident sitting on the side of his bed rolling tobacco. Advised resident that I will come back to try and check his skin Note documented by Register Nurse (RN) BBB. Interview with RN BBB reference R#71 being seen with tobacco product. She requested to view the noted, validate that was her note. She further stated that with this incident she would had done something else prior and would have notified the DON. She also stated that this type of incident would have required an discussion in morning meeting. Review of Annual MDS dated [DATE] for R#71 revealed the following a coding for Tobacco Use. Quarterly MDS dated [DATE] revealed no coding for tobacco use. Observation on 1/30/17 at 2: 20 p.m. revealed R#71 smoking with no apron. Observation 1/31/17 at 2:25 p.m. revealed R#71 smoking with no apron and being monitored by CNA EE and CNA TT. Observation on 1/31/17 at 4:46 p.m. revealed R#71 smoking with no apron and being monitored by Receptionist Central Supply Clerk (a total of 18 residents smoking without smoking aprons-R51, R80, R23, R40, R81, R99, R116, R46, R60, R70, R38, R103, R64, R111, R104, R69, R21, R105). Observation 2/1/17 at 2:20 p.m. R#71 revealed smoking with no apron monitored by CNA TT (total 17 residents observed smoking without smoking aprons-R52, R99, R105, R116, R81, R46, R38, R64, R111, R69, R60, R51, R70, R80,R40). Observation on 2/2/17 at 9:30 a.m. revealed R#71 smoking with no apron and being monitored by CNA OO (total 18 residents smoking without aprons- R52, R99, R105, R116, R81, R69, R60, R51, R21,R103,R70, R80, R38,R46, R104,R81,R64 ). Observation on 2/2/17 at 2:15 p.m. revealed R#71 smoking with apron and being monitored by Director of Nursing, DON', Assistant Director of Nursing ADON, Social Service Director and CNA WW. This consisted of a smaller group of 12 residents smoking with apron. Observation 2/3/17 1:30 p.m. smoking with apron and being monitored by DON. This consisted of a smaller group of 12 residents wearing apron. Observation 2/4/17 7:30 p.m. smoking with apron and being monitored by DON, CNA AA and CNA UU. This consisted of a smaller group of 12 residents all wearing apron. Interview on 2/1/1 at 12:20 p.m. with R#71 revealed no incidents of self-hazardous dangerous behaviors of dropping ashes on clothes during cigarette break resulting in a burn. R#71 reported never ever wearing an apron and staff never encouraged him/her to wear an apron during smoke break. R#71 reported smoking at least five 5 times a day. Interview on 2/3/17 at 2:22 p.m. with R#71 verified received education about the smoking requirements, which included wearing an apron, prohibition from keeping smoking supplies cigarettes, lighters, and etc on personal belongings, and safety hazardous from the DON, SW, and ADON along with other residents. At this time R#71 verified that he signed and received copy of the new smoking policy. 14. Observation of resident R#40 smoking on 2/1/2017 at 9:30 a.m. during designated smoke break without a protective smoking vest in place while smoking. Resident interview at 12:37 p.m. reveals R#40 resident currently smokes five times daily, he has not been burned while smoking nor has he witnessed any other residents burned while smoking. The resident states he does not wear a protective smoking vest while smoking although, he has worn in the past but staff stopped providing them (residents) with a protective smoking vest while smoking. Record review of last Quarterly Smoking evaluation dated 7/6/2015 with a lock date of 7/6/2015 reveals the resident has a history of tobacco use, he currently uses tobacco products, the resident has impaired cognition with a vision deficit. The smoking evaluation reveals the resident is to wear a protective smoking apron for safety while smoking, he cannot light his own cigarette. Review of Smoking evaluation dated 1/31/2017 reveals the resident has a History of tobacco use, and currently uses tobacco products, the resident does not have impaired cognition he does have a vision deficit, the resident can light his own cigarette. Review of Quarterly care plan Initiated 1/12/2016 and revised on 5/5/2016 reveal the resident is care planned for smoking privileges at the facility. Observation 1/31/17 at 2:25 p.m. smoking not wearing an apron. Observation on 1/31/17 1:30 p.m. and 1/31/17 at 2:25 p.m. R#40 was not wearing an apron per Smoking evaluation. Observation 2/3/17 1:30 p.m. smoking with apron and being monitored by DON. This consisted of a smaller group of 12 residents wearing apron. Observation 2/4/17 at 7:50 p.m. smoking with apron and being monitored by DON, CNA AA and CNA UU. Resident observed was wearing an apron. 15. Review of clinical record for R#21 revealed the following diagnosis : [MEDICAL CONDITIONS], parkinson disease, lack of coordination, muscle weakness. Interview on 2/1/1 at 2:35 p.m. with R#21 BIMS-3 unable to interview secondary to confusion. The last smoking assessment Smoking Evaluation completed on 2/22/15 . Noted smoking assessment was coded for the following: need a smoking apron and vision deficit . Review of plan of care completed on 5/21/15 revealed CP was not coded for smoking. Review of Admission MDS dated [DATE] for R#21 revealed the following a coding for Tobacco Use. Quarterly MDS dated [DATE] revealed no coding for tobacco use. Observation on 1/30/17 at 2:20 p.m. R#21 smoking with no apron. Observation 1/31/17 at 2:25 p.m. R#21 smoking with no apron and being monitored by CNA EE and CNA TT. Observation on 1/31/17 at 4:46 p.m. revealed R#21 smoking with no apron and being monitored by Receptionist Central Supply Clerk (a total of 18 residents smoking without smoking aprons-R51, R80, R23, R40, R81, R99, R116, R46, R60, R70, R38, R103, R64, R111, R104, R69, R71, R105). Observation 2/1/17 at 2:20 p.m. R#21 revealed smoking with no apron monitored by CNA TT(total 17 residents observed smoking without smoking aprons-R52, R99, R105, R116, R81, R46, R38, R64, R111, R69, R60, R51, R70, R80,R40, R71). Observation on 2/2/17 at 9:30 a.m. revealed R#21 smoking with no apron and being monitored by CNA OO (total 16 residents smoking without aprons- R52, R99, R105, R116, R81, R69, R60, R51, R103,R70, R80, R38,R46, R71,R81,R64 ). Observation on 2/2/17 at 2:15 p.m. R#21 smoking with apron and being monitored by Director of Nursing, DON', Assistant Director of Nursing ADON, Social Service Director and CNA WW. This consisted of a smaller group of 4 four residents smoking with apron. Interview on 2/3/17 at

Based on observation, record review, resident and staff interviews, and facility policy titled, Smoking Residents and Employee's, it was determined that the facility failed to revise the care plan to provide smoke aprons for sixteen of twenty-three residents (R) (#53, 54, 51, 71, 81, 116, 100, 105, 60, 38, 23, 64, 111, 21, 12, 59, 87, 120, 72, 30, 69, 163 and 152) of thirty-three (33) reviewed for smoking; and for one (1) resident (#49) who had a contracture. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census 116 residents. The sample was 62. On 2/2/2017, a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the immediate jeopardy on 2/2/17 at 8:52 a.m. The noncompliance related to the immediate jeopardy (IJ) was identified to have existed on 1/30/17. The facility submitted a Credible Allegation of Compliance (AOC) on 2/2/17 related to the immediate jeopardy. The immediate jeopardy was removed on 2/4/17. A Credible Allegation of Compliance (AOC) was received on 2/2/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AOC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 2/4/17. The facility remained out of compliance at a lower scope and severity at F279 S/S:D, F280 S/S:D, F323 S/S: D, F490 S/S:D, and F520 S/S:D, while the facility continued management level staff oversight of resident smoking assessments and procedures to ensure the safety of residents that smoke. This oversight process also includes analysis of facility staff ' s conformance with the facility ' s Policies and Procedures, and while the facility develops and implements the Plan of Correction (POC); and the facility ' s Quality Assurance (QA) monitors the effectiveness of the systemic changes. In-service materials and records were reviewed. Observation and interviews were conducted with residents and staff to ensure they demonstrated knowledge of facility Policies and Procedures governing residents smoking safely. Resident records were reviewed to ensure that resident assessments were current and accurate. Cross refer to F 323 Findings include: Review of the facility's policy titled, Smoking, Residents and Employees revealed: 1. The facility will have a designated smoking area and smoking will be prohibited in any other area. This area will be located outside the facility and identified by a Designated Smoking Area sign. 2. Smoking policies will be reviewed with employees during orientation and annually during inservice training. 3. All residents will be supervised during smoking. Residents will not be permitted to smoke without the direct supervision of a responsible staff member, visitor, or volunteer 4. Residents will not be permitted to smoke outside of the designated smoking times. 5. All residents who smoke will be assessed upon admission, quarterly, and PRN (as needed) as conditions warrant for safety equipment needs. Examples of equipment include smoking aprons and assistive devices. 6. All smoking equipment will not be retained by the resident at any time. All smoking equipment for residents will be left with the charge nurse and stored in a secured area. Review of the facility Smoking Times revealed the following smoke times per Unit and designated smoking area: Unit 1 and Unit 2: 7:30 a.m., 9:30 a.m., 2:30 p.m., 4:30 p.m., 7:30 p.m. and 9:30 p.m. Unit 3: 6:30 a.m., 9:00 a.m., 1:30 p.m., 4:00 p.m. and 6:30 p.m. Smoke breaks take place on the Smoke porch. 1. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed that R#72 currently used tobacco products. Review of the Annual MDS dated [DATE] revealed that the resident was severely cognitively impaired and did not currently use tobacco products. Review of the care plan dated 1/26/16 and reviewed by staff on 12/2/16 revealed that there were no interventions to address smoking safety. On 1/30/17 at 4:00 p.m., R#72 was sitting on the smoking porch with ten (10) other residents. One (1) staff member passed out cigarettes and lighted the cigarettes for the residents. None of the residents were observed to hold their own smoking materials. R#72 was observed to drop a long ash onto his sweat pants and immediately brush it off. Activity Staff BBB, who was standing next to the resident also brushed off the resident's pants where the ash dropped. The resident was not wearing a smoke apron or any other protective covering at that time. The resident continued to smoke while holding the cigarette over his lap. Slight tremors were noted to the resident's right hand holding the cigarette. Observation of the resident's clothing at that time revealed no burn holes. Interview with Activity Staff BBB on 1/30/17 at 4:29 p.m., revealed that R#72 had smoked since his admission. Interview with the Director of Nursing (DON) on 2/1/17 at 1:02 p.m., revealed that every resident who smoked should have a smoking evaluation and a care plan for smoking. 2. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed that R#53 had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was alert and oriented and that he currently used tobacco. Review of the resident's comprehensive care plan dated 1/12/17 and reviewed by staff on 1/26/17 revealed that there were no interventions to address the residents' ability to smoke safely. On 1/31/17 at 12:25 p.m., R#53 was sitting in his wheelchair in the parking lot past the facility boundaries smoking unsupervised and without wearing a smoking apron. Observation of the resident at that time revealed that he smoked safely and that there were no burn holes in his clothing. R#53 stated at that time that he comes outside whenever he wants to smoke and that he is unsupervised at those times. Continued interview revealed that he did not wear a smoke apron while smoking and that he kept his smoking materials, cigarettes and lighter with him. A pack of cigarettes and a lighter were observed resting in the resident's lap at that time. On 2/1/17 at 8:15 a.m. R#53 was sitting in his wheelchair in the parking lot past the facility boundaries smoking unsupervised and without wearing a smoke apron. Interview with the Director of Nursing (DON) and Social Services Director (SSD) on 2/1/17 at 1:02 p.m., revealed that any resident who smokes should have a care plan to address smoking safety. Further interview with the DON at that time revealed that R#53 signed himself out to smoke off campus. Continued interview with the DON revealed that R#53 should give all his smoking materials to the nurses for storage at the nurses' station after smoking. Further interview with the SSD at that time revealed that she did not know if R#53 was care planned for unsupervised smoking. Observation on 2/1/17 at 1:25 p.m., R#53 was in his room. Upon request, he opened his book bag hanging on the back of his wheelchair and retrieved a pack of cigarettes and a lighter. 3. Review of the Quarterly MDS dated [DATE] revealed that R#87 had a Brief Interview for Mental Status (BIMS) score of 10 indicating that she was alert and oriented with some short-term and long-term memory problems. Review of the Annual MDS dated [DATE] revealed that the resident currently used tobacco products. Review of the care plan dated 12/23/16 and reviewed 12/30/16 revealed that there were no interventions to address the residents ability to smoke safely. Review of the Smoking Evaluation dated 5/31/16 revealed that the resident currently used tobacco products and needed to wear a smoke apron. On 1/30/17 at 4:00 p.m. and 6:35 p.m., R#87 was smoking on the smoke porch with the supervision of one staff person. However, the resident was not wearing a smoke apron at the times of the observations. Observation of the resident revealed no burn holes in clothing. Interview with R#87 on 2/3/17 1:24 p.m., revealed that about 9 months ago she was attempting to sit in a chair on the smoke porch and the leg of the chair slipped causing her to tilt and causing her cigarette to touch her dress that she was wearing. Continued interview revealed that the lit cigarette burned a hole in her dress but, did not burn her. Further interview with R#87 revealed that she did not notify staff that she had burned her clothing while smoking. review of the resident's medical record revealed [REDACTED]. 4. Review of the Admission MDS dated [DATE] revealed that R#12 currently used tobacco products. Review of the Quarterly MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating that he had some short-term and long-term memory problems. Review of the care plan dated 2/25/16 and reviewed 12/12/16 revealed that there were no interventions to address the residents ability to smoke safely. Review of the Smoking Evaluation dated 8/17/16 revealed that R#12 currently used tobacco products and needed a smoking apron for safety. On 1/30/17 at 6:27 p.m., R#12 was smoking on the smoke porch with the supervision of one staff member. However, R#12 was not wearing an apron at that time. There were no burn holes observed in the resident's clothing at that time. 5. Record review for R#163 revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 5 indicating that she was cognitively impaired and that she currently used tobacco products. Review of her comprehensive care plan dated 1/31/17 revealed no interventions to ensure that the resident smoked safely. Review of the Smoking Evaluation dated 1/24/17 revealed that the resident needed a smoke apron. However, R#163 was not on the original list of residents who smoked that was provided by the facility on 1/30/17. Review of her medical record revealed no indication that the resident had burned herself while smoking. R#163 was not observed to smoke on 1/30/17. On 1/31/17, R#163 wore a smoke apron while smoking. 6. Review of the medical record for R#54 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed that the resident currently used tobacco products. Review of the Quarterly MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3 indicating that the resident was severely cognitively impaired. Review of the care plan dated 6/3/16 and reviewed 12/15/16 revealed that there were no interventions to ensure the resident's safety while smoking. Review of the Smoking Evaluation dated 1/19/17 revealed that the resident did not need to wear an apron while smoking. R#54 was not observed to smoke on 1/30/17 and 1/31/17. On 2/1/17 at 7:45 a.m., the resident was wearing a smoke apron while smoking. 7. Review of the medical record for R#59 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9 indicating that she was alert and oriented with some confusion. Review of the Annual MDS dated [DATE] revealed that she currently used tobacco products. Review of the care plan dated 6/13/16 and reviewed 12/15/16 revealed that there were no interventions to ensure the resident's safety while smoking. Review of the Smoking Evaluation dated 8/27/15 revealed that the resident required a smoke apron while smoking. The resident was not observed to smoke all days of the survey. Interview with R#59 on 1/31/17 at 9:55 a.m., revealed that the residents did not wear smoke aprons and that the facility quit with them months ago. Interview with R#59 on 2/1/17 12:10 p.m. revealed that she did not smoke because she did not have any money to buy cigarettes. 8. Review of the medical record for R#120 revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9 indicating that she was alert and oriented with some confusion and that she did not currently use tobacco products. Review of the care plan dated 1/14/16 and reviewed 12/23/16 revealed that there were no interventions to ensure the resident's safety while smoking. Although the resident was not observed to smoke during the survey, she was on the initial list of residents who smoked provided by the facility on 1/30/17 as well as the revised list of smokers provided by the facility on 2/1/17. 9. Review of the medical record for R #30 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 indicating that she was alert and oriented with some confusion and that she currently used tobacco products. Review of the care plan dated 12/15/16 and reviewed 12/30/16 revealed that there were no interventions to ensure the resident's safety while smoking. Review of the Smoking Evaluation dated 12/2/16 revealed that the resident needed a smoke apron. On 1/30/17 at 4:00 p.m. and 6:30 p.m. The resident was smoking on the smoke porch with the supervision of one staff member. The resident was wearing a smoke apron at those times. Interview with CNA QQ on 1/31/17 at 9:20 a.m. revealed that R#30 had dropped ashes on herself while smoking and that staff had been instructed to ensure that she wore a smoke apron each time she smoked. Interview with R#30 on 2/1/17 at 12:20 p.m. revealed that she dropped ashes on her pants while smoking but the ashes did not burn her or her clothing. Continued interview revealed that staff place a smoke apron on her at every smoke break. 10. Review of clinical record for The Admission Minimum Data Set ((MDS) dated [DATE] for R#99 revealed the following a coding for tobacco use. The Quarterly MDS dated [DATE] revealed no coding for tobacco use and Review of the Brief Interview Mental Status (BIMS) revealed a score of six (6). A score of (7-0) indicate severely impaired. revealed the following [DIAGNOSES REDACTED]. The last smoking assessment Smoking Evaluation was completed on 10/12/16. The assessment were checked and coded for the following: a smoking apron required. The plan of care for R#99 dated 10/18/16 revealed that R#99 was care planned for #99 smoking. However, the care plan did not address specific interventions for a smoke apron usage based on R#99's smoking evaluation dated 10/12/16. Nurses Notes for R#99 from 7-1-16 to 2-1-17 revealed no documentation of tobacco or tobacco products in possession of resident outside of supervised smoke area without supervision from staff. Observation on 1/30/17 at 2:20 p.m. Resident R#99 was not wearing a smoke apron. Observation on 1/31/17 at 4:46 p.m. revealed R#99 smoking with no apron and being monitored by Receptionist Central Supply Clerk. 11. Record review R#40 revealed last Quarterly Smoking evaluation dated 7/6/2015 with a lock date of 7/6/2015 reveals the resident has a history of tobacco use, he currently uses tobacco products, the resident has impaired cognition with a vision deficit. The smoking evaluation reveals the resident is to wear a protective smoking apron for safety while smoking, he cannot light his own cigarette. Review of (Other) Smoking evaluation dated 1/31/2017 reveals the resident has a History of tobacco use, and currently uses tobacco products, the resident does not have impaired cognition he does have a vision deficit, the resident can light his own cigarette. Review of Quarterly care plan Initiated 1/12/2016 and revised on 5/5/2016 reveal the resident is care planned for smoking privileges at the facility. Resident Observation of resident R#40 smoking on 2/1/2017 at 9:30 a.m. during designated smoke break without a protective smoking vest in place while smoking. Resident interview at 12:37 p.m. reveals R#40 resident currently smokes five Times daily, he has not been burned while smoking nor has he witnessed any other residents burned while smoking. The resident states he does not wear a protective smoking vest while smoking although, he has worn in the past but staff stopped providing them (residents) with a protective smoking vest while smoking. Observation 1/31/17 at 2:25 p.m. smoking not wearing an apron Observation on 1-30-17 1:30 p.m. and 1/31/17 at 2:25 p.m. R#40 was not wearing an apron per Smoking evaluation. Observation 2/3/17 1:30 p.m. smoking with apron and being monitored by DON. This consisted of a smaller group of 12 residents wearing apron. Observation 2/4/17 at 7:50 p.m. smoking with apron and being monitored by DON, CNA AA and CNA UU. Res was wearing an apron. 12. Review of clinical record for R#81 revealed the following Diagnosis: [REDACTED]. Review of the BIMs revealed a score of 8 eight (moderately impaired). Review of Annual Minimum Data Set ((MDS) dated [DATE] for R#81 revealed the following; no coding for tobacco use. Review of The Quarterly MDS dated [DATE] revealed no coding for tobacco use. The last smoking Smoking Evaluation was completed on 9/29/15. The Smoking assessment was coded for the following: smoking apron needed. Review of The plan of care for R#81 dated 12/21/16 revealed R#81 was not care planned for smoking. Interview On 2/1/17 at 12:15 p.m. R#81 reported no incident of self-hazardous dangerous behaviors of dropping ashes on self or clothes during cigarette break resulting in a burn. R#81 also reported never witnessing any resident having a burn injury from a cigarette during smoke break and that staff never encouraged him to wear an apron during smoke break. R#81 confirmed smoking at least 5 five times a day. On 2/3/17 at 2:14 p.m. R#81 verified receiving education about the smoking requirements, which included wearing an apron, prohibition from keeping smoking supplies cigarettes, lighters, and etc., on personal belongings, and safety hazardous from the Director of Nursing (DON), Social Worker (SW), and Assistant Director of Nursing (ADON) along with other residents. R#81 verified that he signed and received copy of the new smoking policy. 