Every finding on record at Miracle Hill Nursing & Rehabilitation Center, Inc

Based on record review, interviews, and facility policy review, the facility failed to fully inform the residents of the risks and benefits and alternate treatment options for 1 of 3 residents sampled for the use of psychotropic medications (Resident #4).The findings included: On 6/29/26, a review of Resident #4's medical record was conducted. Resident #4 was admitted to the facility on [DATE] and discharged on 2/16/26. Review of Resident #4's medical history revealed he had diagnoses that included dementia with psychotic disturbances. Physician's orders included Memantine 5 milligrams (mg) dated 2/9/26 (a medication used to treat moderate to severe Alzheimer's disease), Mirtazapine 7.5 mg dated 2/9/26 (a medication used to treat depression), and Rivastigmine 9.5 mg patch dated 2/10/26 (a medication used to treat moderate to severe Alzheimer's disease). Further record review revealed on 2/12/26 Resident #4 became combative and aggressive and a one-time order of Haldol 5 mg (an antipsychotic medication used to treat severe behavioral problems) was ordered and administered at approximately 8:00 PM. A new order of Haldol 5 mg every 12 hours as needed for agitation and combativeness was written on 2/12/26 and discontinued on 2/14/26. A progress note created by Staff A, Registered Nurse (RN) stated Resident #4 had become increasingly aggressive, agitated and combative and new orders were obtained. Documentation did not include that representative was made aware of the new medication orders. On 6/30/26 at 9:05 AM, an interview was conducted with the facility's Director of Nursing (DON). She reviewed Resident #4's medical record and confirmed there was no evidence that Staff A communicated with Resident #4's representative about the new orders for receiving Haldol or that Staff A provided education regarding the use of and the new orders for Haldol. The DON stated Staff A was no longer employed at the facility. The DON further stated the expectation was for staff to communicate with resident's representatives on any status changes and new orders and to provide education. A review of the facility policy titled Psychotropic Medication Use, revised date February 2025 was conducted. The policy stated prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: a. a non-pharmacological alternative, B. the indications and rationale for the recommendation; c. the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings); and d. the resident's/representative's right to accept or decline the treatment.

Based on interviews and record review, the facility failed to ensure that staff administered medications ordered to treat a urinary tract infection for 2 of 3 residents reviewed after their return to the facility following hospitalization.(Residents #1 and #3)The findings include:Record reviewsOn 11/18/25, a review of Resident #1's electronic medical record (EMR) showed that this resident was admitted to the hospital on [DATE] for nausea and vomiting and received a diagnosis of urinary tract infection (UTI) and sepsis syndrome. Upon discharge back to facility on 10/9/25, the physician ordered Augmentin 875/125mg with instructions for Resident #1 to take 1 tablet by mouth two times daily until 10/22/25. Upon review of the EMR, no order was found for this medication; therefore, it does not appear that staff administered the medication as ordered.On 11/19/25, a review of Resident #3's EMR revealed that the resident was admitted to the hospital on [DATE] and received a diagnosis of acute cystitis, a type of urinary tract infection. The resident was discharged back to the facility on [DATE] with an order for the antibiotic Ofloxacin 400 mg BID to be administered twice daily. Upon review of the EMR, no order for this medication was found; therefore, it does not appear that staff administered the medication.Staff interviewOn 11/19/25 at approximately 9:00 a.m., the Director of Nursing was interviewed. She was asked why the staff did not start the resident's antibiotics as ordered. She stated that the hospital is supposed to send the discharge medication reconciliation with the resident upon return to facility. She reported ongoing issues with receiving paperwork from the hospital and this resident's orders must have been missed. She was asked what the facility's process is to ensure staff complete discharge medication reconciliation upon a resident's re-admission. She stated that the resident's primary nurse is responsible for reviewing the reconciliation and ensuring that prescribed medications are ordered. Policy reviewThe facility policy (last revised April of 2019) entitled Administering Medications, states medications are administered in a safe and timely manner, and as prescribed. 4. states medications are administered in accordance with prescriber orders, including any required time frame.'

Based on interviews, record review, and facility policy review, the facility failed to implement the plan of care for 1 of 4 residents sampled for medication administration (Resident #3).The findings include:On 8/26/25 at 10:45 AM, an interview was conducted with Resident #3. He stated he had not received one medication, a Clonidine patch (a medicine used to treat high blood pressure but can also treat Attention Deficit Hyperactivity Disorder), for weeks. Resident #3 further stated nursing had told him the pharmacy delivered a pill instead of a patch. On 8/26/25, a review of Resident #3's medical record was conducted. The resident was admitted to the facility on [DATE] from hospital. Resident #3 had diagnoses that included bipolar disorder. The plan of care included administering medications as ordered related to behavioral problems. Physician's orders included Clonidine HCL tablet 0.2 mg apply transdermally every Wednesday for behavior/mood.The Medication Administration Record (MAR) revealed Resident#3 did not receive the Clonidine patch on 8/13/25 and 8/20/25. The MAR indicated see progress notes on these dates. Progress notes dated 8/13/25 stated Clonidine HCl Oral Tablet 0.2 mg, apply 0.2 mg transdermal one time a day every Wed for Behavior/Mood not available, reordered. Progress notes dated 8/20/25 stated Clonidine HCl Oral Tablet 0.2 MG Apply 0.2 mg transdermal one time a day every Wed for Behavior/Mood on order. Hospital discharge medications dated 8/3/25 stated to continue clonidine HCL 0.2 mg transdermal every Wednesday. On 8/26/25 at 11:03 AM, an interview was conducted with Staff A, Licensed Practical Nurse (LPN). She was aware that Resident #3 had a pill instead of a patch delivered by pharmacy. She stated she had notified the Director of Nursing (DON) today. On 8/26/25 at 3:53 PM, an interview was conducted with the DON. She stated she did not understand how the Pharmacy did not identify the fact that the medication was supposed to be a patch. She further stated that the receiving nurse should have looked at the order and called the Pharmacy instead of accepting the medication. On 8/27/25 at 11:12 AM, the DON provided pharmacy reorder forms faxed to the Pharmacy on 8/13/25. The reorder form requested Clonidine 0.2 mg patch for Resident #3. The DON reviewed the discharge order from the hospital stating Clonidine 0.2 mg patch and compared with the order entered upon admission on [DATE] stating Clonidine 0.2 mg tablet to be given transdermal. The DON stated the expectation was for nurses to communicate with unit manager and notify the Medical Director to clarify the order. On 8/27/25 at 11:37 AM, an interview was conducted via telephone with the Medical Director. He was made aware of the issue with Resident #3 not receiving the medication ordered because of the discrepancy on Resident#3's order placed into the electronic medical record and subsequent medication administration record. The Medical Director stated he would expect either the pharmacy or the nurses to contact him to clarify the order if needed. The facility policy named Pharmacy Services Overview (revised April 2019) states, Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. The facility policy named Administering Medications (revised April 2019) states, Medications are administered in a safe and timely manner, and as prescribed. Bullet 4 states medications are administered in accordance with prescriber orders, including any required time frame. The facility policy named Accepting delivery of medications (revised November 2022) states, Any errors in receiving medications are brought to the attention of the pharmacist and director of nursing services. Policy further stated the dispensing pharmacy, consultant pharmacist, and director of nursing services were notified of medication order errors. The facility policy named, Medication and Treatment orders (revised July 2016) states, Orders for medications and treatments will be consistent with principles of safe and effective order writing. Bullet 9 states orders of medications must include: a name and strength of the drug. B. number of doses, start and stop date, and/or specific duration on therapy; c. dosage and frequency of administration d. route of administration e. clinical condition or symptoms for which the medication is prescribed f. any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, therapeutic medication monitoring, etc.)The facility policy named Medication orders (revised November 2014) states, The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Medication orders: when recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered.

Based on observation, interviews, and record reviews, the facility failed to ensure that a resident was free from harm and neglect when it failed ensure that residents with diabetes mellitus receive their insulin and/or blood glucose monitoring as ordered for 1 of 16 residents diagnosed with diabetes mellitus. (Resident #90) The findings include: A medical record review was conducted on Resident# 90, who was admitted in the facility on 11/10/2024. Resident #90 was noted to have an elevated blood glucose of 583 mg/dl and elevated A1C of 11.4% on 12/23/2024. There was no documented intervention or orders to address the elevated blood glucose level and elevated A1C. Record review showed no nursing actions and no medical orders had taken place on these laboratory results. Hospital records were reviewed and on 02/24/2025, the resident was transported to the hospital emergency room due to altered mental status. Resident #90 was diagnosed with diabetic ketoacidosis, encephalopathy, and a urinary tract infection (UTI). Resident #90 was readmitted to the same facility on 02/26/2025 with a new diagnosis of diabetes mellitus showing on the doctor's notes. Per the record review on 06/04/2025, Resident #90 had a glucose level of 593 mg/dl and an elevated A1C of 16.9%. The night shift nurse called the advance practice nurse and reported the laboratory results. Orders of insulin and additional blood glucose checks were received from the medical provider. On 06/05/2025 at 09:15 am, Resident #90 was transported by two Emergency Medical Staff (EMS) personnel to the hospital's emergency room (ER) for altered mental status. Staff P, a Certified Nursing Assistant, was asked about the current blood glucose level. The staff responded that the resident is not diabetic. The two EMS personnel did not check the blood glucose level. The resident was transported to the hospital ER. Staff O, a Licensed Practical Nurse, was asked about the reason for the previous hospitalization of Resident# 90 on 02/24/25. She stated it was due to a UTI. She verified that there has never been blood sugar checks since Resident #90 was re-admitted on [DATE]. Record reviews showed the Minimum Data Set (MDS) did not have the active diagnosis of diabetes mellitus. The care plan reviewed on 06/02/2025 showed the care plan for diabetes mellitus was noted by dietary but not nursing. There was no diabetes in the diagnosis list, no diabetes medications, and no glucose check in the medication administration record. Progress notes of the Advance Practice Registered Nurse (APRN) did not document a diabetes diagnosis and post hospitalization history and assessment of Resident #90. On 06/05/25 at 11:30 AM an interview with Staff H, Unit Manager, confirmed that nightly chart checks have to be performed by night shift nurse on duty. Then the Assistant Director of Nursing (ADON) and Staff H checked if nightly chart checks are being done. Staff H said she just started as unit manager in April 2024 and the diabetes mellitus assessment and doctor's order for Resident #90 was missed on 02/26/2024. Chart checks were not completed nightly including on 06/04/2025. Upon further record review, the orders from medical director to start the insulin and blood glucose checks orders were found in the physical chart and were not carried out by the nursing staff. Staff S, the MDS nurse, performed the nursing admission screening history and documented new onset diabetic. During interview with facility administrator on 06/05/2025 at 1:55pm, he said unfortunately the nurses who were there at the time are no longer here. So, we can only move forward and try to ensure this never occurs again. The Administrator agreed the process failed.

