Every finding on record at Oak View Health And Rehabilitation

Based on review of facility policy, observation and interview, the facility failed to ensure outdated/expired medications and biologicals were removed from 1 of 4 treatment carts. The facility additionally failed to ensure 1 of 1 medication carts and 1 of 1 treatment carts on Unit 400 was locked while unattended. The facility further failed to ensure one vial of insulin was labeled with an open date and discard date in 1 of 2 medication rooms.Findings include: Review of the facility policy titled, Medication Access and Storage, states as the policy, It is the policy of this facility to store all drugs and biologicals in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures:2. Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 12. Outdated or discontinued medications are removed from stock upon discovery and disposed of according to procedures for medication destruction. Outdated medications are reordered from the pharmacy, if a current order exists. During an observation on 05/26/2026 at 12:39 PM, of medication cart 700 center, revealed the medication cart was unlocked and unattended. There was no nurse in the vicinity of the cart. During an observation on 05/26/2026 at 12:41 PM, of a treatment cart on 700 center, revealed the treatment cart unlocked and unattended. During an interview on 05/26/2026 at 12:44 PM, Registered Nurse (RN)3 confirmed that the 2 carts were unlocked and she stated she had just stepped away to the restroom. During an observation on 05/27/2026 at 9:45 AM, of the Treatment Cart on 4th Hall, revealed 5 individual pads of XLTA Hydro Capillary 5 cm x 5 cm (2x 2) Sterile, with lot #202103 was expired on 03/2026. XLTA Hydro Capillary, 6 pads, 10 x 10 (4 x 4) with Lot# 202103 was expired on 03/2026. One bottle of Ready Prep, manufactured by Medline, Providone - Iodine 10% Solution with Lot #23DJA062 was expired on 03/2025. The above medications and biologicals were verified by RN5 and removed from storage. During an observation on 05/28/2026 at 8:25 AM, of the 4th Hall Medication room, revealed one vial of Insulin Lispro 100u/ml opened with Lot #D766068C with expiration date of 07/21/2027, with no opened date and no expiration date.During an interview on 05/28/2026 at 8:27 AM, Licensed Practical Nurse (LPN)3 Unit Manager, confirmed the findings and stated, when a medication is opened, it should be dated.

Based on review of facility policy, observation, record review and interview, the facility failed to ensure Resident (R)5, R98 and R23, were afforded an ongoing program of activities, based on their personal preferences and interests for 3 of 3 residents reviewed for activities. Findings include: Review of the facility policy titled, Activities Program, states, as the policy, It is the policy of this facility to implement an ongoing resident centered activities program that incorporates the resident's interests, hobbies and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being and independence. It is also the policy of this facility to create opportunities for each resident to have meaningful life by supporting his/her domains of wellness (security, autonomy, growth, connectedness, identity, joy, and meaning). Procedures: Activities are planned according to the resident's preferences, needs, and abilities. Every resident will be interviewed for preferences. Equipment and supplies are available and accessible to accommodate each resident who chooses to participate in an activity. 4. Daily newspapers, current magazines, and a variety of reading materials are available and accessible to all residents. 5. Socialization activities will be made available through: group discussion, conversation, recreation, visiting, arts and crafts, and music. 6. Physical activities will also be made available such as games, sports, and exercises which develop and maintain strength, coordination, and range of motion. Review of R98's Face Sheet revealed R98 was admitted to the facility on [DATE], with diagnoses which included, but was not limited to, encephalopathy, major depressive disorder, and psychosis. Review of the Activity Care Plan initiated on 04/01/2026, states R98 enjoys the following activities: board games, cards, bingo, word searches, exercise, sermons, reading, his religion, trips, shopping, being outdoors, watching tv, gardening, parties, dogs, and keeping up with the news. Interventions/Tasks on the care plan were as follows: invite to scheduled activities, needs assistance/escort to activity functions, offer leisure materials, and provide activities calendar monthly. Review of the Activity Tracker for April 2026 listed TV/Radio/Movies every day. R98 had coffee, salon, and snack/beverage one time each in the month of April 2026. Review of the Activity Tracker for May 2026 listed TV/Radio/Movies every day. No other activities of interest listed on the care plan was offered. During an interview with the Activity Director on 05/28/2026 at 1:15 PM, the Activity Director stated employment with the facility had been almost a year. The Activity Director further stated the priority was to start with the group activities, then Memory Care, and then room visits. The Activity Director stated we are working towards this and confirmed R98 was up in his/her chair watching TV daily. Review of R23's Face Sheet revealed R23's admission date was 11/02/2022, with diagnoses including, but not limited to, alcohol use unspecified, with alcohol induced persisting amnestic disorder, mood disorder due to known physiological condition with depressive features, and depression. Review of R23's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 04/29/2026, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating R23's cognition was moderately impaired. Review of R23's Activity Care Plan with a start date of 05/19/2026, and a target completion date of 08/10/2026, revealed R23 enjoys biking, enjoys keeping his room very tidy, and he also enjoys drinking ginger ale, hard pretzel sticks, and Hershey's chocolate kisses. He enjoys the Grateful Dead band. Most of the time, he prefers to have the blinds in his room closed. During an observation on 05/26/2026 at 11:39 AM, R23 was observed lying in bed in the dark with the blinds and door closed. During an observation on 05/27/2026 at approximately 11:03 AM, R23 was observed in the room with the door and blinds closed. With no lights on in the room facing the window. During an observation on 05/28/2026 at approximately 11:57 AM R23 was observed lying in bed, in the dark, with blinds closed, asleep. During an interview on 05/26/26 at 11:39 AM, R23 states, This place is a joke. R23 states he does not participate in activities by choice because they do not offer anything he wants to do. R23 further stated, I do not want to draw circles and color. During an interview on 05/28/2026 at 8:37 AM, the Activity Director (AD) states she has been the AD in the facility for approximately 1 year. The AD states R23 does not like group activities; sometimes she does 1:1 activities in his room. The AD confirmed the activity sheets for April and May 2026 reflected R23 was in his room watching TV independently for the majority of the months and did not participate in activities on the locked unit. The AD further stated there is a fenced courtyard that the residents could use if he wants to go outside. The AD states she will get with the locked unit manager to see if R23 can utilize the courtyard sometimes. During an interview on 05/28/2026 at 11:33 AM, Licensed Practical Nurse (LPN)2 states R23 sometimes refuses to get out of bed when asked. LPN2 states the resident does not like to be around a lot of people but prefers to do things with staff 1:1. During an interview on 05/28/2026 at approximately 11:40, R23 states he would love to have activities other than what he sees the other residents have on the locked unit. I would like to do something different, maybe go outside and get off this floor and out of this bed sometimes. During an interview on 05/28/2026 at approximately 2:01 PM, the Director of Nursing (DON) states that activity expectations are to know what the resident likes and tailor activities around the resident. For residents on the locked unit, her expectations are for a 1:1 activity visit with activities on the unit. The DON states that R23 is taken on walks with the unit manager, where R23 is walked through the facility. The DON revealed that staff do not document the walks with R23. Review of R5's Face Sheet revealed the facility admitted R5 with diagnoses including, but not limited to muscle weakness, dysphagia and stroke. Review R5's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/2026, revealed a Brief Interview for Mental Status score of 5 out of 15, which indicated R5 had severe cognitive deficit. Review of R5's comprehensive plan of care revealed a focus area of activities. The focus area states, Resident enjoys the following activities: bingo, country music, reading, praying and being outdoors. He also enjoys watching tv, parties, dogs/pets and keeping up with the news. Review of the activity attendance sheets provided by the Activity Director, revealed R5 participated in daily TV independently. R5 was not afforded any of the activities related to his preferences. During an interview on 05/28/2026 at 8:04 AM, the Activities Director (AD) confirmed that R5 had only received the television on in his room as an activity and was not offered any of the care planned activities of his preference. The AD also stated that she was in the process of initiating a one on one activity program for residents that did not want to attend out of room activities. At this time the AD confirmed that R5 had not been included in any of his activity preferences.

Based on review of facility policy, observation, record review and interview, the facility failed to implement the Comprehensive Plan of Care related to providing a program of activity preferences for Resident (R)5 and R98, for 2 of 3 residents reviewed for activities. Findings include: Review of the undated facility policy titled, Activities Program, states, as the policy, It is the policy of this facility to implement an ongoing resident centered activities program that incorporates the resident's interests, hobbies and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being and independence. It is also the policy of this facility to create opportunities for each resident to have meaningful life by supporting his/her domains of wellness (security, autonomy, growth, connectedness, identity, joy, and meaning). Procedures: Activities are planned according to the resident's preferences, needs, and abilities. Every resident will be interviewed for preferences. Equipment and supplies are available and accessible to accommodate each resident who chooses to participate in an activity. 4. Daily newspapers, current magazines, and a variety of reading materials are available and accessible to all residents. 5. Socialization activities will be made available through: group discussion, conversation, recreation, visiting, arts and crafts, and music. 6. Physical activities will also be made available such as games, sports, and exercises which develop and maintain strength, coordination, and range of motion. Review of R5's Face Sheet revealed the facility admitted R5 with diagnoses including, but not limited to muscle weakness, dysphagia and stroke. Review of R5's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/2026, revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated a severe cognitive deficit. Review of R5's comprehensive plan of care revealed a focus area of activities. The focus area states, Resident enjoys the following activities: bingo, country music, reading, praying and being outdoors. He also enjoys watching tv, parties, dogs/pets and keeping up with the news. Review of the activity attendance sheets provided by the Activity Director, only contained daily TV independently. R5 was not afforded any of the activities related to his preferences. During an interview on 05/28/26 at 8:04 AM, the Activity Director confirmed that R5 had only received tv as an activity and was not offered any of the care planned activities of his preference. The Activity Director also stated that she was in the process of initiating a one on one activity program for residents that did not want to attend out of room activities. At this time the Activity Director confirmed that R5 had not been included in any of his activity preferences. Review of R98's Face Sheet revealed R98 was admitted to the facility on [DATE], with diagnoses which included, but was not limited to, encephalopathy, major depressive disorder, and Psychosis. Review of the Activity Care Plan initiated on 04/01/2026, states R98 enjoys the following activities: board games, cards, bingo, word searches, exercise, sermons, reading, his religion, trips, shopping, being outdoors, watching tv, gardening, parties, dogs, and keeping up with the news. Interventions/Tasks on the care plan were as follows: invite to scheduled activities, needs assistance/escort to activity functions, offer leisure materials, and provide activities calendar monthly. Review of the Activity Tracker for April 2026 listed TV/Radio/Movies every day. R98 had coffee, salon, and snack/beverage one time each in the month of April 2026. Review of the Activity Tracker for May 2026 listed TV/Radio/Movies every day. No other activities of interest listed on the care plan was offered. During an interview with the Activity Director on 05/28/2026 at 1:15 PM, the Activity Director stated employment with the facility had been almost a year. The Activity Director further stated the priority was to start with the group activities, then Memory Care, and then room visits. The Activity Director further stated we are working towards this. The Activity Director confirmed the resident is up in their chair watching TV daily.

Based on review of facility policy, observation and interview, the facility failed to ensure an excessive amount of lint was removed from 2 of 2 clothes dryers.Findings include: Review of the undated facility policy titled, Dryer Lint Removal and Laundry Room Safety, states, Laundry staff must clean lint from the dryer lint screen after each load has been dried and remove lint from under and around dryers according to the posted deep-clean schedule. During an observation on 05/28/2026 at 8:33 AM, of the laundry room dryers revealed 2 of 2 clothes dryers with an excessive build up of lint. The lint was hanging from the baskets and all around the wiring above the baskets. During an interview on 05/28/2026 at 8:35 AM, the Housekeeping Supervisor confirmed the findings and provided a lint removal log that was checked as if the 2 dryers were lint free. During an interview on 05/28/2026 at 8:50 AM, the Maintenance Director also confirmed the excessive build up of lint in the 2 of 2 clothes dryers.

Based on review of facility policy, observation and interview, the facility failed to follow safe infection control practices related to transporting soiled linen on 1 of 4 nursing units. Specifically, Certified Nursing Assistant (CNA)3 failed to bag soiled linen at point of use and was observed carrying the soiled linen down the hallway utilizing only a pair of gloves during one of one observation of a CNA transporting soiled linen unbagged. Review of the facility policy titled, Laundry Policy, states under Regulatory Basis and Guidance, Soiled linen must be stored and transported in enclosed or covered nonabsorbent containers or washable laundry bags, with no sorting or rinsing outside the laundry service area.Staff must handle, store, wash, and transport linens in a way that prevents the spread of infection. Contaminated laundry must be handled as [NAME] as possible, with minimum shaking, and bagged or placed in a container at the location where it is used.Roles and Responsibility:Nursing and care staff: Bag or secure soiled linen and resident clothes at the point of use and route them to the soiled linen rooms for pickup. Follow standard precautions.Soiled Linen Handling and TransportNurse and caregivers should always place all soiled linen and resident clothes into a tied bag or coveed nonabsorbent container or washable laundry bag at the point of use before taking it to the soiled linen rooms for pickup.Transport soiled linen in a way that prevents leakage, exposure, and spread of contamination. A random observation on 05/28/2026 at 10:36 AM, Certified Nursing Assistant #3, CNA3 was observed bringing soiled linen from a resident room. CNA3 was wearing gloves and walking down the hall holding her gloved hands away from her body. CNA3 was trying to get to a soiled laundry bin that was being pushed down the hall by another CNA before it was transported to the laundry. During a interview on 05/28/2026 at 10:37 AM CNA3 stated, I work for Hospice and not this facility. This surveyor reminded the CNA, that it is still an infection control issue to just carry soiled linen down the hallway and unbagged. During the interview with CNA3, she did not agree that it was an infection control concern carry soiled linen down the hallway by other residents sitting in wheel chairs and propelling themselves down the hallway. During an interview with the Administrator, he provided an inservice document for CNA3, and signed by CNA3 and states, Infection Control whne transporting clean/dirty linen must always be in a plastic bag for transport. Soiled linen bust be in a bag prior to putting it in a [NAME].

Based on review of facility policy, manufacturer's recommendation, observation, and interview, the facility failed to ensure Resident (R)126 was free from significant medication errors. Specifically, Registered Nurse (RN)4 failed to correctly prime an insulin pen prior to administering a physician ordered dose of insulin. RN4 additionally failed to properly administer the insulin via an insulin pen for 1 of 1 residents observed receiving insulin.Findings include: Review of the facility policy titled, Insulin Pen Medication Administration, states as the policy, It is the policy of this facility that insulin will be administered based on manufacturer recommendations and best practice guidelines. Procedures:3. Apply disposable pen needle onto pen. Prime the pen needle with 2 units of insulin (or per manufacturer guidelines) before each injection.4. Dial the correct dose in the dose window.5. Select appropriate injection site and clean with alcohol wipe. Hold pen at 90-degree angle to skin and insert pen needle into the subcutaneous tissue.6. Once injected, continue to depress the button until the dial has returned to 0 and for an additional 5-10 seconds (or per manufacturer guidelines). Review of the manufacturer's guidelines titled, How to use your Lantus Solostar Pen, states:Step 1. Remove the pen cap with clean hands.Step 2. Wipe the pen tip (rubber seal) with an alcohol swab. Remove the protective seal from the new needle, line the needle up straight with the pen, and screw the needle on. Do not make the needle too tight. After you have attached the needle, take off the outer needle cap.Step 3. Dial a test of 2 units. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test 2 more times, if there is still no insulin coming out, use a new needle and do the safety test again.Step 4. Select the dose. Make sure the window shows 0 and then select the dose. Otherwise you will inject more insulin than you need.Step 5. Clean the site with an alcohol swab. Keep the pen straight, insert the needle into the skin. Use your thumb to press the injection button all the way down . When the number in the dose window returns to 0 as you inject, slowly count to 10 before removing. (Counting to 10 will make sure you get the full insulin dose.) Review of R126's Face Sheet revealed the facility admitted R126, with a diagnosis including but not limited to Diabetes Mellitus Type 2. Review of R126 electronic medical record revealed R126 was to receive 35 units of Lantus Insulin via a kwik pen each am. During an observation on 05/27/2026 at 8:30 AM, RN4 took the insulin pen from the medication cart and removed the outer cap. RN4 then, holding the insulin pen horizontally, dialed 2 units and pressed the injection button. RN4 then wiped the hub and placed the needle and laid the pen on the top of the medication cart. Before going into R126's room, this surveyor said, I did not see you prime the pen. At that time RN4 stated, I primed the pen with the 2 units before I ever put the needle on. During the observation on 05/27/2026 at 8:30 AM, RN4, went into R126's room, and took the insulin pen in hand and gave the resident the injection and failed to hold the pen in place after pressing the injection button all the way down, for the recommended 7 to 10 seconds. During an interview on 05/27/2026 at 8:34 AM, RN4 confirmed that she had not primed the pen correctly and had not held the needle in place at the injection site for the recommended 7 to 10 seconds, to ensure R126 received the required physician ordered dose of Lantus Insulin.