13. Review of clinical record for R#23 revealed the following [DIAGNOSES REDACTED]. Review of the BIMS for R#23 and score of 11 that indicates moderately impaired. Review of The Annual Minimum Data Set ((MDS) dated [DATE] for R#23 revealed the following a coding for tobacco use. The Quarterly MDS dated [DATE] revealed no coding for tobacco use. The last smoking assessment Smoking Evaluation was completed on 6/20/16. The Smoking assessment was coded for the following: does not need a smoking apron, light his own cigarette, and coded for impaired cognition. The Plan of care for R#23 dated 9/19/16 was not care plan for smoking. Review of Nurses Notes for R#23 from 7-1-16 to 2-1-17 revealed no documentation of tobacco or tobacco products in possession of resident outside of supervised smoke area without supervision from staff. Interview on 2/1/1 at 12:36 p.m. with R#23 revealed no incidents of self-hazardous dangerous behaviors of dropping ashes on clothes during cigarette break resulting in a burn. R#23 reported staff never encouraged him/her to wear an apron during smoke break. R#23 stated he smokes at least 3-4 times a day. Interview on 2/3/17 at 2:19 p.m. with R#23 verified received education about the smoking requirements, which included wearing an apron, prohibition from keeping smoking supplies cigarettes, lighters, and etc on personal belongings, and safety hazardous from the DON, SW, and ADON along with other residents. R#23 verified that he signed and received copy of the new smoking policy. 14. Review of clinical record for R#71 revealed the following Diagnosis: [REDACTED]. Brief Interview Mental Status (BIMs) for R#71 revealed a score of 11 (moderately impaired). Review of Annual MDS dated [DATE] for R#71 revealed the following a coding for Tobacco Use. Review Quarterly MDS dated [DATE] revealed no coding for tobacco use. Review of the last smoking assessment Smoking Evaluation completed on 12/14/16. Noted smoking assessment was coded for the following: need a smoking apron. Review of R#71 Plan of care completed on 9/22/16 for R(71) was not care planed for smoking. Observation on 1/30/17 at 2: 20 p.m. revealed R#71 smoking with no apron. 15. Review of clinical record for R#21 Review of Admission MDS dated [DATE] for R#21 revealed the following a coding for Tobacco Use. Quarterly MDS dated [DATE] revealed no coding for tobacco use revealed the following diagnosis : [MEDICAL CONDITIONS], parkinson disease, lack of coordination, muscle weakness. Interview on 2/1/1 at 2:35 p.m. with R#21 BIMS-3 (score means severely impaired) unable to interview secondary to confusion. The last smoking assessment Smoking Evaluation completed on 2/22/15. Noted smoking assessment was coded for the following: need a smoking apron and vision deficit . Review of plan of care completed on 5/21/15 revealed CP was not coded for smoking. Observation on 1/30/17 at 2:20 p.m. R#21 smoking with no apron. Observation 1/31/17 at 2:25 p.m R#21 smoking with no apron and being monitored by CNA EE and CNA TT. Observation on 1/31/17 at 4:46 p.m. revealed R#21 smoking with no apron and being monitored by Receptionist Central Supply Clerk. 16. Review of clinical record for R#60 revealed the following Diagnosis: [REDACTED]. Review of Brief Interview Mental Status BIMS revealed a score of 9 nine (moderate impaired). Review of clinical record for R#60 revealed last smoking assessment Smoking Evaluation completed on 11/23/15. Noted smoking assessment was coded for the following: need a smoking apron and coded for impaired cognition. Review of the plan of care completed on 1/14/16 revealed. Care plan was not coded for smoking. Review of Admission MDS dated [DATE] for R#60 revealed the following a coding for tobacco use. Quarterly MDS dated [DATE] revealed no coding for tobacco use. Observation 2/1/17 at 2:20 p.m. R#60 revealed smoking with no apron monitored by CNA TT. Interview 2/1/1 at 2:35 p.m. with R#60 revealed no incidents of self-hazardous dangerous behaviors of dropping ashes on clothes during cigarette break resulting in a burn, reported never witness any resident having a burn injury from a cigarette during smoke break, reported never wore an apron. Reported smoke at least 5 times a day. Interview on 2/3/17 at 2:30 p.m with R#60 verified received education about the smoking requirements, which included swearing an apron, prohibition from keeping smoking supplies cigarettes, lighters, and etc on personal belongings, and safety hazardous from the DON, SW, and ADON. Interview with Director of Nurses and Social Services Director on 2/1/17 at 1:03 pm related to the facilities smoking assessments. It was reported that smoking the smoking assessment is done at admission and anytime there is a change in condition. When questioned about the policy requiring admission, quarterly, and as needed due to changes SSD reported that quarterly assessments are not being done. The expectation is that after a smoking assessment is completed a smoking care plan will be completed. SSD denies that any residents have ever been burned while smoking. Interview with on 02/02/2017 2:30 p.m. with DON revealed that prior to this week it was the responsibility of the charge nurses to complete the smoking evaluations for residents. DON reported that he was unsure as to why the care plans and smoking evaluations were not updated. DON further reported that residents refused to wear the smoking aprons and that is why they were not wearing them. DON acknowledged that there is no documentation to support the claim of resident's refusing to wear the smoking aprons. 2/1/17 1:00 p.m. Interview with the Director of Nursing and the Social Service Director. The DON stated that nurses do the Smoking Evaluation forms and he and the SS Director review these. They are done on initial and when there is a change in condition even though their policy states these are to be done quarterly also. The DON and SS Director confirmed the policy at that time. The SS Director stated once they are assessed the care plan is update or one is initiated. The SS Director stated they don't know of any residents being burned or burned clothing. If staff sees this they report it to the DON or the SS Director and another Smoking Evaluation is completed. If the Evaluation states a smoking apron is to be used the expectations of the DON and SS Director state that they will be in place. The aid assisting with smoking are under the supervision of the Charge Nurses and that it is their responsibility to ensure aprons are worn. Interview on 2/02/2017 at 2:48 p.m. with Administrator for clarification on when issues with the smoking program were identified. Administrator reported that about three weeks ago she identified that there were inconsistencies in how the smoking evaluations were being done and it was determined that one person needed to be responsible for completing the evaluations. ****The facility implemented the following actions to remove the Immediate Jeopardy (Allegation of Compliance): 1. On February 1, 2017, the Director of Nursing in-serviced all on-duty staff on the policy and procedures and what the expectations were for the staff in regards to patient safety while smoking. All care plans and smoking assessments were immediately pulled and audited for accuracy. 2. On February 2, 2017, after notification of the Immediate Jeopardy situation, the need for aprons for all smokers was addressed. All smoking residents will be wearing aprons to protect them and ensure their safety during smoke breaks. 3. One Hundred percent (I00%) of smoking residents will be wearing aprons. Ten additional smoke aprons were ordered at approximately 10:20 a.m. on 02/02/2017. 4. We will have a total of 22 aprons. Of the 33 smokers we have in total, the residents smoke by units. Unit I and Unit II smoke together and Unit III smokes at a different time. 5. Unit I and Unit II will be broken into groups of 12 people to smoke at a time; providing for a safer ratio for the resident's safety. 6. The new aprons that were ordered today were requested to be overnighted with estimated receipt on 02/03/2017. There will be 1 staff member per 12 residents. 7. There were residents who were identified as smokers who had no Care Plan in place. 8. All smokers have been audited by Social Services Director and Director of Nursing on 02/01/2017 and 02/02/2017. Any resident who is identified as a smoker, regardless of the frequency they smoke, has a care plan in place. There are 33 total smoking residents. Care plans were updated to include residents being evaluated for smoking privileges and being safe to smoke during supervised breaks. 9. Their interventions were updated to include wearing a smoke apron, using facility provided ashtrays, following the smoking policy, agreeing to secure smoking equipment with nurse, and understanding in emergency situations smoking privileges could be suspended. 10. There were residents who were assessed to be wearing aprons, but were not wearing them. One Hundred percent (100%) of the 33 smoking residents will now wear aprons during smoke break to ensure their safety. 11. There were 2 residents who did not have smoking assessments at all. All 33 smoking residents have been reassessed as of 02/02/2017 by Social Services Director and Director of Nursing. 12. According to assessments, there were 18 residents assessed for aprons to be worn. Of those 18 only 1 resident actually wore an apron during observations. All residents who smoke from 02/02/2017 forward will be wearing aprons prior to smoking. 13. One (1) resident was observed with smoking equipment in their possession. Resident was educated by Administrator on 02/01/2017 and immediately surrendered his cigarettes and lighter. The resident understands that he/she is to surrender his/her equipment upon return to the facility when he/she is signed out. He/she will surrender to his/her nurse who will secure them. Resident will be part of the audits mentioned below. Should resident violate the policy he/she will be verbally warned and any repeat offense will result in a 30-day discharge from the facility. 14. There were residents identified as smokers who were not listed on the (original) list the surveyors have. The entire census was evaluated for smokers and the list has been corrected as of 02/02/2017 by Social Services Director. All care plans and assessments have been updated as well by Social Services and Director of Nursing. There were 3 names added to the list, 2 that were merely overlooked when originally given to the surveyors and 1 was a newer admission that was reported as a smoker by staff and assessed and care planned. Two residents were removed from the list as they are no longer smokers. 15. Two residents were observed to have ashes fall in their laps during smoke break. Both residents who the surveyor identified to have ashes on them were assessed by the treatment nurse. Treatment nurse performed a head to toe assessment on 02/02/2017 and no skin issues were present. Medical Director notified by Assistant Director of Nursing on 02/02/2017. 16. The smoking policy has been revised as of 02/02/2017 to include how we will handle any violations of the smoking policy. 17. One Hundred Forty (140) of 140 staff members have been educated on the policy, which is now 100% of the staff. 18. Resident meeting was held 02/02/2017 by Social Services and the Director of Nursing, to notify all residents of new policy as well as new smoke break times. 26 of the 33 smoking residents attended meeting and verbally acknowledged their understanding of the new policy and the importance of their safety to us. All 33 residents were given a copy of the new policy. 19. All employees have been in-serviced on 02/01/2017, 02/02/2017, and 02/03/2017. Following this in-service all employees will be annually re-educated to the facility's smoking policy to ensure the continued safety of the residents. The policy will be revie

Based on observation of smoking breaks, staff and resident interviews, review of the facility's policy titled, Smoking: Residents and Employees, and clinical record review it was determined that the facility failed to ensure that one resident (R#53) did not maintain his smoking supplies on his person as per the facility's policy; failed to provide smoke aprons to prevent possible injuries per the Smoking Evaluations for eighteen 18 residents (R#163, R#99, R#54, R#38, R#72, R#30, R#69, R#64, R#40, R#59, R#120, R#111, R#87, R#104, R#12, R#53, R#70, R#103) who were observed smoking without a smoke apron; failed to accurately assess the current smoking status of one resident (R#72) in order to determine safety needs and the resident was observed to drop ashes on his person; failed to complete on-going Smoking Evaluations as per facility policy for residents (R#82, R#7, R#59, R#87, R#12, R#72) and failed to develop care plans with interventions to ensure the safety of twenty-three (23) residents who smoked from a sample of thirty-three (33) residents who were reviewed for smoking. On 2/2/17, a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the immediate jeopardy on 2/2/17 at 8:52 a.m. The noncompliance related to the immediate jeopardy (IJ) was identified to have existed on 1/30/17, the date Resident (R#72) dropped ashes on himself and the facility failed to update a smoking assessment for this resident and failed to create a smoking care plan. The facility submitted a Credible Allegation of Compliance (AOC) on 2/2/17 related to the immediate jeopardy. The immediate jeopardy continued through 2/3/17, and was removed on 2/4/17. A Credible Allegation of Compliance (AOC) was received on 2/2/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AOC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 2/4/17. The facility remained out of compliance at a lower scope and severity at F279 S/S:D, F280 S/S:D, F282 S/S:D, F323 S/S: D, F490 S/S:D, and F520 S/S:D, while the facility continued management level staff oversight of resident smoking assessments and procedures to ensure the safety of residents that smoke. This oversight process also includes analysis of facility staff ' s conformance with the facility ' s Policies and Procedures, and while the facility develops and implements the Plan of Correction (POC); and the facility ' s Quality Assurance (QA) monitors the effectiveness of the systemic changes. In-service materials and records were reviewed. Observation and interviews were conducted with residents and staff to ensure they demonstrated knowledge of facility Policies and Procedures governing residents smoking safely. Resident records were reviewed to ensure that resident assessments were current and accurate Findings include: Review of the facility's policy titled, Smoking, Residents and Employees revealed: 1. The facility will have a designated smoking area and smoking will be prohibited in any other area. This area will be located outside the facility and identified by a Designated Smoking Area sign. 2. Smoking policies will be reviewed with employees during orientation and annually during inservice training. 3. All residents will be supervised during smoking. Residents will not be permitted to smoke without the direct supervision of a responsible staff member, visitor, or volunteer 4. Residents will not be permitted to smoke outside of the designated smoking times. 5. All residents who smoke will be assessed upon admission, quarterly, and PRN (as needed) as conditions warrant for safety equipment needs. Examples of equipment include smoking aprons and assistive devices. 6. All smoking equipment will not be retained by the resident at any time. All smoking equipment for residents will be left with the charge nurse and stored in a secured area. Review of the facility Smoking Times revealed the following smoke times per Unit and designated smoking area: Unit 1 and Unit 2: 7:30 a.m., 9:30 a.m., 2:30 p.m., 4:30 p.m., 7:30 p.m. and 9:30 p.m. Unit 3: 6:30 a.m., 9:00 a.m., 1:30 p.m./, 4:00 p.m. and 6:30 p.m. Smoke breaks take place on the Smoke porch. During the survey, thirty-three (33) residents (#51, 80, 116, 100, 46, 105, 152, 70, 38, 103, 64, 111, 104, 69, 40, 71, 81, 99, 60, 23, 21, 53, 54, 82, 7, 12, 59, 87, 120, 72, 115, 30 and 163) were identified to currently smoke. Review of the medical records for the thirty-three (33) residents revealed that twenty-three (23) of the residents (#53, 54, 51, 71, 81, 116, 100, 105, 60, 38, 23, 64, 111, 21, 12, 59, 87, 120, 72, 30, 69, 163 and 152) did not have care plans to address their smoking safety. 1. Review of the medical record for Resident (R)#72 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to Hospice services on 5/27/16 for Alzheimer's dementia. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed that the resident currently used tobacco products. Review of the current Annual MDS dated [DATE] revealed that the resident was severely cognitively impaired and did not currently use tobacco products. The care plan dated 1/26/16 reviewed by staff on 12/2/16 revealed that there were no interventions to address smoking safety. Review of the last Smoking Evaluation dated 3/1/15 revealed that the resident did not currently use tobacco products. There was no indication that staff had evaluated the resident for safe smoking on an on-going basis as per facility smoking policy. On 1/30/17 at 4:00 p.m., R#72 was sitting on the smoking porch with ten (10) other residents. One (1) staff member passed out cigarettes and lighted the cigarettes for the residents. None of the residents were observed to hold their own smoking materials. Only one resident (R#30) was observed to wear a smoke apron. R#72 was observed to drop a long ash onto his sweat pants and immediately brush it off. Activity Staff BBB, who was standing next to the resident also brushed off the resident's pants where the ash dropped. The resident was not wearing a smoke apron or any other protective covering at that time. The resident continued to smoke while holding the cigarette over his lap. Slight tremors were noted to the resident's right hand holding the cigarette. Observation of the resident's clothing at that time revealed no burn holes. Interview with Activity Staff BBB on 1/30/17 at 4:29 p.m., revealed that R#72 had smoked since his admission. Continued interview revealed that she had not observed him drop ashes on his person while smoking but, that she does not supervise the smoke breaks very often. Further interview with BBB revealed that to her knowledge none of the residents have been burned while smoking. Continued interview revealed that the residents' smoking supplies are kept in a box in the locked medication room behind the nurses station. Further interview revealed that if a resident caught on fire she would utilize the fire blanket that was kept on the smoke porch. On 1/30/17 at 6:27 p.m. R#72 was sitting on the smoking porch with seventeen additional residents. One staff person was supervising at that time. Staff had placed a smoke apron on the resident but, the apron did not completely cover the sides of the resident's torso or his thighs. The resident did not drop ashes on his person at that time. R#72 and R#30 were the only residents observed to wear smoke aprons at that time. Interview with Certified Nursing Assistant (CNA) QQ on 1/31/17 at 9:20 a.m. revealed that she frequently supervises smoke breaks for Unit 3, the secured unit. Continued interview revealed that when she first started working at the facility four (4) years ago, it was mandatory that all residents who smoked wear smoke aprons. Further interview revealed that the aprons have eventually disappeared over time and the facility did not order more. Continued interview revealed that all residents have not worn smoke aprons since at least Spring 2016 but that none of the residents have been burned to her knowledge. Interview with CNA CCC on 1/31/17 at 4:20 p.m., revealed that all residents who smoke should wear smoke aprons and that the facility just received new aprons because the previous ones had torn up. Review of the medical record since May 2015 revealed no documentation regarding R#72 dropping ashes on his person, burning himself while smoking, or any unsafe smoking practices. Interview with the Director of Nursing (DON) and the Social Serviced Director (SSD) on 2/1/17 at 1:02 p.m., revealed that the Charge Nurses completed the smoking evaluations on admission or any time there is a change in a resident's condition. Continued interview with the DON revealed that he and the Social Services Director (SSD) checked the evaluations to ensure that they were completed. Continued interview with the SSD at that time revealed that Quarterly smoking evaluations were not completed. Further interview with the DON revealed that every resident who smoked should have a smoking evaluation and a care plan for smoking. Continued interview with the DON and SSD revealed that none of the residents had been burned while smoking. Further interview with the SSD revealed that she did not know why the residents were not wearing smoke aprons on 1/30/17 at 4:00 p.m. if they had been assessed as needing smoke aprons. The DON stated at that time that he monitored the smoke breaks once every 2-3 weeks to ensure that the residents were smoking safely. The SSD stated at that time that she only monitored the smoke breaks if there was a problem. Interview with the Administrator on 2/2/17 at 8:54 a.m. revealed that staff had not notified her that R#72 had dropped ashes on his sweat pants while smoking on 1/30/17 at 4:00 p.m. Further interview with the Administrator revealed that she may look out the window once a day at the residents who smoked outside but had not identified any problems. Interview with the DON on 2/2/17 at 2:50 p.m. revealed that some residents had refused to wear the smoke aprons and staff did not require them to wear the aprons because it was a dignity issue. Further interview revealed that none of the residents or their responsible parties had signed refusals to wear smoke aprons because there were no incidences of residents being burned. Although staff stated that R#72 had smoked since his admission, the facility failed to accurately assess the resident's smoking status on the Smoking Evaluation dated 3/1/15 and on the 1/23/17 Annual MDS. The facility failed to complete on-going Smoking Evaluations as per facility policy after 3/1/15. Furthermore, the facility failed to develop a comprehensive care plan to include interventions to address the resident's ability to smoke safely. 2. Review of the medical record for R#53 revealed he was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was alert and oriented and that he currently used tobacco. Review of the resident's comprehensive care plan dated 1/12/17, reviewed by staff on 1/26/17 revealed that there were no interventions to address the resident's ability to smoke safely. Further review of the medical record for R#53 revealed that staff had failed to complete an Admission smoking evaluation per facility policy to determine the resident's ability to smoke safely. On 1/31/17 at 12:25 p.m., R#53 was sitting in his wheelchair in the parking lot past the facility boundaries smoking unsupervised and without wearing a smoking apron. Observation of the resident at that time revealed that he smoked safely and that there were no burn holes in his clothing. R#53 stated at that time that he comes outside whenever he wants to smoke and that he is unsupervised at those times. Continued interview revealed that he did not wear a smoke apron while smoking and that he kept his smoking materials, cigarettes and lighter with him. A pack of cigarettes and a lighter were observed resting in the resident's lap at that time. On 2/1/17 at 8:15 a.m. R#53 was sitting in his wheelchair in the parking lot past the facility boundaries smoking unsupervised and without wearing a smoke apron. Interview with R#53 on 2/1/17 at 11:50 a.m. revealed that since his admission on 1/5/17, he had not observed any of the residents on Unit 1 and Unit 2 wear smoke aprons while smoking and only one resident (R#30) wears a smoke apron on Unit 3. Interview with the Director of Nursing (DON) and Social Services Director (SSD) on 2/1/17 at 1:02 p.m., revealed that smoking evaluations were supposed to be done on admission and any time there was a change in the resident's condition. Continued interview with the DON revealed that any resident who smokes should have a care plan to address smoking safety. Further interview with the DON at that time revealed that R#53 signed himself out to smoke off campus. Continued interview with the DON revealed that R#53 should give all his smoking materials to the nurses for storage at the nurses station after smoking. Further interview with the SSD at that time revealed that she did not know if R#53 was care planned for unsupervised smoking. On 2/1/17 at 1:25 p.m., R#53 was in his room. Upon request, he opened his bookbag hanging on the back of his wheelchair and retrieved a pack of cigarettes and a lighter. Interview with Licensed Practical Nurse (LPN) KK on 2/2/17 at 8:10 a.m. revealed that she did not obtain any smoking materials for the resident from the nurses station when he goes out to smoke. Interview with Central Supply Staff DDD on 2/2/17 at 8:10 a.m. revealed that she did not obtain smoking supplies from the nurses station when the resident smoked. Continued interview revealed that she had loaned him a lighter before. Review of the Progress Note dated 1/10/17 at 5:41 a.m. revealed that the resident went outside a few times last night to smoke. Continued review of the medical record revealed that there were no indications that the resident had burned himself. The facility failed to complete an Admission Smoking Evaluation for R#53 to determine his ability to smoke safely. The facility failed to develop a comprehensive care plan to include interventions to ensure the resident's ability to smoke safely. The facility failed to ensure that R#53 adhered to the facility smoking policy to keep all smoking materials at the nurses station and not on his person. 