Resident #50 On 6/02/25 at 1:17 PM, an interview was conducted with Resident #50. The resident looked disheveled and had her hair was unbrushed and oily. She stated she had only two showers since she was admitted to the facility. She further stated that both showers happened with Occupational Therapy (OT) staff members. A review of Resident #50's medical record was conducted. This resident was admitted on [DATE] with diagnoses that included needing assistance with Activities of Daily Living (ADL). The plan of care included ADL self-care deficit related to decreased functional mobility and activity tolerance and generalized weakness. Interventions included nursing staff providing ADL care to ensure daily needs. A review of documentation related to bathing indicated Resident #50 was scheduled for showers on Tuesdays, Thursdays, and Saturdays. Bathing documentation revealed OT provided bathing services on 5/1/25 and 5/16/25 and Certified Nursing Assistants (CNAs) provided bathing on 5/16, 5/22 and 5/25. On 6/03/25 at 2:38 PM, an interview was conducted with Staff A, Registered Nurse (RN) and a unit manager. She stated Resident #50's shower documentation had not been properly documented. Staff A agreed that, if it had not been documented, it had not been done. A review of Facility policy: Activities of daily living (ADL) supporting dated 2001 stated: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing dressing, grooming, and oral care). Based on record review, staff interviews, observations, and family interviews, the facility failed to provide the necessary services to maintain good grooming and personal hygiene on 3 of 3 residents. (Residents #13, #44, and #50) The findings include: Resident #13 On 06/02/25 at 11:04 AM, Resident #13 was observed with her hair matted and tangled around the back of the head. When asked about this, Resident #13 was unable to communicate. A second observation on 6/03/25 at 10:30 AM revealed her to be in the same state. On 06/04/25 at 10:30 AM , Staff G, a Certified Nursing Assistant (CNA) was asked how she documents baths/showers. She stated that they log them into the electronic medical record and stated she documents tasks every shift. She stated she also documents on bath sheets located in the binder at nurse's station. A record review of Resident #13 showed no documentation of bathing for the past 30 days. The bath book was reviewed and no bath was indicated for Resident #13 for June. 06/04/25 at 11:19 AM, an interview was performed with the Unit Manager. The Unit Manager brought bath sheets from May 2025. The bath sheets indicate that Resident #13 has had only 4 clearly documented baths in the month of May on 5/5/25, 5/16/25, 5/22/25, and 5/23/25. No other documentation of baths or attempts to bathe were noted. On 06/04/25 at 12:06 PM, an interview was performed with the Assistant Director of Nursing (ADON). The ADON stated that refusals should also be charted in the progress notes. Resident #44 On 06/02/25 at 01:34 PM, a strong smell of urine was noted coming from the resident's body. During a phone interview with the responsible family member on 6/2/25 at 5:00 PM, the family member stated Resident #44 has not had a shower since November. She stated, He only has sponge baths and sits in urine soaked clothes. She states that has she made grievance reports and talked to the staff. On 06/03/25 at 10:29 AM, an interview with the resident indicated that he had a bath on 06/02/2025. Per the grievance logs, on 12/02/2024, the family member stated that staff are not providing bathing care for her loved one. The form stated that the issue had been resolved on 12/5/24 and the family was informed they could call anytime. Then on 02/05/2025, the family member again informed the administrator that CNAs did not care for Resident #44 properly and she had to step in and do some of the resident's care. The form indicated that the staff would be encouraged to complete all personal care on a daily basis. On 06/04/25 at 10:30 AM, the bath sheets were requested for May 2025 for Resident #44. The sheets revealed that he received showers on 5/7/25, 5/16/25, 5/21/25, and 5/28/25. The sheets also indicated he refused personal care on 5/2/25, 5/5/25, and 5/12/25.

room [ROOM NUMBER] On 06/02/2025 during the tour of the facility, it was noted that the floor in room [ROOM NUMBER] was sticky and a dried brown substance was noted on the floor and wall of the room in the corner left side of the doorway facing the hallway. (Photographic evidence obtained) On 6/3/26 a follow up observation was made of room [ROOM NUMBER] at approximately 12:00 PM, which revealed the dried brown substance in the left corner of the doorway had been removed from the floor, however remained on the wall. On 6/4/25 at approximately 2:45 PM, another observation was made of room [ROOM NUMBER]. The wall remained with a dried brown substance and the floor remained sticky. An interview was conducted with Nurse B, a Licensed Practical Nurse (LPN), who was responsible for the residents on this hallway. Nurse B confirmed that the floor was sticky and the wall with the dried brown substance needed to be cleaned. Based on observations and interviews, the facility failed to provide a sanitary, orderly, and comfortable environment in 2 of 90 occupied rooms. (rooms [ROOM NUMBERS]) The findings include: room [ROOM NUMBER] An observation in room [ROOM NUMBER] was conducted with Staff M, Maintenance, on 6/4/25 at approximately 9:00 am. The following was observed: One of the resident's bedside table was missing paint with particle board showing along edges and at the top of the drawers. The top drawer was missing a knob used to open the drawer. The paint on the wall beside the head of the bed was scraped and scratched showing various layers of paint and gouged down to the plaster underneath. The wall behind the head of the other bed had deep metal grey colored scratches in the paint all along where the bed was positioned. An interview was conducted with Staff M about the walls and dresser conditions. He stated the bed is positioned against the wall and, whenever the head of the bed is raised, it scrapes against the wall. He states he has attempted to repaint it, but it keeps getting scratched up while the bed remains flush against the wall. When asked about the bedside table's poor condition, he acknowledged it needed replacing.

Based upon record review and interviews, the facility failed to identify and properly code an assessment correctly upon admission to facility. (Resident #27) The findings include: Resident #27 was admitted to the facility on [DATE] with an admitting diagnosis of end stage renal disease, dependence on renal dialysis, Type 2 diabetes with neuropathy, Atherosclerotic Heart disease, Chronic ischemic heart disease, Hypertension, Cardiac pacemaker, Cirrhosis of the liver, Heart Failure, AFIB, Osteoarthritis, and Pneumonia. The Minimum Data Set (MDS) assessment with a date of 04/28/25 reveals these diagnoses were not coded on the admission comprehensive assessment. An interview was conducted on 6/4/25 at 10:26 AM with the MDS Coordinator. The MDS Coordinator acknowledged that the admission diagnoses of Resident #27 was not coded correctly on the MDS assessment.

Based on record reviews and interviews, the facility failed to forward a resident for a level 2 Preadmission Screening and Resident review (PASARR) for 1 of 2 residents residents sampled for PASARR. (Resident #51) The findings include; On 6/3/25, a record review was conducted for Resident #51. The resident had a PASARR form, dated 7/16/20. The formed had depression checked off at that time and had dementia checked off at that time. On the PASARR Completion sections, it was checked the facility needed to request a level 2 screening due to suspicion of serious mental illness. There was no documentation in the record for a level 2 screening. On 06/03/25 at approximately 12:15 PM an interview was conducted with staff development staff, a Registered Nurse (RN) who stated she assists with compliance with the PASARR being accurate and up to date. Stated when she started in 2021 has not updated his PASARR and it should have been done but she will start working on it today. 06/03/25 at approximately 02:40 PM an interview was conducted with the Administration who stated they do not have a specific policy for PASAAR they just follow the regulation. The Administrator returned later and present a policy but the policy did not address the timing of the PASARRS or the completeness.

Based on record reviews and interviews, the facility failed to update the Preadmission Screening and Resident Review (PASARR) for 1 of 2 residents sampled for PASARR. (Resident #51) The findings include: On 6/3/25, a record review was conducted for Resident #51. The resident had a PASARR form dated 7/16/20. The form listed depression and dementia as diagnoses at the time. On the PASARR Completion section, it was recommended that the facility needed to request a level 2 screening due to the suspicion of serious mental illness. There was no documentation in the record for a Level 2 screening. A diagnosis of bipolar disorder was added on 7/21/23. Anxiety disorder was diagnosed on [DATE]. However, no further actions on a Level 2 PASSAR review were noted. On 06/03/25 at approximately 12:15 PM, an interview was conducted with the Staff Development Nurse, who stated she assists with compliance with the PASARR being accurate and up to date. She stated when she started in 2021 and acknowledged the PASARR was not followed up as required. On 06/03/25 at approximately 02:40 PM, an interview was conducted with the Administrator, who stated they do not have a specific policy for PASARR, they just follow the regulations. The Administrator returned later and presented a policy but the policy did not address the timing of the PASARR.

Resident #27 Resident #27 was admitted to facility on 04/22/25 with admitting diagnoses of End stage renal disease, dependence on renal dialysis, Type 2 diabetes with neuropathy, Atherosclerotic Heart disease, Chronic ischemic heart disease, Hypertension, Cardiac pacemaker, Cirrhosis of the liver, Heart Failure, AFIB, Osteoarthritis, and Pneumonia. Resident 27's plan of care revealed he has a risk for falls, complications of anticoagulant medication use, activity involvement, ADL self-care performance, potential for complications related to dialysis, potential for complications related to diabetes, and the potential for complications related to cardiovascular disease with a pacemaker. No goals or interventions are documented for each focus problem identified. An interview with Staff Member Q was conducted on 06/04/25 at 10:26 AM. She revealed that they have 14-21 days to complete a care plan that was initiated from the admission assessment. She acknowledged Resident #27 had incomplete care plans in his medical records since his admission to the facility on [DATE]. Based on interview and record review, the facility failed to complete a plan of care for 2 of 5 residents sampled for care plans. (Resident #28 and #27) The findings include: Resident #28 On 6/3/25 a record review was conducted for Resident #28. The comprehensive care plan for Resident #28, dated 2/10/25, was left incomplete. The care plan under the focus point for activities contained directions to SPECIFY: Independent/dependent on staff etc for meeting the resident's emotional, intellectual, physical, and social needs. This was not completed as instructed. The care plan included instructions to SPECIFY i.e. 3-5 times weekly the goal for the number of times resident will participate in activities weekly. This was not completed as instructed. On 6/4/25 at approximately 10:33 AM an interview was conducted with Staff Q, Licensed Practical Nurse, Minimum Data Set Coordinator (LPN/MDS), about the care plan for Resident #28 being incomplete for activities. She agreed the care plan is incomplete and stated that it would be fixed.