Based on observation, interview, and review of facility policy, the facility failed to provide Resident (R)119 dignity during respiratory care, for 1 of 4 residents reviewed for dignity. Findings include: Review of the facility policy titled Policy/ Procedure - Nursing Administration Resident Right, Dignity and Privacy last revised November 2023, revealed, It is policy of this facility that all residents be treated with kindness, dignity, and respect. Procedures include that the staff shall display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings. Residents shall be examined and treated in a manner that maintains privacy of their bodies. A closed door or drawn curtain shields the resident from passers-by; people not involved in the care of the resident shall not be present without the resident's consent while they are being examined or treated. Review of R119's Face Sheet revealed R119 was admitted to the facility on [DATE], with diagnoses including but not limited to, persistent vegetative state, tracheostomy status, bed confinement status, and aphasia. Review of R119's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/29/26, revealed that R119 was unable to complete a Brief Interview for Mental Status (BIMS) due to his vegetative state. Further review of the MDS revealed that R119 is dependent on staff for all Activities of Daily Living (ADLS). During an observation on 05/26/26 at 3:01 PM, revealed two staff members, Registered Nurse (RN)1 and RN2, providing tracheostomy care to R119 without the privacy curtain pulled or the door closed in his room. R119's care could be observed from the hallway and was visible to anyone who walked past his room at this time. During an interview on 05/26/26, with RN1 and RN2 after they finished providing tracheostomy care to R119, revealed that they should have provided R119 with dignity by closing the door or pulling the privacy curtain. During an interview on 05/28/26 at 5:35 PM, the Director of Nursing (DON) and Administrator revealed that their expectation is that all facility staff provide residents with dignity during care.

Based on observation, interview, and record review, the facility failed to ensure Resident (R)155 and R139 was allowed the right to self-determination. Specifically, the facilitation of preferences related to attending activities and Activities of Daily Living (ADL) schedule, for 1 of 5 residents reviewed for choices.Findings include: Review of R155's Face Sheet revealed R155 was admitted to the facility on [DATE], with diagnoses including but not limited to muscle weakness, anxiety disorder, mood disorder due to known physiological condition with mixed features, and chronic respiratory failure. Review of R155's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/09/26, revealed R155 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that R155 had moderate cognitive impairment. Further review of the MDS revealed that it is very important to R155 to attend/do activities with groups of people. R155 requires set up or clean up assistance with upper and lower body dressing and needs supervision/touching assistance with personal hygiene. Review of R155's Care Plan, last revised on 04/20/26, revealed R155 has a self-care deficit related to weakness, chronic obstructive pulmonary disease (COPD), respiratory failure, depression, anxiety, mood disorder, and incontinence. Interventions include, promote dignity and privacy, encourage to discuss feeling about self-care deficit, requires supervision/touching assistance with personal hygiene and upper/lower body dressing. Review of R139's Face Sheet revealed R139 was admitted to the facility on [DATE], with diagnoses including but not limited to, anxiety disorder, dementia with anxiety, chronic pain, and essential tremor. Review of R139's MDS with an ARD of 03/10/26, revealed that R139 had a BIMS score of 14 out of 15, which indicates that she is cognitively intact. Further review of the MDS revealed that R139 is dependent on staff for upper/lower body dressing, personal hygiene, and for toileting hygiene. Review of R139's Care Plan, last revised on 01/19/26, revealed, R139 has self-care deficit related to right femur fracture, weakness, she is incontinent and has dementia, essential tremors, diabetes mellitus, bipolar disorder, depression, and anxiety. Interventions include, bed mobility, dressing (assistance of one staff for dressing), transfer (one assist), encouragement to participate to the fullest extent possible with interaction and requires partial/moderate assistance with personal hygiene care. Review of R139's Care Plan last revised on 09/29/25, revealed, R139 enjoys bingo, arts and crafts, outdoor patio and special events. R139 prefers independent leisure time acts such as playing games on her personal phone, intervention include encourage R139 to take rest breaks between activities and treatments, inviting and encourage to join groups of her interest, offering leisure materials, and providing a monthly calendar. Review of the May 2026 Activity Calendar revealed the following activities for 05/26/26; Coffee Social at 10:30 AM, Trivia at 11:00 AM, May Birthday Bash at 2:00 PM, and Family Feud at 3:00 PM. During an observation and interview on 05/26/26 at 11:09 AM, revealed R155 in bed waiting for staff to assist her with personal hygiene and ADL care. During the interview with R155, questions were asked related to choices of schedules and call light response times. R155 and her roommate, R139, both stated that staff answer the call light but don't actually come back to assist residents with care. R155 stated that she, at times, does like to attend activities, but today preferred not to attend any, but was just waiting on her CNA so she could get dressed for the day and had been waiting since after breakfast for someone to come back to help her. During an observation and interview on 05/26/26 at 11:14 AM, R139 revealed that she prefers to have staff assist her with ADL care before 10:00 AM, so she can attend activities. During the interview with R139, she stated that for the past few weeks, staff have not been adhering to her preference related to her ADL schedule, because of this she has been late attending several activities or missed the opportunity to attend activities in the morning altogether. R139 stated, This past Sunday, [05/24/26] I was late attending the church service that we have here at the facility. I hate to be late to things, but especially church. I was late because I had a difficult time finding a Certified Nursing Assistant (CNA) who could assist me with dressing. Today [05/26/26] I wanted to attend the coffee social in the dining room, but it's probably almost over because it started at 10:30 AM and I've been waiting for about an hour. Staff come into the room and say they are going to come back, but don't and turn off my call light. During the interview with R139 this surveyor requested that the resident press her call light again because it was currently not on. Shortly after pressing the call light (approximately 1 minute), CNA1 entered the room and told R139 that she was not her current CNA but would go and find the resident's assigned CNA. During an observation on 05/26/26 at 11:22 AM, revealed CNA1 and CNA2 entered the resident's room. CNA2 stated that she was unsure of who the resident's aid was for the day and had entered the room looking for another staff member and is currently working on a different unit of the facility. CNA1 explained to R139 that her assigned aid was assisting another resident at this time. During this observation, no staff member attempted to assist the resident with ADL care. During an observation and interview on 05/26/26 at 11:42 AM, R139 revealed a second request for the resident to press her call light for assistance. During an observation and interview on 05/26/26 at 11:44 AM, revealed that the Administrator entered the room, stating that he saw the resident's call light was on and that all staff are expected to respond to the resident's call lights. During this observation, R139 became upset with the Administrator and stated that she had been waiting over an hour for assistance with dressing so she could attend activities that began at 10:30 AM. During the interview the Administrator apologized to the resident and stated that he would be back shortly with staff so that the resident could get dressed for the day. During an observation and interview on 05/26/26 at 11:48 AM, revealed that the Administrator, Unit Manager, and a Licensed Practical Nurse (LPN) entered the room to provide ADL care to R139 and her roommate, who had also been waiting for assistance with ADL care. During an interview on 05/28/26 at 5:25 PM, the Director of Nursing (DON) and Administrator revealed that their expectation is for staff to adhere to residents' preferences with their schedule's related to ADL care, the Administrator further stated that he expects staff to respond to residents' call lights within 15 minutes.

Based on review of facility policy, observation, interviews, and record review, the facility failed to (1) properly store food in 1 of 1 kitchen. Additionally, the facility failed to (2) ensure proper sanitization in the three compartment sink and the dishwasher in 1 of 1 kitchen. On [DATE] at 2:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On [DATE] at 5:44 PM, the Administrator and Director of Nursing were notified that the failure to use sanitizer in the three compartment sink and dishwasher constituted Immediate Jeopardy (IJ) at F812. On [DATE] at 5:44 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.60 - Food and Nutrition Services. On [DATE], the facility provided an acceptable IJ Removal Plan. On [DATE], the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F812 at a lower scope and severity of F. Findings include: (1) Review of the facility policy titled Food, Dry Storage of, with a reviewed date of ,d+[DATE], documented, It is the policy of the facility that all non-perishable foods shall be stored utilizing methods which maximize nutrient retention, food appearance, and food quality. Procedures: . 5. All food storage bins or containers shall be maintained in clean condition and labeled with the contents. Review of the facility policy titled Food Receiving and Storage with revised date of ,d+[DATE], documented, Policy Interpretation and Implementation: . 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated . 12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day . During an interview on [DATE] at 9:50 AM, the Dietician stated that she works part-time 8 hours per week and has more of a clinical based role and is not involved in the day-to-day operations. The Dietician concluded that she was not aware that the kitchen staff was not using sanitizer in the three compartment sink or for dishwasher use. During the initial tour of the kitchen on [DATE] at 9:00 AM, revealed the following: Dry storage: 2 - 6 pounds (lbs) cases of corn stored on the floor. 1 - 9 oz can not label and was also dented. 1 - 3 lbs 2 oz Campbell's vegetable soup can was dented. 2 cases of [NAME] choice corn stored on the floor. (one case with 6 cans & 1 case with 5 cans) 2 packs of hoagie/sub rolls not dated or labeled. 1 pack of Wonder dinner rolls expired on [DATE]. Freezer: 1 box containing eight different unidentified food items. 2 bags of unidentified food not labeled and not dated. 1 bag of tater tots not tabled and not dated. 3 bags of an unknown food, wrapped in cellophane not labeled and not dated. 1 bag of breadsticks not labeled and not dated. Refrigerator: 1 case of sweet potatoes not labeled or dated and the surface of the sweet potatoes had a white fuzzy substance. 1 bag of diced onions not labeled and not dated. 1 pack of sharp cheddar cheese not dated. 1 honey ham not labeled or dated. On [DATE] at 9:45 AM, the acting Certified Dietary Manager (CDM) confirmed these items and removed them from storage. Review of the Temperature Logs for the refrigerator and freezer for the month of [DATE], revealed missing temperatures on [DATE] and [DATE] - [DATE]. Further review of the Temperature Logs revealed the log had not been started for the month of February 2025. (2) Review of the undated facility policy titled Dishwashing: Machine Operation, documented, Procedure: 1. All dishwashing machines should be operated according to manufacturer recommendations. Tableware, utensils, and pots and pans should be cleaned and sanitized . or a chemical-sanitizing dishwashing machine that uses a chemical sanitizing solution. 4. If the machine is found to be out of the acceptable range for either final rinse temperature or proper chemical sanitizing concentration, do not proceed to wash dishes. Review of the facility policy titled Dishwashing: Manual, documented, All pots and pans shall be cleaned by washing, rinsing, and sanitizing . 4. The pots and pans will be . sanitized by either heat or chemicals in the third compartment. Review of the undated Manufacturer Label titled, NSF Operational Requirements as Manufactured by CMA Dishmachines revealed the following: Wash Temp. - Minimum 120 degrees Fahrenheit, Recommended 140 degrees Fahrenheit ., Rinse Temp. - Minimum 120 degrees Fahrenheit, Recommended 140 degrees Fahrenheit, Required - 50 PPM Available Chlorine. During an observation and interview on [DATE] at approximately 1:00 PM, Kitchen Crew (KC)1 was utilizing the dishwasher to wash dishes. Cook1 proceeded to test the sanitization level of the dishwasher. Cook1 pulled a test strip and dipped it in the overflow of the dishwasher. The test strip did not give a reading of the sanitization level. Cook1 proceeded to check it again and received the same results. Cook1 and Kitchen Manager (KM)1 (who came from a sister property to assist) began troubleshooting and determined that the dishwasher was not receiving sanitizer. On the floor next to the dishwasher were three buckets that provided chemicals to the dishwasher. One bucket contained liquid dish machine detergent, one bucket contained liquid [NAME] metal safe dish machine detergent and the other bucket contained [NAME] Dri rinse aid. Neither of the buckets contained sanitizer. Additionally, observation of the temperature gauge on the exterior of the dishwasher revealed the temperature of the dishwasher, after multiple cycles, was 94 degrees Fahrenheit. KM1 stated there was no dishwasher sanitizer in the building and she would borrow one from her home facility. Further observation revealed the lunch meal was on the steam table and kitchen staff preparing to plate food on regular plates. During an observation on [DATE] at approximately 1:15 PM, revealed the wash compartment of the three compartment sink was full of water with the top of a metal pot sticking out the top of the water. The rinse compartment and the sanitizing compartment were both empty. The three compartment sink was set up with an automatic dispenser which dispensed Array Ultimate Sanitizer and Array [NAME] Pot and Pan Detergent connected to the appropriate compartments. During an interview [DATE] at 1:30 PM, Cook1 stated she usually uses all three compartments when she washes dishes, but rarely washes dishes. Cook1 further stated, that some staff use all three compartments and some don't. Cook1 concluded that the rinse compartment of the three compartment sink is stopped up. During an interview on [DATE] at 1:35 PM, Kitchen Crew (KC)2 stated, she has worked at the facility for 7 months and has never seen anyone use that side of the sink (sanitizer compartment). During an interview on [DATE] at approximately 1:35 PM, KM1 revealed the dishwasher broke on [DATE] and was fixed on [DATE]. KM1 revealed the kitchen was using Styrofoam containers when the dishwasher was down, but was still using regular cups to serve the residents. KM1 further stated the cups were being washed in the three compartment sink. The kitchen switched from Styrofoam containers to regular plates on [DATE]. KM1 verified the concerns with the temperature and sanitization of the dishwasher and the sanitization in the three compartment sink. After KM1 verified these concerns, direction was given to staff to switch back to Styrofoam containers. During multiple interviews with staff, to include Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants, on [DATE] from 4:19 PM to 4:27 PM, all confirmed the use of heated plates during lunch and dinner service on [DATE]. The facility's removal plan included the following: 1. Corrective action for residents found to have been affected by this deficiency:: Sanitizer for dishwasher and 3-compartment sink was properly installed by Dietary Resource. All dishes, pots, pans, and utensils were washed and sanitized due to the alleged deficient practice by dietary staff after education was provided by Dietary Resource. Every shift monitoring for three days for signs and symptoms of foodborne illness due to potential cross-contamination was placed on all residents who take food and/or drink by mouth was entered by Unit Manager and Clinical Resource. 2. Corrective action for residents that may be affected by the deficiency: The Medical Director was notified of the IJ on [DATE] at 6:34 PM. All residents who take food and/or drink by mouth have the potential to be affected by the deficient practice. Sanitizer for dishwasher and 3-compartment sink was properly installed by Dietary Resource. All dishes, pots, pans, and utensils were washed and sanitized due to the alleged deficient practice by dietary staff after education was provided by Dietary Resource. Every shift monitoring for three days for signs and symptoms of foodborne illness due to potential cross-contamination was placed on all residents who take food and/or drink by mouth was entered by Unit Manager and Clinical Resource. 3. Other Plan of Removal actions: All dietary staff currently working were educated on [DATE] by Dietary Resource on proper use of sanitizer for dishwasher and 3-compartment sink. All dietary staff will receive education on proper use of sanitizer for dishwasher and 3-compartment sink prior to the start of their next shift. Education will be included as part of the annual skills fair and new hire orientation for all kitchen staff. An adhoc QAPI meeting regarding the items in the IJ template completed on [DATE]. Attendees included the following: Medical Director, Administrator, DON, ADON, Clinical Resource, Clinical Market Lead; and included the Plan of Removal items and interventions. Daily audit of sanitizer detergent for proper hook up and function to dishwasher and 3-compartment sink x12 weeks and monitored by Dietary Manager or Designee. Daily audit of dishwasher to ensure the machine is functioning at manufacturer recommendations and specifications to included temperature monitoring. Audit will be completed x12 weeks. Dietary Manager or Designee will report findings and analysis of reviews to the QA&A committee monthly with additional follow-up and recommendation as needed until substantial compliance is achieved and maintained. Date of Compliance: [DATE]