3. Review of the medical record for R#82 revealed that he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the current Quarterly MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating that he had some cognitive impairment. Review of the Annual MDS dated [DATE] revealed that staff left the section J1300 blank regarding the resident's status for smoking. The care plan dated 3/17/16 and reviewed by staff on 1/26/17 revealed that the resident was safe to participate in supervised smoke breaks with interventions that the resident would be financially responsible for all smoking equipment and that he would comply with the restriction to keep any smoking materials on his person or in his room. The Smoking Evaluation dated 9/11/15 revealed that R#82 currently used tobacco products and that a smoking apron was needed. On 1/30/17 at 4:00 p.m. and 6:30 p.m., R#82 was on the smoking porch smoking with the supervision of one staff member. However, R#82 was not wearing a smoke apron at those times. Observation of the resident at those times revealed that the resident did not drop ashes on his person and there were no burn holes in the resident's clothing. Interview with R#82 on 2/1/17 at 11:55 a.m. revealed that he had never burned himself while smoking nor had he observed another resident burned. Further interview revealed that the nurses kept his smoking materials at the nurses station. Review of the medical record for R#82 since 2/2016 revealed no indication that the resident had burned himself while smoking. The facility failed to ensure that R#82 wore a smoke apron while smoking per his Smoking Evaluation dated 9/11/15. Furthermore, staff failed to complete on-going Smoking Evaluations as per facility smoking policy. 4. Review of the medical record for R#87 revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the current Quarterly MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating that she was alert and oriented with some short-term and long-term memory problems. Review of the Annual MDS dated [DATE] revealed that the resident currently used tobacco products. The care plan dated 12/23/16 was reviewed on 12/30/16 revealed that there were no interventions to address the resident's ability to smoke safely. Review of the Smoking Evaluation dated 5/31/16 revealed that the resident currently used tobacco products and needed to wear a smoke apron. On 1/30/17 at 4:00 p.m. and 6:35 p.m., R#87 was smoking on the smoke porch with he supervision of one staff person. However, the resident was not wearing a smoke apron at those times. Observation of the resident revealed no burn holes in her clothing. Interview with R#87 on 2/3/17 1:24 p.m., revealed that about 9 months ago she was attempting to sit in a chair on the smoke porch and the leg of the chair slipped causing her to tilt and causing her cigarette to touch her dress that she was wearing. Continued interview revealed that the lit cigarette burned a hole in her dress but, did not burn her. Further interview with R#87 revealed that she did not notify staff that she had burned her clothing while smoking. review of the resident's medical record revealed [REDACTED]. The facility failed to ensure that R#87 wore a smoke apron while smoking on 1/30/17 at 4:00 p.m. and 6:35 p.m. per her Smoking Evaluation dated 5/31/16. The facility failed to complete on-going Smoking Evaluations after 5/31/16 as per facility policy. The facility failed to develop a comprehensive care plan for R#87 to include interventions to ensure the resident's safe smoking. 5. Review of the medical record for R#12 revealed that he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed that the resident currently used tobacco products. Review of the current Quarterly MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating that he had some short-term and long-term memory problems. The care plan dated 2/25/16 reviewed on 12/12/16 revealed that there were no interventions to address the resident's ability to smoke safely. The Smoking Evaluation dated 8/17/16 revealed that R#12 currently used tobacco products and needed a smoking apron for safety. On 1/30/17 at 6:27 p.m., R#12 was smoking on the smoke porch with the supervision of one staff member. However, R#12 was not wearing an apron at that time. There were no burn holes observed in the resident's clothing at that time. The facility failed to ensure that R#12 wore a smoke apron while smoking as per his Smoking Evaluation dated 8/17/16. The facility failed to complete on-going Smoking Evaluations after 8/17/16 as per facility policy. The facility failed to develop a comprehensive care plan to include interventions to ensure the resident's safe smoking. 6. Review of the medical record for R#7 revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the current Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired. Review of the Annual MDS dated [DATE] revealed that the resident currently used tobacco products. The resident's comprehensive care plan dated 2/16/16 revealed interventions to ensure the resident's safety while smoking. The Smoking Evaluation completed 8/9/15 revealed that the resident needed a smoke apron while smoking. On 1/31/17, R#7 was observed to wear a smoke apron while smoking. The facility failed to complete on-going Smoking Evaluations as per policy after 8/9/15. 7. Review of the medical record for R#59 revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the current Quarterly MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9 indicating that she was alert and oriented with some confusion. Review of the Annual MDS dated [DATE] revealed that the resident currently used tobacco products. The resident's comprehensive care plan dated 9/7/15 revealed that there were interventions to monitor the resident for signs of respiratory distress related to her smoking and [DIAGNOSES REDACTED]. The Smoking Evaluation dated 8/27/15 revealed that the resident needed a smoke apron while smoking. During the survey, the resident was not observed to smoke. The facility failed to complete on-going Smoking Evaluations after 8/27/15 as per facility policy. 8. Review of the medical record for R#163 revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 5, indicating that she was cognitively impaired and that she currently used tobacco products. Review of the Smoking Evaluation initiated 1/24/17 revealed that it was not completed until 2/1/17 and indicated that the resident needed a smoke apron while smoking. Review of the comprehensive care plan dated 1/31/17 revealed that there were no interventions to ensure the resident's safety while smoking. The facility failed to complete the Smoking Evaluation until after surveyor inquiry on 2/1/17. The facility failed to develop a comprehensive care plan to include interventions to ensure the resident smoked safely. 9. Record review reveals Resident #38 (R#38) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record Review of the current Quarterly MDS dated [DATE] section C- Cognitive Status revealed the resident has a BIMS score of 12. Resident is a bilateral amputee. Review of Annual MDS 5/12/16 section J- Health Conditions, reveals the resident currently uses tobacco products. Observation of R#38 on 1/30/17 at 9:30 a.m. revealed the resident in the designated smoking area, smoking without a smoke apron with fifteen (15) other smoking residents smoking without a smoke apron for safety. Resident observed smoking on 1/31/17 at 9:30 a.m. in designated smoking area smoking without a smoke apron, one certified nursing assistant (CNA) available to assist eighteen (18) residents smoking in the smoking area without smoke aprons on for safety. 10. Record review revealed R#69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., COPD, Muscle weakness, Anxiety disorder, Major depressive disorder. Observed R#69, on 2/1/17 at 9:30 a.m. smoking in the designated smoking area without wearing a smoking apron. Record review revealed R#69 was assessed by staff to wear a smoke apron during smoking breaks. Interview with R#69 on 2/1/17 at 10:15 a.m. revealed she has not been burned while smoking nor has she seen another resident get burned while smoking. Interview further revealed the resident is currently smoking five to six times a day, she does not wear a protective smoke apron when smoking, she further revealed they use to but staff stopped giving them out. Record review of the care plan dated 2/16/16 revealed the resident is not care planned for smoking, the smoking evaluation dated 11/16/16, revealed the resident has a history of tobacco use and currently uses tobacco products. She does not have impaired cognition nor does she have a vision deficit. The assessment revealed R#69 is to wear a protective smoke apron while smoking. R#69 has a BIMS score of 10. 11. Record review (RR) reveals the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of R#103 on 1/30/17 at 9:30 a.m. revealed the resident in the designated smoking area, smoking without a smoke apron with fifteen (15) other smoking residents. The resident was smoking from other residents cigarettes, because he did not have his own cigarettes. R#103 observed smoking on 1/31/17 at 9:30 a.m. in designated smoking area smoking without a smoke apron on, the resident was sharing a cigarette with two other residents secondary to him not having any cigarettes of his own. There is one certified nursing assistant (CNA) available to assist eighteen (18) residents smoking in the smoking area without smoke aprons on for safety. Observed R#103 at 9:30 a.m. smoke break on 2/2/17 sitting and talking with other residents, then asking resident to let him have the rest of their cigarette. The resident received a half smoked cigarette from two residents during this smoke break. The resident was observed smoking without a protective smoke apron. Further observation on 2/2/17of the resident at 1:56 p.m. revealed the resident not smoking during the designated smoke break secondary to not having any cigarette's. Interview with R#103 on 2/2/17 at 12:25 p.m. reveals the resident is currently smoking occasionally when he has his own cigarettes he states if he does not have any he will ask someone for a cigarette. He reveals he has not been burned while smoking nor has he seen any other resident burned while smoking, he states he does not use a smoke apron while smoking, he states has not been offered one during smoke break at this facility. Record review of the Admission Smoking evaluation dated 11/10/16 revealed the resident has a history of tobacco use and he currently uses tobacco products, the resident does not have impaired cognition but has a vision deficit he is blind in his right eye. Further review reveals the resident can light his own cigarette. The resident was no longer observed at smoking breaks smoking during the duration of the survey. 12. R#104 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the nursing notes revealed no issues with the resident's smoking routine. Record Review of the smoking evaluation dated 8/30/15 revealed the resident does not have Impaired Cognition or a vision deficit, the resident was assessed as having to wear a protective smoking apron while smoking for safety. Record review of care plan dated 8/5/16 revealed the resident is care planned for Smoking Privileges. Resident observation on 1/30/17 at 9:30 a.m. revealed the resident in the designated smoking area, smoking without a smoke apron with fifteen (15) other smoking residents who were also smoking without a smoke apron for safety. Resident observation on 2/1/17 at the 9:30 a.m. smoke break R#104 was observed coughing profusely while smoking without a smoke apron. R#104 was observed on 2/2/2017 at 9:30 a.m. in the designated smoking area smoking without a smoke apron in place. The resident was observed coughing as soon as he started to smoke. 13. Record review revealed R#111 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nursing notes revealed no smoking incidents involving the resident. Further review reveals the resident has a BIMS of 11 and has moderate cognitive impairment. Resident observation on 1/30/17 at 9:30 a.m. revealed the resident in the designated smoking area, smoking without a smoke apron with fifteen (15) other smoking residents smoking without a smoke apron for safety. Resident observed smoking on 1/31/17 at 9:30 a.m. in designated smoking area smoking without a smoke apron on, one certified nursing assistant (CNA) available to assist eighteen (18) residents smoking in the smoking area without smoke aprons on for safety. Interview with the R#111 on 2/1/17 at 12:20 p.m. revealed the resident currently smokes three times daily, she revealed that she has not been burned while smoking, nor has she seen another resident burned while smoking. The resident revealed she does not wear a protective smoke apron while smoking, she remembers wearing one in the past but no longer wears one, and staff stated they did not have any smoke aprons. Record review of the last Quarterly smoking evaluation dated 8/15/15 and prior to, revealed the resident has a history of tobacco use but does not currently use tobacco products. Review of the last Quarterly Care plan dated 2/22/16 revealed the resident is not currently care planned for smoking. Observation of R#111 at the 9:30 smoke break on 2/2/17 revealed the resident smoking without a smoke apron. The resident was not offered a smoke apron during this time by staff. 14. Record review revealed R#70 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Re-admitted [DATE], the resident was care planned for smoking on admission, he has a smoking evaluation suggesting he needs a protective smoke apron while smoking. Review of the Quarterly smoking assessment dated [DATE] revealed the resident has history of tobacco use and currently uses tobacco products. Record review revealed the resident does not have impaired cognition nor does he have a vision deficit. Review reveals the frequency of the resident smoking times are four times daily, section F (safety) reveals the resident can light his own cigarette. Section F of the smoking assessment had been edited later during the survey process to reflect that the resident was needing a smoking apro

Based on observation of resident smoke breaks, review of the facility's Smoking Policy and clinical record review, resident and staff interviews, the facility failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and/or psychosocial well-being of each resident; failed to ensure that their Smoking Policy and smoking care planned interventions were being fully implemented related to all smoking materials being kept in a locked box/cart maintained by the staff, and failed to ensure that smoking care plans and smoking assessments were updated and completed to ensure that residents that smoke were able to smoke safely. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on 1/30/17 was 116 residents. The sample was 62. On 2/02/17, a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the immediate jeopardy on 2/2/17 at 8:52 a.m. The noncompliance related to the immediate jeopardy (IJ) was identified to have existed on 1/30/17, the date Resident (R#72) dropped ashes on self and the facility failed to update a smoking assessment for this resident and failed to create a smoking care plan. The facility submitted a Credible Allegation of Compliance (AOC) on 2/2/17 related to the immediate jeopardy. The immediate jeopardy continued through 2/3/17, and was removed on 2/4/17. A Credible Allegation of Compliance (AOC) was received on 2/2/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AOC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 2/4/17. The facility remained out of compliance at a lower scope and severity at F279 S/S:D, F280 S/S:D, F323 S/S: D, F490 S/S:D, and F520 S/S:D, while the facility continued management level staff oversight of resident smoking assessments and procedures to ensure the safety of residents that smoke. This oversight process also includes analysis of facility staff ' s conformance with the facility ' s Policies and Procedures, and while the facility develops and implements the Plan of Correction (POC); and the facility ' s Quality Assurance (QA) monitors the effectiveness of the systemic changes. In-service materials and records were reviewed. Observation and interviews were conducted with residents and staff to ensure they demonstrated knowledge of facility Policies and Procedures governing residents smoking safely. Resident records were reviewed to ensure that resident assessments were current and accurate. Findings include: Interview on 2/1/17 at 1:41 pm with DON and Administrator revealed that residents are normally educated regarding smoking during the admission process. It was reported that residents are not required to sign off confirming that they have received the education regarding the smoking policy for the facility. The Administrator reported that the admission packet does not necessarily state the facility policy on smoking but states that residents are responsible for paying for their own smoking items. It was also reported that there must always be a staff person to supervise smoke breaks but there is not a set ratio for staff to resident. Interview on 2/1/17 at 1:48 pm with Social Services Director (SSD) who reported that the nurses should educate residents on admission regarding the smoking policy. SSD further reported that she sometimes talks to residents during resident council regarding the smoke. It was also reported that in the past there were smoking contracts for residents that smoked but these have not been used since 2013 or 2014. SSD confirmed that the residents listed on the smoking list were the only residents that smoke in the facility. Interview with Administrator on 2/1/17 at 5:00 p.m. and was informed that a R#53 was observed in his room with smoking materials. Administrator stated that she was aware that R#53 checks himself out to smoke but his smoking materials should be given to his nurse when he signs back into the facility. Administrator left to go speak with resident and it was discovered that he was signed out and smoking. Administrator reported that she would follow up with resident when he signed back into the building. Interview on 2/1/17 at 5:15 pm with Central Supply in regards to when smoking aprons were last ordered. Central Supply reported that she was not aware of the exact date but reported that she received as shipment a few months ago. Central Supply further reported that she does not have an invoice to show when the last shipment of aprons came in. It was further reported that there is always a minimum of four smoking aprons in stock at all times. The administrator then reported that she could contact cooperate to have an invoice emailed to her. Administrator further reported that she had spoken to R#53 and he no longer has his smoking materials on him. Interview on 2/2/17 at 8:54 a.m. with the facility Administrator who was informed that the team was calling an immediate jeopardy (IJ) related to the care and services for residents that smoke. Administrator revealed that staff had not notified her that R#72 had dropped ashes on his sweat pants while smoking on 1/30/17 at 4:00 p.m. Further interview with the Administrator revealed that she makes daily rounds and may look out the window once a day at the residents who smoked outside but had not identified any problems. Administrator further reported that she felt that a new smoking assessment should be completed whenever residents go out and return to the facility. Interview on 2/2/17 at 2:08 p.m. with the Administrator who reported that the charge nurses were responsible for assuring that the smoking assessments were complete. It was further reported that MDS was responsible for assuring that the care plans were completed for each resident. Administrator reported that she realized about three weeks ago that there may have been some issues related to the smoking program. She went on to report that she was not sure where the break was regarding the care plans and assessments not being completed. A decision was made during the past three weeks to centralize who is completing the smoking assessments. It was reported that some residents did not want to wear smoking aprons but the Administrator could not answer why in general residents were not wearing them. Interview with on 2/2/17 2:30 p.m. with DON revealed that prior to this week it was the responsibility of the charge nurses to complete the smoking evaluations for residents. DON reported that he was unsure as to why the care plans and smoking evaluations were not updated. DON further reported that residents refused to wear the smoking aprons and that is why they were not wearing them. DON acknowledged that there is no documentation to support the claim of resident's refusing to wear the smoking aprons. Interview on 2/02/2017 at 2:48 p.m. with the Administrator for clarification on when issues with the smoking program were identified. Administrator reported that about three weeks ago she identified that there were inconsistencies in how the smoking evaluations were being done and it was determined that one person needed to be responsible for completing the evaluations. Administrator further reported that it was not until surveyors began asking questions about the smoking program that she realized that the smoking issues that had been discussed with her staff a few weeks back had not been followed up on. Smoking concerns were identified but were not formally placed in the quality assurance program. Interview with the Administrator and DON on 2/3/17 at 10:05 a.m. revealed that there had not been any new hires from 1/30/17 to 2/4/17 who would have required an in-service on the smoking policy prior to their start of work. Continued interview revealed that all employees will be in-serviced on the smoking policy annually. Interview with the Administrator on 2/3/17 at 12:31 p.m. revealed that staff now know who smokes based on the smoking list and the smoking list will be kept in the locked box with residents smoking materials. It was further reported that staff have been informed that if there are any issues identified during a smoking break she is to be notified and staff supervising the smoking breaks should assure that the smoking apron fully covers each resident. Interview on 2/9/17 at 9:00 p.m. with the Administrator and DON. It was reported that they knew that there were inconsistencies related to the administration and consent of the influenza (flu) and pneumococcal (pnuemo) vaccines. This is being addressed thru the reassignment of staff duties to complete tasks. The Administrator reported that issues have been identified with the Restorative program and there is a need to reeducate staff related to documentation. It was also reported that the facility is working on a communication form so that all departments will be made aware of important information regard residents. ****The facility implemented the following actions to remove the Immediate Jeopardy (Allegation of Compliance): 1. On February 1, 2017, the Director of Nursing in-serviced all on-duty staff on the policy and procedures and what the expectations were for the staff in regards to patient safety while smoking. All care plans and smoking assessments were immediately pulled and audited for accuracy. 