Based upon interview, observation, and record review, the facility failed to consistently perform services to prevent pressure ulcers for 1 of 1 residents observed for pressure ulcers. (Resident #50) The findings include: On 06/02/25 at 1:17 PM, an interview was conducted with Resident #50. During the interview, she stated she had developed a pressure ulcer because staff was not helping her enough during incontinence episodes. A review of Resident #50's medical record was conducted on 6/4/25. The resident was admitted on [DATE]. The plan of care included a risk of skin breakdown due to decreased mobility, incontinence, and fragile skin. Interventions included weekly skin checks. The physician's orders included a skin assessment every week and to notify the physician of any breakdown. The most recent skin assessment was documented on 5/24/25 and stated groin, buttocks and perineal area redden with excoriation. There were no new orders or progress notes indicating resident's skin issues had been addressed. On 6/04/25 at 12:58 PM, an interview was conducted with Director of Nursing (DON). DON reviewed resident #50's skin assessment documentation and stated last assessment was supposed to be done on 5/31. She further stated the treatment administration record was signed off on that day, but the skin assessment was not completed. DON stated that the expectation was to order a barrier cream if there was an excoriation noted, and further assessment.

Based upon record reviews, observations, and interviews, the facility failed to properly assess and provide services for 1 of 1 residents reviewed for range of mobility care. (Resident #40) The findings include: Observations of Resident #40 on 6/2/25, 6/3/25, and 6/4/25 revealed a contracture to her left upper extremity. Resident #40 was observed with her left arm and hand contracted to her upper chest and abdomen area. Resident #40 stated she has not had any therapy or restorative services since she has been at the facility. Record review on 6/3/25 revealed Resident #40 was admitted to the facility with impairment to left upper and left lower extremities related to contractures. Resident #40 admitting diagnosis to the facility revealed a contracture to her left hand. Her care plan included alteration in musculoskeletal status related to contracture with a goal that Resident #40 will remain free of complications related to contracture and immobility. Further review of the medical record reveals no therapy screening or restorative program was initiated for her. An interview with the Director of Therapy on 6/4/25 at 2:00 pm revealed that a therapy screen was conducted on 5/2/25, 4/1/25, and 1/15/25. No documentation of screening was observed and provided by the Director of Therapy. A progress note was obtained by the Director of Therapy that was dated 11/18/24 revealed that a physical therapy screening was completed and that Resident #40 presented with contracted left upper and lower extremity in a flexor pattern with no change in functional mobility at this time due to the resident being bedbound. A progress note was obtained from the Director of Therapy dated 5/14/24 revealing the resident was admitted to the facility and had a contracted left hand to her chest. The Director of Therapy confirmed that the only screening that was conducted for Resident #40 was after she had falls, but no documentation was completed or could be provided at this time. When asked about the restorative program and if Resident #40 was on the case load, the Director stated that, to his knowledge the resident was not on any restorative program but that I would need to check with the restorative nurse. Upon asking who was over the restorative program and who makes referrals to the restorative program he revealed that nursing was overseeing the restorative program, and the therapist / therapy department would make referrals to the program if it was indicated at the time of screening or discharge from therapy services. An interview with restorative nurse on 6/4/25 at 03:00 PM reveals resident 40 has not received any services from restorative for splinting or range of motion since her admission on [DATE].

Based on observations, record review, and interviews, the facility failed to provide care and services for 2 out 2 residents receiving hemodialysis. (Resident #27 and #82) The findings include: Record reviews of Resident #27 and Resident #82 revealed no physician orders for dialysis care, services, and treatments. No physician orders were in place to monitor the Permacath (a special intravenous device that medical professionals insert into a blood vessel that allow less interrupted access to the bloodstream over an extended period) for Resident #27. A physician's order was written on 04/23/25 for Resident #27 to receive dialysis on Monday, Wednesday, and Friday at 8:00 am. However, the physician's order does not reveal where Resident #27 receives dialysis, what time Resident #27 is to be transported to the dialysis center, or to hold medications while the resident is at the dialysis center since his admission to facility on 4/22/25. Resident #82 also has no physician's orders to indicate the resident is receiving dialysis services and treatments. There were no physician orders initiated to monitor fistulas site for bruit and thrill, monitor for signs of infection, bleeding, pressure bandage, swelling at site, and what time and what facility Resident #82 was to receive his dialysis treatments from. No physician's orders were observed to hold medications while at the dialysis center since admission on [DATE]. An interview was conducted on 6/4/25 at 11:18 AM with Staff Member H, a Licensed Practical Nurse (LPN). She revealed that staff nurses on the unit are to monitor and assess a dialysis resident prior to going to their treatments and upon returning to the facility after their treatments. The nurses assess the dialysis port site for signs of infection and bleeding, assess the bruit and thrill, and document in the medical record their assessment and findings in a progress note. She also revealed that morning medications for Resident #27 are not administered on the days he goes to dialysis due to Resident #27 leaving the facility prior to administration time. Staff member H was asked if physician's orders should be in the medical chart for residents receiving dialysis and for monitoring fistula and port sites before and after treatments. Staff Member H agreed that there should be physician's orders in the medical record. Staff Member H reviewed the physician orders and confirmed that no physician orders for dialysis care and treatments are in the medical chart for neither Resident #27 nor Resident #82. An interview was conducted with the Director of Nursing on 6/4/25 at 01:00 PM. She agreed that physician's orders for dialysis care and treatments should be documented in the medical record and staff nurses should be monitoring dialysis port and fistulas prior to going for their dialysis treatments and upon their return from dialysis treatments. A review of the facility's policy and procedures revealed the facility is responsible for verifying physician orders, measure blood pressure and pulse, and observing shunt sites prior to transporting to dialysis center. Upon return from dialysis the facility is responsible for verifying orders, measure blood pressure and pulse, observe and assess the dressing at the access site.

Based on observations, interviews and record reviews, the facility failed to provide medications as ordered for 2 of 5 residents observed during medication administration observations. (Resident #79 and #21) The findings include: On 6/3/25 at approximately 9:12 AM, a medication administration observation was conducted with Nurse C, a Licensed Practical Nurse (LPN), for Resident #79. Nurse C indicated that the medication Zoloft (a medication used to treat depression), which was ordered for Resident #79, was not in the cart. After informing the resident that the medication had not come in from the pharmacy, Nurse C went to the facility's emergency medication supply Omnicell to see if the medication was available. The medication Zoloft was not stored in the Omnicell. Nurse C indicated that she would notify the physician, and the pharmacy to have it sent in. On 6/4/25 at approximately 9:25 AM, a medication administration observation was conducted with Nurse D, a Registered Nurse (RN), for Resident #21. During the medication administration observation, it was noted that the medication Coreg 12.5 mg oral tablet (a medication used to treat heart failure) that was ordered for Resident #21 was not on the cart. Nurse D checked the facility's emergency medication supply Omnicell to see if the medication was available, but the Omnicell did have Coreg 3.125mg, however only 3 tablets were available, which was not enough to reach the correct dose of 12.5mg. Nurse D indicated that she would notify the pharmacy and the physician of the medication not being available. On 6/4/25 at approximately 10:15 AM, an interview was conducted with the Director of Nursing (DON), who indicated that it is her expectation for routine medications that all nurses on the hall reorder the medications from the pharmacy 7 days prior to running out of the medication. If the medication does not arrive, then for the nurse to check to see if it is available in the Omnicell. If not in the Omnicell, then they are to notify the pharmacy and have sent in from our back up pharmacy. The DON further indicated that the medications should be available and not run out.

Based on observations, interviews, and facility policy review, the facility failed to store medications in accordance with currently accepted professional principles and include the appropriate expiration date when applicable for 2 of 2 medication carts reviewed for medication storage. The findings include: On 6/4/25 at approximately 1:30 PM, an observation was made of the Northwest 18 hall medication cart with Nurse C, a Registered Nurse (RN). When Nurse C opened the medication cart, in the top drawer, 3 medication cups were sitting in the top drawer with medications inside. The medication cups were noted to have numbers written on the outside of the cups. Nurse C indicated that one of the residents was not in their room when she pulled up their medications to administer them. Nurse C went on to indicate that she then labeled the cup and set it in the cart to administer when the resident returned. Nurse C indicated that the other 2 cups of medications were for 2 other residents that she had pulled up to give as well. When asked Nurse C what the facility policy is for medications that are prepared and the resident is not available, Nurse C indicated that the policy is to discard the medications if not given in the discard solution, and to not pre-pull medications. Further inspection of the medication cart revealed 4 bottles of eye drops without an opened date indicated on the labeled bag and one bag of nebulizer medication without an opened date indicated on the labeled bag. Nurse C confirmed that the medications should be dated when opened due to shortened expiration dates once opened. On 6/4/25 at approximately 1:50 PM, an observation was made of the East 45 hall medication cart with Nurse B, a Licensed Practical Nurse (LPN), which revealed 2 bottles of eye drop medications without an opened date indicated on the bag label and one narcotic card of Tramadol (a medication used to treat pain) in the narcotic box with 9 tablets remaining. Upon review of the narcotic sign out sheet, the count indicated that there should be 10 tablets remaining in the card. A review of the resident's medication administration record revealed no sign out on the record for the tramadol by the nurse. An interview with Nurse B at approximately 1:55 PM was conducted. Nurse B indicated that he had medicated the resident approximately an hour ago and had forgotten to sign the medication out at the time. (Photographic evidence obtained) On 6/4/25 at approximately 1:58 PM, an interview was conducted with the Administrator and the Director of Nursing (DON). The DON indicated that it is her expectation that medications should be dated at the time of opening the medication to ensure the discard of medications per pharmaceutical recommendations, and that narcotics should be signed out on the narcotic count book and on the Electronic Medication Administration Record at the time of administering. Review of the facility policy titled 5.3 Storage and Expiration Dating of Medications and Biologicals (effective date 12/01/07, last revised 08/01/24), revealed the following: Applicability: Policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes, and needles. Procedure: General Storage Procedures 11. Once any medications or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has a shortened expiration date once open or opened. 11.1 Facility staff may record the calculated expiration date based on date opened on the primary medication container. 11.4 When an ophthalmic solution has a manufacturer shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container. Review of the facility policy titled 5.4 Inventory Control of Controlled Substances (effective date 12/01/07 last revised 8/01/24), revealed: Applicability: Policy 5.4 sets forth the procedures for inventory control of controlled substances. Procedure: 1. With respect to Schedule II controlled substances: 1.1 Facility should maintain separate individual controlled substance records on all schedule II medications and any medication with a potential for abuse or diversion in the form of a declining inventory using the Controlled Substances Declining Inventory Record. These records should include: 1.1.1 Resident Name, 1.1.2 Prescription number 1.1.3 Medication name, strength, dosage form, dosage 1.1.4 Total quantity received by facility 1.1.5 Date and time of administration 1.1.6 Quantity remaining, and 1.1.7 Name and Signature of person administering the medication.