Based on observation, record review, and interviews, the facility failed to ensure Resident (R)424's code status was accurately reflected in the medical record. This involved one (R424) of 32 residents reviewed for advanced directives. On [DATE] at 4:05 PM, the Administrator was notified that the failure constituted Immediate Jeopardy (IJ) at F578. On [DATE] at 7:48 AM, the facility submitted an acceptable plan of removal for the IJ at F578. Implementation of the removal plan was verified on [DATE] at 11:15 AM. The IJ was verified to be removed as of [DATE]. Findings Include: Review of the facility's policy titled, Care and Treatment, Subject: Advance Directives, revised ,d+[DATE] revealed Once the advance directive or information regarding resident preferences regarding treatment options is received by the facility, it will be confirmed in the resident medical record and communicated to members of the care plan team. The facility will also notify the attending physician of advance directives so that, if necessary, appropriate orders can be documented in the resident's medical record and plan of care. Review of R424's electronic medical record (EMR) revealed his code status orders were CPR/Full Code- no tube feed effective [DATE]. R424's care plan reflects Full Code status. R424's EMR contained a paper Emergency Medical Services Do Not Resuscitate Order signed by R424's Responsible Party (RP) and a physician on [DATE] requesting DNR status. There was also a Physician order dated [DATE] at 1845 for DNR, which was signed by a Nurse and a Physician. On [DATE] at 12:16 PM, R424, who had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate intact cognition stated, I want to die, I don't want them to save me. During a telephone interview on [DATE] at 12:30 PM, R424's RP confirmed R424 wishes to be a DNR. During an interview on [DATE] at 2:15 PM with Licensed Practical Nurse (LPN)1 and Registered Nurse (RN)1, they stated, If there was a code, we would go to PointClickCare (PCC) and verify the code status. We will check vitals and start CPR. We then would call out for a Code Blue and then continue to monitor with CPR until EMS comes and takes over. During an interview with LPN2 on [DATE] at 2:19 PM, she stated in order to verify code status, she would check the EMR. When asked to confirm R424's code status, LPN2 went into the EMR and stated he was a Full Code. During an interview with the Director of Nursing (DON) on [DATE] at 2:30 PM, she stated she would look under the MISC tab in the EMR for the code status and look at the doctor ' s orders. If a resident was not breathing, they would call a code blue . During an interview with the Minimum Data Set (MDS) Nurse on [DATE] at 3:20 PM, she stated the care plan should be updated related to the Resident's Physician's orders. During a consecutive interview with the DON on [DATE] at 3:32 PM, she confirmed R424 had conflicting code statuses' and she would need to look into it. Review of the facility plan of removal included the following: The following measures were immediately implemented upon notification of the facility: 1. Corrective action for residents found to have been affected by this deficiency: -Resident #424 preferred level intensity was reviewed with responsible party and order was corrected in point click care (PCC). 2. Corrective action for residents that may be affected by the deficiency: -The Medical Director was notified of the IJ on [DATE] at 4:39 PM. -All residents have the potential to be affected by the deficient practice. -On [DATE] at 4:30 PM to 8:00 PM, a full house audit of current residents was reviewed by the Director of Nursing and validated that preferred level of intensity and signed DNR order matches the order in PCC and care plan. No other residents were identified to be affected by the alleged deficiency. 3. Other Plan of Removal Actions: -On [DATE] at 4:15 PM, an in-service was prepared by the DON and initiated by the Assistant Director of Nursing (RN) for all licensed nurses, medical records personnel, and social services employees. The in-service included the advanced directives policy and how to transcribe orders correctly. -Education will be included as part of the annual skills fair and new hire orientation for licensed nurses, medical records personnel, and social services employees. -An ad hoc meeting regarding the items in the IJ template completed [DATE]. Attendees included the following: Medical Director, Administrator, DON, ADON, Clinical Resource, Clinical Market Lead; and included the Plan of Removal items and interventions. -Changes in advanced directives will be reviewed daily clinical meeting 5x a week x12 weeks and monitored by Director of Nursing or Designee. -DON or Designee will report findings and analysis of reviews to the QA&A committee monthly with additional follow-up and recommendation as needed until substantial compliance is achieved and maintained. Date of Compliance: [DATE]

Based on review of the facility policy, record review, and interviews, the facility failed to ensure Resident (R)103's wound was properly managed, resulting in R103 acquiring maggots inside the wound bed on the resident's right heel. On 02/07/25 at 3:18 PM, the Administrator and the Director of Nursing (DON) was notified that the failure ensure R103's wound was properly managed, constituted Immediate Jeopardy (IJ) at F686. On 02/07/25 at 3:18 PM, the survey team provided the Administrator and the DON with a copy of the Centers for Medicare and Medicaid Services (CMS) IJ Template, informing the facility IJ existed as of 10/03/24. The IJ was related to 42 CFR 483.25 Quality of Care. On 02/11/25, the facility provided an acceptable IJ Removal Plan. On 02/11/25, the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The IJ is considered at Past Noncompliance as of 10/04/24. An extended survey was conducted in conjunction with the Complaint Survey for noncompliance at F686, constituting substandard quality of care. Findings include: Review of the facility policy titled, Skin Management System revised on 01/2025, documented It is the policy of this facility that any resident .or that residents admitted with wounds will not develop signs and symptoms of infection, unless the resident's clinical condition makes the development unavoidable. 5. A report of all wounds and their progress will be updated by the treatment nurse weekly. Review of R103's Face Sheet revealed R103 was admitted to the facility initially on 06/19/24, with a readmission on 10/28/24, with diagnoses including but not limited to: pressure ulcer of right heel- stage 4, osteomyelitis, ankle and foot, methicillin resistant staphylococcus aureus infection as the cause. Review of R103's Physician Orders dated 09/30/24 revealed, paint right heel with betadine, cover with ABD pad, every day shift for wound healing; cleanse right heel with dakins, apply mesalt and border every day shift for wound healing. Review of Physician Orders dated 10/03/24, revealed, cleanse right hell with Dakins solution and apply Mesalt and border gauze every day shift for wound healing and as needed. Review of R103's Progress Notes dated 10/03/24, documented, During report nurse stated resident has maggots in right heel wound. Review of Nurses Notes dated 10/03/24 at 7:10 PM, revealed, Doctor notified and new orders to send resident out for further evaluation. Review of pictures and videos provided by staff, of the wound and maggots, revealed a gauze soaked with a wet brown substance and maggots in the wound on the heel of the resident, with the center of the wound dark brown and white surrounding. Maggots were also observed moving on the bed beside the resident's foot. Review of R103's Hospital Discharge Documentation timestamped with a service date/time of 10/28/2024 at 1419 EDT indicated, Patient is an 89 y/o male with Hypertension and cartoid artery stenosis was sent from nursing home because the staff there noticed maggots on a right heel wound . During an interview on 02/04/25 at 11:24 AM, R103 revealed that he has wounds on both heels and they were only blisters when he was admitted to the facility. R103 stated that his left heel had maggots in it (later confirmed to be the right heel). R103 explained that he is not sure how the maggots got in the wound, but he knows if a fly lands on it, it lays eggs. R103 further revealed that he went to the hospital and stated, they flushed them out at the hospital. During an interview on 02/06/25 at 10:18 AM, Licensed Practical Nurse (LPN)8, revealed R103 has two pressure ulcers that are on both heels. Wound care rounds are done every week and wound care is done on Mondays, Wednesdays, and Fridays, I think. LPN8 stated, The wound doctor comes once a week. R103 wasn't admitted initially on this unit, so not sure if he was admitted with the wounds. The wounds were present when R103 was transferred to this unit. Maggots were in the wound before he came to this unit. LPN8 further revealed, The treatment for R103's wound is to clean the wound, apply hydrofera blue, and a border gauge, not wrapped with anything. LPN8 further revealed that R103 has an order for heel boots and he only wears them in bed, but when he is in his wheelchair, he likes a pillow under his feet over the foot rest. During a telephone interview on 02/06/25 at 11:14 AM, LPN6 revealed that she is familiar with R103 and confirmed there were maggots in his wound. LPN6 explained that when she came on shift she was informed by the nurse on day shift that the resident had maggots in his wound and she inquired with the nurse of what they were going to do about it. She then stated that the day shift nurse informed her that she had called the Assistant Director of Nursing (ADON) and Registered Nurse (RN)3 and was told to only dress the wound and not to clean it or do anything else. LPN6 stated that her response was that she was not going to allow that, therefore she called the DON, who informed her that she wasn't aware of the situation and advised her to call the doctor. LPN6 states that she called the doctor (whose name she could not recall) and the doctor told her to send the resident out to the ER, since they were not there to look at it. LPN6 stated she called 911. LPN6 further explained that although she had worked with the resident days before the discovery of the maggots, she was not aware that the resident had any wounds because wounds were taken care of during the day and she didn't have to do anything with them. LPN6 revealed that Certified Nursing Assistant (CNA)1 stated that it had been going on. During an interview on 02/06/25 at 1:40 PM, the ADON revealed that she was not aware of maggots in R103's wound. The ADON states I believe we saw him on Wednesday during rounds with the wound doctor and there was nothing unordinary with the wound and he was sent out a day or two later. The ADON continued to explain that a nurse, either the floor nurse or the unit manager called her to inquire if there was a change in the resident's treatment plan and she further explained that she believed that at that time the treatment was Dakins wet to moist. The ADON further states no one told me about maggots. During an interview on 02/06/25 at 3:06 PM, LPN7 revealed she was doing a dressing change with the assistance of a CNA and this was her first time working with the resident and the CNAs. LPN7 explained that when she saw the bugs, that appeared to be maggots in the resident's wound and she took a picture of just the resident's foot and sent it to RN3 via text seeking advice on how to treat. LPN7 stated that she was told that the resident had a history of parasitic infections and to treat the wound with Dakin's and dress it as best she could and that the wound nurse, who is also the ADON would take care of it the next morning when she comes in and for her not to chart it. LPN7 further explained that this incident happened around 6 PM, there was no Dakin's on hand, and she reported the incident to the night nurse when she came in. LPN7 states that she ended her shift at 7 PM and later texted the DON around 9 PM, after arriving home, to inform her of what happened. LPN7 further explains that when she saw the maggots it was only about 3-5, there was no date on the dressing she was removing, so she wasn't sure how long the dressing had been on the resident, and that the resident didn't appear to be in any pain or distress. LPN7 further revealed that she was informed that by the time the night nurse sent the resident out, the wound was swarming with maggots. During an interview on 02/07/25 at 10:53 AM, RN3 revealed that she is unable to recall the exact day but stated it was late in the day because she had already left the building. RN3 stated that she was made aware that R103 had maggots in his wound, when she received a call from LPN7 stating that she was doing a dressing change and saw maggots in the resident's wound. RN3 stated that she received a picture of the wound with maggots from LPN7 and she then sent the photo to the ADON, who is also the wound care nurse, and the ADON confirmed to her that she could see them in the photo. RN3 stated that she was not able to see the maggots at first but then zoomed in and was able to see them. RN3 stated that the ADON advised her to instruct LPN7 to clean the wound with Dakins wet to dry and change the dressing. RN3 further explains that by this time she was communicating back and forth with LPN7 and the ADON, and the ADON was communicating back and forth with the DON. During an interview on 02/07/25 at 11:28 AM, the DON revealed that she could not recall the exact conversation, and she was going by the notes entered, that it was alleged that R103 had maggots in his wound. The DON explained that she received a call from the ADON stating that she was getting an order to change the treatment and then she received a call from the night nurse informing her that she received a report that R103 had maggots in his wound and she had called the physician and was sending him out to the hospital. The DON stated that R103 was sent out the hospital and the hospital never verified there were any maggots in the wound. The following measures were immediately implemented upon notification of the facility: 1. Corrective action for residents found to have been affected by this deficiency: a. R103 was found to be affected by the alleged deficient practice. b. On 10/3/2024 at 6:50 pm LPN received report on R103. At 7:05 pm LPN notified physician of findings. Order was received to send resident to emergency room for evaluation. At 7:30 pm EMS was called and at 7:50 resident left the facility with EMS. c. On 10/4/2024 Director of Nursing Services reviewed R103 TAR (treatment administration record) for September 2024 and October 2024. Treatment administered per order. 2. Corrective action for residents that may be affected by the deficiency: a. Residents with wounds have the potential to be affected by the alleged deficient practice. b. On 10/4/2024 an audit of all wounds was completed by Assistant Director of Nursing (RN) and Unit Manager (RN). No changes were noted to any of the wounds. c. On 10/4/2024 all direct care licensed nurses received wound care education. d. On 10/4/2024 maintenance director completed facility wide observation for pests, insects, or any related issues. No issues were identified. e. Although no issues were identified during maintenance audit, facility administrator wanted to ensure every intervention was implemented due to the seriousness of the allegation. On 10/4/2024 maintenance director contacted Terminix and requested an additional preventative visit and facility administrator ordered air curtain fans for all high traffic doors. 3. Other Plan of removal actions: a. The Medical Director was notified of the IJ on 02/07/2025 at 4:30 pm. b. An adhoc QAPI meeting regarding the items in the IJ template completed on 02/07/2025. Attendees included the following: Medical Director, Administrator, DON, ADON, Clinical Resource, Clinical Market Lead; and included the Plan of Removal items and interventions. c. Wound care education is included as part of the annual skills fair and new hire orientation for all licensed nurses. d. Maintenance Director completed weekly audits x8 weeks (10/10/24-11/29/2024) of facility for presence of insects, pests, or any other related issues. e. Registered nurses on nursing management team completed weekly audits x 8 weeks (10/10/24-11/29/2024) of wounds for any changes in condition. f. Findings were reported to QAPI committee monthly with additional follow-up and recommendation as needed until substantial compliance is achieved and maintained. g. The aforementioned incident was self-reported and subsequently cleared without citation on 12/4/24.