2. On February 2, 2017, after notification of the Immediate Jeopardy situation, the need for aprons for all smokers was addressed. All smoking residents will be wearing aprons to protect them and ensure their safety during smoke breaks. 3. One Hundred percent (I00%) of smoking residents will be wearing aprons. Ten additional smoke aprons were ordered at approximately 10:20 a.m. on 02/02/2017. 4. We will have a total of 22 aprons. Of the 33 smokers we have in total, the residents smoke by units. Unit I and Unit II smoke together and Unit III smokes at a different time. 5. Unit I and Unit II will be broken into groups of 12 people to smoke at a time; providing for a safer ratio for the resident's safety. 6. The new aprons that were ordered today were requested to be overnighted with estimated receipt on 02/03/2017. There will be 1 staff member per 12 residents. 7. There were residents who were identified as smokers who had no Care Plan in place. 8. All smokers have been audited by Social Services Director and Director of Nursing on 02/01/2017 and 02/02/2017. Any resident who is identified as a smoker, regardless of the frequency they smoke, has a care plan in place. There are 33 total smoking residents. Care plans were updated to include residents being evaluated for smoking privileges and being safe to smoke during supervised breaks. 9. Their interventions were updated to include wearing a smoke apron, using facility provided ashtrays, following the smoking policy, agreeing to secure smoking equipment with nurse, and understanding in emergency situations smoking privileges could be suspended. 10. There were residents who were assessed to be wearing aprons, but were not wearing them. One Hundred percent (100%) of the 33 smoking residents will now wear aprons during smoke break to ensure their safety. 11. There were 2 residents who did not have smoking assessments at all. All 33 smoking residents have been reassessed as of 02/02/2017 by Social Services Director and Director of Nursing. 12. According to assessments, there were 18 residents assessed for aprons to be worn. Of those 18 only 1 resident actually wore an apron during observations. All residents who smoke from 02/02/2017 forward will be wearing aprons prior to smoking. 13. One (1) resident was observed with smoking equipment in their possession. Resident was educated by Administrator on 02/01/2017 and immediately surrendered his cigarettes and lighter. The resident understands that he/she is to surrender his/her equipment upon return to the facility when he/she is signed out. He/she will surrender to his/her nurse who will secure them. Resident will be part of the audits mentioned below. Should resident violate the policy he/she will be verbally warned and any repeat offense will result in a 30-day discharge from the facility. 14. There were residents identified as smokers who were not listed on the (original) list the surveyors have. The entire census was evaluated for smokers and the list has been corrected as of 02/02/2017 by Social Services Director. All care plans and assessments have been updated as well by Social Services and Director of Nursing. There were 3 names added to the list, 2 that were merely overlooked when originally given to the surveyors and 1 was a newer admission that was reported as a smoker by staff and assessed and care planned. Two residents were removed from the list as they are no longer smokers. 15. Two residents were observed to have ashes fall in their laps during smoke break. Both residents who the surveyor identified to have ashes on them were assessed by the treatment nurse. Treatment nurse performed a head to toe assessment on 02/02/2017 and no skin issues were present. Medical Director notified by Assistant Director of Nursing on 02/02/2017. 16. The smoking policy has been revised as of 02/02/2017 to include how we will handle any violations of the smoking policy. 17. One Hundred Forty (140) of 140 staff members have been educated on the policy, which is now 100% of the staff. 18. Resident meeting was held 02/02/2017 by Social Services and the Director of Nursing, to notify all residents of new policy as well as new smoke break times. 26 of the 33 smoking residents attended meeting and verbally acknowledged their understanding of the new policy and the importance of their safety to us. All 33 residents were given a copy of the new policy. 19. All employees have been in-serviced on 02/01/2017, 02/02/2017, and 02/03/2017. Following this in-service all employees will be annually re-educated to the facility's smoking policy to ensure the continued safety of the residents. The policy will be reviewed and acknowledged with all new hires prior to their start of work, and they will then be placed on the annual in-service of education on this topic. 20. Administrator and Director of Nursing made room to room rounds to validate there is no smoking equipment at 12:00 p.m. on 02/02/2017. Upon completion of the room to room rounds, there were no cigarette equipment confiscated from anyone in the facility. Nothing present in rooms. 21. Director of Nursing and RN Supervisor will observe each designated smoke break to ensure smoking aprons are in place while smoking. Any observations of unsafe practices will be reported to the Administrator immediately. Administrator to follow protocol of verbal warning for first offense and 30-day discharge from the facility for safety for any violating resident. If an employee is in violation the Administrator will follow disciplinary action procedures. This will be audited daily for 2 weeks and then 3 times per week for 10 weeks. 22. Director of Nursing to audit all new admissions and current smokers on a quarterly, annual, and significant change basis to ensure assessment was complete and care plan was updated to follow recommendations by assessment findings. This will be monitored 5 times per week times 12 weeks. 23. Administrator and/or Social Services will audit 7 smoking residents per day 5 times per week for 2 weeks, then 5 residents a week times 10 weeks to ensure the rooms are free of smoking equipment. Audits will be reviewed for compliance weekly by Director of Nursing and Administrator. These will be monitored through the QA process for 3 months to ensure compliance and will be reviewed as needed thereafter. ****The State survey agency validated the implementation of the facility's Allegation of Compliance as follows: 1 (a.). Review of the employee roster and sign-in sheets revealed that all on-duty staff were inserviced on February 1, 2017 on the policy and procedures and what the expectations were for the staff in regards to resident safety while smoking. During interviews on 2/3/17 at 1:00 p.m. with LPN FF (7:00 a.m. -7 P.m. shift); at 2:50 p.m. with CNA OO (7:00 a.m.-3:00 p.m. shift); at 1:09 p.m. with CNA QQ (7:00 a.m.-3:00 p.m.); at 3:36 p.m. with CNA KKK (3:00 p.m.-11:00 p.m. shift); at 3:55 p.m. with CNA LLL (3:00 p.m.-11:00 p.m. shift);and at 4:07 p.m. with the Maintenance Supervisor, they confirmed that they had been inserviced on the smoking policy which included that all residents who smoked had to wear a smoke apron that covered the resident completely, if a resident refused to wear the apron then the resident could not smoke and they would report to the DON and/or Administrator, that only 12 residents to one staff person were allowed to smoke at designated times, that residents' smoking materials were kept in in the locked medication room at the nurses station, that if a resident was observed with smoking materials in their possession/room, the smoking materials were confiscated and the resident reported to the nurse/ADON/DON/Administrator, and that a list of residents who smoke is kept in the container which housed the residents' smoking materials. 1 (b.). Review of the audits completed by the Social Services Director and Director of Nursing on 2/1/17 and 2/2/17 revealed that the facility identified thirty three (33) residents who smoked and that twenty-three (23) of the thirty three (33) residents did not have care plans in place to address smoking safety. On 2/3/17, the facility provided smoking care plans for all thirty three (33) residents who currently smoked regardless of the frequency the resident smoked and Smoking Evaluations for R#53 and R#163. Review of care plans and assessments on 2/3/17 revealed that all smokers had a smoking care plan and smoking assessment. 2. On 1/31/17 at 8:57 a.m., ten (10) residents from Unit 3 were on the smoke porch with the supervision of one staff member. A smoke apron was placed on each of four residents prior to providing and lighting their cigarettes. The other six residents waited to smoke until one of the four residents finished smoking and relinquished their smoke apron. All of the residents who smoked at that time wore a smoke apron while smoking. Review of the audits completed on 2/2/17 by the Social Services Director and Director of Nursing revealed that two residents (R#53 and #163) did not have smoking evaluations. Staff completed smoking evaluations on all 33 residents R#53, R#54, R#51, R#80, R#40, R#7, R#71, R#81, R#99, R#82, R#116, R#100, R#46, R#105, R#60, R#70, R#38, R#152 , R#64 , R#111 , R#21, R#104, R#12, R#59, R#87, R#120, R#72, R#115, R#30, R#163, R#103, R#23, and R#69) who smoked. Observation on 2/2/2017 at 1:56 p.m. twelve (12) residents were noted to have on protective smoking aprons while smoking, staff present were the DON, SSD notifying residents when to enter smoking area, ADON assisting the Certified Nursing Assistant (CNA) with distribution of the cigarette's to the residents. Second half of smoking residents entered the smoking area at 2:15 p.m., smoke aprons placed on four (4) residents by staff before distribution of cigarettes to residents. Observation of R#111 on 2/2/17 at 1:56 p.m. of the resident revealed the resident wearing a smoke apron while smoking with eleven (11) other residents also wearing smoke aprons while smoking for safety. DON, ADON, WW, and SSD assisting with smoke break. Observation on 2/2/17 at 2:00 p.m., 2:30 p.m. and 4:00 p.m. of R#46 and R#152 revealed a smoking apron was on the resident and he was safely smoking at that time. The RN supervisor and the DON were present supervising the activity. Observation of smoke break on 2/4/17 at the 8:30 a.m. revealed that residents on Unit 3, were all observed to be wearing smoke aprons that were covering their body appropriately and using facility provided ashtrays. Observation of smoke break on 2/4/17 at 10:00 a.m. for residents on Unit 1 and 2. Residents were observed to be wearing smoking aprons. 3, 4, 5, 6. On 1/31/17 at 8:57 a.m., ten (10) residents from Unit 3 were on the smoke porch with the supervision of one staff member. A smoke apron was placed on each of four residents prior to providing and lighting their cigarettes. The other six residents waited to smoke until one of the four residents finished smoking and relinquished their smoke apron. All of the residents who smoked at that time wore a smoke apron while smoking. Observation of the smoke break on Unit 3 on 2/3/17 at 4:02 p.m. revealed that residents' #12, 30, 54, 72, 7, 87, 82, 115 and 152 were smoking on the smoking porch and all were wearing aprons that completely covered their persons. The residents were supervised by the DON, ADON and one CNA at that time. Observation of the smoke break on 2/4/17 at 7:35 a.m. revealed that residents' #64, 71, 105, 104, 81, 69, 21, 51, 70, 38 and 99 wore smoke aprons while smoking and were supervised by the ADON and DON. At 7:41 a.m., R#60 arrives and staff place a smoke apron on him prior to providing him a cigarette and lighting it for him. Observation of smoke break on 2/4/17 at 8:47 a.m. revealed R#54, R#32, R#82, R#152, R#12, R#87, R#72, R#115, and R#30 to all be wearing smoking aprons. RN Supervisor and DON present to supervise this smoke break. Observation of smoke break on 2/4/17 at 10 a.m. revealed R#51, R#71, R#81, R#116, R#46, R#105, R#60, R#111, R#21, R#104, R#69, and R#38 to all be wearing smoking aprons. DON and ADON present to supervise this smoke break. 10 additional smoke aprons observed in blue storage containers. Observation of smoke break on 2/4/17 at 10:15 a.m. revealed R#40, R#99, R#70, and R#64 to all be wearing smoking aprons. DON and ADON present to supervise this smoke break. All residents who smoked on Unit 1 and Unit 2 and on Unit 3 were observed to wear smoke aprons during smoke breaks on 2/2/17, 2/3/17 and 2/4/17. 7, 8, 9. On 2/3/17, the facility provided smoking care plans for all thirty three (33) residents who currently smoked regardless of the frequency the resident smoked. Review of the care plans revealed that interventions included that the residents were evaluated for smoking safety during supervised smoke breaks, that they must wear a smoke apron while smoking, that they must use the facility provided ashtrays, that they must follow the facility smoking policy, that they must secure their smoking equipment with the nurse and that in emergency situations smoking privileges could be suspended. Revised smoking list reviewed and care plan for each person listed on care plan confirmed on 2/3/17. Interventions on care plans confirmed for each of the 33 smoking residents on 2/3/17. Revised smoking list reviewed and care plan for each smoking resident (R#53, R#54, R#51, R#80, R#40, R#7, R#71, R#81, R#99, R#82, R#116, R#100, R#46, R#105, R#60, R#70, R#38, R#152 , R#64 , R#111 , R#21, R#104, R#12, R#59, R#87, R#120, R#72, R#115, R#30, R#163, R#103, R#23, and R#69) listed on care plan confirmed on 2/3/17.R# 152, R#163, and #69 added to smokers list. Interventions on care plans confirmed for each of the 33 smoking residents (R#53, R#54, R#51, R#80, R#40, R#7, R#71, R#81, R#99, R#82, R#116, R#100, R#46, R#105, R#60, R#70, R#38, R#152 , R#64 , R#111 R#21, R#104, R#12, R#59, R#87, R#120, R#72, R#115, R#30, R#163, R#103, R#23, and R#69) on 2/3/17. Smoking interventions included wearing a smoke apron, using facility provided ashtrays, following the facility smoking policy, all smoking equipment to be secured with the nurse, and smoking privileges to be suspended during emergencies. 10, 12. During observations of the smoke breaks on 1/30/17 at 4:00 p.m. on Unit 3, only one resident (R#30) was observed to wear an apron while smoking. During observation of the smoke break on 1/30/17 at 6:27 p.m., only R#30 and R#72 wore smoke aprons while smoking. On 1/31/17 at 8:57 a.m., ten (10) residents from Unit 3 were on the smoke porch with the supervision of one staff member. A smoke apron was placed on each of four residents prior to providing and lighting their cigarettes. The other six residents waited to smoke until one of the four residents finished smoking and relinquished their smoke apron. All of the residents who smoked at that time wore a smoke apron while smoking. (See observations listed in 3 through 9) 11. Review of the Smoking Evaluations completed by the SSD and DON on 2/2/17 revealed that all 33 residents who smoked had Smoking Evaluations to determine their ability to smoke safely. Revised smoking list was reviewed and care plan for each smoking resident (R#53, R#54, R#51, R#80, R#40, R#7, R#71, R#81, R#99, R#82, R#116, R#100, R#46, R#105, R#60, R#70, R#38, R#152 , R#64 , R#111 , R#21, R#104, R#12, R#59, R#87, R#120, R#72, R#115, R#30, R#163, R#103, R#23, and R#69) listed on care plan confirmed on 2/3/17.R# 152, R#163, and #69 added to smokers list. 13. There were thirty two (32) residents listed as smokers on the original list of smokers provided by the facility on 1/30/17. During observations of smoke breaks on 1/31/17 and 2/1/17, three (3) additional residents (#163, #69 and #152) were identified as smokers. Review of the census audit completed by the Social Services Director by 2/2/17 revealed that two (2) of the smokers on the original list (R#122 and #98) no longer smoked. The list of smokers was revised to include thirty three (33) residents (R#53, R#54, R#51, R#80, R#40, R#7, R#71, R#81, R#99, R#82, R#116, R#100, R#46, R#105, R#60, R#70, R#38, R#152 , R#64 , R#111 , R#21, R#104, R#12, R#59, R#87, R#120, R#72, R#115, R#30, R#163, R#103, R#23, and R#69). Smoking assessments reviewed and confirmed for all 33 smoking residents (R#53, R#54, R#51, R#80, R#40, R#7, R#71, R#81, R#99, R#82, R#116, R#100, R#46, R#105, R#60, R#70, R#38, R#152 , R#64 , R#111 , R#21, R#104, R#12, R#59, R#87, R#120, R#72, R#115, R#30, R#163, R#103, R#23, and R#69). Smoking aprons are identified as needed for all 33 smoking residents. Revised smoking list reviewed and care plan for each person listed on care plan confirmed on 2/3/17. R#122 and R#98 were removed from the smoking list and were not observed smoking throughout the survey. R#53 was educated by the Administrator on 2/1/17 and immediately surrendered his cigarettes and lighter. The resident was instructed that he had to surrender his equipment to the nurse upon return to the facility. Interview with R#53 on 2/4/17 at 9:15 a.m., revealed that he was in-serviced by staff on the new smoking policy and smoke times and received a copy of the smoke policy. Continued interview revealed that he has to sign out his cigarettes and lighter from the nurses prior to smoking and then relinquish his cigarettes and lighter to the nurses when he signs himself back into the facility. Interview with Central Supply staff DDD on 2/3/17 at 10:02 a.m., revealed that she was instructed by the Administrator to obtain resident's cigarettes and lighter from the nurses and escort the resident out past the facility boundary to smoke. Continued interview revealed that she was to ensure that the resident hand over his cigarettes and lighter when he signs himself back into the facility and she will give them to the nurse. Observation on 2/3/17 at 11:19 a.m., R#53 was smoking past the facility boundaries. He was observed to wheel himself back into the facility, sign himself in and hand over his cigarettes and lighter to Central Supply Staff DDD who was monitoring the front desk. DDD documented on a form the date and time that R#53 signed himself out with his cigarettes and lighter and the date and time that he signed himself in with his cigarettes and lighter. DDD then provided the cigarettes and lighter to the nurse to secure in the medication room. 14. Review of the census audit completed by the Social Services Director by 2/2/17 revealed that two (2) of the smokers on the original list (R#122 and #98) no longer smoked and were removed from the revised list. R#163, 69 and #152 were added to the revised list of smokers. The list of smokers was revised to include thirty three (33) residents (#51, 80, 116, 100, 46, 105, 152, 70, 38, 103, 64, 111, 104, 69, 40, 71, 81, 99, 60, 23, 21, 53, 54, 82, 7, 12, 59, 87, 120, 72, 115, 30 and 163) who currently smoked. 15. The revised smoking policy for residents with a revision date of 2/2/17 revealed the following: All smoking equipment for residents will be left with the charge nurse and stored in a secure area. If any such equipment is found in a resident's room, or on their person, staff will explain to the resident why the articles must be removed and given to the charge nurse for storage. Family and physician will be notified as needed. Should a resident be identified as having any type of smoking equipment on them, they will receive a verbal warning of safety violations. Any further violations will lead to a 30-day discharge from the facility. One resident (#53) was observed to have smoking materials in his possession. The resident was educated by the Administrator on 2/1/17 and immediately surrendered his cigarettes and lighter. The resident was instructed that he had to surrender his equipment to the nurse upon return to the facility. Interview with R#53 on 2/4/17 at 9:15 a.m., revealed that he was in-serviced by staff on the new smoking policy and smoke times and received a copy of the smoke policy. Continued interview revealed that he has to sign out his cigarettes and lighter from the nurses prior to smoking and then relinquish his cigarettes and lighter to the nurses when he signs himself back into the facility. Interview with Central Supply staff DDD on 2/3/17 at 10:02 a.m., revealed that she was instructed by the Administrator to obtain resident's cigarettes and lighter from the nurses and escort the resident out past the facility boundary to smoke. Continued interview revealed that she was to ensure that the resident hand over his cigarettes and lighter when he signs himself back into the facility and she will give them to the nurse. On 2/3/17 at 1119 a.m., R#53 was smoking past the facility boundaries. He was observed to wheel himself back into the facility, sign himself in and hand over his cigarettes and lighter to Central Supply Staff DDD who was manning the front desk. DDD documented on a form the date and time that R#53 signed himself out with his cigarettes and lighter and the date and time that he signed himself in with his cigarettes and lighter. DDD then provided the cigarettes and lighter to the nurse to secure in the medication room. Interview on 2/3/17 at 2:55 p.m. with Medical Director who confirmed that he had been notified of R#72 and R#70 dropping ashes on themselves. Medical Director denied that he has ever been notified of any resident from the facility burning self while smoking. Review of medical record for R#72 revealed a skin assessment was completed on 2/2/17 noting skin intact. Review of medical record for R#70 revealed a skin assessment was completed on 2/2/17 noting skin intact. 16. Review of the revised smoking policy dated 2/2/17 revealed the following revisions: The policy also included that if a resident failed to follow the policy, he/she would receive a verbal warning for the first offense and a 30 day discharge notice for a subsequent offense. All smoking equipment for residents will be left with the charge nurse and stored in a secure area. If any such equipment is found in a resident's room, or on their person, staff will explain to the resident why the articles must be removed and given to t