Based on observations, interviews and record reviews, the facility failed to ensure the Quality Assurance and Program Improvement Program (QAPI) identified and prioritized problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information and corrective actions addressed gaps in systems, and were evaluated for effectiveness. Specifically the facility failed to provide medications to meet the needs for 2 of 5 residents observed during medication administration observations. (Resident #79, and #21). The findings include: On 5/23/25, a complaint survey conducted at the facility revealed the facility failed to ensure medications were available and administered to two residents. A plan of correction was submitted to the State Agency which stated, .2. In order to identify if there were any other residents affected by the alleged deficient practice, the DON, ADON, and Unit Managers were assigned with reviewing all current resident charts to ensure physicians orders are being followed and all medications were appropriately administered and documented in the MAR. 3. To ensure systematic change, the Unit Managers were assigned to review the MARS weekly to ensure compliance with facility policies. If the Unit Manager was not in the building, then the ADON and DON would review to ensure compliance. If a concern is detected by the reviewer, it will develop ways to immediately remediate any outstanding issues to ensure that the alleged deficient practice does not recur. 4. In order to endure that the alleged deficient practice does not recur, the ADON and DON will report the findings of their audits of the MARs to the Quality Assurance Committee. The QA Committee and the facility clinical team will monitor findings monthly. Based on the QA review, additional training should be implemented if necessary or disciplinary action should be taken regarding a nurse who fails to consistently comply with facility policies regarding medication administration and following physician orders. On 6/3/25 at approximately 9:12 AM, a medication administration observation was conducted with Nurse C, a Licensed Practical Nurse (LPN), for Resident #79. Nurse C indicated that the medication Zoloft (a medication used to treat depression), which was ordered for Resident #79, was not in the cart. After informing the resident that the medication had not come in from the pharmacy, Nurse C went to the facility's emergency medication supply Omnicell to see if the medication was available. The medication Zoloft was not stored in the Omnicell. Nurse C indicated that she would notify the physician, and the pharmacy to have it sent in. On 6/4/25 at approximately 9:25 AM a medication administration observation was conducted with Nurse D, a Registered Nurse (RN), for Resident #21. During the medication administration observation, it was noted that the medication Coreg 12.5 mg oral tablet (a medication used to treat heart failure) that was ordered for resident #21, was not on the cart. Nurse D checked the facility's emergency medication supply Omnicell to see if the medication was available, the Omnicell did have Coreg 3.125mg, however only 3 tablets were available which was not enough to reach the correct dose of 12.5mg. Nurse D indicated that she would notify pharmacy and the physician of the medication not being available. On 6/4/25 at approximately 10:15 AM, an interview was conducted with the Director of Nursing, (DON), who indicated that it is her expectation for routine medications that all nurses on the hall reorder the medications from pharmacy 7 days prior to running out of the medication. If the medication does not arrive, then for the nurse to check to see if it is available in the Omnicell, if not in Omnicell to then notify the pharmacy and have sent in from our back up pharmacy. The DON further indicated that the medications should be available and not run out. 06/05/25 11:09 AM, an interview was conducted with the Nursing Home Administrator and the Director of Nursing. When they were presented with these concerns and others found during thesurvey, the Administrator stated they do not have current QA plans related to these deficiencies but they did have a plan for the Pharmacy related to thyroid medication. When advised that we had more than one resident who didn't receive pharmacy medications due to them being unavailable, the Administrator agreed that they QAPI plan was ineffective and that it should have addressed more than just thyroid medications. The root cause is medications not being available. The facility only reviewed and audited thyroid medications.

Based on record review and staff interview, the facility failed to provide documentation that 2 of 5 residents received education and were offered a Influenza immunizations. (Residents #41 and #83) The findings include: A review of Resident #41's medical record provided by the Director of Nursing (DON) indicated that influenza immunization was administered on a future date of 11/06/25. A review of Resident #83's documentation provided by the DON also shows that the influenza immunization was administered on a future date of 11/06/25. An interview with the Director of Nursing (DON) was conducted on 06/05/25 at 12:52 pm inquiring how often the Flu, Pneumonia, and COVID vaccines should be offered. The DON stated they are offered yearly in the fall. The DON was made aware of the issues with the documentation with Residents #41 and #83. Upon exit, the facility was not able to provide current information of the influenza vaccines for these two residents.

Based on record review and staff interview, the facility failed to provide documentation that 2 of 5 residents received education and were offered a COVID immunization. (Resident #83 and #44) The findings included: A review of Resident #83's documentation shows that the COVID immunization was refused however no signature of the resident or a responsible party was present. Resident #44's medical record was missing Education and Consent or Declination of COVID immunization. The Director of Nursing (DON) was conducted on 06/05/25 at 12:52 pm inquiring about the COVID vaccine process. The DON stated they are offered yearly in the fall. The DON and Administrator were informed of the missing information for Residents #44 and #83. This information was not presented prior to the exit of the survey.

Based on observations, staff interview, document review, and policy review, the facility failed to maintain a fully functional resident call system in 4 of 8 sampled facility bedrooms. (Rooms 11, 36, 18, and 48) The findings include: An observation of bedroom [ROOM NUMBER] (A and B beds) was conducted on 4/14/25 at 1:24 PM. The bedroom call light system was tested for both A and B bed and found to be not functional. An observation of bedroom [ROOM NUMBER] (A and B beds) was conducted on 4/14/25 at 1:50 PM. The bedroom call light system was tested and found to be not functional. An observation of unoccupied resident bedroom [ROOM NUMBER] was conducted on 4/15/25 at 9:18 AM. Resident bedroom [ROOM NUMBER]'s call light system was not functional. An observation of unoccupied resident bedroom [ROOM NUMBER] was conducted on 4/15/25 at 9:22 AM. Both A and B bed were missing call lights cords rendering the call system for room [ROOM NUMBER] not functional. (Photographic evidence obtained.) An interview was conducted with the Administrator on 4/14/25 at 3:05 PM. When asked how the facility monitored the functionality of the resident call system, he stated a company comes in every 6 months to check the entire system. He stated they were in the facility about 2 weeks ago and identified they needed some replacement call light boxes. He acknowledged that the resident call system was old. The Administrator was asked if he had any evidence of the facility staff checking the call light system between the 6 months visits conducted by the company. The Administrator provided 2 service request documents from dated 3/4/25 indicating that the call system is obsolete and is working to quote a new system. Bad call stations were found in rooms [ROOM NUMBER]. Another invoice dated 3/28/25 indicated again they went over the nurse call system with customer. This invoice again stated that rooms [ROOM NUMBER] needed new call stations. The invoice stated, System is obsolete and cannot order new parts for repair. Customer is going to look for parts for repairs. A follow-up interview was conducted with the Administrator on 4/15/25 at 12:16 PM. He stated a company had to make parts for the resident call system and that was why it took so long to get parts for repairs. He was able to provide an audit from 3/11/25 for all call lights in facility, which indicated that the resident call system in room [ROOM NUMBER]B bed was not working and repaired on 3/12/25, the light for the 39B bed was not working and repaired 3/12/25, the lights for room [ROOM NUMBER] A and B were not working and repaired on 3/12/25, and 50 B bed not working and repaired on 3/12/25. He stated that was the only audit he could find. The facility policy for Residents Call System (revised September 2022; version 1.0) states, residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. The resident call system remains functional at all times. The resident call system is routinely maintained and tested by the maintenance department. Review of an additional undated facility policy for Maintaining Call Light System in Nursing Home indicated Miracle Hill Nursing and Rehabilitation Center is committed to maintaining a fully operational call light system that meets the needs of our residents. Regular monitoring, maintenance, and timely repairs are crucial to ensure compliance with federal and state regulations. The maintenance staff will routinely conduct an inspection of the call light system to ensure that all components are functioning properly. If the maintenance staff identified a problem that cannot be resolved during monthly monitoring, they will attempt to trouble shoot the issue using their training skills. If the issue remains unresolved, the maintenance staff will contact the outside contractor for immediate assistance.

Based on record review, staff interview, and policy review, the facility failed to follow pharmacy documentation procedures for administration of medications for 2 of 4 sampled residents receiving thyroid medications. (Resident #2 and #3) The findings include: Resident #2 A review of Resident #2's January, February, and March 2025 physician orders and medication administration record (MAR) revealed that Resident #2 was ordered to receive Levothyroxine 125 mcg by mouth daily at 6:00 AM for hypothyroidism through 3/10/25. The MARs for January, February, and March 2025 revealed that the medication was not signed off as administered on 1/10/25, 1/19/25, 1/27/25, 2/2/25, 2/16/25, 3/3/25, 3/7/25, and 3/8/25. A physician order revealed that the Levothyroxine dose was increased to 150 mcg daily on 3/11/25. The March 2025 MAR revealed that the 150 mcg dose was blank and not signed of as administered on 3/30/25. Resident #2's record revealed that the resident was seen by a metabolic physician assistant (PA) on 12/18/24. The note documented by the PA indicated the lab results on 12/11/24 had a high thyroid stimulating hormone reading. The resident stated she had not been taking her medication lately and the dose of Levothyroxine was increased. A follow up visit with the same PA was documented on 3/18/25. The PA documented her labs on March 4, 2025 had a high thyroid stimulating hormone reading. The March note indicated it looks like the patient has not been taking her levothyroxine replacement at the nursing facility. The plan indicated the dose of Levothyroxine would be increased again and the patient's daughter would try to take over giving the thyroid medication. Resident #3 A review of Resident #3's medical record revealed current physician orders indicating he is ordered to receive Levothyroxine 75 mcg by mouth daily at 6:00 AM. The February 2025 MAR indicated no documentation of the Levothyroxine administration on 2/3/25, 2/8/25, 2/13/25, 2/21/25, and 2/27/25. The March 2025 MAR indicates no documentation of the Levothyroxine medication administration on 3/3/25, 3/7/25, 3/18/25, and 3/22/25. An interview was conducted with the Director of Nursing (DON) on 4/15/25 at 9:37 AM. The DON stated documentation of medication administration should occur at the time of administration. The DON was aware of Resident #2's labs and the daughter had reported she was coming in the evening and administering the levothyroxine. The facility had to educate the daughter against doing so as it could cause the resident to be overmedicated. Review of the facility policy Documentation of Medication Administration (revised November 2022; version 1.2) revealed that a medication administration record is used to document all medications administered. Administration of medication is documented immediately after it is given.