Based on the facility policy, record reviews and interviews, the facility failed to ensure Resident (R)170 was free from neglect. Specifically R170 sustained a femur fracture on [DATE], and was not sent out for medical treatment for an extended period of time causing prolonged, agonizing pain, and suffering for 1 of 1 resident reviewed for neglect. On [DATE], the State Agency (SA) identified that the facility's failure to ensure R170 was free from neglect instituted Immediate Jeopardy (IJ) at F600. The IJ Template was presented to the Administrator on [DATE] at 3:32 PM. The facility presented an acceptable IJ Removal plan on [DATE] at 4:02 PM. The implementation of the removal plan was verified on [DATE] and confirmed as removed on [DATE]. The facility remained out of compliance at a scope and severity of D Findings Include: Review of the facility policy titled, Resident Rights, Subject, Abuse Prevention and Prohibition, (revised 2/2018), states as the facility Policy: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Resident's must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. Definitions: Abuse - willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Adverse event - is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Neglect - is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility admitted R170 on [DATE] with diagnoses including, but not limited to, dementia with behaviors, anxiety, depression, and malignant neoplasm of the right kidney. The quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 out of 15, which indicated severe cognitive deficits. Review of the progress note dated [DATE] at 07:05 AM revealed a nurse's note that stated: Acetaminophen Tablet 650 milligrams [mg], give 1 tablet by mouth every 6 hours as needed for MILD PAIN, not to exceed 3 grams in 24 hours. Review of the progress note dated [DATE] at 09:05 AM revealed a nurse's note that stated: At 06:45, CNA called nurse to room [ROOM NUMBER]. Myself and the PM nurse entered the room and noted the resident lying on his left side, beside his wheel chair. The resident was complaining of pain to his left leg and hip. His left upper leg noted to be larger than right and with a large knot on the upper front of his leg. Resident unable to move his left leg. Also noted to have a hematoma to head, front of scalp. No open areas noted to head. Neuro checks done. The DON (Director of Nursing), the physician and the personal representative notified. Order received for STAT x-ray left hip and left leg. At 07:05 AM, resident was given Tylenol for pain. Awaiting x-ray. R170 was not sent out to the hospital for treatment immediately after being found on the floor and injured and there was no documentation of the time R170 fell only the time he was found on the floor by a CNA. Review of the progress note dated [DATE] at 1406 revealed a nurse's note that stated: X-ray of left hip and left leg obtained earlier. Order received to send to ER for evaluation and treatment. Attempted several times to contact resident's son - left messages to call facility. Son, RP (Responsible Party) did return call and was told of order to send his father to ER. EMS called and here to transport resident to hospital. Report called to ER nurse. Review of the June '24 physician orders revealed that R170 only had Acetaminophen 650 mg ordered for MILD PAIN, and no other pain medications were on the MAR (Medication Administration Record) until R170 returned from the hospital on [DATE] with an order for Hospice. Review of the Comprehensive Plan of Care for R170 revealed, the resident is high risk for falls related to muscle weakness, difficulty in walking, unsteadiness on feet, encephalopathy, cognitive loss and dementia, hyperlipidemia, hypothyroidism, atrial fibrillation, hypertension, gastroesophageal reflux disease and episodes of bladder incontinence. Resident has a colostomy. Resident had an actual fall with poor communication/comprehension. Unsteady gait, and confusion. He is focused on going home and packing his items. He sundown's in the evening. He is noncompliant with safety measures with walking, sit to stand from wheelchair. There is no start date, but the problems were resolved on [DATE], after resident was deceased . Review of the radiology report dated [DATE], which resulted at 11:55:54 AM, revealed as the results of a Femur 2 views left, states, The study is somewhat limited due to the patient's condition. There is an acute moderately displaced fracture in the mid distal shaft of the left femur with some overriding of the fracture fragments. Angulation deformity is present on the lateral view. Review of a fall risk assessment dated [DATE] revealed a score of 16 which indicated R170 was high risk for falls. Review of a fall risk assessment dated [DATE] revealed a score of 13 ensuring R170 is considered a high fall risk. No other fall risk assessments were provided. Review of a physician's order dated [DATE] at 12:22 PM states, May send to ER for evaluation and treatment. Review of a the ER visit on [DATE] revealed R170 was seen on [DATE] at 13:51 and states: X-rays were obtained later in the day which demonstrated midshaft femur fracture. It is angulated and displaced. There is no evidence that the skin was violated. The hospital course states, Resident was noted to have left midshaft femur fracture and Buck's traction was applied. Orthopedics consulted however patient did have some agitation related to dementia and being unfamiliar setting requiring medications. He was to be taken for surgery however he was noted to have supraglottic tracheal mass and the procedure was canceled. Family ultimately decided for initiation of hospice care at the nursing center. During an interview on [DATE] at 04:58 PM with Certified Nursing Assistant (CNA)2 concerning the fall that R170 sustained, she stated, he laid there hollering and crying in pain for 7 hours before being sent out to the hospital and had only Tylenol for the pain. During an interview on [DATE] at 05:18 PM with the Attending Physician, he stated he remembered this resident well and stated he would expect the nursing staff to send the resident to the hospital immediately if there was any indication of an injury from a fall. During an interview on [DATE] at 10:10 AM with Licensed Practical Nurse (LPN)10 she stated, I arrived at around 06:30 AM for my shift and the resident was still on the floor. I did not hear him hollering, the CNA came and got us. When we entered the room he was leaning against the bed and his left leg was so swollen we had to cut his pants off. He was real drowsy and if you touched his leg he would yell out. We kept calling the Director of Nursing (DON) to inform her that the resident really needed to go out to the hospital. When I called the last time she stated that the doctor had ordered an x-ray to be done here in the facility. The x-ray was ordered STAT and I think they came about 11:00 AM or so. The x-ray tech asked me to look at the film and you could plainly see his femur was fractured. LPN10 stated she called the DON to come and look at the x-ray and she refused. I really have no idea what time he fell, but his leg was so swollen, I believe he had fallen earlier in the morning. During an interview on [DATE] at 11:05 AM with CNA4, she stated, I got here around 06:40 AM for my shift and I heard the night shift nurse on the phone with the CNA, she said she went to check on him, and he was fine and then the CNA went to carry out the linen, and then she saw him on the floor. He was in a low bed, so I am really not sure if he fell from the bed or from his wheel chair. CNA4 stated, I walked down there and he was sitting up leaning against the bed with his eyes closed like he was very drowsy. The DON never came and looked at him. The x-ray tech showed up about 11 or 11:30 AM. When EMS got here they had to give him IV medication because he was hurting so bad. He had 2 knots sticking up on the upper part of his leg. I'm not sure what time he fell, I was not here during the night. I work day shift. The following measures were immediately implemented upon notification of the facility: 1. Corrective action for residents found to have been affected by the deficiency: a. R170 was found to be affected by the alleged deficient practice. b. On [DATE] at 6:45 am R170 was assessed by LPN. Provider was notified of findings and STAT x-rays were ordered. c. On [DATE] at 7:05 am, Tylenol was administered for pain by LPN. d. On [DATE] at 8:00 am, follow up Tylenol administration was documented as Resident resting with eyes closed. No facial grimacing noted. e. On [DATE] STAT x-ray results were reported by Trident Mobile 11:55 am f. On [DATE] order was received to send R170 to emergency room for evaluation of fracture at 12:22 pm. g. On [DATE] R170 was assessed by Dr. at 1:51 pm at Conway Medical Center Emergency Room. 2. Corrective action for residents that may be affected by the deficiency: a. The Medical Director was notified of the IJ on [DATE] at 4:30 pm. b. All residents have the potential to be affected by the alleged deficient practice. c. Residents who had a fall in the past 24 hours ([DATE]-[DATE]) were reviewed. One resident was identified. Resident was assessed by Registered Nurse on [DATE] at 5:57 pm with no signs of pain noted. 3. Other Plan of Removal Actions: a. All licensed nurses currently working were educated on [DATE] by Director of Nursing Services about pain management. b. All certified nurse aides currently working were educated on [DATE] by Unit Manager (Registered Nurse) on the process of reporting pain to the licensed nurse on duty. c. All licensed nurses will receive education on pain management prior to the start of their next shift. d. All certified nurse aides will receive education on the process of reporting pain to the licensed nurse on duty prior to the start of their next shift. e. Education will be included as part of the annual skills fair and new hire orientation for all nursing staff. f. An adhoc QAPI meeting regarding the items in the IJ template completed on [DATE]. Attendees included the following: Medical Director, Administrator, DON, ADON, Clinical Resource, Clinical Market Lead; and included the Plan of Removal items and interventions. g. The Clinical Interdisciplinary Team will review falls, including pain, 5 days a week in Morning Clinical Meeting. h. Findings will be reported to QAPI committee monthly with additional follow-up and recommendations as needed until substantial compliance is achieved and maintained. Compliance Date: [DATE]

Based on review of the facility documentation and interviews, the facility failed to employ a qualified, full-time Social Worker as required by regulation. Findings include: Review of the facility's Social Services Staff-Job Description indicated, Essential Duties and Responsiblities: Assist in the development, administering, and coordinating of department policies and procedures, Participate in discharge planning, development and implementation of social care plans and resident assessments . During an interview on 02/04/25 at 1:38 PM, the Social Worker Interim/Designee (SWI), confirmed that she does not have a license, or social worker certification. She has been working in the position of Social Services Designee for approximately 1 month. She is also currently the Central Supply Coordinator. The SWI indicated she held the position as Social Worker Designee last year with the following dates: February through October 2024 and November through December 2024. The SWI stated, the full time SW was let go. During the Resident Council Meeting on 02/05/25 at 10:00 AM with the surveyors, multiple residents conveyed the facility did not have a Licensed Social Worker and has not for a period of time. During an interview with the Administrator on 02/04/25 at approximately 3:15 PM, he confirmed the facility does not have a Social Worker currently in the facility. Administrator reported facility is in the process of hiring a fulltime SW, but there is none presently. During an interview with Unit Manager (UM)4 on 02/05/25 at 9:38 AM, she stated, She is here for guidance so the SWI. She confirmed she does not have a SW Degree. UM4 stated she has been working with SWI off and on because there have been two (2) social workers in between time, from last year to this year, but she is not familiar with many SW duties.

Based on interviews and record review, the facility failed to employ a certified dietary manager. Findings include: Review of the facility policy titled Dietary Services - Staffing Policy, with an approval date of 11/21/22, documented, Policy Explanation and Compliance Guidelines for Staffing: 3. If a qualified dietician or other clinically qualified nutrition professional is not employed full-time, the facility will designate a person to serve as the director of food and nutrition services who: a. For designations prior to Nov. 28, 2016, meets the requirements not later than 5yrs after Nov, 28, 2016 or no later than one year after Nov. 28, 2016 for designations after Nov. 28, 2016 is: i. A certified dietary manager. ii. A certified food service manager. iii. Has similar national certification for food service management and safety from a national certifying body; or . Review of an Order Confirmation-Invoice/Receipt dated 04/19/24, revealed the acting Certified Dietary Manager is enrolled in a course from the University of North Dakota for Pathway III(b) - Dietary Manager Training. During an interview on 02/07/25 at 9:50 AM, the Registered Dietician (RD) stated, that she is aware that the current certified dietary manager is not certified and has voiced concerns regarding food safety. The RD further stated, that she only works part-time, 8 hours per week and is not involved in the day-to-day operations. The RD concluded that she has offered the facility a contract interim travel CDM to provide coverage until the acting CDM becomes certified. During an interview on 02/11/25 at 10:15 AM, the acting Certified Dietary Manager (CDM) stated, I am currently enrolled in an online program and will be a Certified Dietary Manager by no later than April 2025, but I hope to complete the program earlier by March 2025.

Based on review of the facility policy, observations, and interviews, the facility failed to ensure expired medications were removed and not stored with other medications in use for residents in 5 of 6 medication carts and 2 of 4 medication rooms. Findings include: Review of the facility policy titled, Medication Access and Storage, E kit access with a revision date of 7/2022, states under procedures: 11. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction and reordered from pharmacy, if a current order exists. 12. Any opened vial without an open date will be discarded immediately and replaced with a new vial. Any medication that cannot be verified as to the expiration date, either due to not being dated when opened, or unclear shelf life, shall be discarded immediately and replaced. Review of the facility policy titled, Administering Medications, with a revision date of 04/2019, states under policy: 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. An observation and interview on 02/05/25 at 07:40 AM of the Medication Storage Room on the 4th Station revealed the following: Blood collection tubes with blue top, expired on 12/31/24. Blood Collection tubes with the brown top, expired on 07/31/24. Protect IV 22 gauge x 1 inch IV Catheter expired on 08/11/24. Ceftriaxone 2 (grams)Gm/50 ml (milliliter) 2 bags, expired 01/21/25. Ceftriaxone 2 Gm/50 ml, 2 bags expired on 01/24/25. Unit Manager (UM)4, accompanied surveyor during review of 4th station medication room. UM4 verified that the blood collection tubes, IV catheter, and IV bags of Ceftriaxone were expired. UM4 stated, The expired IV bags are stored in the med room refrigerator, because we have no refrigeration to send the IV bags back to pharmacy. An observation and interview on 02/05/25 at 07:50 AM of the 2nd station Medication Storage room revealed the following: Tresiba Flextouch 200 unit Insulin pen with an open date of 11/01/24. The label states to discard after 56 days. Blood collection tubes with blue top, expired on 12/31/24. Blood Collection tubes with the striped brown top, expired on 12/31/24. 3M Steri-Strip Reinforced Skin Closures, with an expiration date of 10/24. UM2, accompanied surveyor during review of the 2nd station medication storage room. UM2 verified that the blood collection tubes, the Tresiba Flextouch insulin pen, and the Steri-Strip Reinforced Skin Closures were expired. An observation and interview on 02/05/25 at 09:15 AM of the Medication Cart on 500 hall revealed the following: Vitamin D-3 10 mcg [micrograms] (400 IU) expired 11/24. Lasix 20 mg [milligrams] tablet, expired 02/01/25. UM5 stated, The Lasix just came from the pharmacy yesterday. The medications were confirmed as expired. An observation and interview on 02/06/25 at 11:30 AM of the 4th station, East cart revealed the following: Insulin Lispro 100 Unit/ml opened 12/27/24 and expired 01/17/25. Lispro 100 Unit/ml opened, but no open date and no expiration date on bottle. Insulin Glargine-YFGN U100 opened, but no open date and no expiration date on bottle x 3. Insulin Lispro 100 Unit/ml opened on 01/03/25 and expired 01/31/25. Insulin Lispro 100 Unit/ml opened 01/01/25 and expired 01/29/25. Alendronate Sodium 70 mg tablet, was belonging to an individual resident was stored with stock medication. Kerendia 10 mg tablets, belonging to an individual resident was stored with stock medication. Baclofen 10 mg tablets, belonging to an individual resident, was stored with stock medication. Acidophilus Probiotic was stored in med cart and not refrigerated after opening, as instructed on medication bottle. Amoxicillin 500 mg capsules expired on 01/02/25. Geri-Lanta regular strength antacid and antigas liquid, 12 fluid ounces, expired 07/24. Metronidazole 250 mg, individual pill noted with the stock medication in the cart. Fish Oil 1000 mg softgels, stock medication expired 01/25. Licensed Practical Nurse (LPN)1 confirmed the medications as expired. During an interview with LPN1, on 02/06/25 at 12:07 PM, regarding the 4th station, East medication cart revealed, We refill the insulins in the refrigerator. I understand why they are expired. They run out so fast. I look at them when I think about it. Normally, I placed home meds in the slot in the area with their meds. During an interview on 02/06/25 at 12:10 PM with LPN2 revealed, We put them in the cart, meds brought in from home. They are usually medications that are rare that we do not keep in stock. We have Baclofen, so I don't understand why those medicines were in the cart. During an observation on 02/06/25 at 12:45 PM of 200 hall Medication cart revealed the following, Mirtazapine 15 mg tablets, expired 01/02/25 with 25 pills left in a 30 pill card. Ropinirole 1 mg tablets expired 01/02/25 with 29 pills left in a 30 pill card. Levothyroxine 25 mg tablets expired 01/02/25 with 2 pills left in a 30 pill card. On 02/06/25 at 01:15 PM, Registered Nurse (RN)3 verified the expiration dates. During an observation on 02/06/25 at 01:17 PM of the 100 hall medication cart revealed the following, Potassium CL ER 20 MEQ tablets expired on 01/02/25 with 8 pills left in a 30 pill card. Promethazine 25 mg tablets expired on 01/31/25, with 20 pills left in a 30 pill card. Brilinta 90 mg tablets expired on 01/02/25 , with 11 pills left in a 28 pill card. Potassium CL ER 20 MEQ tablets expired on 01/02/25, with 24 pills left in a 30 pill card. Pantoprazole Sod DR 40 mg tablets expired on 01/02/25 with 25 pills left out of a 30 pill card. Vitamin D-3 10 mcg (400 IU) 100 film-coated tablets ,expired 11/24. Geri Care Gas Relief Simethicone 80 mg chewable tablets, 100 tablets expired 09/24. Ipratropium Bromide 0.5 mg and Albuterol Sulfate 3 mg inhalation solution, 2 packs of 5 vials each expired on 08/24. Calcium 600 dietary supplements, 60 tablets expired 01/25. On 02/06/25 at 01:30 PM, RN2 verified the expiration dates. During an observation on 02/07/25 at 03:46 PM of 4th Station, [NAME] Cart revealed the following, Procure Allergy Relief Loratadine Antihistamine 10 mg, 300 tablets expired 10/24. Buspirone HCL 7.5 mg tablets expired on 01/31/25, with 7 tablets out of a 51 tablets left on card. Eliquis 5 mg tablets expired on 01/02/25, with 20 tablets left out of a 28 tablet card. Dynarex Suction Tubing, expired on 08/28/24. During an interview on 02/07/25 at 03:46 PM, LPN2 revealed, Nurses should check expiration dates before pulling the medication out of the medication cart and again before punching the medication out of the medication card and again before returning the medication card to the medication cart. If the medication is expired, it should be pulled from the cart and the pharmacy should be notified. During an interview on 02/11/25 at 09:50 AM with the Director of Nursing (DON), she revealed there was a problem with the pharmacy. The DON stated, We received the medications after the expiration date noted on the medication cards. We had discussions with the pharmacy. The pharmacy can prove this if need be. My expectation is that the medications are given per the seven rights of medication administration.