Based on record review, and interviews, the facility failed to maintain an effective Quality Assurance (QA) program that systematically reviewed quality of care related to 33 residents (R#53, R#54, R#51, R#80, R#40, R#7, R#71, R#81, R#99, R#82, R#116, R#100, R#46, R#105, R#60, R#70, R#38, R#152 , R#64 , R#111 , R#21, R#104, R#12, R#59, R#87, R#120, R#72, R#115, R#30, R#163, R#103, R#23, and R#69) who smoke. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on 1/30/17 was 116 residents. The sample was 62. On 2/2/17, a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the immediate jeopardy on 2/2/17 at 8:52 a.m. The noncompliance related to the immediate jeopardy (IJ) was identified to have existed on 1/30/17, the date Resident (R#72) dropped ashes on self and the facility failed to update a smoking assessment for this resident and failed to create a smoking care plan. A Credible Allegation of Compliance (AOC) was received on 2/2/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AOC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 2/4/17. The facility remained out of compliance at a lower scope and severity at F279 S/S:D, F280 S/S:D, F323 S/S: D, F490 S/S:D, and F520 S/S:D, while the facility continued management level staff oversight of resident smoking assessments and procedures to ensure the safety of residents that smoke. This oversight process also includes analysis of facility staff ' s conformance with the facility ' s Policies and Procedures, and while the facility develops and implements the Plan of Correction (POC); and the facility ' s Quality Assurance (QA) monitors the effectiveness of the systemic changes. In-service materials and records were reviewed. Observation and interviews were conducted with residents and staff to ensure they demonstrated knowledge of facility Policies and Procedures governing residents smoking safely. Resident records were reviewed to ensure that resident assessments were current and accurate. Findings include: Interview on 2/1/17 at 1:41 p.m. with the Director of Nursing (DON) and Administrator revealed that residents are normally educated regarding smoking during the admission process. It was reported that residents are not required to sign off confirming that they have received the education regarding the smoking policy for the facility. The Administrator reported that the admission packet does not necessarily state the facility policy on smoking but states that residents are responsible for paying for their own smoking items. It was also reported that there must always be a staff person to supervise smoke breaks but there is not a set ratio for staff to resident. Interview on 2/1/17 at 1:48 p.m. with Social Services Director (SSD) who reported that the nurses should educate residents on admission regarding the smoking policy. SSD further reported that she sometimes talks to residents during resident council regarding smoke break. It was also reported that in the past there were smoking contracts for residents that smoked but these have not been used since 2013 or 2014. SSD also revealed that the residents listed on the smoking list were the only residents that smoke in the facility. Interview with the Administrator on 2/1/17 at 5:00 p.m. revealed they were informed that R#53 was observed in his room with smoking materials. The Administrator stated that she was aware that R#53 checks himself out to smoke but that his smoking materials should be given to his nurse when he signs back into the facility. The Administrator left to go speak with resident and discovered that he was signed out and smoking. The Administrator reported that she would follow up with resident when he signed back into the building. Interview on 2/1/17 at 5:15 p.m. with Central Supply in regards to when smoking aprons were last ordered. Central Supply reported that she was not aware of the exact date but reported that she received a shipment a few months ago. Central Supply further reported that she does not have an invoice to show when the last shipment of aprons came in. It was further reported that there is always a minimum of four smoking aprons available at all times. The administrator then reported that she could contact corporate to have an invoice emailed to her. The Administrator further reported that she had spoken to R#53 and he no longer has his smoking materials on him. Interview on 2/2/17 at 8:54 a.m. with the Administrator, was informed that an immediate jeopardy (IJ) related to the care and services for residents that smoke. The Administrator revealed that staff had not notified her that R#72 had dropped ashes on his sweat pants while smoking on 1/30/17 at 4:00 p.m. Further interview with the Administrator revealed that she makes daily rounds and may look out the window once a day at the residents who smoked outside but had not identified any problems. The Administrator further reported that she felt that a new smoking assessment should be completed whenever residents go out and return to the facility. Interview on 2/2/17 at 2:08 p.m. with the Administrator revealed that the charge nurses were responsible for assuring that the smoking assessments were complete also revealed that Minimum Data Set (MDS) personnel were responsible for assuring that the care plans were completed for each resident that smoke. The Administrator reported that she realized about three weeks ago that there may have been some issues related to the smoking program and continued to report that she was not sure where the break down was regarding the care plans and assessments not being completed. The administrator also stated that some residents did not want to wear smoking aprons but could not answer why in general residents were not wearing them. Interview on 2/2/17 2:30 p.m. with the DON revealed that prior to this week it was the responsibility of the charge nurses to complete the smoking evaluations for residents. The DON reported that he was unsure as to why the care plans and smoking evaluations were not updated. He further reported that residents refused to wear the smoking aprons and that is why they were not wearing them. The DON acknowledged that there is no documentation to support his claim of resident's refusing to wear the smoking aprons. Interview on 2/2/2017 at 2:48 p.m. with the Administrator for clarification on when issues with the smoking program were identified. The Administrator reported that about three weeks ago she identified that there were inconsistencies in how the smoking evaluations were being done and it was determined that one person needed to be responsible for completing the evaluations and further revealed that it was not until surveyors began asking questions about the smoking program that she realized that the smoking issues that had been discussed with her staff a few weeks back had not been followed up on and that smoking concerns were identified but were not formally placed in the quality assurance program (QAA). Interview with the Administrator and DON on 2/3/17 at 10:05 a.m. revealed that there had not been any new staff hired from 1/30/17 to 2/4/17 who would have required an in-service on the smoking policy prior to their start of work. Continued interview revealed that all employees will be in-serviced on the smoking policy annually. Interview with the Administrator on 2/3/17 at 12:31 p.m. revealed that staff now know which residents smoke based on the smoking list and the smoking list will be kept in the locked box with residents smoking materials. It was further reported that staff have been informed that if there are any issues identified during a smoking break she is to be notified and staff supervising the smoking breaks should assure that the smoking apron fully covers each resident. ****The facility implemented the following actions to remove the Immediate Jeopardy (Allegation of Compliance): 1. On February 1, 2017, the Director of Nursing in-serviced all on-duty staff on the policy and procedures and what the expectations were for the staff in regards to patient safety while smoking. All care plans and smoking assessments were immediately pulled and audited for accuracy. 2. On February 2, 2017, after notification of the Immediate Jeopardy situation, the need for aprons for all smokers was addressed. All smoking residents will be wearing aprons to protect them and ensure their safety during smoke breaks. 3. One Hundred percent (I00%) of smoking residents will be wearing aprons. Ten additional smoke aprons were ordered at approximately 10:20 a.m. on 02/02/2017. 4. We will have a total of 22 aprons. Of the 33 smokers we have in total, the residents smoke by units. Unit I and Unit II smoke together and Unit III smokes at a different time. 5. Unit I and Unit II will be broken into groups of 12 people to smoke at a time; providing for a safer ratio for the resident's safety. 6. The new aprons that were ordered today were requested to be overnighted with estimated receipt on 02/03/2017. There will be 1 staff member per 12 residents. 7. There were residents who were identified as smokers who had no Care Plan in place. 8. All smokers have been audited by Social Services Director and Director of Nursing on 02/01/2017 and 02/02/2017. Any resident who is identified as a smoker, regardless of the frequency they smoke, has a care plan in place. There are 33 total smoking residents. Care plans were updated to include residents being evaluated for smoking privileges and being safe to smoke during supervised breaks. 9. Their interventions were updated to include wearing a smoke apron, using facility provided ashtrays, following the smoking policy, agreeing to secure smoking equipment with nurse, and understanding in emergency situations smoking privileges could be suspended. 10. There were residents who were assessed to be wearing aprons, but were not wearing them. One Hundred percent (100%) of the 33 smoking residents will now wear aprons during smoke break to ensure their safety. 11. There were 2 residents who did not have smoking assessments at all. All 33 smoking residents have been reassessed as of 02/02/2017 by Social Services Director and Director of Nursing. 12. According to assessments, there were 18 residents assessed for aprons to be worn. Of those 18 only 1 resident actually wore an apron during observations. All residents who smoke from 02/02/2017 forward will be wearing aprons prior to smoking. 13. One (1) resident was observed with smoking equipment in their possession. Resident was educated by Administrator on 02/01/2017 and immediately surrendered his cigarettes and lighter. The resident understands that he/she is to surrender his/her equipment upon return to the facility when he/she is signed out. He/she will surrender to his/her nurse who will secure them. Resident will be part of the audits mentioned below. Should resident violate the policy he/she will be verbally warned and any repeat offense will result in a 30-day discharge from the facility. 14. There were residents identified as smokers who were not listed on the (original) list the surveyors have. The entire census was evaluated for smokers and the list has been corrected as of 02/02/2017 by Social Services Director. All care plans and assessments have been updated as well by Social Services and Director of Nursing. There were 3 names added to the list, 2 that were merely overlooked when originally given to the surveyors and 1 was a newer admission that was reported as a smoker by staff and assessed and care planned. Two residents were removed from the list as they are no longer smokers. 15. Two residents were observed to have ashes fall in their laps during smoke break. Both residents who the surveyor identified to have ashes on them were assessed by the treatment nurse. Treatment nurse performed a head to toe assessment on 02/02/2017 and no skin issues were present. Medical Director notified by Assistant Director of Nursing on 02/02/2017. 16. The smoking policy has been revised as of 02/02/2017 to include how we will handle any violations of the smoking policy. 17. One Hundred Forty (140) of 140 staff members have been educated on the policy, which is now 100% of the staff. 18. Resident meeting was held 02/02/2017 by Social Services and the Director of Nursing, to notify all residents of new policy as well as new smoke break times. 26 of the 33 smoking residents attended meeting and verbally acknowledged their understanding of the new policy and the importance of their safety to us. All 33 residents were given a copy of the new policy. 19. All employees have been in-serviced on 02/01/2017, 02/02/2017, and 02/03/2017. Following this in-service all employees will be annually re-educated to the facility's smoking policy to ensure the continued safety of the residents. The policy will be reviewed and acknowledged with all new hires prior to their start of work, and they will then be placed on the annual in-service of education on this topic. 20. Administrator and Director of Nursing made room to room rounds to validate there is no smoking equipment at 12:00 p.m. on 02/02/2017. Upon completion of the room to room rounds, there were no cigarette equipment confiscated from anyone in the facility. Nothing present in rooms. 21. Director of Nursing and RN Supervisor will observe each designated smoke break to ensure smoking aprons are in place while smoking. Any observations of unsafe practices will be reported to the Administrator immediately. Administrator to follow protocol of verbal warning for first offense and 30-day discharge from the facility for safety for any violating resident. If an employee is in violation the Administrator will follow disciplinary action procedures. This will be audited daily for 2 weeks and then 3 times per week for 10 weeks. 22. Director of Nursing to audit all new admissions and current smokers on a quarterly, annual, and significant change basis to ensure assessment was complete and care plan was updated to follow recommendations by assessment findings. This will be monitored 5 times per week times 12 weeks. 23. Administrator and/or Social Services will audit 7 smoking residents per day 5 times per week for 2 weeks, then 5 residents a week times 10 weeks to ensure the rooms are free of smoking equipment. Audits will be reviewed for compliance weekly by Director of Nursing and Administrator. These will be monitored through the QA process for 3 months to ensure compliance and will be reviewed as needed thereafter. ****The State survey agency validated the implementation of the facility's Allegation of Compliance as follows: 1 (a.). Review of the employee roster and sign-in sheets revealed that all on-duty staff were inserviced on February 1, 2017 on the policy and procedures and what the expectations were for the staff in regards to resident safety while smoking. During interviews on 2/3/17 at 1:00 p.m. with LPN FF (7:00 a.m. -7 P.m. shift); at 2:50 p.m. with CNA OO (7:00 a.m.-3:00 p.m. shift); at 1:09 p.m. with CNA QQ (7:00 a.m.-3:00 p.m.); at 3:36 p.m. with CNA KKK (3:00 p.m.-11:00 p.m. shift); at 3:55 p.m. with CNA LLL (3:00 p.m.-11:00 p.m. shift);and at 4:07 p.m. with the Maintenance Supervisor, they confirmed that they had been inserviced on the smoking policy which included that all residents who smoked had to wear a smoke apron that covered the resident completely, if a resident refused to wear the apron then the resident could not smoke and they would report to the DON and/or Administrator, that only 12 residents to one staff person were allowed to smoke at designated times, that residents' smoking materials were kept in in the locked medication room at the nurses station, that if a resident was observed with smoking materials in their possession/room, the smoking materials were confiscated and the resident reported to the nurse/ADON/DON/Administrator, and that a list of residents who smoke is kept in the container which housed the residents' smoking materials. 1 (b.). Review of the audits completed by the Social Services Director and Director of Nursing on 2/1/17 and 2/2/17 revealed that the facility identified thirty three (33) residents who smoked and that twenty-three (23) of the thirty three (33) residents did not have care plans in place to address smoking safety. On 2/3/17, the facility provided smoking care plans for all thirty three (33) residents who currently smoked regardless of the frequency the resident smoked and Smoking Evaluations for R#53 and R#163. Review of care plans and assessments on 2/3/17 revealed that all smokers had a smoking care plan and smoking assessment. 2. On 1/31/17 at 8:57 a.m., ten (10) residents from Unit 3 were on the smoke porch with the supervision of one staff member. A smoke apron was placed on each of four residents prior to providing and lighting their cigarettes. The other six residents waited to smoke until one of the four residents finished smoking and relinquished their smoke apron. All of the residents who smoked at that time wore a smoke apron while smoking. Review of the audits completed on 2/2/17 by the Social Services Director and Director of Nursing revealed that two residents (R#53 and #163) did not have smoking evaluations. Staff completed smoking evaluations on all 33 residents R#53, R#54, R#51, R#80, R#40, R#7, R#71, R#81, R#99, R#82, R#116, R#100, R#46, R#105, R#60, R#70, R#38, R#152 , R#64 , R#111 , R#21, R#104, R#12, R#59, R#87, R#120, R#72, R#115, R#30, R#163, R#103, R#23, and R#69) who smoked. Observation on 2/2/2017 at 1:56 p.m. twelve (12) residents were noted to have on protective smoking aprons while smoking, staff present were the DON, SSD notifying residents when to enter smoking area, ADON assisting the Certified Nursing Assistant (CNA) with distribution of the cigarette's to the residents. Second half of smoking residents entered the smoking area at 2:15 p.m., smoke aprons placed on four (4) residents by staff before distribution of cigarettes to residents. Observation of R#111 on 2/2/17 at 1:56 p.m. of the resident revealed the resident wearing a smoke apron while smoking with eleven (11) other residents also wearing smoke aprons while smoking for safety. DON, ADON, WW, and SSD assisting with smoke break. Observation on 2/2/17 at 2:00 p.m., 2:30 p.m. and 4:00 p.m. of R#46 and R#152 revealed a smoking apron was on the resident and he was safely smoking at that time. The RN supervisor and the DON were present supervising the activity. Observation of smoke break on 2/4/17 at the 8:30 a.m. revealed that residents on Unit 3, were all observed to be wearing smoke aprons that were covering their body appropriately and using facility provided ashtrays. Observation of smoke break on 2/4/17 at 10:00 a.m. for residents on Unit 1 and 2. Residents were observed to be wearing smoking aprons. 3, 4, 5, 6. On 1/31/17 at 8:57 a.m., ten (10) residents from Unit 3 were on the smoke porch with the supervision of one staff member. A smoke apron was placed on each of four residents prior to providing and lighting their cigarettes. The other six residents waited to smoke until one of the four residents finished smoking and relinquished their smoke apron. All of the residents who smoked at that time wore a smoke apron while smoking. Observation of the smoke break on Unit 3 on 2/3/17 at 4:02 p.m. revealed that residents' #12, 30, 54, 72, 7, 87, 82, 115 and 152 were smoking on the smoking porch and all were wearing aprons that completely covered their persons. The residents were supervised by the DON, ADON and one CNA at that time. Observation of the smoke break on 2/4/17 at 7:35 a.m. revealed that residents' #64, 71, 105, 104, 81, 69, 21, 51, 70, 38 and 99 wore smoke aprons while smoking and were supervised by the ADON and DON. At 7:41 a.m., R#60 arrives and staff place a smoke apron on him prior to providing him a cigarette and lighting it for him. Observation of smoke break on 2/4/17 at 8:47 a.m. revealed R#54, R#32, R#82, R#152, R#12, R#87, R#72, R#115, and R#30 to all be wearing smoking aprons. RN Supervisor and DON present to supervise this smoke break. Observation of smoke break on 2/4/17 at 10 a.m. revealed R#51, R#71, R#81, R#116, R#46, R#105, R#60, R#111, R#21, R#104, R#69, and R#38 to all be wearing smoking aprons. DON and ADON present to supervise this smoke break. 10 additional smoke aprons observed in blue storage containers. Observation of smoke break on 2/4/17 at 10:15 a.m. revealed R#40, R#99, R#70, and R#64 to all be wearing smoking aprons. DON and ADON present to supervise this smoke break. All residents who smoked on Unit 1 and Unit 2 and on Unit 3 were observed to wear smoke aprons during smoke breaks on 2/2/17, 2/3/17 and 2/4/17. 7, 8, 9. On 2/3/17, the facility provided smoking care plans for all thirty three (33) residents who currently smoked regardless of the frequency the resident smoked. Review of the care plans revealed that interventions included that the residents were evaluated for smoking safety during supervised smoke breaks, that they must wear a smoke apron while smoking, that they must use the facility provided ashtrays, that they must follow the facility smoking policy, that they must secure their smoking equipment with the nurse and that in emergency situations smoking privileges could be suspended. Revised smoking list reviewed and care plan for each person listed on care plan confirmed on 2/3/17. Interventions on care plans confirmed for each of the 33 smoking residents on 2/3/17. Revised smoking list reviewed and care plan for each smoking resident (R#53, R#54, R#51, R#80, R#40, R#7, R#71, R#81, R#99, R#82, R#116, R#100, R#46, R#105, R#60, R#70, R#38, R#152 , R#64 , R#111 , R#21, R#104, R#12, R#59, R#87, R#120, R#72, R#115, R#30, R#163, R#103, R#23, and R#69) listed on care plan confirmed on 2/3/17.R# 152, R#163, and #69 added to smokers list. Interventions on care plans confirmed for each of the 33 smoking residents (R#53, R#54, R#51, R#80, R#40, R#7, R#71, R#81, R#99, R#82, R#116, R#100, R#46, R#105, R#60, R#70, R#38, R#152 , R#64 , R#111 R#21, R#104, R#12, R#59, R#87, R#120, R#72, R#115, R#30, R#163, R#103, R#23, and R#69) on 2/3/17. Smoking interventions included wearing a smoke apron, using facility provided ashtrays, following the facility smoking policy, all smoking equipment to be secured with the nurse, and smoking privileges to be suspended during emergencies. 10, 12. During observations of the smoke breaks on 1/30/17 at 4:00 p.m. on Unit 3, only one resident (R#30) was observed to wear an apron while smoking. During observation of the smoke break on 1/30/17 at 6:27 p.m., only R#30 and R#72 wore smoke aprons while smoking. On 1/31/17 at 8:57 a.m., ten (10) residents from Unit 3 were on the smoke porch with the supervision of one staff member. A smoke apron was placed on each of four residents prior to providing and lighting their cigarettes. The other six residents waited to smoke until one of the four residents finished smoking and relinquished their smoke apron. All of the residents who smoked at that time wore a smoke apron while smoking. (See observations listed in 3 through 9) 11. Review of the Smoking Evaluations completed by the SSD and DON on 2/2/17 revealed that all 33 residents who smoked had Smoking Evaluations to determine their ability to smoke safely. Revised smoking list was reviewed and care plan for each smoking resident (R#53, R#54, R#51, R#80, R#40, R#7, R#71, R#81, R#99, R#82, R#116, R#100, R#46, R#105, R#60, R#70, R#38, R#152 , R#64 , R#111 , R#21, R#104, R#12, R#59, R#87, R#120, R#72, R#115, R#30, R#163, R#103, R#23, and R#69) listed on care plan confirmed on 2/3/17.R# 152, R#163, and #69 added to smokers list. 13. There were thirty two (32) residents listed as smokers on the original list of smokers provided by the facility on 1/30/17. During observations of smoke breaks on 1/31/17 and 2/1/17, three (3) additional residents (#163, #69 and #152) were identified as smokers. Review of the census audit completed by the Social Services Director by 2/2/17 revealed that two (2) of the smokers on the original list (R#122 and #98) no longer smoked. The list of smokers was revised to include thirty three (33) residents (R#53, R#54, R#51, R#80, R#40, R#7, R#71, R#81, R#99, R#82, R#116, R#100, R#46, R#105, R#60, R#70, R#38, R#152 , R#64 , R#111 , R#21, R#104, R#12, R#59, R#87, R#120, R#72, R#115, R#30, R#163, R#103, R#23, and R#69). Smoking assessments reviewed and confirmed for all 33 smoking residents (R#53, R#54, R#51, R#80, R#40, R#7, R#71, R#81, R#99, R#82, R#116, R#100, R#46, R#105, R#60, R#70, R#38, R#152 , R#64 , R#111 , R#21, R#104, R#12, R#59, R#87, R#120, R#72, R#115, R#30, R#163, R#103, R#23, and R#69). Smoking aprons are identified as needed for all 33 smoking residents. Revised smoking list reviewed and care plan for each person listed on care plan confirmed on 2/3/17. R#122 and R#98 were removed from the smoking list and were not observed smoking throughout the survey. R#53 was educated by the Administrator on 2/1/17 and immediately surrendered his cigarettes and lighter. The resident was instructed that he had to surrender his equipment to the nurse upon return to the facility. Interview with R#53 on 2/4/17 at 9:15 a.m., revealed that he was in-serviced by staff on the new smoking policy and smoke times and received a copy of the smoke policy. Continued interview revealed that he has to sign out his cigarettes and lighter from the nurses prior to smoking and then relinquish his cigarettes and lighter to the nurses when he signs himself back into the facility. Interview with Central Supply staff DDD on 2/3/17 at 10:02 a.m., revealed that she was instructed by the Administrator to obtain resident's cigarettes and lighter from the nurses and escort the resident out past the facility boundary to smoke. Continued interview revealed that she was to ensure that the resident hand over his cigarettes and lighter when he signs himself back into the facility and she will give them to the nurse. Observation on 2/3/17 at 11:19 a.m., R#53 was smoking past the facility boundaries. He was observed to wheel himself back into the facility, sign himself in and hand over his cigarettes and lighter to Central Supply Staff DDD who was monitoring the front desk. DDD documented on a form the date and time that R#53 signed himself out with his cigarettes and lighter and the date and time that he signed himself in with his cigarettes and lighter. DDD then provided the cigarettes and lighter to the nurse to secure in the medication room. 14. Review of the census audit completed by the Social Services Director by 2/2/17 revealed that two (2) of the smokers on the original list (R#122 and #98) no longer smoked and were removed from the revised list. R#163, 69 and #152 were added to the revised list of smokers. The list of smokers was revised to include thirty three (33) residents (#51, 80, 116, 100, 46, 105, 152, 70, 38, 103, 64, 111, 104, 69, 40, 71, 81, 99, 60, 23, 21, 53, 54, 82, 7, 12, 59, 87, 120, 72, 115, 30 and 163) who currently smoked. 