Based on observations, staff interviews, resident interviews, record reviews and policy reviews, the facility failed to develop smoking care plans which addressed supervision requirements for 4 of 11 residents (#3, 40, 82 and 343) who smoke tobacco products, and required supervision while smoking. Resident #3, who was assessed as requiring supervision while smoking, was observed on the smoking patio smoking a lit cigarette without supervision, and the resident's care plan did not indicate if the resident required supervision to smoke. This failure placed residents who require supervision while smoking at risk for serious injury or death from [MEDICAL CONDITION] fire. Additionally, the facility failed to implement the plan of care for 1 of 1 residents reviewed for bowel and bladder (resident #91). The situation resulted in a finding of immediate jeopardy. The facility Administrator was notified of the findings of immediate jeopardy on 8/27/19 at 5:49 PM. The immediate jeopardy was removed on 8/29/19 at 5:00 PM when the facility provided evidence of immediate corrective actions. The deficient practice remained at a scope and severity level of a D. Cross reference F689 and F926. The findings include: Safe Smoking Resident #3 An observation of resident #3 was conducted on 8/26/19 at 3:08 PM. The resident was observed sitting in a chair on the fenced in smoking porch smoking a lit cigarette. No staff were located on the smoking porch at that time. Approximately 5 minutes later employee A (therapy certified nursing assistant) came out on the smoking porch. On 8/26/19 at approximately 3:17 PM, employee A asked resident #3 where he obtained a cigarette and lighter. Resident #3 indicated resident #82 gave it to him. Resident #82 was observed to be sitting on the smoking porch with a cigarette box and lighter in her possession. Employee A stated resident #3 should not be smoking without staff supervision and confirmed he was smoking when she arrived on the smoking porch. Review of resident #3's medical record revealed a Smoking - Safety Screen dated 7/12/19 which indicated Resident is safe to smoke with supervision. Resident #3 had a current care plan in place for smoking with a target date of 11/21/19, which revealed he is a smoker; however the care plan did not indicate if the resident required supervision to smoke. Review of the smoking policy acknowledgement form signed by the resident representative on 6/28/18 revealed the smoking policy had been reviewed with the representative and they understood the facility was a smoke free facility. The policy stated that if the resident was evaluated to be safe, the resident would be allowed to smoke at the designated times, in the designated outdoor smoking area with supervision. If the resident did not adhere to the smoking policy the resident smoking privileges could be revoked. The policy goes on to state that anytime there is a change in my mental or physical abilities the resident would be reassessed for inclusion into the smoking programs. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/15/19 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. Review of the annual MDS with ARD of 2/15/19 revealed he had a BIMS score of 11 indicating moderate cognitive impairment. Review of a psychiatric note 7/29/19 revealed resident #3 had a [DIAGNOSES REDACTED]. His self care skills are impaired and he needs cues or assistance to perform them. He is disoriented to date and not aware of current events. The current president could not be named. Vocabulary and fund of knowledge suggest cognitive functioning in the retarded range. Insight into illness is poor. Social judgment is poor. Resident #40 An observation of resident #40 was conducted on 8/28/19 at 1:09 PM. The resident was outside on the smoking porch smoking a cigarette with staff present. Review of resident #40's record revealed no safe smoking evaluation was completed. The record revealed a current care plan in place for smokes tobacco with a target date of 9/27/19, however, the care plan did not indicate if the resident required supervision to smoke. Resident #82 On 08/27/19 at approximately 4:25 PM, Resident #82 was observed in the dining room. She was asked about smoking and if the facility had her wear anything before she smokes. She stated she doesn't have to wear anything. She stated the facility has smoking breaks every couple of hours and that a staff member gives her cigarettes from a locked box. She stated she had an extra cigarette on her when Resident #3 asked her for it and she gave it to him. On 08/27/19 a record review was conducted for Resident #82, a resident on the facility's smoking list. The resident was admitted into the facility on [DATE] with a readmission date of [DATE]. Readmission MDS, dated [DATE], indicates under Section J1300 - Current Tobacco Use - yes. A review of the resident's last Safe Smoking Evaluation, dated 07/09/19, summarizes that Resident may smoke independently or with set up - Resident must be supervised by staff, volunteer or family member at all times when smoking. The resident had a smoking care plan created on 03/16/18 with interventions that include: Provide resident with smoking [NAME]et; Resident will demonstrate ability to physically hold cigarette whiling smoking; and resident will demonstrate safe technique for putting out matches or lighter and disposing of ash. The resident's required supervision needs were not included in the care plan. Resident #343 A record review was conducted on 08/27/19 for resident #343 which revealed the resident had been admitted to the facility on [DATE]. The Smoking Safety Screen was updated on 8/26/19 at 6:05 PM, the evening of the first day of the survey, indicating he was safe to smoke with supervision. The admission MDS with an ARD of 8/16/19 indicated the resident was a current tobacco user. The current care plan did not address smoking and supervision. On 08/28/19 at approximately 8:35 AM, the resident was observed asking for a lighter while holding a cigarette butt on the smoking patio. This was not a facility designated smoking time. On 08/28/19 at approximately 8:52 AM, interview with Staff D, a Certified Nursing Assistant (CNA), confirmed the resident was in possession of 2 cigarette butts (photographic evidence obtained). An interview was conducted with the Administrator, DON and Social Services Director (SSD) on 8/28/19 at 4:00 PM. The Administrator and DON stated all residents should be supervised when smoking at the smoking times. There was no formal process to supervise residents on the smoking patio during non-smoking times. The SSD stated the facility care plans residents based on the smoking assessments and confirmed there was no inclusion of the supervision required for each resident to smoke during the care plan process. Further interview was conducted with the SSD on 8/29/19 at 10:08 AM. She stated if a resident smokes at the time of the comprehensive assessment a care plan regarding smoking should be generated. She thought she had covered everyone she had on the smoking list. The immediate jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan and verification of corrective actions. The facility held an ad-hoc QAPI (Quality Assurance and Performance Improvement) meeting on 8/29/2019 regarding smoking policies. The QAPI committee reviewed, updated and immediately implemented updated smoking policy and procedure related to smoking and storage of supplies. Immediately retrained all currently working staff (65 of the total 146) on the new Smoking policy including changes to the following: Give one cigarette at a time; make sure that the cigarettes smoked are smoked or discarded prior to giving any additional cigarettes; supervise residents at all designated smoke times; if residents are witnessed having any smoke materials or smoking products - ask them to relinquish them and report the incident to the administrator or designee. All staff will be retrained prior to working their next shift. Additionally, the updated policy and immediate actions needed was sent via Text or 'All Call', message to all staff on 8/29/19. Staff retraining was verified by the survey team via staff interviews. At least 10 staff were interviewed onsite, and all were able to verbalize the new policy. The new Smoking Policy and care plans were discussed with all residents that were identified as residents that smoke or use tobacco on 8/29/19. This was verified by the survey team who either observed resident retraining or interviewed residents. The new Smoking Policy was mailed to all responsible parties of residents that were identified as residents that smoke or use tobacco on 8/29/19. The information mailed was reviewed by the survey team. Safe Smoking Evaluations for smoking residents were completed or updated for all residents who smoke on both 8/26/19 and 8/29/19. The updated evaluations were reviewed by the survey team for all 11 residents. All smoking care plans were reviewed and updated as indicated to reflect whether a resident required supervision. The updated care plans were reviewed by the survey team. Designated staff (DON, Unit Managers, Nurses) were educated on 8/29/19 to re-assess residents that smoke at a minimum on Admission, Quarterly, Annually and if significant change to a resident's cognitive capabilities, hearing, vision or physical ability or when there is an accident of unsafe smoking observed or reported. Staff retraining was verified by the survey team via staff interviews. To ensure no current resident has any smoking supplies in their rooms, on 8/29/19, the facility interviewed and inspected all resident rooms who smoke with the resident's permission. The accessibility of matches and lighters will be kept in a container and not with resident. For the next 3 months, room checks will be done at least 5 times weekly to ensure that residents are not hiding the cigarettes in their rooms. No smoking paraphernalia was observed by the survey team in any resident room. The facility developed a staff list that designates staff that will supervise residents when smoking during designated smoke times. This list was reviewed by the survey team on 8/29/19. The survey team, additionally, observed residents smoking during multiple smoking cessions on 8/27, 8/28 and 8/29/19, and no further incidents of residents smoking unsupervised were identified. Bowel and Bladder Resident #91 On 08/26/19 at approximately 3:35 PM, Resident #91 was observed in his room, in bed. There was a strong smell of feces coming from the resident. A review of Resident #91 electronic charting Task record for Bowel and Bladder Elimination showed inconsistent documentation of the resident's bowel habits. There had been no documented bowel movement since 08/20/19 - despite the resident having a bowel movement on 08/26/19, as per observation/smell. On 08/28/19 at approximately 4:45 PM interviews were conducted with Staff Member M and N, both CNAs, regarding the bowel and bladder log for Resident #91. The resident's bowel and bladder report indicated the last BM (bowel movement) for Resident #91 was on 08/20/19. The CNAs both stated the CNA is to inform the nurse if the resident has not had a BM in 3 days. There was an additional CNA sitting at the nurse's station - she stated she remembered that afternoon, later in the shift - when the resident had a BM, she stated it was a different CNA that had changed him. She confirmed that this information should have been recorded in the electronic record. A review of Resident #91's care plan, dated 05/10/2017, Monitor bowel elimination pattern every shift and document. Review of the facility policy regarding Care Plans (revised [DATE]) revealed the purpose was to keep care plans updated as the resident need changes and to ensure each resident's needs are reflected by their plan of care. The plan must be individualized to the resident receiving the care and consistent with resident's needs, risk, and limitations. The care plan staff will revise, modify, and update them quarterly.