Based on review of the facility policy, record review, and interviews, the facility failed to assure residents who have authorized the facility to manage any personal funds, have ready and reasonable access to those funds for 4 of 5 residents (R)22, R60, R83, and R100. Findings include: Review of the facility's policy titled Resident Rights, revised date 11/2007, revealed, It is the policy of this facility that our facility manages the personal funds of a resident when such request is made by the resident. 4. The resident may withdraw his/her request for the facility to manage his/her personal funds at any time by submitting a written notice to the administrator. Review of R22's Face Sheet revealed R22 was admitted to the facility on [DATE] with diagnoses including but not limited to: asthma, type 2 diabetes mellitus with diabetic polyneuropathy, and chronic pain syndrome. Review of R22's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/24 revealed R22 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R22 was cognitively intact. Review of R60's Face Sheet revealed R60 was admitted to the facility on [DATE] with diagnoses including but not limited to: insomnia, generalized anxiety disorder, major depressive disorder, and chronic obstructive pulmonary disease. Review of R60's Admission MDS with an ARD of 11/05/24 revealed R60's BIMS score of 11 out of 15, indicating R60 had moderate, cognitive impairment. Review of R83's Face Sheet revealed R83 was admitted to the facility on [DATE] with diagnoses including but not limited to: polyosteoarthritis, unsteadiness on feet, and muscle weakness. Review of R83's Admission MDS with an ARD of 12/27/24 revealed R83's BIMS score of 13 out of 15, indicating R83 had moderate, cognitive impairment. Review of R100's Face Sheet revealed R100 was admitted to the facility on [DATE] with diagnoses including but not limited to: metabolic encephalopathy, type 2 diabetes mellitus with hyperglycemia, and dementia. Review of R100's Admission MDS with an ARD of 11/13/24 revealed R100 had a BIMS score of 15 out of 15, indicating R22 was cognitively intact. During an interview on 02/11/25 at 12:22 PM, R22 stated, I was unable to get funds on the weekend. During an interview on 02/11/25 at 12:40 PM, R60 stated, No, we are not able to get our money on the weekend. During an interview on 02/11/25 at 12:46 PM, R83 stated, They told me I didn't have any money. During an interview on 02/11/25 at 1:01 PM, R100 stated, I didn't know I had any money I could request. During an interview on 02/11/25 at 01:16 PM, the Administrator stated, Yes, the residents can receive their funds on the weekends. The receptionist distributes the funds that we keep in a lock box. During an interview on 02/11/25 at 01:20 PM, Receptionist stated, We request the resident get their personal funds prior to the weekend, on Friday. Especially, if their family is coming to get them on the weekend. The resident is physically unable to get their money on the weekend. If a family member comes in and want to take them out on the weekend, we will ask them to bring us the receipt, and we can reimburse them the money they spent. During an interview on 02/11/25 at 01:25 PM, Administrator stated, I may have misinformed you. I spoke to our receptionist, and I was informed our receptionist has not been trained on personal funds.

Based on observation, interviews, and record review, the facility failed to ensure physician order was in place for the use oxygen for Resident (R)219, for 1 of 3 residents reviewed. Findings include: Review of the facility policy titled Oxygen Administration - Policy, with an approval date of 01/09/19, documented, Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician . Review of R219's Face Sheet revealed R219 was admitted to the facility on [DATE], with diagnoses including but not limited to: cystitis without hematuria. Review of R219's unspecified Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/25, revealed R219 had a Brief Interview for Mental Status (BIMS) score of 12 out of 14 indicating R219 had moderate cognitive impairment. Review of R219's Physician Orders did not reveal an order for the use of oxygen. Review of R219's Progress Notes dated 01/20/25, documented, She was comfortably lying in bed with HOB [head of bed] elevated and O2 per nasal cannula. During an observation on 02/04/25 at an unspecified time, revealed R219 laying in bed receiving oxygen at 3 liters per minute (LPM) via nasal cannula. During an interview on 02/10/25 at 11:30 AM, Registered Nurse (RN)7 stated, after reviewing the residents orders, There is no active order for oxygen. She shouldn't be on oxygen unless it was an acute situation and even then, we would still get an order. The providers note from the 4th, showed O2 as needed. It doesn't look like the order was transcribed.

Based on review of the facility policy, observations, record review, and interviews, the facility failed to provide care and services, specifically heel and ankle protection devices and a wedge cushion for offloading, while in bed per Physician orders, for Resident (R)11. Findings include: Review of the facility policy titled, Physician Orders, revised 11/2024 states: Recording Orders, Treatment Orders - When recording treatment orders, specify the treatment, frequency and duration of the treatment. Example: Apply 4 x 4 duoderm with border to stage 1 ulcer to coccyx; change every 3 days and as needed per wound care protocol. Implementing Orders, 1. Orders should be followed as written. 2. Physician should be notified if order is not followed for any reason. The facility admitted R11 on 06/27/2007 with diagnoses including, but not limited to, Alzheimer's disease, bipolar disorder, chronic kidney disease, acute kidney failure, psychotic disturbance, mood disturbance, anxiety, anemia and hypothyroidism. Review of the medical record on 02/06/2025 at 11:00 AM revealed physician orders for 1)bilateral heel boots while in bed every shift with a start date of 01/29/25 at 07:00 PM and a revision date of 01/30/25 and 2) Wedge cushion while in bed every shift with a start date of 01/03/25 at 07:00 PM and a revision date of 01/03/25. An observations on 02/04/25 at 09:18 AM revealed R11 lying in bed. Bilateral heels were elevated on a pillow, but there are no heel boots present and there was no wedge in the bed as per Physician's orders. An interview was attempted with R11, however, R11 does not speak, but nods yes or no. An observations on 02/04/25 at 02:20 PM revealed R11 lying in bed. Bilateral heels are elevated on a pillow, but there are no heel boots present and there is no wedge in the bed. During an interview on 02/07/25 at 01:35 PM with Certified Nursing Assistant (CNA)6 revealed, R11 did not have her heel booties on 02/04/25 and 02/05/25 because I could not find them. I had to go to the linen closet and get her another pair. I did not know about the wedge. I am glad you told me. I will ask about that. During an interview with Registered Nurse (RN)3 on 02/07/25 at 01:38 PM revealed, My expectation is that the CNAs ensure that the heel booties are found and on the resident. The heel booties should be washed every three days, unless they are visibly soiled. During an interview on 02/11/25 at 10:50 AM, the Director of Nursing (DON) stated, She would expect that staff follow Doctor's orders. If the Doctor's order cannot be followed, the Physician should be notified and I should be made aware.

Based on interviews and record review, the facility failed to ensure appropriate Registered Nurse (RN) coverage for 8 consecutive hours, daily 7 days a week as required by regulation. Findings include: Review of Oakview Health and Rehabilitation Daily Staffing Sheets with a date span of 11/04/24-01/31/25 revealed, the facility did not have appropriate coverage of a RN, 8 consecutive hours daily for the dates of 11/09/24, 12/21/24, 12/22/24, 12/25/24, 01/01/25, 01/04/25, and 01/05/25. During an interview on 02/06/25 at 10:05 AM, Certified Nursing Assistant (CNA)8 stated, There is never enough staff. Most the of the time, there is one CNA to 9-11 residents and when the census is low, it's about 8-10 residents to one CNA. CNA8 stated she believes that a RN is on duty during the day, but she is not sure. She stated, Shortages are due to turnovers and sickness. During an interview on 02/06/25 at 11:02 AM, Licensed Practical Nurse (LPN)9 stated, She has no role in staffing, but does try to ensure that staff is here for coverage. LPN9 stated she obtains coverage from the scheduler and if she is unable to obtain coverage, she takes the cart. This happens at least 2-4 times a month. She also stated, sometimes she works as a CNA as well, this happens once every 3 months. LPN9 works 12 hour shifts, all shifts including being on call for weekends. When on call, LPN9 stated, I work wherever the need is. There is usually one LPN and one RN working day shift and two RNs working on the night shift, on alternate days. There has been times when an RN did not work in the Specialty Care Unit during the night or day. It has never been a time that I can recall, when a RN could not be reached. The Assistant Director Of Nursing (ADON) is contacted and comes in on nights and weekends, if needed. During an interview on 02/06/25 at 12:52 PM, the Director of Nursing (DON) revealed she oversees the process for staffing. The DON helps solve problems with issues involving staffing and is aware of call offs and help to post shifts with agencies. In the event that the facility cannot obtain coverage, the CNA scheduler helps cover shifts. Unit Managers work together as floor nurses and as CNAs when needed. The Assistant Director of Nursing (ADON) works at this capacity as well and makes the monthly schedule for CNAs. The DON makes the monthly schedules for the licensed nurses. The facility always has RN coverage, even on the weekends. The DON has not had to cover any medication carts on the floor. The ADON has covered medication carts and has help CNAs as needed. During an interview with the Administrator on 02/06/25 at 2:30 PM, he provided additional documentation of RN coverage, however, was unable to provide documentation to cover the dates of 11/09/24, 12/21/24, 12/22/24, 12/25/24, 01/01/25, 01/04/25, and 01/05/25.

Based on review of the facility policy, record reviews and interviews, the facility failed to ensure Resident(R)40 and/or their representative was invited to and allowed to participate in care plan meetings, for 1 of 2 residents reviewed. Finding Include: Review of the facility policy titled Care Planning - Resident Participation - Policy and Signature Forms dated 10/31/22 revealed, our nursing facility supports the residents right to be informed of and participate in a care planning and treatment (implementation of care). Further review revealed, the facility will inform the resident, in a language he or she can understand, of resident rights regarding planning and implementing care, including the right to be informed of his or her total health status. The facility will discuss the plan of care with resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative. The Facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan if they consent to the request. Record review of R40's Face Sheet revealed R40 was admitted to the facility on [DATE] with diagnoses including but not limited to: severe cognitive impairment, dementia and limited range of motion. Record review of R40's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/25, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating R40 was severely cognitively impaired. Record review of a facility document titled Care Plan Review Plan revealed, R40 nor her representative was present during the Care Plan meeting conducted on 01/21/25. The documented Care Plan Participants signature section of the form revealed R40 refused to participate in the care plan meeting and the resident's representative attended via phone, however R40 is severely cognitively impaired. During a phone interview on 02/05/25 at 5:45 PM with R40's Representative (RR) revealed, discussion of a careplan was not offered. RR states no one called or reached out to her concerning her spouse's Care Plan. Resident nor Representative was aware of what a care plan should be or was in place. During an interview on 02/06/25 at 10:30 AM with MDS Assistant and MDS Coordinator revealed the initial care plan process. During admission, a Baseline Care Plan is initiated. Invitations are printed and given to the resident or mailed to the resident representative by the facility receptionist. MDS Assistant states, Care Plan Meetings are conducted and reviewed every 3 months and completed in the conference room. MDS Coordinator states, They do not have proof the resident or resident representative was informed that care plan meeting was scheduled.