15. The revised smoking policy for residents with a revision date of 2/2/17 revealed the following: All smoking equipment for residents will be left with the charge nurse and stored in a secure area. If any such equipment is found in a resident's room, or on their person, staff will explain to the resident why the articles must be removed and given to the charge nurse for storage. Family and physician will be notified as needed. Should a resident be identified as having any type of smoking equipment on them, they will receive a verbal warning of safety violations. Any further violations will lead to a 30-day discharge from the facility. One resident (#53) was observed to have smoking materials in his possession. The resident was educated by the Administrator on 2/1/17 and immediately surrendered his cigarettes and lighter. The resident was instructed that he had to surrender his equipment to the nurse upon return to the facility. Interview with R#53 on 2/4/17 at 9:15 a.m., revealed that he was in-serviced by staff on the new smoking policy and smoke times and received a copy of the smoke policy. Continued interview revealed that he has to sign out his cigarettes and lighter from the nurses prior to smoking and then relinquish his cigarettes and lighter to the nurses when he signs himself back into the facility. Interview with Central Supply staff DDD on 2/3/17 at 10:02 a.m., revealed that she was instructed by the Administrator to obtain resident's cigarettes and lighter from the nurses and escort the resident out past the facility boundary to smoke. Continued interview revealed that she was to ensure that the resident hand over his cigarettes and lighter when he signs himself back into the facility and she will give them to the nurse. On 2/3/17 at 1119 a.m., R#53 was smoking past the facility boundaries. He was observed to wheel himself back into the facility, sign himself in and hand over his cigarettes and lighter to Central Supply Staff DDD who was manning the front desk. DDD documented on a form the date and time that R#53 signed himself out with his cigarettes and lighter and the date and time that he signed himself in with his cigarettes and lighter. DDD then provided the cigarettes and lighter to the nurse to secure in the medication room. Interview on 2/3/17 at 2:55 p.m. with Medical Director who confirmed that he had been notified of R#72 and R#70 dropping ashes on themselves. Medical Director denied that he has ever been notified of any resident from the facility burning self while smoking. Review of medical record for R#72 revealed a skin assessment was completed on 2/2/17 noting skin intact. Review of medical record for R#70 revealed a skin assessment was completed on 2/2/17 noting skin intact. 16. Review of the revised smoking policy dated 2/2/17 revealed the following revisions: The policy also included that if a resident failed to follow the policy, he/she would receive a verbal warning for the first offense and a 30 day discharge notice for a subsequent offense. All smoking equipment for residents will be left with the charge nurse and stored in a secure area. If any such equipment is found in a resident's room, or on their person, staff will explain to the resident why the articles must be removed and given to the charge nurse for storage. Family and physician will be notified as needed. Should a resident be identified as having any type of smoking equipment on them, they will receive a verbal warning of safety violations. Any further violations will lead to a 30-day discharge from the facility 17. Review of the employee roster and sign-in sheets revealed that 100% of staff (140 employees) were inserviced by February 3, 2017 on the policy and procedures and what the expectations were for the staff in regards to resident safety while smoking. Interviews on 2/3/17 at 1:00 p.m. with LPN FF (7:00 a.m. -7 P.m. shift); at 2:50 p.m. with CNA OO (7:00 a.m.-3:00 p.m. shift); at 1:09 p.m. with CNA QQ (7:00 a.m.-3:00 p.m.); at 3:36 p.m. with CNA KKK (3:00 p.m.-11:00 p.m. shift); at 3:55 p.m. with CNA LLL (3:00 p.m.-11:00 p.m. shift); at 4:07 p.m. with the Maintenance Supervisor; and on 2/4/17 at 6:30 a.m. with LPN MMM (7:00 p.m.-7:00 a.m.); at 6:35 a.m. with CNA NNN (11:00 p.m.-7:00 a.m.); at 6:45 a.m. with LPN OOO (7:00 p.m. -7:00 a.m.); and at 6:48 a.m. with CNA PPP (11:00 p.m.-7:00 a.m.), they all confi

Based on observation, record review, staff interview, and facility Resident Midnight Census form review, the facility failed to ensure resident supervision regarding wandering behavior by failing to provide security of door key cards utilized for entrance/exit door access, and failing to provide a system which ensured the monitoring of the whereabouts and presence of residents per facility protocol, for two (2) residents who resided on the 300 Hall Memory Care Unit (#9 and #21), and one (1) resident who resided on the 200 Hall (#87), all of whom had cognitive impairment and a known history of falls and/or wandering, on the survey sample of twenty-four (24) residents. Specifically for Resident #21 who had known histories of wandering and falls, the resident was observed on 02/03/2014 at 7:05 p.m. to be seated in a chair and unsupervised in a dark, fenced patio outside of the Memory Care Unit. Resident #21 had exited the Memory Care Unit through an exit door utilizing a key card which was assigned to, and assigned to be stored on, the Unit medication cart. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on February 5, 2014 at 5:35 p.m. The non-compliance related to the immediate jeopardy was identified to have existed as of February 3, 2014 (the date Resident #21 exited the Memory Care Unit through an exit door without the knowledge of staff by utilizing a key card which was assigned to the Unit's medication cart but to which the resident had gained access), continued through February 6, 2014, and was removed on February 7, 2014. The facility implemented a credible allegation of jeopardy removal on February 6, 2014. During the February 5, 2014, 5:35 p.m. interview referenced above, the Administrator stated that key cards were issued to some, but not all, staff upon employment, and that an extra key card was placed on each medication cart. These key cards were utilized by staff to access locked doors which were accessible by the cards. However, the Administrator acknowledged that there was no system in place to monitor, and to therefore ensure, that staff maintained all key cards securely. An allegation of jeopardy removal was received on February 6, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 7, 2014, and the facility remained out of compliance at a lower scope and severity of "E" while the facility completed a process which involved the retraining, via staff in-service, of available staff related to Policy revisions made to ensure adequate security regarding door key cards and adequate supervision for residents at risk of wandering, but continued to provide in-service training to staff who were initially unavailable for training, upon the return to work. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about key card security and resident monitoring and supervision related wandering behavior. Observations were made to assess staffs' provision of supervision of these residents. Findings include: 1. Record review for Resident #21 revealed an Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date of 07/25/2013 which documented, in Section C-Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Section I - Active [DIAGNOSES REDACTED]. Section G - Functional Status documented that the resident needed only supervision/oversight with locomotion, and Section J - Health Conditions documented that the resident had experienced recent falls. Section E - Behavior documented that Resident #21 had experienced hallucinations and delusions, and that the resident had exhibited wandering behavior. Related to Resident #21's wandering behavior as indicated on the 07/25/2013 MDS referenced above, a Progress Notes (PN) entry of 12/01/2013 at 11:24 p.m. for Resident #21 documented that the resident was pacing up and down the hallway, and a 12/02/2013, 11:32 a.m. PN documented that Resident #21 continued to pace in and out of the room and down the hallway. A PN of 12/08/2013 at 3:36 p.m. documented that Resident #21 was noted pacing up and down the hallway, and a PN of 12/09/2013 at 3:17 a.m. documented that the resident had been up all shift pacing to the Activity Room and back to the Nurse's Station. PNs of 12/15/2013 at 3:42 p.m., 12/18/2013 at 3:27 a.m., and 12/24/2013 at 1:42 a.m. documented that Resident #21 was packing up and down the hallways, and a PN of 12/26/2013 at 1:03 a.m. documented that the resident was pacing repeatedly. PN entries of 01/02/2014 at 12:39 a.m., 01/07/2014 at 12:30 a.m., and 01/18/2014 at 3:28 p.m. documented that Resident #21 continued with pacing behavior. Additionally, related to Resident #21's history of falls per the 07/25/2013 MDS, a PN entry of 07/13/2013 at 05:25 p.m. for Resident #21 documented that as the resident was ambulating on the facility's porch, he/she had attempted to pull the door open and stumbled backwards and fell , landing on the buttocks and sustaining no injuries. A subsequent PN entry of 12/16/2013 at 11:45 a.m. documented that Resident #21 was observed walking and holding onto the wall, and then fell to the floor, again sustaining no injuries. During a tour of the facility conducted on 02/03/2014 at 7:05 p.m. with the Assistant Director of Nursing (ADON) in attendance, the ADON used her key card to unlock the exit door which was located at the end of the 300 Hall/Memory Care Unit and which lead to a patio outside of the facility. When this exit door was opened, the interior lighting from within the facility illuminated Resident #21, who was observed sitting in a chair in the otherwise dark fenced exterior patio into which this exit door opened. Resident #21 was observed to be alone, seated approximately twenty (20) to thirty (30) feet from the exit door, in the dark and unsupervised. Resident #21 was observed to be wearing blue jeans, a shirt, a light jacket and shoes. (A check of the National Oceanic And Atmospheric Administration weather report for 02/03/2014 revealed that the exterior environmental temperature at 6:58 p.m. on that date was 74 degrees Fahrenheit.) During this observation, a light fixture was observed to be located above the exit door to the fenced patio area, but this light fixture was not functional, and therefore the patio area was dark. Upon this observation of Resident #21 on the exterior patio unattended, facility staff returned the resident to the interior of the facility. During an observation conducted on 02/03/2014 at 7:25 p.m., the exit door referenced in the observation above was accessed and opened via a key card. Upon exit through this door and entry into the Memory Care Unit patio area where Resident #21 had been observed seated in the dark earlier in the evening, the patio was still not illuminated, and was thus still dark. The use of flashlights revealed a chain link fence, measuring approximately fifteen (15) feet in height, surrounding the patio area. As the area was toured, the ground within this fenced patio was observed to be uneven. A subsequent observation of this Memory Care Unit patio on 02/04/2014 at 8:00 a.m. revealed a pile of limbs and/or roots along the rear fence, a root approximately five feet in length protruding above the surface of the ground, and a drain pipe in the patio area which had a loose drain cover which could be removed. During an interview with the Maintenance Director conducted on 02/04/2014 at 3:05 p.m., the Maintenance Director acknowledged that the dust-to-dawn light located at the exit door of the Memory Care Unit had needed repair. He stated that he had been asked by staff to check the light on the previous evening of 02/03/2014, and that when checked, he had determined that a sensor on the light had malfunctioned. During an interview with the ADON conducted during the 02/03/2014, 7:05 p.m. tour observation referenced above, the ADON was questioned about Resident #21 being found outside of the facility unattended. The ADON stated that the Memory Care Unit exit door locked automatically, and a key card was required to unlock the door from both the inside and the outside. The ADON also stated she did not know how Resident #21 had gotten outside of the facility, or how long the resident had been outside. During an interview conducted on 02/03/2014 at 7:45 p.m. with Licensed Practical Nurse (LPN) "AA" who was a medication nurse on the Memory Care Unit where Resident #21 resided, LPN "AA" stated that earlier in the evening of 02/03/2014 at approximately 6:45 p.m. (approximately twenty (20) minutes prior to Resident #21 being found outside on the patio unattended), she had ushered another resident in from the patio area, which was a smoking area. LPN "AA" stated that when she returned the other resident to the Unit at around 6:45 p.m., Resident #21 was not in the patio area at that time and was still inside of the Memory Care Unit, and that therefore Resident #21 had exited the Memory Care Unit to the patio area sometime after 6:45 p.m. LPN "AA" further stated that, upon Resident #21's return to the interior of the facility after being found outside (per the 02/03/2014, 7:05 p.m. observation referenced above), Resident #21 told her that he/she had exited the facility through the Unit exit door using a card. At that time, LPN "AA" presented the key card which she identified as the card found during a search of Resident #21's person after the resident's return to the Memory Care Unit. LPN "AA" stated that staffs' physical inspection of Resident #21 had revealed the key card in the resident's shoe. LPN "AA" stated that Resident #21 had been unable to tell her where he/she obtained the key card, but that all facility staff had key cards and it was unknown to which staff member the key card found in Resident #21's possession belonged. During an interview with LPN "AA" conducted the next day on 02/04/2014 at 3:50 p.m., LPN "AA" stated she had noticed that a key card was missing from the medication cart on 02/03/2014 (the date the Resident #1 exited the facility without the knowledge of staff and was later found to have a key pass card on his/her person). LPN "AA" stated that when the key card had been discovered missing on 02/03/2014, none of the staff had admitted to having seen the missing key card, but further stated that no residents or resident rooms had been searched in an attempt to located the missing key card when it was discovered missing. She stated after the key card was found on Resident #21's person on the evening of 02/03/2014 (after his/her exit from the building utilizing the key card), the card had been placed back in the Memory Care Unit medication cart, where it was assigned to be stored. LPN "AA" further stated that she did not know how or where Resident #1 had obtained the medication cart key card prior to his exit from the facility on 02/03/2014, but that the resident did have a history of taking items and hiding them. During an interview with the ADON conducted on 02/05/2014 at 9:20 a.m., the ADON stated, as had LPN "AA" in the 02/04/2014, 3:50 p.m. interview referenced above, that Resident #21 had a history of [REDACTED]. During this interview, the ADON was also questioned regarding the facility's procedure utilized to account for the location and presence of residents, including those residents having wandering behavior. The ADON stated that nurses made rounds every two (2) hours to ensure residents were accounted for, but acknowledged there was no documentation to that effect. The ADON also stated that in addition to every-two-hour rounds, nurses did a shift-change report and walked from room-to-room to observe residents. During an interview with the Director of Nursing (DON) conducted on 02/05/2014 at 10:55 a.m. regarding Resident #21's 02/03/2014 unattended exit from the facility via the Memory Care Unit exit door, the DON stated that when the door was locked each evening, staff did a resident headcount to make sure all residents were accounted for. However, the DON acknowledged that this nightly resident headcount was not documented. During a subsequent interview with the DON conducted on 02/06/2014 at 10:00 a.m., the DON was questioned about the facility's procedure for accounting for the location and presence of residents. The DON stated, as had the ADON in the 02/05/2014, 9:20 a.m. interview referenced above, that nurses did a resident headcount via observation every shift, but acknowledged that this resident count was only recorded at midnight each night. During this interview, the DON produced a copy of a document entitled the Resident Midnight Census which documented once-daily monitoring of each facility resident, but the DON provided no additional evidence to indicate that facility staff were monitoring residents each shift, per facility protocol, to ensure their presence and safety. Based on the above, the facility failed to develop and implement a system which permitted access to security key cards, intended to allow entrance and exit through locked doors, to only facility staff authorized for their use. This failure allowed Resident #21, who had severe cognitive impairment, a history of taking items from others, a history of wandering behavior, and a history falls, to obtain a security key card which had been assigned to a medication cart, utilize the key card to exit a Memory Care Unit exit door after dark without the knowledge of staff, and gain access to an unlighted exterior facility patio which had uneven ground, a root which protruded above ground-level, and piled wood. 2. Record review for Resident #87 revealed a Quarterly MDS having an Assessment Referenced Date of 11/10/2013 which documented in Section C - Cognitive Patterns that the resident had been unable to complete the BIMS interview, but that the resident had both short-term and long-term memory problems, and severe impairment in cognitive skills for daily decision-making. Section I - Active [DIAGNOSES REDACTED]. Section G - Functional Status documented that the resident required only the limited assistance of staff with locomotion, and Section E - Behavior documented that Resident #87 had experienced hallucinations, delusions, and also wandering behavior during four (4) to six (6) days of the look-back period. In addition to Resident #87's MDS referenced above which indicated that the resident had wandering behavior, the resident's Care Plan identified, as a Focus area, that the resident had wandering behavior and was an elopement risk. An observation conducted on 02/05/2014 at 11:00 a.m. revealed Resident #87 to be ambulating up and down the 200 Unit hallway using a rolling walker. However, even though Resident #87 was severely impaired in cognitive skills for decision-making, had short and long-term memory problems, experienced hallucinations and delusions, and was ambulatory with a known history of wandering behavior, further review of the resident's clinical record revealed no evidence to indicate that facility nursing staff routinely monitored the whereabouts and presence of Resident #87 to ensure his/her safety. During a 02/06/2014, 10:00 a.m. interview with the DON, the DON was questioned regarding the procedure and protocol utilized by facility nursing staff to monitor residents, including Resident #87, who were at risk for wandering/elopement. During this interview, the DON stated that nursing staff were to conduct a count of residents each shift to allow for the monitoring for the presence of residents. However, the DON further stated that the only actual recorded monitoring of the facility's resident headcount was accomplished utilizing the Resident Midnight Census form, which reflected only once-nightly resident monitoring. The DON acknowledged that there was no evidence of resident monitoring related to other shifts. Based on the above, despite Resident #87 having short and long-term memory problems, hallucinations, delusions, severe impairment in cognitive skills for decision-making, and a known history of wandering behavior, the facility failed to provide a system which ensured the provision of nursing staff monitoring each shift, per protocol, intended to determine the presence and whereabouts of residents. This failure to ensure monitoring placed Resident #87 at an increased risk for wandering/elopement. 