Based on observations, staff interviews, resident interviews, record reviews and policy reviews, the facility failed to ensure adequate supervision of residents who smoke tobacco products for 1 of 11 residents (#3) who required supervision while they were smoking. Resident #3, who was assessed as requiring supervision while smoking, was observed on the smoking patio smoking a lit cigarette without supervision. The facility failed to implement a policy to ensure adequate supervision of residents who smoke and failed to develop a written policy regarding safe storage of resident smoking materials. This had the potential to affect all 11 residents that the facility identified as residents who smoke, (residents #3, 5, 14, 36, 40, 82, 88, 90, 92, 343 and 394). The facility failed to assess 3 of 11 residents for safe smoking practices as indicated in the facility smoking policy (#14, 40 and 90). The facility failed to develop smoking care plans which included smoking supervision requirements for 4 of 11 residents (#3, 40, 82 and 343) who smoked tobacco products. This failure placed residents who smoke at risk for serious injury/impairment/death from [MEDICAL CONDITION] fire. The situation resulted in a finding of immediate jeopardy. The facility Administrator was notified of the findings of immediate jeopardy on 8/27/19 at 5:49 PM. The immediate jeopardy was removed on 8/29/19 at 5:00 PM when the facility provided evidence of immediate corrective actions. The deficient practice remained at a scope and severity level of a D. Cross reference F656 and F926. The findings include: On 8/26/19 the facility provided a list indicating residents #3, 5, 14, 36, 40, 82, 88, 90, 92, 343 and 394 smoked tobacco products. The list had been updated on 8/19/19. Resident #3 An observation of resident #3 was conducted on 8/26/19 at 3:08 PM. The resident was observed sitting in a chair on the fenced-in smoking porch smoking a lit cigarette. No staff were located on the smoking porch at that time. Approximately 5 minutes later employee A (therapy certified nursing assistant) came out on the smoking porch. On 8/26/19 at approximately 3:17 PM, employee A asked resident #3 where he obtained a cigarette and lighter. Resident #3 indicated resident #82 gave it to him. Resident #82 was observed to be sitting on the smoking porch with a cigarette box and lighter in her possession. Employee A stated resident #3 should not be smoking without staff supervision and confirmed he was smoking when she arrived on the smoking porch. Review of resident #3's medical record revealed a Smoking - Safety Screen dated 7/12/19 which indicated Resident is safe to smoke with supervision. Resident #3 had a current care plan in place for smoking with a target date of 11/21/19, which revealed he is a smoker however the care plan did not indicate if the resident required supervision to smoke. Further review of the care plan revealed he picks up cigarette butts that have already been smoked. The goal indicated resident will smoke safely at designated areas through next review date. The care plan interventions included explain to resident the danger of smoking other's cigarette butts; make family aware of behavior; remove cigarette butts from smoking area; resident will ask for smoking materials; resident will demonstrate ability to physically hold the smoking device while smoking; resident will demonstrate safe technique for putting out matches or lighter and disposing of ash; resident will demonstrate the ability to verbalize understanding that smoking materials are for use only in designated smoking areas; safe smoking screen completed on admission and as needed and smoking policy given to resident and/or responsible party. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/15/19 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. Review of the annual MDS with ARD of 2/15/19 revealed he had a BIMS score of 11 indicating moderate cognitive impairment. Review of a psychiatric note 7/29/19 revealed resident #3 had a [DIAGNOSES REDACTED]. His self care skills are impaired and he needs cues or assistance to perform them. He is disoriented to date and not aware of current events. The current president could not be named. Vocabulary and fund of knowledge suggest cognitive functioning in the retarded range. Insight into illness is poor. Social judgment is poor. Review of the smoking policy acknowledgement form signed by the resident representative on 6/28/18 revealed the smoking policy had been reviewed with the representative and they understood the facility was a smoke free facility. The policy stated that if the resident was evaluated to be safe, the resident would be allowed to smoke at the designated times, in the designated outdoor smoking area with supervision. If the resident did not adhere to the smoking policy the resident smoking privileges could be revoked. The policy goes on to state that anytime there is a change in mental or physical abilities the resident would be reassessed for inclusion into the smoking programs. A follow up interview was conducted with employee A (therapy certified nursing assistant) on 8/28/19 at 9:40 AM. She stated she recalled observing resident #3 smoking when she arrived on Monday (8/26/19) to the smoking area. She confirmed no staff were in the area before she arrived. Employee A indicated resident #3 obtained the cigarette from resident #82. She confirmed resident #82 had a lighter in her possession and should not have a lighter in her possession. She recalled observing resident #82 with a cigarette box in her lap and she believes the resident stated she had one cigarette left in the box after she gave resident #3 the cigarette. Resident #82 On 08/27/19, a record review was conducted for Resident #82. The resident was admitted into the facility on [DATE] with a readmission date of [DATE]. The readmission MDS, dated [DATE], indicated under Section J1300 - Current Tobacco Use - yes. A review of the resident's last Safe Smoking Evaluation, dated 07/09/19 summarized that Resident may smoke independently or with set up and resident must be supervised by staff, volunteer or family member at all times when smoking. The resident care plan dated 03/16/18 indicated smokes tobacco. Interventions include: Provide resident with smoking [NAME]et; Resident will demonstrate ability to physically hold cigarette whiling smoking; and resident will demonstrate safe technique for putting out matches or lighter and disposing of ash. The resident's required supervision needs were not included in the care plan. On 08/27/19 at approximately 4:25 PM, Resident #82 was observed in the dining room. She was asked about smoking and if the facility had her wear anything before she smokes. She stated she doesn't have to wear anything. She stated the facility has smoking breaks every couple of hours and that a staff member gives her cigarettes from a locked box. She stated she had an extra cigarette on her when Resident #3 asked her for it and she gave it to him. Resident #14 A review of resident #14's record revealed no safe smoking evaluation completed however the resident was observed to be outside on the smoking porch smoking cigarettes with a smoking apron in place and staff supervising on 8/28/19 at 9:13 AM, 11:06 AM and 1:10 PM. The record revealed a current care plan in place for smokes tobacco with a target date 9/5/19. The interventions included supervision requirements. Resident #36 Resident #36 was not observed to smoke tobacco during the survey. The resident was identified as a tobacco smoker on a list updated 8/19/19 provided by the facility on 8/26/19. An interview with resident #36 was conducted on 8/27/19 at 11:51 AM. The resident stated he does not smoke tobacco at the facility. Review of resident #36's record revealed an admission 5 day MDS with an ARD of 4/4/19 indicating the resident does not use tobacco products. Resident #36 had no care plan in place for smoking tobacco. An interview was conducted with employee B (licensed practical nurse for resident #36) on 8/27/19 at 2:17 PM. She stated resident #36 does not smoke. Resident #40 A review of resident #40's record revealed no safe smoking evaluation was completed however the resident was observed smoking a cigarette outside on the smoking porch on 8/28/19 at 1:09 PM, staff were present. The record revealed a current care plan in place for smokes tobacco with a target date of 9/27/19, however, the care plan did not indicate if the resident required supervision to smoke. Resident #90 On 08/27/19, a record review was conducted for Resident #90. The resident was admitted into the facility on [DATE], a Safe Smoking evaluation was partially completed on 08/02/19, but failed to summarize the results of the evaluation (page 1) and determine the supervision needs of the resident (page 2). The resident had a smoking care plan created on 08/08/19 that included supervision requirements. The MDS, dated [DATE] indicates yes for tobacco use. Resident #5 A record review conducted for resident #5 revealed a Smoking Care Plan dated 9/4/18, with a revision date of 5/25/19, which stated Provide resident with smoking supervision. Further review of the record revealed a Smoking Safety Screen dated the evening of first day of the survey, 8/26/19, which stated, Safe to smoke with supervision. Review of the MDS for Tobacco Use revealed Yes with an with an ARD of 8/18/19. On 8/27/19 at approximately 11:05 AM, Resident #5 was interviewed and stated, I've been smoking since I was 2 years old. Resident #88 On 8/27/19 at approximately 11:06 AM, Resident #88 