Based on review of facility policy, record review, and staff interviews, the facility failed to ensure 1 of 3 residents environment were free of accident hazards/supervision/ devices. This failure had the potential to place the resident at risk for serious harm, injury, impairment, or death. On 05/11/22 at an unknown time, Resident (R) 1 had a successful elopement. Through multiple interviews with staff, R1 was last seen between 1:00 AM and 2:00 AM on 05/11/22. At 7:45 AM, R1 was found by local police at a nearby residence 2 blocks away from the facility. R1 was transported to the hospital, assessed, and discharged with a skin tear to his right lower wrist. R1 was wearing blue jeans and a striped button-up shirt. The temperature was recorded at 57 degrees Fahrenheit. On 05/13/22 at 5:03 PM, the survey team provided the Administrator with a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template, notifying the facility IJ existed at F689 due to the facility's neglect to adequately monitor R1, who had a diagnosis of Alzheimer's Disease, with an effective date of 05/11/22. On 05/13/22 at approximately 8:15 PM, the facility provided an acceptable IJ Removal Plan related to F689. The immediacy of the IJ was removed as of 5/13/22. The IJ was lowered to scope and severity of D, no actual harm with the potential for more than minimal harm that is not IJ. Findings include: Review of the facility's Wandering, Unsafe Resident Policy, last revised August 2014, revealed: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Review of the facility's Elopements policy last revised December 2007, Staff shall investigate and report all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing R1 was admitted to the facility on [DATE] from an acute hospital with diagnoses including, but not limited to, difficulty in walking, muscle weakness, dementia with behavioral disturbances, and Alzheimer's disease. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date of 12/16/21 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R1 was cognitively intact. Review of R1's Elopement Evaluation dated 03/10/22 revealed he was at risk for elopement and had a history of or attempting to leave the facility without informing staff. Further review revealed that R1 verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door. Clinical Suggestions noted to monitor frequently, utilize exit alarm(s), personalize the room with familiar objects and/or photographs, and notify staff of elopement risk. Review of R1's comprehensive care plan with a revision date of 03/15/22 revealed Behavior: R1 has had increased instances of wandering and voiced a desire to leave the facility without permission. He declined to wear a wander guard and will not cooperate to wear the device. recently discontinued on 03/09/22 .Interventions included: Approach wandering resident in a positive, calm, and accepting manner .If wandering away from unit, instruct staff to stay with resident, converse and gently persuade to walk back to a designated area with them. implement facility protocol for locating an eloped resident, monitor and document target behaviors, note which exits resident favors for elopement from facility. Alert staff working near those exits, place resident in area where frequent observation is possible, provide diversional activities, and psych evaluation/consult as needed/ as ordered. Review of the facility's accident/incident report dated 05/11/22 at 4:07 PM revealed at 6:45 AM, staff was unable to locate R1 in the facility. Staff on duty immediately initiated an investigation to locate R1. While local police were in the facility to gather information about R1's elopement, they received a call that someone was on a porch in a residential area about 2 blocks away from the facility. Staff and the police went to the location and confirmed it was R1. R1 reported to staff that he fell and got a scratch on his arm. R1 stated he refused to return to the facility and the police offered to take him to the emergency room for further evaluation. After discharge from the local hospital, R1 was transported back to the facility by EMS. Review of R1's Hospital Discharge Summary dated 05/11/22 at 10:12 AM revealed he was discharged back to the facility with a skin tear to the right arm. No further injuries were noted by emergency room staff. On 5/13/22 at 11:30 AM, review of the facility's internal investigation report revealed a statement from Certified Nursing Assistant (CNA)1 indicating: On the morning of Wednesday, May 11, 2022, from 3:00 AM - 7:00 AM that morning I was in the dining area at 3:00 AM. I sat there until 4:30 AM. At 4:30 AM, I started my last rounds for the morning. Earlier that morning I saw R1 come to the nursing desk around 1:00 AM - 2:00 AM. R1 was wearing blue jeans and seemed to be a striped button-up shirt is what it appeared to be. I entered R1's room at about 5:00 AM and his bed was empty. I assumed R1 was in the bathroom at that moment. So, I went to bed B and gave care to that patient and left the room. After I finished my rooms I had on the 600 halls, I went on the 500 hall and cared for those patients. When I finished care for the patients down 500 halls, at that time it was 6:45 AM. The morning shift nurse asked me when the last time was, I have seen R1 because R1 was not in his room or in the bathroom and I told her it was about 1:00 AM - 2:00 AM. After that everyone started searching for R1. An interview on 05/13/22 at 11:45 AM with the Director of Nursing (DON) revealed she was not on duty but was aware of the R1's elopement from the facility. The DON stated on 05/11/22 at 6:45 AM, she got a call from staff reporting R1 was missing. The DON stated R1 was found at 7:45 AM on a porch at a residential home not far away. R1 was wearing Pj's, a flannel jacket, and shoes. The DON stated R1 refused to come back to the facility and requested to go to the emergency room for evaluation. The DON stated R1 was assessed by a nurse and she found a scratch on his right arm. The DON stated that this is R1's first elopement, and he refuses to wear his wander guard. The DON did not reveal if the facility considered any alternatives for R1 due to him refusing to wear a wander guard. An interview on 05/13/22 at 12:27 PM with the Administrator revealed on 05/11/22, she received a call from the facility staff that R1 eloped from the facility. The Administrator stated she could not recall the time however staff had called a code silver, indicating a resident was missing. The Administrator stated while police were investigating the whereabouts of R1, they received a call stating someone was on a porch. The Administrator stated facility staff and the police went to the home and confirmed the person was R1. The Administrator revealed staff conducted an assessment on R1 and reported he had a skin tear on his right arm. The Administrator stated she was unsure of the local temperature that day, but recalls it was mild and overcast. The Administrator stated staff reported R1 had on shoes, pants, a shirt, and a jacket. The Administrator stated that after R1 refused to return to the facility, he was transported to a local hospital by EMS. The Administrator revealed R1 refused to wear his wander guard, even though he is at high risk for elopement. The Administrator further revealed R1 eloped from the facility by exiting out of a window of another room. The Administrator did not confirm if the facility considered any alternatives for R1 due to him refusing to wear a wander guard. An interview on 5/13/22 at 12:45 PM with the Maintenance Director (MD) revealed he checks the wander guard doors daily to ensure they are working properly. The MD stated he has not had any issues with the wander guards or doors and provided copies of wanderguard check logs for February, March, April, and May 2022. The MD also provided a map displaying rooms with wander guard devices to keep windows from being opened greater than 7 inches. The MD further stated R1 did not have a wander guard because he refused to wear it. An interview on 05/13/22 at 1:45 PM with R1 revealed he does not want to be in the facility. R1 stated he left the facility at 3:00 AM through a window and could not tell anyone where he went because it was a secret. R1 stated he had to leave the facility to retrieve his medical records from the hospital. R1 stated he needed the records because he does not receive the care he needs at the facility. R1 stated it was not cold outside and he remembers wearing a T-shirt, jacket, pants, and tennis shoes. R1 further stated staff asked him to wear a wander guard when he first got there but he refused because God told him he was not supposed to wear that thing. An interview on 05/13/22 at 4:30 PM with Licensed Practical Nurse (LPN)1 revealed on 05/11/22 at 6:45 AM, a code silver was called indicating a resident was missing. LPN1 stated she is unsure of what happened to R1 while he was away from the facility but to her knowledge this was R1's first elopement. An interview on 05/13/22 at 5:25 PM with CNA1 revealed on 05/11/22 at approximately 4:30 AM, she conducted rounds and did not see R1 in his bed. CNA1 stated she assumed R1 was in the bathroom but did not look to see if R1 was in the bathroom. CNA1 stated at 6:00 AM, the nurse asked her when was the last time she saw R1 because he was not in his room. CNA1 stated the nurse called the Administrator, DON, and local police to report R1 was not in the facility. When asked about temperatures, CNA1 stated she was unsure of the exact temperature, but revealed it was cold outside. CNA1 stated R1 was found at a house across the road and was transported to the hospital for evaluation. CNA1 stated she was unsure if it was R1's first elopement and revealed he is at risk for wandering/elopement. An interview on 05/16/22 at 2:55 PM with R1's son revealed the facility reported R1's elopement on 05/11/22. R1's son stated the facility stated they could not locate R1. R1's son confirmed that this was the first time R1 had eloped from the facility but had several previous elopements from home before he was admitted to the facility. The facility's removal plan for F689 included: The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement), The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering., The resident's care plan will indicate the resident is at risk for an elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included, and a missing resident is considered a facility-wide emergency. If a resident is missing, the elopement/missing resident emergency procedure will be initiated. (Conway Manor Wandering/Unsafe Resident Policy) 1. On 5/11/22, at approximately 6:45 AM, facility staff contacted Director of Nursing stating R1 was unable to be found. Director of Nursing immediately directed staff to initiate code silver protocol including notifying police. Police were notified at approximately 6:55 AM. 2. A full count was completed to validate all other residents were present in the facility- no other concerns were identified. This was initiated on 5/11/22 at approximately 7:00 AM. 3. A full search of the facility was conducted as well as a search in parking lot and outside grounds surrounding the facility. This was initiated immediately and stayed active until resident was found. 4. At approximately 7:30 AM police officer that was on scene was notified over radio that a nearby homeowner reported there was an elderly man on his porch. Officer and facility staff immediately responded to location of [NAME] Street. While responding to the home, the homeowner called the facility to let them know that Rl was at his house safe. 5. At approximately 7:45 AM resident was assessed by facility LPN. Body audit revealed a superficial skin tear to his right arm. Rl told police officer he was not returning to Conway Manor and requested to go to the hospital. EMS transferred R1 to hospital. RP and MD notified of incident at this time. 6. Police Officer spoke with Rl RP/POA about resident's desire to not return to Conway Manor and RP/POA stated he wanted his father to return to Conway Manor after he was cleared from the hospital. 7. Following verification that resident was safely found, an investigation was initiated per facility policy that confirmed Rl was observed by staff at approximately 2:00 AM at the nurse's station, fully dressed and at his baseline with no complaints voiced & displayed no evidence of intent to exit the facility. Further investigation, including interviews of on-site staff, indicate no facility exit door alarms were triggered or disarmed on the night of 5/10/22. An interview of the resident by LNHA at local hospital on 5/11/22 revealed that the resident exited the window of room 608. 8. The Maintenance Staff completed an inspection of all memory care unit windows to validate they were not broken or open. This was completed on 5/11/22 at 8:30 AM. All wander guard doors were also validated for proper functioning on 5/11/22 at 7:00 AM. Facility initiated q 15 minute checks on all residents on memory care unit until unit was identified as secure. 9. A review of the medical record completed on 5/11/22 indicates R1 has a BIMS score of a 15. Has had elopement evaluations completed per policy. Resident was previously identified as an elopement risk and was placed on the memory care unit for closer observation as an intervention. Resident was ordered a wander guard device, but removed device stating it was against his religion. At that time resident was moved to a different room on the memory care unit that the window open to a fenced in area. 10. Based on evidence obtained in the facility's investigation, the Administrator consulted with Fire and Life Safety and in collaboration with the maintenance director concluded all windows in the facility would be secured at 7 inches to prevent future issues of a similar nature. This was completed on the memory care unit on 5/11/22 at 4:00 PM and the rest of the facility on 5/13/22 at 5:00 PM. 11. Education was initiated on 5/11/22 at 12:30 PM with on-site facility employees on Elopement, Wandering/Exit Seeking, and Abuse/Neglect. This education is still in process and will be completed with all Licensed Nurses, nursing assistants, Licensed Therapist, therapy assistants, dietary staff, environmental services staff, and ancillary staff before their next worked shift. This information will be presented in new hire orientation. 12. R1 returned to facility from emergency department on 5/11/22 at approximately 11:45 AM and was immediately placed on 1:1 observation. No new diagnoses or orders accompanied resident. Resident arrived in stable condition. Resident returned facility fully clothed including a hat, jacket, and shoes. Resident left facility appropriately dressed for temperature in the high 50's, low 60's as stated on localcondition.com. 13. On 5/11/22, at 12:17 PM, Rl's elopement evaluation was updated to reflect recent occurrence. 14. On 5/11/22 at 1:34 PM, Rl 's BIMS assessment was updated and was a 15. 15. On 5/11/22, Rl's care plan was updated to reflect applicable information. 16. On 5/12/22, nursing staff completed updated elopement assessments on all residents and initiated interventions on any resident who had a change in their assessment. Care plans were updated reflecting interventions. 17. Maintenance Director or Maintenance Assistant will monitor facility windows daily for 4 weeks and then weekly for 2 months to ensure they are secured at 7 inches. The nurse managers will monitor the 24 hr report, daily, Monday-Friday, for 4 weeks then weekly for 2 months for evidence of residents exiting facility without staff knowledge. 18. Results of monitoring will be presented to the Quality Assurance and Performance Improvement Committee for recommendations for a period of 3 months. Any concerns identified will be addressed at time of discovery. Implementation of the removal plan was verified through observations, staff interviews, and record reviews on 05/13/22. Observation verified that all windows have a device in place to prevent opening too wide for entrance or exit. Documentation review revealed staff was educated on elopement and wandering policy and procedures.