3. Record review for Resident #9 revealed a Quarterly MDS having an Assessment Reference Date of 01/13/2014 which documented in Section C - Cognitive Patterns that the resident had BIMS Summary Score of "00", indicating severe cognitive impairment, and Section I - Active [DIAGNOSES REDACTED]. Section E - Behavior documented that Resident #9 had experienced both hallucinations and delusions, and had experienced wandering behavior from one (1) to three (3) days, during the look-back period, and Section G - Functional Status documented that the resident required only supervision/oversight with locomotion about the facility. An observation of Resident #9 conducted on 02/05/2014 at 8:50 a.m. revealed the resident to be constantly walking down the hallway, at times pausing but continuing to walk in place, even during pauses. Resident #9 was also observed as he/she appeared to be engaged in a conversation with another individual who was not actually present. However, even though Resident #9 had severe cognitive impairment, experienced hallucinations and delusions, was ambulatory, and had a known history of wandering behavior, further review of Resident #9's clinical record revealed no evidence to indicate that facility nursing staff routinely monitored the resident's whereabouts and presence to ensure his/her safety. During an interview with the DON conducted on 02/06/2014 at 10:00 a.m., the DON stated that nurses were to do a resident count every shift to monitor for the whereabouts of residents, but acknowledged that this count was documented only at midnight each night, via the Resident Midnight Census form, and that there was no evidence of monitoring for other shifts. Based on the above, despite Resident #9 having hallucinations, delusions, severe impairment in cognitive skills for decision-making, and a known history of wandering behavior, the facility failed to provide a system which ensured that nursing staff monitored each shift, per facility protocol, to determine the resident's presence and whereabouts. This failure placed Resident #9 at an increased risk for wandering. The immediate jeopardy was determined to have been removed on 02/07/2014, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On February 3, 2014, after the discovery of Resident #21 in the facility's exterior patio, the resident was returned to his/her room and was determined to be in possession of a door key card. This key card was removed and secured on the Memory Care Unit medication cart. B. On February 3, 2014, the Maintenance Director made repairs to the outdoor lighting fixture located in the outdoor patio area where Resident #21 had been found to be unattended and in the dark. C. On February 5, 2014, the ADON, Social Services Director, and MDS Coordinator completed Elopement Risk Assessments for all facility residents to identify elopement risk. D. On February 5, 2014, all resident Care Plans were updated, based on the Elopement Risk Assessments, for all residents deemed as being at risk for elopement. E. On February 5, 2014, the facility modified the Policy For Assignment Of Employee Key Cards to require that only two (2) key cards would be active on Unit 3. All other current employee door key cards were deactivated by the Human Resources Director. The two (2) remaining and active Unit 3 key cards would be maintained on the Unit narcotic key ring. The Charge Nurse was to sign off on the Narcotic Signature Sheet when he/she was in receipt of the key ring with the attached key card. Additionally, the designated Charge Nurse would sign off on the Narcotic Signature Sheet with the nurse-to-nurse narcotic count. This new Policy For Assignment Of Employee Key Cards would be incorporated into the employee orientation process for all newly hired staff. F. On February 5, 2014, the facility modified protocol to require that the designated Charge Nurse would document the presence of key cards every two (2) hours, via the Key Card Audit Tool, to ensure that key cards are maintained on the narcotic ring. This audit process will continue to be completed, using the Key Card Audit Tool, every two (2) hours for two (2) weeks, then once per shift daily. This completed Key Care Audit Tool would be reviewed by the DON daily. G. On February 5, 2014, the facility modified protocol to require the completion of an audit by CNAs of the location of all residents every two (2) hours for two (2) weeks, then once per shift daily. This audit of resident location would be documented on the Midnight Census Report, and the completed audit tool would be reviewed by the DON daily. H. On February 5, 2014, the facility modified the inspection and maintenance schedule for exterior facility lighting to require that the Maintenance Director conduct an audit of all exterior facility lighting fixtures every two (2) hours from 6:00 p.m. to 6:00 a.m. for two (2) weeks, then once per shift daily. This exterior lighting fixture inspection by the Maintenance Director would be documented on the Exterior Light Audit Tool, which would then be reviewed by the Administrator daily upon completion. I. On February 6, 2014, the facility had provided in-service training to all licensed nursing staff and CNAs regarding the newly modified and implemented Policy for Assignment Of Employee Key Cards, which involved the new processes of key card maintenance and security, resident monitoring, and facility exterior lighting inspection. Staff received training on the Key Card Audit Tool, the Midnight Census Report Audit Tool, and the Exterior Light Audit Tool. As of February 6, 2014, a total of 121 facility employees had completed this in-service training. One (1) employee was on leave-of-absence at that time, and would receive this in-service training upon returning to work. J. On February 6, 2014, the facility initiated the procedure by which the audit results of the Key Card Audit Tool and Midnight Census Report Audit Tool, completed daily by the DON, and of the Exterior Light Audit Tool, completed daily by the Administrator, would be reported to the Quality Assessment/Performance Improvement (QA/PI) Committee on a monthly basis for the Committee's review. This review will continue for three (3) months and/or until substantial compliance is achieved, to provide for the ongoing evaluation of the need for procedural modifications or staff training. Based on these corrective actions which had been developed and implemented by the facility on February 6, 2014, as outlined above, the immediacy of the deficient practice was removed on February 7, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. As of February 5, 2014, the facility had reviewed and then modified the Policy For Assignment Of Employee Key Cards to require that only two (2) key cards would be active on Unit 3. These two (2) key cards would be maintained on the Unit narcotic key ring, and the Charge Nurse would sign the Narcotic Signature Sheet when in receipt of the key card, and would then audit the presence of key cards every two (2) hours via the Key Card Audit Tool. Also on February 5, 2014, the facility modified protocol to require a resident location audit every two (2) hours for two (2) weeks, then once per shift daily, to be documented on the Midnight Census Report. In addition, on February 5, 2014, the facility initiated exterior lighting audits by the Maintenance Director every two (2) hours from 6:00 p.m. to 6:00 a.m. for two (2) weeks, then once per shift daily, to be documented on the Exterior Light Audit Tool. However, February 5, 2014 development and implementation of the audit procedures referenced above, via the Key Card Audit Tool, Midnight Census Report Audit Tool, and Exterior Light Audit Tool was only two (2) days prior to the February 7, 2014 exit date of this standard survey, thus not allowing sufficient time to fully assess facility staffs' ongoing application of, and compliance with, these newly-implemented audit procedures. Additionally, by February 6, 2014, the facility had provided in-service training to a total of 121 licensed nursing staff and CNAs regarding the newly modified and implemented Policy for Assignment Of Employee Key Cards, and the procedural changes involving the Key Card Audit Tool, the Midnight Census Report Audit Tool, and the Exterior Light Audit Tool. However, as of that date, one (1) employee had been unavailable for training and was to receive this training upon the return to work. In addition, on February 6, 2014, the facility initiated the procedure by which the DON's oversight audit results of the Key Card Audit Tool and Midnight Census Report Audit Tool, and of Administrator's oversight audit results of the Exterior Light Audit Tool would be reported monthly to the QA/PI Committee for review. However, as of the February 7, 2014 exit date of this standard survey, the complete QA/PI Committee had not yet met to begin the process of evaluation and oversight of these newly-implemented facility procedures, but rather was scheduled to meet on February 12, 2014 to begin this process. Thus, the Committee's ongoing process of facility procedural oversight could not be fully evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to an "E" level.

Based on observation, record review, and staff interview, the facility failed to ensure review and revision of the Care Plan, regarding known histories of removing items from others and/or wandering behavior, for one (1) resident (#21), who had severe cognitive impairment and had known histories of wandering behavior and of removing and retaining items which belonged to others, and for one (1) resident (#9), who had hallucinations, [MEDICAL CONDITIONS], and a known history of wandering behavior, on the total survey sample of twenty-four (24) residents. The facility's failure to revise the Care Plan and develop effective interventions to address Resident #21's known wandering behavior and history of taking items resulted in Resident #21 exiting the building without the knowledge of staff after gaining access to a door key card and utilizing the key card to exit a door on the Memory Care Unit. Resident #21 was later found after dark, seated in a chair and unsupervised in the fenced patio outside of this Memory Care Unit. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on February 5, 2014 at 5:35 p.m. The non-compliance related to the immediate jeopardy was identified to have existed as of February 3, 2014 (the date Resident #21 exited the Memory Care Unit through an exit door without the knowledge of staff by utilizing a key card which was assigned to a Unit medication cart but to which the resident had gained access), continued through February 6, 2014, and was removed on February 7, 2014. The facility implemented a credible allegation of jeopardy removal on February 6, 2014. During the February 5, 2014, 5:35 p.m. interview referenced above, the Administrator acknowledged the incident during which Resident #21 had gained access to a door key card and had wandered out of the facility through a locked exit door, and acknowledged the lack of a method of monitoring to ensure staff securely maintained key cards. An allegation of jeopardy removal was received on February 6, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 7, 2014, and the facility remained out of compliance at a lower scope and severity of "E" while the facility completed a process which involved the retraining, via staff in-service, of available staff related to Policy revisions made to ensure adequate security regarding door key cards and adequate supervision for residents at risk of wandering, but continued to provide in-service training to staff who were initially unavailable for training, upon the return to work. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about key card security and resident monitoring and supervision related wandering behavior. Observations were made to assess staffs' provision of supervision of these residents. Findings include: 1. Record review for Resident #21 revealed a Quarterly Minimum Data Set (MDS) of 01/22/2013 which documented an Entry Date of 10/19/2012. Section I - Active [DIAGNOSES REDACTED]. Section E - Behavior documented that Resident #21 had not exhibited any wandering behavior during the look-back period. However, a Quarterly MDS of 04/15/2013 documented in Section E - Behavior that Resident #21 had exhibited wandering behavior during one (1) to three (3) days of the look-back period. A subsequent, 07/25/2013 Annual MDS documented in Section E - Behavior that Resident #21 had continued to exhibit wandering behavior during one (1) to three (3) days of the look-back period. The Care Area Assessment Summary of this 07/25/2013 MDS identified that the Care Area of behavior had triggered, and that Resident #21's behavioral symptoms would be addressed in the Care Plan. However, review of Resident #21's comprehensive Care Plan revealed no evidence to indicate that the facility had reviewed and revised the resident's Care Plan to reflect the problem of the resident's having wandering behavior, or had developed Interventions to address this wandering behavior to ensure the resident's safety. This was despite the fact that the 04/15/2013 and 07/25/2013 MDS assessments referenced above had identified that Resident #21 exhibited continuing wandering behavior. Also, during a 02/05/2014, 9:20 a.m. interview, the ADON stated that in addition to Resident #21 having wandering behavior, the resident had a behavior which involved a history of taking items from others. However, further review of Resident #21's Care Plan, as referenced above, revealed no evidence to indicate that the facility had reviewed and revised the resident's Care Plan to reflect this known behavior of the resident taking items from others, or had developed Interventions to address this behavior. During a facility tour on 02/03/2014 at 7:05 p.m., the Assistant Director of Nursing (ADON) unlocked and opened an exit door of the Memory Care Unit via a key card, and at that time, Resident #21 was observed seated in a chair, unattended by staff, in a dark fenced patio into which this exit door opened. During an interview with the ADON at the time of this observation, the ADON acknowledged that Resident #21 had exited the facility unattended by staff. During an interview with Licensed Practical Nurse "AA" conducted on 02/03/2014 at 7:45 p.m., LPN "AA" acknowledged Resident #21's exit from the facility unattended, and stated that after Resident #21 was taken back inside, the resident stated he/she had used a card to exit the locked door. She further acknowledged that a key card had been found on Resident #21's person when searched. During a subsequent interview of 02/04/2014 at 3:50 p.m., LPN "AA" stated that the key card found in Resident #21's possession after his/her unattended exit on 02/03/2014 was a key card which was assigned to the Memory Care Unit medication cart, and which had been missing. During an interview with the MDS Coordinator conducted on 02/06/2014 at 11:45 a.m., the MDS Coordinator stated that she had not been informed of Resident #21 having wandering behavior, or of the resident's history of taking items from others, until 02/05/2014 (during this standard survey). The MDS Coordinator further acknowledged that the Care Plan of Resident #21 had not been revised to include the history of wandering or the history of taking items, or to include Interventions to address these problems. She stated the resident's Care Plan had been updated once she was informed of the problems on 02/05/2014. Further review of Resident #21's Care Plan revealed a Focus area, dated as having been initiated on 02/05/2014, identifying that the resident wandered aimlessly through the Unit, with accompanying Interventions to address this identified problem. This Care Plan also contained a Focus area, dated as having been initiated on 02/06/2014, identifying that Resident #21 had the potential to remove items that did not belong to him/her, with accompanying Interventions to address this identified problem. Based on the above, despite Resident #21 having known histories of wandering behavior and of taking items which did not belong to him/her, the facility failed to review and revise the resident's Care Plan to develop Interventions to address these known problems. The facility therefore failed to develop and implement effective Interventions to instruct staff on how to provide care and supervision for Resident #21 regarding the resident's behaviors of wandering and taking items from others. This failure allowed Resident #21 to obtain a security key card which was assigned to a medication cart and to utilize the card to exit the facility through an exit door, after dark and without the knowledge of staff. Resident #21 was then found seated on an unlighted exterior patio, unattended by facility staff. Cross refer to F323, example 1, for more information regarding Resident #21. 2. Record review for Resident #9 revealed the Annual MDS of 10/13/2013 documented, in Section I - Active Diagnoses, the resident's [DIAGNOSES REDACTED]. Section C - Cognitive Patterns documented that Resident #9 had exhibited continuous signs and symptoms of [MEDICAL CONDITION], and documented in Section E - Behavior that the resident had hallucinations and [MEDICAL CONDITION] during the look-back period. Section E - Behavior further documented that Resident #9 had not exhibited wandering behavior during the period. However, a subsequent Quarterly MDS of 01/13/2014 documented in Section E - Behavior that Resident #9 had not only continued to experience hallucinations and [MEDICAL CONDITION], but had also exhibited wandering behavior from one (1) to three (3) days during the look-back period. However, review of Resident #9's comprehensive Care Plan revealed that the Care Plan did identify the resident's [DIAGNOSES REDACTED]. However, further review of Resident #9's Care Plan revealed no evidence to indicate the Care Plan had been reviewed and revised to identify that the resident had exhibited wandering behaviors, as indicated on the 01/13/2014 MDS referenced above, or to reflect any Interventions to address this wandering behavior. Further review of Resident #9's record revealed that, in addition to there being no planned Interventions to address the resident's known wandering behavior, there was also no evidence to indicate that nursing staff routinely monitored to ensure Resident #9's presence. Cross refer to F323, example 3, for more information regarding Resident #9. The immediate jeopardy was determined to have been removed on 02/07/2014, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On February 3, 2014, after the discovery of Resident #21 in the facility's exterior patio, the resident was returned to his/her room and was determined to be in possession of a door key card. This key card was removed and secured on the Memory Care Unit medication cart. B. On February 3, 2014, the Maintenance Director made repairs to the outdoor lighting fixture located in the outdoor patio area where Resident #21 had been found to be unattended and in the dark. C. On February 5, 2014, the ADON, Social Services Director, and MDS Coordinator completed Elopement Risk Assessments for all facility residents to identify elopement risk. D. On February 5, 2014, all resident Care Plans were updated, based on the Elopement Risk Assessments, for all residents deemed as being at risk for elopement. E. On February 5, 2014, the facility modified the Policy For Assignment Of Employee Key Cards to require that only two (2) key cards would be active on Unit 3. All other current employee door key cards were deactivated by the Human Resources Director. The two (2) remaining and active Unit 3 key cards would be maintained on the Unit narcotic key ring. The Charge Nurse was to sign off on the Narcotic Signature Sheet when he/she was in receipt of the key ring with the attached key card. Additionally, the designated Charge Nurse would sign off on the Narcotic Signature Sheet with the nurse-to-nurse narcotic count. This new Policy For Assignment Of Employee Key Cards would be incorporated into the employee orientation process for all newly hired staff. F. On February 5, 2014, the facility modified protocol to require that the designated Charge Nurse would document the presence of key cards every two (2) hours, via the Key Card Audit Tool, to ensure that key cards are maintained on the narcotic ring. This audit process will continue to be completed, using the Key Card Audit Tool, every two (2) hours for two (2) weeks, then once per shift daily. This completed Key Care Audit Tool would be reviewed by the DON daily. G. On February 5, 2014, the facility modified protocol to require the completion of an audit by CNAs of the location of all residents every two (2) hours for two (2) weeks, then once per shift daily. This audit of resident location would be documented on the Midnight Census Report, and the completed audit tool would be reviewed by the DON daily. H. On February 5, 2014, the facility modified the inspection and maintenance schedule for exterior facility lighting to require that the Maintenance Director conduct an audit of all exterior facility lighting fixtures every two (2) hours from 6:00 p.m. to 6:00 a.m. for two (2) weeks, then once per shift daily. This exterior lighting fixture inspection by the Maintenance Director would be documented on the Exterior Light Audit Tool, which would then be reviewed by the Administrator daily upon completion. I. On February 6, 2014, the facility had provided in-service training to all licensed nursing staff and CNAs regarding the newly modified and implemented Policy for Assignment Of Employee Key Cards, which involved the new processes of key card maintenance and security, resident monitoring, and facility exterior lighting inspection. Staff received training on the Key Card Audit Tool, the Midnight Census Report Audit Tool, and the Exterior Light Audit Tool. As of February 6, 2014, a total of 121 facility employees had completed this in-service training. One (1) employee was on leave-of-absence at that time, and would receive this in-service training upon returning to work. J. On February 6, 2014, the facility initiated the procedure by which the audit results of the Key Card Audit Tool and Midnight Census Report Audit Tool, completed daily by the DON, and of the Exterior Light Audit Tool, completed daily by the Administrator, would be reported to the Quality Assessment/Performance Improvement (QA/PI) Committee on a monthly basis for the Committee's review. This review will continue for three (3) months and/or until substantial compliance is achieved, and will provide for the ongoing evaluation of the need for procedural modifications or staff training. Based on these corrective actions which had been developed and implemented by the facility on February 6, 2014, as outlined above, the immediacy of the deficient practice was removed on February 7, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. As of February 5, 2014, the facility had reviewed and then modified the Policy For Assignment Of Employee Key Cards to require that only two (2) key cards would be active on Unit 3. These two (2) key cards would be maintained on the Unit narcotic key ring, and the Charge Nurse would sign the Narcotic Signature Sheet when in receipt of the key card, and would then audit the presence of key cards every two (2) hours via the Key Card Audit Tool. Also on February 5, 2014, the facility modified protocol to require a resident location audit every two (2) hours for two (2) weeks, then once per shift daily, to be documented on the Midnight Census Report. In addition, on February 5, 2014, the facility initiated exterior lighting audits by the Maintenance Director every two (2) hours from 6:00 p.m. to 6:00 a.m. for two (2) weeks, then once per shift daily, to be documented on the Exterior Light Audit Tool. However, February 5, 2014 development and implementation of the audit procedures referenced above, via the Key Card Audit Tool, Midnight Census Report Audit Tool, and Exterior Light Audit Tool was only two (2) days prior to the February 7, 2014 exit date of this standard survey, thus not allowing sufficient time to fully assess facility staffs' ongoing application of, and compliance with, these newly-implemented audit procedures. Additionally, by February 6, 2014, the facility had provided in-service training to a total of 121 licensed nursing staff and CNAs regarding the newly modified and implemented Policy for Assignment Of Employee Key Cards, and the procedural changes involving the Key Card Audit Tool, the Midnight Census Report Audit Tool, and the Exterior Light Audit Tool. However, as of that date, one (1) employee had been unavailable for training and was to receive this training upon the return to work. In addition, on February 6, 2014, the facility initiated the procedure by which the DON's oversight audit results of the Key Card Audit Tool and Midnight Census Report Audit Tool, and of Administrator's oversight audit results of the Exterior Light Audit Tool would be reported monthly to the QA/PI Committee for review. However, as of the February 7, 2014 exit date of this standard survey, the complete QA/PI Committee had not yet met to begin the process of evaluation and oversight of these newly-implemented facility procedures, but rather was scheduled to meet on February 12, 2014 to begin this process. Thus, the Committee's ongoing process of facility procedural oversight could not be fully evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to an "E" level.