was observed on the screened smoking porch, but the resident was not observed to be smoking. Resident #88 denied smoking or tobacco use. A record review for Resident #88 revealed a Smoking Safety Screen that was dated 8/21/19, which stated Safe to smoke with supervision. The initial smoking care plan dated 10/24/17, last updated 8/26/19, stated Resident 88 smokes tobacco daily, but is non-compliant with smoking schedule and smoking safety. Resident #92 On 8/27/19 at approximately 5:34 PM, Resident #92 was observed on the screened smoking porch. At this time the resident was interviewed and stated he smoked, but he was not observed to have cigarettes at the time of the interview. Resident #92 record review revealed the Smoking Safety Screen was completed on 8/26/19, the first day of the survey, which stated, Safe to smoke with supervision. The Smoking care plan was updated on 8/21/19. The MDS coded Yes on J 1300 Tobacco Use with an ARD listed as,5/9/19. Resident #394 On 08/27/19, a record review was conducted for Resident #394. The resident was admitted into the facility on [DATE]. A review of the resident's baseline care plan information indicated the resident does not smoke. On 08/27/19 at 11:30 AM, a brief interview was conducted with Resident #394 who stated he smokes, but he has not smoked at the facility. Resident #343 A record review was conducted on 08/27/19 for resident #343 which revealed the resident had been admitted to the facility on [DATE]. The Smoking Safety Screen was updated on 8/26/19 at 6:05 PM, the evening of the first day of the survey, indicating he was safe to smoke with supervision. The MDS with an ARD of 8/16/19 indicated the resident was a current tobacco user. The current care plan did not address smoking and supervision. On 08/28/19 at approximately 8:35 AM, the resident was observed asking for a lighter while holding a cigarette butt on the smoking patio. This was not a facility designated smoking time. On 08/28/19 at approximately 8:52 AM, interview with Staff D, a Certified Nursing Assistant (CNA), confirmed the resident was in possession of 2 cigarette butts (photographic evidence obtained). An interview was conducted with the Director of Nursing (DON) on 8/27/19 at 1:56 PM. The DON provided a written procedure for storage of resident smoking materials. She stated the procedure was not in writing until today (8/27/19), but they have been doing this for years. The smoking items are placed into the lock boxes behind the west nursing station and can only be accessed by the designated individual at the appointed smoke breaks (7 AM, 9 AM, 11 AM, 3 PM, 5 PM and 7 PM). She stated if staff observed a resident with cigarettes that were not provided by staff, the staff should identify these residents and report any resident smoking that is not on the smoking list, then staff will meet with the resident to determine if they want to smoke and a safe smoking screen will be completed. An interview was conducted with the Administrator, Director of Nursing (DON) and Social Services Director (SSD) on 8/28/19 at 4:00 PM. The Administrator and DON stated all residents should be supervised when smoking at the smoking times. There was no formal process to supervise residents on the smoking patio during non-smoking times. The DON reiterated that there was no policy in place prior to the survey for storage of resident smoking materials and no process was in place to ensure residents did not have smoking materials on their person. The DON stated the safe smoking evaluations should be completed on each resident annually, on admission, quarterly and with a significant change. The SSD stated the facility care plans residents based on the smoking assessments and confirmed there was no inclusion of the supervision required for each resident to smoke during the care plan process. Further interview was conducted with the SSD on 8/29/19 at 10:08 AM. She stated if a resident smokes at the time of the comprehensive assessment a care plan regarding smoking should be generated. She thought she had covered everyone she had on the smoking list. A telephone interview was conducted with the Medical Director on 8/29/19 at 10:31 AM. He stated he was not aware of the immediate jeopardy situation identified by the survey team. He understood all residents are observed while they are smoking. He further stated all residents should be observed while smoking. Review of the facility Smoking Policy dated 7/11/18 revealed it is the policy of the facility to establish and maintain safe resident practices. This is a Non-Smoking facility. Each resident of the facility who smokes must undergo a Safe Smoking Evaluation, the results of which shall be maintained in the resident's care plan. The Evaluation must be performed at the following intervals, at a minimum: Admission, Quarterly, Annually, at a significant change in the resident's cognitive capabilities, hearing or vision or physical ability or there has been an incident of unsafe smoking observed or reported. The interdisciplinary team shall be consulted in determining whether the resident has any smoking privileges, restrictions or concerns. Any restrictions or concerns should be documented in the resident's care plan and all personnel responsible for the resident's direct care shall be alerted to these issues. There will be 7 facility wide supervised smoking times. They will be: 7 AM, 9 AM, 11 AM, 1 PM, 3 PM and 7 PM. Each resident may smoke 2 cigarettes during these times. Supervision will be provided by staff during the designated smoking times. Accessibility of matches and lighters by residents who need supervision when smoking will be limited: smoking articles will be kept at each nurses' station. Review of the facility assessment dated [DATE] was conducted on 8/29/19. The facility assessment did not include how the facility would staff and meet the needs for supervision of residents who smoke. An interview was conducted with the facility Administrator on 8/29/19 at 9:52 AM. The Administrator stated the facility assessment did not include the service of supervision of smoking. She stated the assessment was in place when she became the Administrator on (MONTH) 28, 2019. Prior to the survey, the process to review the assessment and update had been started but not completed. The immediate jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan and verification of corrective actions. The facility held an ad-hoc QAPI (Quality Assurance and Performance Improvement) meeting on 8/29/19 regarding smoking policies. The QAPI committee reviewed, updated and immediately implemented updated smoking policy and procedure related to smoking and storage of supplies. Immediately retrained all currently working staff (65 of the total 146) on the new Smoking policy including changes to the following: Give one cigarette at a time; make sure that the cigarettes smoked are smoked or discarded prior to giving any additional cigarettes; supervise residents at all designated smoke times; if residents are witnessed having any smoke materials or smoking products - ask them to relinquish them and report the incident to the administrator or designee. All staff will be retrained prior to working their next shift. Additionally, the updated policy and immediate actions needed was sent via Text or 'All Call', message to all staff on 8/29/19. Staff retraining was verified by the survey team via staff interviews. At least 10 staff were interviewed onsite, and all were able to verbalize the new policy. The new Smoking Policy was discussed with all residents that were identified as residents that smoke or use tobacco on 8/29/19. This was verified by the survey team who either observed resident retraining or interviewed residents. The new Smoking Policy was mailed to all responsible parties of residents that were identified as residents that smoke or use tobacco on 8/29/19. The information mailed was reviewed by the survey team. Safe Smoking Evaluations for smoking residents were completed or updated for all residents who smoke on both 8/26/19 and 8/29/19. The updated evaluations were reviewed by the survey team for all 11 residents. All smoking care plans were reviewed and updated as indicated to reflect whether a resident required supervision. The updated care plans were reviewed by the survey team. Designated staff (DON, Unit Managers, Nurses) were educated on 8/29/19 to re-assess residents that smoke at a minimum on Admission, Quarterly, Annually and if significant change to a resident's cognitive capabilities, hearing, vision or physical ability or when there is an accident of unsafe smoking observed or reported. Staff retraining was verified by the survey team via staff interviews. To ensure no current resident has any smoking supplies in their rooms, on 8/29/19, the facility interviewed and inspected all resident rooms who smoke with the resident's permission. The accessibility of matches and lighters will be kept in a container and not with resident. For the next 3 months, room checks will be done at least 5 times weekly to ensure that residents are not hiding the cigarettes in their rooms. No smoking paraphernalia was observed by the survey team in any resident room. The facility developed a staff list that designates staff that will supervise residents when smoking during designated smoke times. This list was reviewed by the survey team on 8/29/19. The survey team, additionally, observed residents smoking during multiple smoking cessions on 8/27, 8/28 and 8/29/19, and no further incidents of residents smoking unsupervised were identified.

Based on observations, staff interviews, resident interviews, record reviews and policy reviews, the facility failed to implement a policy to ensure adequate supervision of residents who require supervision while smoking, and failed to develop a policy regarding storage of resident smoking materials to ensure safe storage of smoking materials for 11 of 11 residents the facility identified as smoking residents (residents #3, 5, 14, 36, 40, 82, 88, 90, 92, 343 and 394). This failure resulted in the observation of 1 of 11 residents (#3), who required supervision for safety while smoking, being observed on the smoking patio smoking a lit cigarette without supervision. This failure of policy implementation and development placed residents who smoke at risk for serious injury or death from [MEDICAL CONDITION] fire and could potentially affect all residents residing in the facility. The census at the time of survey was 98. The situation resulted in a finding of immediate jeopardy. The facility Administrator was notified of the findings of immediate jeopardy on 8/27/19 at 5:49 PM. The immediate jeopardy was removed on 8/29/19 at 5:00 PM when the facility provided evidence of immediate corrective actions. The deficient practice remained at a scope and severity level of a D. Cross reference F656 and F689. The findings include: Review of the facility Smoking Policy dated 7/11/18 revealed it is the policy of the facility to establish and maintain safe resident practices. This is a Non-Smoking facility. Each resident of the facility who smokes must undergo a Safe Smoking Evaluation, the results of which shall be maintained in the resident's care plan. The Evaluation must be performed at the following intervals, at a minimum: Admission, Quarterly, Annually, at a significant change in the resident's cognitive capabilities, hearing or vision or physical ability or there has been an incident of unsafe smoking observed or reported. The interdisciplinary team shall be consulted in determining whether the resident has any smoking privileges, restrictions or concerns. Any restrictions or concerns should be documented in the resident's care plan and all personnel responsible for the resident's direct care shall be alerted to these issues. There will be 7 facility wide supervised smoking times. They will be: 7 AM, 9 AM, 11 AM, 1 PM, 3 PM and 7 PM. Each resident may smoke 2 cigarettes during these times. Supervision will be provided by staff during the designated smoking times. Accessibility of matches and lighters by residents who need supervision when smoking will be limited: smoking articles will be kept at each nurses' station. The policy failed to include specific details regarding storage of materials for residents who do not require supervision. On 8/26/19 the facility provided a list indicating residents #3, 5, 14, 36, 40, 82, 88, 90, 92, 343 and 394 smoked tobacco products. The list had been updated on 8/19/19. Resident #3 An observation of resident #3 was conducted on 8/26/19 at 3:08 PM. The resident was observed sitting in a chair on the fenced-in smoking porch smoking a lit cigarette. No staff were located on the smoking porch at that time. Approximately 5 minutes later employee A (therapy certified nursing assistant) came out on the smoking porch. On 8/26/19 at approximately 3:17 PM, employee A asked resident #3 where he obtained a cigarette and lighter. Resident #3 indicated resident #82 gave it to him. Resident #82 was observed to be sitting on the smoking porch with a cigarette box and lighter in her possession. Employee A stated resident #3 should not be smoking without staff supervision and confirmed he was smoking when she arrived on the smoking porch. Review of resident #3's medical record revealed a Smoking - Safety Screen dated 7/12/19 which indicated Resident is safe to smoke with supervision. Resident #3 had a current care plan in place for smoking with a target date of 11/21/19, which revealed he is a smoker however the care plan did not indicate if the resident required supervision to smoke. Further review of the care plan revealed he picks up cigarette butts that have already been smoked. The goal indicated resident will smoke safely at designated areas through next review date. The care plan interventions included explain to resident the danger of smoking other's cigarette butts; make family aware of behavior; remove cigarette butts from smoking area; resident will ask for smoking materials; resident will demonstrate ability to physically hold the smoking device while smoking; resident will demonstrate safe technique for putting out matches or lighter and disposing of ash; resident will demonstrate the ability to verbalize understanding that smoking materials are for use only in designated smoking areas; safe smoking screen completed on admission and as needed and smoking policy given to resident and/or responsible party. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/15/19 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. Review of the annual MDS with ARD of 2/15/19 revealed he had a BIMS score of 11 indicating moderate cognitive impairment. Review of a psychiatric note 7/29/19 revealed resident #3 had a [DIAGNOSES REDACTED]. His self care skills are impaired and he needs cues or assistance to perform them. He is disoriented to date and not aware of current events. The current president could not be named. Vocabulary and fund of knowledge suggest cognitive functioning in the retarded range. Insight into illness is poor. Social judgment is poor. Review of the smoking policy acknowledgement form signed by the resident representative on 6/28/18 revealed the smoking policy had been reviewed with the representative and they understood the facility was a smoke free facility. The policy stated that if the resident was evaluated to be safe, the resident would be allowed to smoke at the designated times, in the designated outdoor smoking area with supervision. If the resident did not adhere to the smoking policy the resident smoking privileges could be revoked. The policy goes on to state that anytime there is a change in mental or physical abilities the resident would be reassessed for inclusion into the smoking programs. A follow up interview was conducted with employee A (therapy certified nursing assistant) on 8/28/19 at 9:40 AM. She stated she recalled observing resident #3 smoking when she arrived on Monday (8/26/19) to the smoking area. She confirmed no staff were in the area before she arrived. Employee A indicated resident #3 obtained the cigarette from resident #82. She confirmed resident #82 had a lighter in her possession and should not have a lighter in her possession. She recalled observing resident #82 with a cigarette box in her lap and she believes the resident stated she had one cigarette left in the box after she gave resident #3 the cigarette. Resident #82 On 08/27/19, a record review was conducted for Resident #82. The resident was admitted into the facility on [DATE] with a readmission date of [DATE]. The readmission MDS, dated [DATE], indicated under Section J1300 - Current Tobacco Use - yes. A review of the resident's last Safe Smoking Evaluation, dated 07/09/19 summarized that Resident may smoke independently or with set up and resident must be supervised by staff, volunteer or family member at all times when smoking. The resident care plan dated 03/16/18 indicated, .smokes tobacco. Interventions include: Provide resident with smoking [NAME]et; Resident will demonstrate ability to physically hold cigarette whiling smoking; and resident will demonstrate safe technique for putting out matches or lighter and disposing of ash. The resident's required supervision needs were not included in the care plan. On 08/27/19 at approximately 4:25 PM, Resident #82 was observed in the dining room. She was asked about smoking and if the facility had her wear anything before she smokes. She stated she doesn't have to wear anything. She stated the facility has smoking breaks every couple of hours and that a staff member gives her cigarettes from a locked box. She stated she had an extra cigarette on her when Resident #3 asked her for it and she gave it to him. Resident #14 A review of resident #14's record revealed no safe smoking evaluation completed however the resident was observed to be outside on the smoking porch smoking cigarettes with a smoking apron in place and staff supervising on 8/28/19 at 9:13 AM, 11:06 AM and 1:10 PM. The record revealed a current care plan in place for smokes tobacco with a target date 9/5/19. The interventions included supervision requirements. Resident #36 Resident #36 was not observed to smoke tobacco during the survey. The resident was identified as a tobacco smoker on a list updated 8/19/19 provided by the facility on 8/26/19. An interview with resident #36 was conducted on 8/27/19 at 11:51 AM. The resident stated he does not smoke tobacco at the facility. Review of resident #36's record revealed an admission 5 day MDS with an ARD of 4/4/19 indicating the resident does not use tobacco products. Resident #36 had no care plan in place for smoking tobacco. An interview was conducted with employee B (licensed practical nurse for resident #36) on 8/27/19 at 2:17 PM. She stated resident #36 does not smoke. Resident #40 A review of resident #40's record revealed no safe smoking evaluation was completed however the resident was observed smoking a cigarette outside on the smoking porch on 8/28/19 at 1:09 PM, staff were present. The record revealed a current care plan in place for smokes tobacco with a target date of 9/27/19, however, the care plan did not indicate if the resident required supervision to smoke. Resident #5 A record review conducted for resident #5 revealed a Smoking Care Plan dated 9/4/18, with a revision date of 5/25/19, which stated Provide resident with smoking supervision. Further review of the record revealed a Smoking Safety Screen dated the evening of first day of the survey, 8/26/19, which stated, Safe to smoke with supervision. Review of the MDS for Tobacco Use revealed Yes with an with an ARD of 8/18/19. On 8/27/19 at approximately 11:05 AM, Resident # 5 was interviewed and stated, I've been smoking since I was 2 years old. Resident #88 On 8/27/19 at approximately 11:06 AM, Resident #88 was observed on the screened smoking porch, but the resident was not observed to be smoking. Resident #88 denied smoking or tobacco use. The resident had both a current Smoking Safety Screen dated 8/21/19 and a current current care plan dated 10/24/17, and updated 8/26/19. Resident #92 On 8/27/19 at approximately 5:34 PM, Resident #92 was observed on the screened smoking porch. At this time the resident was interviewed and stated he smoked, but he was not observed to have cigarettes at the time of the interview. Resident #92 record review revealed the Smoking Safety Screen was completed on 8/26/19, the first day of the survey, which stated, Safe to smoke with supervision. The Smoking care plan was updated on 8/21/19. MDS (Minimum Data Set) coded Yes on J 1300 Tobacco Use with an Assessment Reference Date (ARD) listed as,5/9/19. Resident #90 On 08/27/19, a record review was conducted for Resident #90. The resident was admitted into the facility on [DATE], a Safe Smoking evaluation was partially completed on 08/02/19, but failed to summarize the results of the evaluation (page 1) and determine the supervision needs of the resident (page 2). The resident had a smoking care plan created on 08/08/19 that included supervision requirements. Resident #394 On 08/27/19, a record review was conducted for Resident #394. The resident was admitted into the facility on [DATE]. A review of the resident's baseline care plan information indicated the resident does not smoke. On 08/27/19 at 11:30 AM, a brief interview was conducted with Resident #394 who stated he smokes, but he has not smoked at the facility. Resident #343 A record review was conducted on 08/27/19 for resident #343 which revealed the resident had been admitted to the facility on [DATE]. The Smoking Safety Screen was updated on 8/26/19 at 6:05 PM, the evening of the first day of the survey, indicating he was safe to smoke with supervision. The admission MDS with an ARD of 8/16/19 indicated the resident was a current tobacco user. The current care plan did not address smoking and supervision. On 08/28/19 at approximately 8:35 AM, the resident was observed asking for a lighter while holding a cigarette butt on the smoking patio. This was not a facility designated smoking time. On 08/28/19 at approximately 8:52 AM, interview with Staff D, a Certified Nursing Assistant (CNA), confirmed the resident was in possession of 2 cigarette butts (photographic evidence obtained). An interview was conducted with the Director of Nursing (DON) on 8/27/19 at 1:56 PM. The DON provided a written procedure for storage of resident smoking materials. She stated the procedure was not in writing until today (8/27/19), but they have been doing this for years. The smoking items are placed into the lock boxes behind the west nursing station and can only be accessed by the designated individual at the appointed smoke breaks (7 AM, 9 AM, 11 AM, 3 PM, 5 PM and 7 PM). She stated if staff observed a resident with cigarettes that were not provided by staff, the staff should identify these residents and report any resident smoking that is not on the smoking list, then staff will meet with the resident to determine if they want to smoke and a safe smoking screen will be completed. An interview was conducted with the Administrator, Director of Nursing (DON) and Social Services Director (SSD) on 8/28/19 at 4:00 PM. The Administrator and DON stated all residents should be supervised when smoking at the smoking times. There was no formal process to supervise residents on the smoking patio during non-smoking times. The DON reiterated that there was no policy in place prior to the survey for storage of resident smoking materials and no process was in place to ensure residents did not have smoking materials on their person. The DON stated the safe smoking evaluations should be completed on each resident annually, on admission, quarterly and with a significant change. The SSD stated the facility care plans residents based on the smoking assessments and confirmed there was no inclusion of the supervision required for each resident to smoke during the care plan process. Further interview was conducted with the SSD on 8/29/19 at 10:08 AM. She stated if a resident smokes at the time of the comprehensive assessment a care plan regarding smoking should be generated. She thought she had covered everyone she had on the smoking list. A telephone interview was conducted with the Medical Director on 8/29/19 at 10:31 AM. He stated he was not aware of the immediate jeopardy situation identified by the survey team. He understood all residents are observed while they are smoking. He further stated all residents should be observed while smoking. The immediate jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan and verification of corrective actions. The facility held an ad-hoc QAPI (Quality Assurance and Performance Improvement) meeting on 8/29/19 regarding smoking policies. The QAPI committee reviewed, updated and immediately implemented updated smoking policy and procedure related to smoking and storage of supplies. Immediately retrained all currently working staff (65 of the total 146) on the new Smoking policy including changes to the following: Give one cigarette at a time; make sure that the cigarettes smoked are smoked or discarded prior to giving any additional cigarettes; supervise residents at all designated smoke times; if residents are witnessed having any smoke materials or smoking products - ask them to relinquish them and report the incident to the administrator or designee. All staff will be retrained prior to working their next shift. Additionally, the updated policy and immediate actions needed was sent via Text or 'All Call', message to all staff on 8/29/19. Staff retraining was verified by the survey team via staff interviews. At least 10 staff were interviewed onsite, and all were able to verbalize the new policy. The new Smoking Policy was discussed with all residents that were identified as residents that smoke or use tobacco on 8/29/19. This was verified by the survey team who either observed resident retraining or interviewed residents. The new Smoking Policy was mailed to all responsible parties of residents that were identified as residents that smoke or use tobacco on 8/29/19. The information mailed was reviewed by the survey team. Safe Smoking Evaluations for smoking residents were completed or updated for all residents who smoke on both 8/26/19 and 8/29/19. The updated evaluations were reviewed by the survey team for all 11 residents. All smoking care plans were reviewed and updated as indicated to reflect whether a resident required supervision. The updated care plans were reviewed by the survey team. Designated staff (DON, Unit Managers, Nurses) were educated on 8/29/19 to re-assess residents that smoke at a minimum on Admission, Quarterly, Annually and if significant change to a resident's cognitive capabilities, hearing, vision or physical ability or when there is an accident of unsafe smoking observed or reported. Staff retraining was verified by the survey team via staff interviews. To ensure no current resident has any smoking supplies in their rooms, on 8/29/19, the facility interviewed and inspected all resident rooms who smoke with the resident's permission. The accessibility of matches and lighters will be kept in a container and not with resident. For the next 3 months, room checks will be done at least 5 times weekly to ensure that residents are not hiding the cigarettes in their rooms. No smoking paraphernalia was observed by the survey team in any resident room. The facility developed a staff list that designates staff that will supervise residents when smoking during designated smoke times. This list was reviewed by the survey team on 8/29/19. The survey team, additionally, observed residents smoking during multiple smoking cessions on 8/27, 8/28 and 8/29/19, and no further incidents of residents smoking unsupervised were identified.