Based on observation, record review, staff interview, and National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules review, the facility failed to ensure the necessary preventive measures by nursing staff, in accordance with professional standards of quality, pertaining to facility entrance/exit door key card security for one (1) resident who resided on the 300 Hall Memory Care Unit (#21), and who had severe cognitive impairment and a known history of wandering, on the survey sample of twenty-four (24) residents. Facility nursing staff failed to take precautionary measures upon the 02/03/2014 discovery of a missing entrance/exit door key card assigned to the Memory Care Unit medication cart. Resident #21 was then found later on 02/03/2014 outside of the Memory Care Unit in a darkened patio, having exited the Unit through an exit door utilizing the missing key card. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on February 5, 2014 at 5:35 p.m. The non-compliance related to the immediate jeopardy was identified to have existed as of February 3, 2014 (the date Resident #21 exited the Memory Care Unit through an exit door without the knowledge of staff by utilizing a key card which was assigned to the Unit's medication cart but to which the resident had gained access), continued through February 6, 2014, and was removed on February 7, 2014. The facility implemented a credible allegation of jeopardy removal on February 6, 2014. During the February 5, 2014, 5:35 p.m. interview referenced above, the Administrator stated that entrance/exit door key cards used to access locked doors were issued to designated staff, and were also placed on medication carts. The Administrator acknowledged the lack of a system to monitor the use and storage of door key cards to ensure security. An allegation of jeopardy removal was received on February 6, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 7, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility completed a process which involved the retraining, via staff in-service, of available staff related to Policy revisions made to ensure adequate security regarding door key pass cards and adequate supervision for residents at risk of wandering, but continued to provide in-service training to staff who were initially unavailable for training, upon the return to work. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about key pass card security and resident monitoring and supervision related wandering behavior. Observations were made to assess staffs' provision of supervision of these residents. Findings include: Review of the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules, revealed that Chapter 2 - Standards of Nursing Practice, Section 2.2.2, Standards Related to Registered Nurse (RN) Responsibility for Nursing Practice Implementation, requires in Section 2.2.2(o) that the nurse takes preventive measures to protect the client. Additionally, Section 2.3.2, Standards Related to LPN/VN Responsibilities for Nursing Practice Implementation, requires in Section 2.3.2(m) that the nurse takes preventive measures to protect the client. Resident #21's Minimum Data Set of 07/25/2013 documented [DIAGNOSES REDACTED]. During a 02/03/2014, 7:05 p.m. observation with the Assistant Director of Nursing (ADON) in attendance, the locked exit door at the end of the Memory Care Unit was opened with a key card to reveal Resident #21 sitting in a chair unattended by staff in a dark fenced patio outside of the facility and adjacent to the Memory Care Unit. During a 02/03/2014, 7:45 p.m. interview with Licensed Practical Nurse (LPN) "AA", a Memory Care Unit medication nurse, LPN "AA" stated that after the resident's return from the patio, the resident stated that he/she had used a card to exit the courtyard door, and that a physical inspection of Resident #21 had revealed a key card in the resident's shoe. During a subsequent 02/04/2014, 3:50 p.m. interview, LPN "AA" revealed that she had actually noticed a medication cart key card missing on 02/03/2014, and that upon inquiry, no nursing staff acknowledged having seen the key card. However, LPN "AA" further acknowledged that, even though the key card was unaccounted for, nursing staff failed to search any residents or resident rooms when the key card was found missing on 02/03/2014 to try to locate the card. LPN "AA" also acknowledged that the key card found in the possession of Resident #21 after the resident's exit from the Memory Care Unit on 02/03/2014 was the missing key card from the Memory Care Unit medication cart. During an interview with the Administrator conducted on 02/03/2014 at 8:30 p.m. regarding the incident involving Resident #21 having obtained a key card and being found outside in the patio unattended earlier that evening after exiting the facility unattended, the Administrator stated that he had been unaware of a missing key card until just prior to this interview. During a subsequent interview conducted on 02/05/2014 at 3:05 p.m., the Administrator stated when a key card was discovered to be lost or missing, he would expect nursing staff to report the lost key card to administrative staff immediately, but acknowledged that the facility's Policy for Assignment of Employee Key Cards failed to require that staff report a lost or missing key card. Based on the above, despite nursing staff having noted a missing medication cart security key card missing on 02/03/2014, nursing staff failed conduct a thorough search in an attempt to locate the missing key card. This failure of nursing staff to safeguard this security key card, and the failure to thoroughly search for the key card once it was discovered to be missing, allowed Resident #21 to obtain and retain the key card, undetected by nursing staff, and to then use the key card to exit the Memory Care Unit exit door without the knowledge of staff. Facility nursing staff therefore failed to provide care to Resident #21 in accordance with professional standards of quality, as defined by the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules, by failing to take the necessary preventive measures to protect the resident. Cross refer to F323, example 1, for more information regarding Resident #21. The immediate jeopardy was determined to have been removed on 02/07/2014, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On February 3, 2014, after the discovery of Resident #21 in the facility's exterior patio, the resident was returned to his/her room and was determined to be in possession of a door key card. This key card was removed and secured on the Memory Care Unit medication cart. B. On February 3, 2014, the Maintenance Director made repairs to the outdoor lighting fixture located in the outdoor patio area where Resident #21 had been found to be unattended and in the dark. C. On February 5, 2014, the ADON, Social Services Director, and MDS Coordinator completed Elopement Risk Assessments for all facility residents to identify elopement risk. D. On February 5, 2014, all resident Care Plans were updated, based on the Elopement Risk Assessments, for all residents deemed as being at risk for elopement. E. On February 5, 2014, the facility modified the Policy For Assignment Of Employee Key Cards to require that only two (2) key cards would be active on Unit 3. All other current employee door key cards were deactivated by the Human Resources Director. The two (2) remaining and active Unit 3 key cards would be maintained on the Unit narcotic key ring. The Charge Nurse was to sign off on the Narcotic Signature Sheet when he/she was in receipt of the key ring with the attached key card. Additionally, the designated Charge Nurse would sign off on the Narcotic Signature Sheet with the nurse-to-nurse narcotic count. This new Policy For Assignment Of Employee Key Cards would be incorporated into the employee orientation process for all newly hired staff. F. On February 5, 2014, the facility modified protocol to require that the designated Charge Nurse would document the presence of key cards every two (2) hours, via the Key Card Audit Tool, to ensure that key cards are maintained on the narcotic ring. This audit process will continue to be completed, using the Key Card Audit Tool, every two (2) hours for two (2) weeks, then once per shift daily. This completed Key Care Audit Tool would be reviewed by the DON daily. G. On February 5, 2014, the facility modified protocol to require the completion of an audit by CNAs of the location of all residents every two (2) hours for two (2) weeks, then once per shift daily. This audit of resident location would be documented on the Midnight Census Report, and the completed audit tool would be reviewed by the DON daily. H. On February 5, 2014, the facility modified the inspection and maintenance schedule for exterior facility lighting to require that the Maintenance Director conduct an audit of all exterior facility lighting fixtures every two (2) hours from 6:00 p.m. to 6:00 a.m. for two (2) weeks, then once per shift daily. This exterior lighting fixture inspection by the Maintenance Director would be documented on the Exterior Light Audit Tool, which would then be reviewed by the Administrator daily upon completion. I. On February 6, 2014, the facility had provided in-service training to all licensed nursing staff and CNAs regarding the newly modified and implemented Policy for Assignment Of Employee Key Cards, which involved the new processes of key card maintenance and security, resident monitoring, and facility exterior lighting inspection. Staff received training on the Key Card Audit Tool, the Midnight Census Report Audit Tool, and the Exterior Light Audit Tool. As of February 6, 2014, a total of 121 facility employees had completed this in-service training. One (1) employee was on leave-of-absence at that time, and would receive this in-service training upon returning to work. J. On February 6, 2014, the facility initiated the procedure by which the audit results of the Key Card Audit Tool and Midnight Census Report Audit Tool, completed daily by the DON, and of the Exterior Light Audit Tool, completed daily by the Administrator, would be reported to the Quality Assessment/Performance Improvement (QA/PI) Committee on a monthly basis for the Committee's review. This review will continue for three (3) months and/or until substantial compliance is achieved, and will provide for the ongoing evaluation of the need for procedural modifications or staff training. Based on these corrective actions which had been developed and implemented by the facility on February 6, 2014, as outlined above, the immediacy of the deficient practice was removed on February 7, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. As of February 5, 2014, the facility had reviewed and then modified the Policy For Assignment Of Employee Key Cards to require that only two (2) key cards would be active on Unit 3. These two (2) key cards would be maintained on the Unit narcotic key ring, and the Charge Nurse would sign the Narcotic Signature Sheet when in receipt of the key card, and would then audit the presence of key cards every two (2) hours via the Key Card Audit Tool. Also on February 5, 2014, the facility modified protocol to require a resident location audit every two (2) hours for two (2) weeks, then once per shift daily, to be documented on the Midnight Census Report. In addition, on February 5, 2014, the facility initiated exterior lighting audits by the Maintenance Director every two (2) hours from 6:00 p.m. to 6:00 a.m. for two (2) weeks, then once per shift daily, to be documented on the Exterior Light Audit Tool. However, February 5, 2014 development and implementation of the audit procedures referenced above, via the Key Card Audit Tool, Midnight Census Report Audit Tool, and Exterior Light Audit Tool was only two (2) days prior to the February 7, 2014 exit date of this standard survey, thus not allowing sufficient time to fully assess facility staffs' ongoing application of, and compliance with, these newly-implemented audit procedures. Additionally, by February 6, 2014, the facility had provided in-service training to a total of 121 licensed nursing staff and CNAs regarding the newly modified and implemented Policy for Assignment Of Employee Key Cards, and the procedural changes involving the Key Card Audit Tool, the Midnight Census Report Audit Tool, and the Exterior Light Audit Tool. However, as of that date, one (1) employee had been unavailable for training and was to receive this training upon the return to work. In addition, on February 6, 2014, the facility initiated the procedure by which the DON's oversight audit results of the Key Card Audit Tool and Midnight Census Report Audit Tool, and of Administrator's oversight audit results of the Exterior Light Audit Tool would be reported monthly to the QA/PI Committee for review. However, as of the February 7, 2014 exit date of this standard survey, the complete QA/PI Committee had not yet met to begin the process of evaluation and oversight of these newly-implemented facility procedures, but rather was scheduled to meet on February 12, 2014 to begin this process. Thus, the Committee's ongoing process of facility procedural oversight could not be fully evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to a "D" level.

Based on record review and staff interview, the facility failed to provide care in accordance with the Care Plan regarding ensuring the safety of one (1) resident (#87), who had severe cognitive impairment and a known history of wandering/elopement, on the survey sample of twenty-four (24) residents. Specifically, Resident #87 had been assessed to have severe cognitive impairment and to be at risk for wandering/elopement. However, the facility failed to ensure the necessary monitoring for Resident #87 to ensure the resident's safety from this wandering/elopement risk. This failure resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on February 5, 2014 at 5:35 p.m. The non-compliance related to the immediate jeopardy was identified to have existed as of February 3, 2014, continued through February 6, 2014, and was removed on February 7, 2014. The facility implemented a credible allegation of jeopardy removal on February 6, 2014. During an interview with the Director Of Nursing (DON) conducted on 02/06/2014 at 10:00 a.m. in regard to the facility's protocol for the supervision of wandering residents or residents at risk for elopement, the DON referenced a shift count for monitoring residents, but acknowledged only once-daily recording of monitoring for the presence of residents. An allegation of jeopardy removal was received on February 6, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 7, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility completed a process which involved the retraining, via staff in-service, of available staff related to Policy revisions made to ensure adequate security regarding door key pass cards and adequate supervision for residents at risk of wandering, but continued to provide in-service training to staff who were initially unavailable for training, upon the return to work. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about key pass card security and resident monitoring and supervision related wandering behavior. Observations were made to assess staffs' provision of supervision of these residents. Findings include: Resident #87's Minimum Data Set of 11/10/2013 documented severe impairment in cognitive skills for decision-making in Section C - Cognitive Patterns, and documented, in Section E - Behavior, that wandering behavior was shown during four (4) to six (6) days of the look-back period. Section I - Active [DIAGNOSES REDACTED]. Review of Resident #87's Care Plan revealed a Focus area, dated as having been initiated on 09/10/2013, which identified that the resident was a wanderer and presented a risk for elopement related to Dementia. This Care Plan specified multiple Interventions to address Resident #87's risk of wandering/elopement, including for staff to offer the resident diversions, provide structured activities, and engage the resident in conversation. The documented Goal for this Focus area addressing Resident #87's wandering/elopement risk was to maintain the resident's safety. However, further record review for Resident #87 revealed no evidence of nursing staffs' routine monitoring of Resident #87 to confirm his/her presence, or to detect his/her absence, in a timely manner to thus ensure his/her safety, as specified by the Care Plan. During a 02/06/2014, 10:00 a.m. interview, the DON acknowledged that, while nursing staff were to do a resident count each shift to monitor for the whereabouts of residents, this count was only recorded nightly at midnight, via the Resident Midnight Census form, and acknowledged that there was no evidence of monitoring for other shifts or times. Cross refer to F323, example 2, for more information regarding Resident #87. The immediate jeopardy was determined to have been removed on 02/07/2014, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On February 3, 2014, after the discovery of Resident #21 in the facility's exterior patio, the resident was returned to his/her room and was determined to be in possession of a door key card. This key card was removed and secured on the Memory Care Unit medication cart. B. On February 3, 2014, the Maintenance Director made repairs to the outdoor lighting fixture located in the outdoor patio area where Resident #21 had been found to be unattended and in the dark. C. On February 5, 2014, the ADON, Social Services Director, and MDS Coordinator completed Elopement Risk Assessments for all facility residents to identify elopement risk. D. On February 5, 2014, all resident Care Plans were updated, based on the Elopement Risk Assessments, for all residents deemed as being at risk for elopement. E. On February 5, 2014, the facility modified the Policy For Assignment Of Employee Key Cards to require that only two (2) key cards would be active on Unit 3. All other current employee door key cards were deactivated by the Human Resources Director. The two (2) remaining and active Unit 3 key cards would be maintained on the Unit narcotic key ring. The Charge Nurse was to sign off on the Narcotic Signature Sheet when he/she was in receipt of the key ring with the attached key card. Additionally, the designated Charge Nurse would sign off on the Narcotic Signature Sheet with the nurse-to-nurse narcotic count. This new Policy For Assignment Of Employee Key Cards would be incorporated into the employee orientation process for all newly hired staff. F. On February 5, 2014, the facility modified protocol to require that the designated Charge Nurse would document the presence of key cards every two (2) hours, via the Key Card Audit Tool, to ensure that key cards are maintained on the narcotic ring. This audit process will continue to be completed, using the Key Card Audit Tool, every two (2) hours for two (2) weeks, then once per shift daily. This completed Key Care Audit Tool would be reviewed by the DON daily. G. On February 5, 2014, the facility modified protocol to require the completion of an audit by CNAs of the location of all residents every two (2) hours for two (2) weeks, then once per shift daily. This audit of resident location would be documented on the Midnight Census Report, and the completed audit tool would be reviewed by the DON daily. H. On February 5, 2014, the facility modified the inspection and maintenance schedule for exterior facility lighting to require that the Maintenance Director conduct an audit of all exterior facility lighting fixtures every two (2) hours from 6:00 p.m. to 6:00 a.m. for two (2) weeks, then once per shift daily. This exterior lighting fixture inspection by the Maintenance Director would be documented on the Exterior Light Audit Tool, which would then be reviewed by the Administrator daily upon completion. I. On February 6, 2014, the facility had provided in-service training to all licensed nursing staff and CNAs regarding the newly modified and implemented Policy for Assignment Of Employee Key Cards, which involved the new processes of key card maintenance and security, resident monitoring, and facility exterior lighting inspection. Staff received training on the Key Card Audit Tool, the Midnight Census Report Audit Tool, and the Exterior Light Audit Tool. As of February 6, 2014, a total of 121 facility employees had completed this in-service training. One (1) employee was on leave-of-absence at that time, and would receive this in-service training upon returning to work. J. On February 6, 2014, the facility initiated the procedure by which the audit results of the Key Card Audit Tool and Midnight Census Report Audit Tool, completed daily by the DON, and of the Exterior Light Audit Tool, completed daily by the Administrator, would be reported to the Quality Assessment/Quality Improvement (QA/PI) Committee on a monthly basis for the Committee's review. This review will continue for three (3) months and/or until substantial compliance is achieved, to provide for the ongoing evaluation of the need for procedural modifications or staff training. Based on these corrective actions which had been developed and implemented by the facility on February 6, 2014, as outlined above, the immediacy of the deficient practice was removed on February 7, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. As of February 5, 2014, the facility had reviewed and then modified the Policy For Assignment Of Employee Key Cards to require that only two (2) key cards would be active on Unit 3. These two (2) key cards would be maintained on the Unit narcotic key ring, and the Charge Nurse would sign the Narcotic Signature Sheet when in receipt of the key card, and would then audit the presence of key cards every two (2) hours via the Key Card Audit Tool. Also on February 5, 2014, the facility modified protocol to require a resident location audit every two (2) hours for two (2) weeks, then once per shift daily, to be documented on the Midnight Census Report. In addition, on February 5, 2014, the facility initiated exterior lighting audits by the Maintenance Director every two (2) hours from 6:00 p.m. to 6:00 a.m. for two (2) weeks, then once per shift daily, to be documented on the Exterior Light Audit Tool. However, February 5, 2014 development and implementation of the audit procedures referenced above, via the Key Card Audit Tool, Midnight Census Report Audit Tool, and Exterior Light Audit Tool was only two (2) days prior to the February 7, 2014 exit date of this standard survey, thus not allowing sufficient time to fully assess facility staffs' ongoing application of, and compliance with, these newly-implemented audit procedures. Additionally, by February 6, 2014, the facility had provided in-service training to a total of 121 licensed nursing staff and CNAs regarding the newly modified and implemented Policy for Assignment Of Employee Key Cards, and the procedural changes involving the Key Card Audit Tool, the Midnight Census Report Audit Tool, and the Exterior Light Audit Tool. However, as of that date, one (1) employee had been unavailable for training and was to receive this training upon the return to work. In addition, on February 6, 2014, the facility initiated the procedure by which the DON's oversight audit results of the Key Card Audit Tool and Midnight Census Report Audit Tool, and of Administrator's oversight audit results of the Exterior Light Audit Tool would be reported monthly to the QA/PI Committee for review. However, as of the February 7, 2014 exit date of this standard survey, the complete QA/PI Committee had not yet met to begin the process of evaluation and oversight of these newly-implemented facility procedures, but rather was scheduled to meet on February 12, 2014 to begin this process. Thus, the Committee's ongoing process of facility procedural oversight could not be fully evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to a "D" level.