Based on review of facility policy, record review, and interviews, the facility neglected to provide adequate supervision for 1 of 3 residents reviewed for accidents, related to wandering. This failure had the potential to place the resident at risk for serious harm, injury, impairment, or death. On 05/11/22 at an unknown time, Resident (R) 1 had a successful elopement. Through multiple interviews with staff, R1 was last seen between 1:00 AM and 2:00 AM on 05/11/22. At 7:45 AM, R1 was found by local police at a nearby residence, 2 blocks away from the facility. R1 was transported to the hospital, assessed, and discharged with a skin tear to his right lower wrist. The temperature was recorded at 57 degrees Fahrenheit. On 05/13/22 at 5:03 PM, the survey team provided the Administrator with a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template, notifying the facility IJ existed at F600 due to the facility's neglect to adequately monitor R1, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/13/22 at approximately 8:15 PM, the facility provided an acceptable IJ Removal Plans related to F600. The immediacy of the IJs was removed as of 5/13/22. The IJ was lowered to scope and severity of D, no actual harm with the potential for more than minimal harm that is not IJ. Findings include: Review of the facility's Abuse Prohibition/Investigative Policy, last revised November 2016, revealed the facility will prohibit abuse, neglect, misappropriation of resident property, and exploitation .Definitions .Neglect; is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .Prevention: Actions to prevent abuse, neglect, involuntary seclusion, and misappropriation of property will include the following: Identifying, correcting, and intervening in situations in which abuse, neglect and/or misappropriation of resident property are more likely to occur. R1 was admitted to the facility on [DATE] from an acute hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date of 12/16/21 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R1 was cognitively intact. Review of R1's Elopement Evaluation dated 03/10/22 revealed he was at risk for elopement and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed that R1 verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door. Clinical Suggestions noted to monitor frequently, utilize exit alarm(s), personalize the room with familiar objects and/or photographs, and notify staff of elopement risk. Review of R1's comprehensive care plan with a revision date of 03/15/22 revealed Behavior: R1 has had increased instances of wandering and voiced a desire to leave the facility without permission. He declined to wear a wander guard and will not cooperate to wear the device. recently discontinued on 03/09/22 .Interventions included: Approach wandering resident in a positive, calm, and accepting manner .If wandering away from unit, instruct staff to stay with resident, converse and gently persuade to walk back to a designated area with them. implement facility protocol for locating an eloped resident, monitor and document target behaviors, note which exits resident favors for elopement from facility. Alert staff working near those exits, place resident in area where frequent observation is possible, provide diversional activities, and psych evaluation/consult as needed/ as ordered. Review of the facility's accident/incident report dated 05/11/22 at 4:07 PM revealed at 6:45 AM, staff was unable to locate R1 in the facility. Staff on duty immediately initiated an investigation to locate R1. While local police were in the facility to gather information about R1's elopement, they received a call that someone was on a porch in a residential area about 2 blocks away from the facility. Staff and the police went to the location and confirmed it was R1. R1 reported to staff that he fell and got a scratch on his arm. R1 stated he refused to return to the facility and the police offered to take him to the emergency room for further evaluation. After discharge from the local hospital, R1 was transported back to the facility by EMS. Review of R1's Hospital Discharge Summary dated 05/11/22 at 10:12 AM revealed he was discharged back to the facility with a skin tear to the right arm. No further injuries were noted by emergency room staff. On 5/13/22 at 11:30 AM, review of the facility's internal investigation report revealed a statement from Certified Nursing Assistant (CNA)1 indicating: On the morning of Wednesday, May 11, 2022, from 3:00 AM - 7:00 AM that morning I was in the dining area at 3:00 AM. I sat there until 4:30 AM. At 4:30 AM, I started my last rounds for the morning. Earlier that morning I saw R1 come to the nursing desk around 1:00 AM - 2:00 AM. R1 was wearing blue jeans and seemed to be a striped button-up shirt is what it appeared to be. I entered R1's room at about 5:00 AM and his bed was empty. I assumed R1 was in the bathroom at that moment. So, I went to bed B and gave care to that patient and left the room. After I finished my rooms I had on the 600 halls, I went on the 500 hall and cared for those patients. When I finished care for the patients down 500 halls, at that time it was 6:45 AM. The morning shift nurse asked me when the last time was, I have seen R1 because R1 was not in his room or in the bathroom and I told her it was about 1:00 AM - 2:00 AM. After that everyone started searching for R1. An interview on 05/13/22 at 11:45 AM with the Director of Nursing (DON) revealed she was not on duty but was aware of the R1's elopement from the facility. The DON stated on 05/11/22 at 6:45 AM, she got a call from staff reporting R1 was missing. The DON stated R1 was found at 7:45 AM on a porch at a residential home not far away. R1 was wearing Pj's, a flannel jacket, and shoes. The DON stated R1 refused to come back to the facility and requested to go to the emergency room for evaluation. The DON stated R1 was assessed by a nurse and she found a scratch on his right arm. The DON stated that this is R1's first elopement, and he refuses to wear his wander guard. The DON did not reveal if the facility considered any alternatives for R1 due to him refusing to wear a wander guard. An interview on 05/13/22 at 12:27 PM with the Administrator revealed on 05/11/22, she received a call from the facility staff that R1 eloped from the facility. The Administrator stated she could not recall the time however staff had called a code silver, indicating a resident was missing. The Administrator stated while police were investigating the whereabouts of R1, they received a call stating someone was on a porch. The Administrator stated facility staff and the police went to the home and confirmed the person was R1. The Administrator revealed staff conducted an assessment on R1 and reported he had a skin tear on his right arm. The Administrator stated she was unsure of the local temperature that day, but recalls it was mild and overcast. The Administrator stated staff reported R1 had on shoes, pants, a shirt, and a jacket. The Administrator stated that after R1 refused to return to the facility, he was transported to a local hospital by EMS. The Administrator revealed R1 refused to wear his wander guard, even though he is at high risk for elopement. The Administrator further revealed R1 eloped from the facility by exiting out of a window of another room. The Administrator did not confirm if the facility considered any alternatives for R1 due to him refusing to wear a wander guard. An interview on 5/13/22 at 12:45 PM with the Maintenance Director (MD) revealed he checks the wander guard doors daily to ensure they are working properly. The MD stated he has not had any issues with the wander guards or doors and provided copies of wanderguard check logs for February, March, April, and May 2022. The MD also provided a map displaying rooms with wander guard devices to keep windows from being opened greater than 7 inches. The MD further stated R1 did not have a wander guard because he refused to wear it. An interview on 05/13/22 at 1:45 PM with R1 revealed he does not want to be in the facility. R1 stated he left the facility at 3:00 AM through a window and could not tell anyone where he went because it was a secret. R1 stated he had to leave the facility to retrieve his medical records from the hospital. R1 stated he needed the records because he does not receive the care he needs at the facility. R1 stated it was not cold outside and he remembers wearing a T-shirt, jacket, pants, and tennis shoes. R1 further stated staff asked him to wear a wander guard when he first got there but he refused because God told him he was not supposed to wear that thing. An interview on 05/13/22 at 4:30 PM with Licensed Practical Nurse (LPN)1 revealed on 05/11/22 at 6:45 AM, a code silver was called indicating a resident was missing. LPN1 stated she is unsure of what happened to R1 while he was away from the facility but to her knowledge this was R1's first elopement. An interview on 05/13/22 at 5:25 PM with CNA1 revealed on 05/11/22 at approximately 4:30 AM, she conducted rounds and did not see R1 in his bed. CNA1 stated she assumed R1 was in the bathroom but did not look to see if R1 was in the bathroom. CNA1 stated at 6:00 AM, the nurse asked her when was the last time she saw R1 because he was not in his room. CNA1 stated the nurse called the Administrator, DON, and local police to report R1 was not in the facility. When asked about temperatures, CNA1 stated she was unsure of the exact temperature, but revealed it was cold outside. CNA1 stated R1 was found at a house across the road and was transported to the hospital for evaluation. CNA1 stated she was unsure if it was R1's first elopement and revealed he is at risk for wandering/elopement. An interview on 05/16/22 at 2:55 PM with R1's son revealed the facility reported R1's elopement on 05/11/22. R1's son stated the facility stated they could not locate R1. R1's son confirmed that this was the first time R1 had eloped from the facility but had several previous elopements from home before he was admitted to the facility. The facility's removal plan for F600 included: Neglect, as defined at 5483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. The physician will order measures required to address the consequences of an abuse situation, such as psychological evaluation or suturing of a laceration. The physician and staff will address appropriately the causes of problematic resident behavior where possible, such as [CONDITION(S)], [CONDITION(S)], and medication side effects. (Conway Manor Neglect Policy) 1. On 5/11/22, at approximately 6:45 AM, facility staff contacted Director of Nursing stating R1 was unable to be found. Director of Nursing immediately directed staff to initiate code silver protocol including notifying police. Police were notified at approximately 6:55 AM. 2. A full count was completed to validate all other residents were present in the facility- no other concerns were identified. This was initiated on 5/11/22 at approximately 7:00 AM. 3. A full search of the facility was conducted as well as a search in parking lot and outside grounds surrounding the facility. This was initiated immediately and stayed active until resident was found. 4. At approximately 7:30 AM police officer that was on scene was notified over radio that a nearby homeowner reported there was an elderly man on his porch. Officer and facility staff immediately responded to location of [NAME] Street. While responding to the home, the homeowner called the facility to let them know that R1 was at his house safe. 5. At approximately 7:45 AM R1 was assessed by facility LPN. Body audit revealed a superficial skin tear to his right arm. Rl told police officer he was not returning to Conway Manor and requested to go to the hospital. EMS transferred R1 to hospital. RP and MD notified of incident at this time. 6. Police Officer spoke with R1's RP/POA about resident' s desire to not return to Conway Manor and RP/POA stated he wanted his father to return to Conway Manor after he was cleared from the hospital. 7. Following verification that resident was safely found, an investigation was initiated per facility policy that confirmed R1 was observed by staff at approximately 2:00 AM at the nurse's station, fully dressed and at his baseline with no complaints voiced & displayed no evidence of intent to exit the facility. Further investigation, including interviews of on-site staff, indicate no facility exit door alarms were triggered or disarmed on the night of 5/10/22. An interview of the resident by LNHA at local hospital on 5/11/22 revealed that the resident exited the window of room [ROOM NUMBER]. 8. The Maintenance Staff completed an inspection of all memory care unit windows to validate they were not broken or open. This was completed on 5/11/22 at 8:30 AM. All wander guard doors were also validated for proper functioning on 5/11/22 at 7:00 AM. Facility initiated q 15 minute checks on all residents on memory care unit until unit was identified as secure. 9. A review of the medical record completed on 5/11/22 indicates R1 has a BIMS score of a 15. Has had elopement evaluations completed per policy. Resident was previously identified as an elopement risk and was placed on the memory care unit for closer observation as an intervention. Resident was ordered a wander guard device, but removed device stating it was against his religion. At that time resident was moved to a different room on the memory care unit that the window open to a fenced in area. 10. Based on evidence obtained in the facility's investigation, the Administrator consulted with Fire and Life Safety and in collaboration with the maintence director concluded all windows in the facility would be secured at 7 inches to prevent future issues of a similar nature. This was completed on the memory care unit on 5/11/22 at 4:00 PM and the rest of the facility on 5/13/22 at 5:00 PM. 11. Education was initiated on 5/11/22 at 12:30 PM with on-site facility employees on Elopement, Wandering/Exit Seeking, and Abuse/Neglect. This education is still in process and will be completed with all Licensed Nurses, nursing assistants, Licensed Therapist, therapy assistants, dietary staff, environmental services staff, and ancillary staff before their next worked shift. This information will be presented in new hire orientation. 12. Resident #1 returned to facility from emergency department on 5/11/22 at approximately 11:45 AM and was immediately placed on 1:1 observation. No new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident returned facility fully clothed including a hat, jacket, and shoes. Resident left facility appropriately dressed for temperature in the high 50s, low 60s as stated on localcondition.com. 13. On 5/11/22, at 12:17 PM, R1's elopement evaluation was updated to reflect recent occurrence. 14. On 5/11/22 at 1:34 PM, R1's BIMS assessment was updated and was a 15. 15. On 5/11/22, R1's care plan was updated to reflect applicable information. 16. On 5/12/22, nursing staff completed updated elopement assessments on all residents and initiated interventions on any resident who had a change in their assessment. Care plans were updated reflecting interventions. 17. Maintenance Director or Maintenance Assistant will monitor facility windows daily for 4 weeks and then weekly for 2 months to ensure they are secured at 7 inches. The nurse managers will monitor the 24hr report, daily, Monday-Friday, for 4 weeks then weekly for 2 months for evidence of residents exiting facility without staff knowledge. 18. Results of monitoring will be presented to the Quality Assurance and Performance Improvement Committee for recommendations for a period of 3 months. Any concerns identified will be addressed at time of discovery. Implementation of the removal plan was verified through observation, staff interviews, and record reviews on 05/13/22. Observation verified resident windows do not fully open and have a 7 maximum opening. Documentation review revealed staff was educated on abuse/neglect policy and procedures.

Based on observation, interview, and record review, the facility failed to provide treatment by administering pain medications for 1 of 1 resident reviewed for pain management (Resident #26). The findings included: Resident #26 was admitted to the facility on [DATE] at 4:15 PM with [DIAGNOSES REDACTED]. On 3/29/2019, Resident #26 reported to the facility that on the night of 3/27/2019, s/he was in pain all night. S/he stated s/he had requested pain medications, but was told by the staff member on duty that s/he did not come with pain medications. Review of Resident #26's discharge paperwork from the hospital and admission paperwork to the facility revealed an order was written for [MEDICATION NAME] 5-325 mg to be given orally every 4 hours as needed for a pain scale of 1-5 for 3 days. This order was reviewed by the facility on 3/27/2019. Review of the Admission Resident Data Set on 4/9/19 at 1:54 PM that was dated 3/27/19 indicated the resident had pain daily (acute, throbbing, cramping, and aching). During an interview with the Director of Nursing on 4/10/19 at 4:30 PM, s/he verified the nurse did not administer the medications as order or follow the facility's protocol for pain. S/he stated the protocol was to assess the resident to obtain a pain level, if no order was written to contact the Physician to obtain an order, and then use the medications in the facility's e-kit if it was a drug that was kept in there. During an interview with the Administrator on 4/10/19 at 5:30 PM, s/he provided a list of medications that were readily available in the e-kit. There was [MEDICATION NAME] available, which was last verified by a check on 2/2/2019. Review of the facility's policy titled, Administering Pain Medications on 4/11/2019 at 2:15 PM, revealed it states acute pain should be assessed every 30-60 minutes after the onset and reassessed as indicated after [MEDICATION NAME] relief is obtained.

Based on observation, record review, and interview, the facility failed to ensure interventions were in place to reduce and or prevent falls for Resident #7 (1 of 7 residents reviewed for accidents). In addition, the facility failed to ensure the safety of residents by failing to secure medications in the medication cart. The findings included: The facility admitted Resident #7 on 4/16/2018 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review on 4/10/2019 at approximately 4:01 PM of the medical record for Resident #7 revealed a fall on 11/27/2018 in which Resident #7 fell out of his/her wheelchair onto his/her left side and complained of shoulder pain. It was determined that Resident #7 had broken his/her left humerus on 11/27/2018. Resident #7 fell again on 12/31/2018, 1/9/2019, 1/10/2019, and 3/23/2019. Interventions put into place on 11/27/2018 after the fall with the fracture included, increased observations by staff and Speech Therapy to evaluate and treat for cognition. Interventions on 12/6/2018 included, educate resident regarding use of call bell to ask for assistance with activities of daily living and transferring. Provide visual aid regarding need to ask for assistance with use of call bell and non skid socks on at all times as tolerated. Resident #7 fell again on 12/31/2018 and interventions put into place were frequent checks, and do not leave resident unattended on the toilet, offer toileting every three hours and non skid socks on at all times. The incident reports for 1/9/2019 and 1/10/2019 could not be found by the facility. Resident #7 fell on [DATE] and the intervention was to remove the resident's recliner from the room. No other interventions were in place to reduce or prevent falls. Review on 4/11/2019 at approximately 11:03 AM of the plan of care for Resident #7 revealed no mention of antirollbacks for the wheelchair and brake extension. The care plan had not been updated with interventions to reduce falls and or prevent falls for Resident #7. During an interview on 4/11/2019 at approximately 11:15 AM with the Unit Manager confirmed that the Plan of Care for Resident #7 had not been reviewed and revised with interventions to reduce and/or prevent falls for Resident #7 after all falls. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 04/10/2019 10:17 AM, review of the 24-Hour Report and Five-Day Follow-Up Report for a facility reported incident revealed the facility reported an in which the Licensed Practical Nurse (LPN) left the medication cart unlocked and unattended for an extended period of time. During an interview on 04/10/19 at 10:58 AM, Resident #25 confirmed he/she recalled the incident. Resident #25 stated he/she first noted the cart unlocked in the morning while staff was picking up the breakfast trays. The resident further stated about 3 ½ hours later, he/she noted the cart was still unlocked. The resident stated that was after the residents had eaten in the dining room and provided a picture on his/her cell phone of the cart being unlocked which was timed at 01:22 PM. Resident #25 stated he/she had wanted to make a point because he/she knew of a couple of residents that liked to rummage and was concerned for their safety. On 04/10/2019 at 4:28 PM, review of the personnel file revealed the LPN had received Disciplinary Action on 03/26/19 which was a first warning for leaving medication cart unlocked. Further review revealed a second warning also dated 3/26/19 that stated, After being counseled today regarding leaving medication cart unlocked (and) unattended - nurse returned to (her/his) med (medication) cart and repeated the same violation. Review of a Disciplinary Action Form for the other LPN on duty indicated s/he saw the medications in the resident's room during the 02:00 PM FSBS (finger stick blood sugar). S/he asked the resident who admitted he/she got them off the other nurse's cart. A notation on the bottom of the LPN's statement signed by the Director of Nursing indicated the incident was brought to her/his attention at 03:00 PM and that the nurse failed to report the incident or take the medications from the resident. During an interview on 04/10/19 at 12:45 PM, the Nursing Home Administrator stated the other LPN on duty confirmed s/he had seen the medications in the resident's room when s/he gave his/her 02:00 PM medications.

Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect and establish policies and procedures to investigate any such allegations for 17 of 26 residents reviewed for abuse and neglect (Residents #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #18, #19, #20, #22, #23, #24, and #25). The facility failed to ensure that all residents remained free from abuse and neglect, failed to ensure that all allegations of abuse were reported timely to the South [NAME]ina (SC) State Agency, and failed to thoroughly investigate all allegations of abuse. The findings included: The facility reported an allegation of resident to resident sexual abuse involving Resident #11 and Resident #12 to the SC State Agency. Review of the Five-day report revealed Resident #12 ambulated with his/her walker into Resident #11's room and with the walker in between them s/he had his/her hands on the resident's shoulders and kissed him/her on the lips. The kiss was observed by a Certified Nursing Assistant (CNA) when s/he went into Resident #11's room after s/he saw Resident #12 go into Resident #11's room. The facility report to the State Agency had one witness listed on the report, CNA #8. Review of Resident #11's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score of 4. Review of Resident #12's Significant Change Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score of 11. The Unit Manager's facility-obtained witness statement dated 12/18/18 indicated it was reported by the CNA that when s/he and the oncoming CNA were rounding for report Resident #12 was seen kissing Resident #11 on the lips. The Unit Manger was told that Resident #12 was standing in Resident #11's room in front of the resident with his/her walker between them. CNA stated that Resident #12 had his/her hands on Resident #11's shoulders and had leaned over his/her walker and kissed Resident #11's lips. The CNA reported that otherwise their bodies were not touching. When observed, Resident #12 was redirected out of resident's room and Resident #11 was redirected up to the nurses' desk. CNA #8's facility-obtained statement dated 12/18/18 indicated s/he was making rounds with another aide to give him/her report and they saw Resident #12 in Resident #11's room kissing him/her. They were in standing position with Resident #12's walker in between them. CNA #8 had Resident #12 stop and s/he went to his/her room. Resident #11 went to the nurses' desk and CNA #8 went and got the nurse and told him/her. In an interview with the surveyor on 4/10/19 at approximately 11:00 AM, Licensed Practical Nurse (LPN) #6 stated Resident #12 was moved to his/her hall about 2 weeks ago. LPN #6 stated Resident #12 has had occurrences of sexual behaviors, when s/he comes out of his room he will follow residents around. S/he will tell them they are beautiful. LPN #6 stated s/he has not seen Resident #12 do anything with a resident, s/he has seen him/her tell a resident s/he is beautiful. Resident #12 will look at residents like s/he is obsessing. LPN #6 stated s/he will redirect Resident #12. LPN #6 stated s/he has had reports Resident #12 will follow residents around, but s/he has not seen him/her. LPN #6 stated Resident #12 will stay in the bed most of the day, but will get up around dinner time. Resident #12 will walk around a lap at night and then go back to his/her room. LPN #6 stated s/he has not witnessed Resident #12 touch a resident, s/he knows to watch him/her when he is up. If s/he sees him go up to a resident, s/he will go ahead and separate the residents. In an interview with the surveyor on 4/10/19 at approximately 11:55 AM, CNA #8 stated s/he was giving report when s/he witnessed the incident on 12/18/18 but does not remember who the CNA was that was with him/her. They were walking by Resident #11's room and looked in to see Resident #12 giving Resident #11 a kiss. CNA #8 pulled Resident #11 out of the room and told the nurse what happened. CNA #8 stated staff have to keep a good eye on Resident #11 because s/he will go into other residents' rooms. Review of the facility's investigative file for the incident on 12/18/18 revealed CNA #8's statement indicated another CNA, coming on for 2nd shift, was with him/her at the time of the incident. Review of the facility's investigation revealed there was no statement in the facility's investigation from a CNA on 2nd shift. The facility's investigation contained statements from the Unit Manager, the two day shift nurses, and CNA #9 (worked 1st shift per Daily Staffing Sheet). CNA #9's facility-obtained statement indicated s/he did not witness the incident. The surveyor requested the Daily Staffing Sheet for 2nd shift on 12/18/18 during the survey but the facility was unable to provide the documentation as requested. While reviewing Resident #11 and Resident #12's medical records related to the incident reported on 12/18/18, a second incident between Resident #11 and Resident #12 was noted as occurring on 12/31/18. Review of the Resident Incident Reports revealed the incident occurred on 12/31/18 at 12:15 PM. The surveyor requested information where the resident to resident incident was reported to the SC State Agency. In an interview with the surveyor on 4/10/19 at approximately 3:20 PM, the administrator stated the incident on 12/31/18 was not reported to the SC State Agency because it was a peck on the cheek. The surveyor reviewed paperwork and pointed out that Resident #12 kissed Resident #11 on the lips. The administrator stated s/he would look into it and get back with surveyor. The administrator did not provide additional information to the surveyor. Review of Resident #11's and Resident #12's Progress Notes dated 12/31/18 revealed at approximately 12:15 PM the unit manger was sitting at the nurses' desk and heard a CNA talking to residents. When the unit manager looked up s/he saw Resident #11 standing next to Resident #12. The unit manager asked the CNA what happened if anything and s/he said that they were just standing in the hall talking and Resident #11 kissed Resident #12 on the cheek and then Resident #12 kissed Resident #11 on the lips. Intervention was to do 15 minute checks for 24 hours and ask the physician for a medication review. In an interview with the surveyor on 4/10/19 at approximately 3:30 PM, the Unit Manager stated the incidents on 12/18/18 and 12/31/18 with Resident #11 and Resident #12 were both kissing incidents. The facility reported an allegation of resident to resident abuse involving Resident #11 and Resident #15 to the SC State Agency on 1/7/19. Review of the initial report revealed Resident #16 was heard yelling out from his/her room. The resident's roommate, Resident #11 was standing next to him/her and Resident #16 stated that Resident #11 hit her/him on the face and hands. Review of the Resident Incident Reports completed for the incident involving Resident #11 and Resident #16 revealed the incident occurred on 1/7/19 at 6:20 PM. Review of the facility's investigative file for the incident revealed it was reported to the SC State Agency on 1/7/19 at 9:47 PM, later than the two hour required reporting timeframe. The facility reported an allegation of resident to resident sexual abuse involving Resident #5 and Resident #11 to the State Agency on 2/7/19. Review of the initial report revealed a CNA was walking down the hall and saw Resident #5 with his arms wrapped around Resident #11 from behind and he was fondling his/her breast. Review of the Resident Incident Reports completed for the incident involving Resident #5 and Resident #11 revealed the incident occurred on 2/7/19 at 11:30 AM. Review of the facility's investigative file for the incident revealed it was reported to the SC State Agency on 2/7/19 at 6:50 PM. The administrator confirmed the incident was not reported within the two hour required reporting timeframe for allegations of abuse. In an interview with the surveyor on 4/11/19 at approximately 1:25 PM, the facility administrator confirmed the initial report of the resident to resident allegation was not reported within 2 hours to the SC State Agency. The administrator stated that staff has been instructed not to report the allegations to the state. They are to report to the administrator or Director of Nursing immediately and one of them will complete the reports and send to the state. The facility reported an allegation of resident to resident sexual abuse involving Resident #5 and Resident #11 to the South [NAME]ina State Agency on 2/7/19. The surveyor requested the facility's investigative file while at the facility. Review of the initial report dated 2/7/19 revealed a CNA was walking down the hall and saw Resident #5 with his arms wrapped around Resident #11 from behind her and he was fondling his/her breast. Review of the Resident Incident Report revealed the incident occurred on 2/7/19 at 11:30 AM. Review of the facility's investigative file revealed there was only one Incident Witness Statement completed. Review of the Daily Staffing Sheet dated 2/7/19 revealed there were seven staff members assigned to the unit on the 7:00 AM-3:00 PM shift. The facility failed to interview staff members (on all shifts) who had contact with the resident during the period of the alleged incident per their Abuse Investigation and Reporting policy. Review of the facility's Abuse Investigation and Reporting policy revealed the individual conducting the investigation will interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Review of the facility's Abuse Investigation and Reporting policy revealed alleged abuse will be reported within two hours. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 04/09/2019 at 2:39 PM, review of a 24-Hour Report for an allegation of abuse revealed the incident occurred on 11/23/18. The report further indicated the incident was reported to the facility on [DATE] at approximately 11:00 AM. Review of the facsimile transmission log revealed it was sent to the SC State Agency at 18:27 (06:00 PM). The Nursing Home Administrator (NHA) confirmed the report was not submitted within 2 hours as required for an allegation of abuse. The facility admitted Resident #15 on 12/20/16 with [DIAGNOSES REDACTED]. On 04/11/19 at 02:17 PM, review of the 24-Hour report of an allegation of verbal abuse against Resident #15 revealed a CNA alleged that another CNA cursed at a resident as s/he was getting the resident up and dressed. Further review revealed the LPN on duty on 01/06/19 indicated the incident occurred around 01:30 PM after the resident's son/daughter asked that the staff get the resident out of bed and the CNAs statements also indicated the incident occurred around 01:30 - 02:00 PM. The RN (Registered Nurse) Supervisor's facility-obtained statement indicated s/he was informed of the incident at 04:00 PM. Review of the facsimile transmission log revealed it was sent to the SC State Agency at 19:00 (07:00 PM) on 01/06/19 which was confirmed by the NH[NAME] Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 04/12/2019 at 10:57 AM, review of the 24-Hour report of an allegation of abuse revealed that on 01/30/19 a CNA reported that on 01/27/19, s/he witnessed physical and verbal abuse by another CNA around 12:30- 01:30 AM. Review of the facsimile transmission log revealed it was sent to the SC State Agency at 17:11 (05:00 PM) on 01/30/19 which was confirmed by the NH[NAME] The facility admitted Resident #19 on 07/24/15 with [DIAGNOSES REDACTED]. On 04/11/2019 at 4:48 PM, review of a 24-Hour Report and staff statements of an allegation of abuse revealed that on 02/02/19, Resident #19 reported an allegation of abuse to the LPN at approximately 07:00 AM. A statement from the Activity Assistant revealed the resident reported the incident to her at 08:00 AM on 02/02/19. Review of the facsimile transmission log revealed it was sent to the SC State Agency at 14:03 PM. The NHA confirmed the report was not submitted within 2 hours as required for an allegation of abuse. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 04/10/2019 at 10:17 AM, review of the 24-Hour Report and Five-Day Follow-Up Report reported the incident as neglect and revealed no documentation of the time the incident occurred. A facility-obtained statement from Resident #25 indicated the incident occurred around lunch time. Review of the disciplinary action for the other LPN on duty indicated s/he saw the medications in the resident's room during the 02:00 PM FSBS (finger stick blood sugar). S/he asked the resident who admitted s/he got them off the other nurse's cart. LPN stated s/he was approached by the Director of Nursing (DON) approximately 20 minutes later about the meds. A notation on the bottom of the LPN's statement signed by the DON indicated the incident was brought to her attention at 03:00 PM and that the nurse failed to report the incident or take the medications from the resident. Review of the facsimile transmission log revealed it was sent to the SC State Agency at 17:35 PM (05:35 PM) on 03/26/19. During an interview on 04/10/19 at 12:45 PM, the NHA stated the CNAs were talking among themselves about Resident #25 having medications in his room which was overheard by medical records staff. The medical records staff member told another LPN on duty. The NHA stated the medical records staff then informed the DON. Per the NHA, the other LPN on duty confirmed s/he had seen the medications in the resident's room when s/he gave his/her 02:00 PM medications. Resident #25 also filed an allegation on 12/14/18 related to a staff member posting information on Facebook including the resident's name sometime in (MONTH) (YEAR). Review of the 24-Hour facsimile transmission log revealed it was sent to the SC State Agency on 12/15/18 at 11:43 AM. During an interview on 04/11/19 at 09:51 AM, the NHA confirmed the 24-Hour report was not submitted timely. Review of the facility's Abuse Investigation and Reporting Policy, Subsection Reporting, revealed 2. All alleged violation (sic) of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two hours if the alleged violation involves abuse OR has resulted in serious bodily injury . Further review of the policy Abuse Investigation and Reporting revealed, Role of the Investigator: 1. The individual conducting the investigation will, as a minimum: Review the completed documentation; Review the resident's medical record to determine events leading up to the incident; Interview the person(s) reporting the incident; Interview any witnesses to the incident; Interview the resident (as medically appropriate); Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; Interview the resident's roommate, family members, and visitors; Interview other residents to whom the accused employee provides care or services; and Review all events leading up to the alleged incident. The facility admitted Resident #22 originally on 1/24/2014 and readmitted on [DATE] with [DIAGNOSES REDACTED]. The facility admitted Resident #23 on 1/18/2019 with [DIAGNOSES REDACTED]. Review on 4/9/2019 at approximately 11:30 AM of an incident of resident to resident abuse between Resident #22 and Resident #23 in which a CNA left a residents room and went to take out the trash and the soiled linen. The CNA went down the hall to put some wipes in the resident's rooms. Resident #23 was observed in Resident #22's room. Resident #23 was leaning over Resident #22 with his/her hand in Resident #22's brief. Resident #23 was moving his/her hand back and forth between his/her legs. The CNA yelled for the nurse and the other CNA that was on duty. The nurse and the CNA on duty came into the room right away. Resident #23 was escorted out of Resident #22's room. Resident #22 was safeguarded, by the facility, against sexual abuse. The facility admitted Resident #8 on 2/10/2017 with [DIAGNOSES REDACTED]. The facility admitted Resident #10 on 8/3/2017 with [DIAGNOSES REDACTED]. Review on 4/10/2019 at approximately 10:52 AM of a incident reported by the facility in which Resident #8 had an altercation with Resident #10. Resident #8 was observed kicking Resident #10 while he/she was ambulating down the hallway with use of a walker. Resident #10 was documented as being involved in previous resident to resident altercations. Resident #10 was not safeguarded against physical abuse by Resident #8 Review on 4/10/2019 at approximately 11:00 AM of the statement dated 12/13/2019 from LPN #6 witnessed and confirmed that Resident #8 had kicked Resident #10 while ambulating down the hall using a walker. The facility admitted Resident #9 on 8/22/2018 with [DIAGNOSES REDACTED]. Review on 4/11/2019 at approximately 12:20 PM of an incident of resident to resident abuse which was reported by the facility revealed Resident #9 in his/her room and was heard yelling. When staff responded, Resident #9 was upset because Resident #8 was agitated and was throwing things at him/her causing a skin tear to his/her lower leg. Resident #9 was not safeguarded from physical abuse by Resident #8. Review on 4/11/2019 at approximately 12:30 PM of the statement from CNA #8 states, I was making rounds, in the room with another resident when I heard objects being thrown and loud voices in this resident's room. So the nurse and I went into Resident #8 and #9's room and Resident #8 was throwing things at Resident #9 and Resident #9 had a big gash in his/her leg. Review on 4/11/2019 at approximately 2:40 PM of the facility policy on Abuse stated, All residents have the right to be free from Abuse. Resident #20 was involved in a resident to resident altercation on 2/15/2019 at 3:15 AM. Review of the facility investigative file on 04/10/2019 at 02:12 PM revealed it documented the facility reported via fax on 2/15/2019 at 6:02 AM. Regulations for resident to resident altercations require a 2 hour reporting time frame. Residents #13 and #14 were involved in a reported incident of resident to resident abuse on 1/5/19 at approximately 5:55 PM. The incident was not reported to the SC State Agency until 1/6/2019 at 1:24 PM. Additionally, Resident #24 was involved in an incident that resulted in abuse on 3/19/19 at approximately 6:15 PM. This incident was not reported to the SC State Agency until 3/21/19 at 1:28 PM. Review of the facility's policy on 4/10/2019 at 1:30 PM titled, Abuse Prohibition/ Investigative Policy states, the facility will prohibit abuse, neglect, misappropriation of resident property, and exploitation.

Based on interview and record review, and review of the facility's policy titled, Use of Restraints, the facility failed to safeguard residents from the use of physical restraints for 1 of 1 residents reviewed for physical restraints (Resident #24). The findings included: Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's incident report revealed on 3/19/2019 between 6:15 and 7 PM Resident #24 was found in bed with both the blanket and bedsheets wrapped tightly around the side rails of the bed. During an interview with Certified Nursing Assistant #2 on 4/10/19 at 5:54 PM, s/he demonstrated to this surveyor how Resident #24 was found in bed. S/he stated Resident #24 was attempting to get up, which is usually a sign that s/he needed to be toileted; however, when entering the room, s/he noticed both the blanket and sheets were tightly wrapped around the siderails on the bed, which the resident was not physically capable of doing him/herself. During an interview with the Director of Nursing on 4/10/19 at 4:19 PM, s/he indicated s/he had a conversation with the responsible party that the resident reportedly tied themselves in the bed before while at home. During an interview on 4/11/19 at 9:52 AM, Licensed Practical Nurse #2, s/he confirmed the resident was restrained by both the sheets and blanket in the bed. Review of the facility's policy titled, Use of Restraints indicates practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: tucking sheets so tightly that a bed-bound resident cannot move.

Based on record reviews, interviews, and review of the facility policy titled, Abuse, the facility failed to ensure residents were free from abuse and/or neglect for 5 of 26 residents reviewed for abuse and neglect related to resident to resident altercations (Residents #6, #9, #10, #11, and #22). The findings included: The facility admitted Resident #22 originally on 1/24/2014 and readmitted on [DATE] with [DIAGNOSES REDACTED]. The facility admitted Resident #23 on 1/18/2019 with [DIAGNOSES REDACTED]. Review on 4/9/2019 at approximately 11:30 AM of an incident of resident to resident abuse between Resident #22 and Resident #23 in which a Certified Nursing Assistant (CNA) left a residents room and went to take out the trash and the soiled linen. The CNA went down the hall to put some wipes in the resident's rooms. Resident #23 was observed in Resident #22's room. Resident #23 was leaning over Resident #22 with his/her hand in Resident #22's brief. Resident #23 was moving his/her hand back and forth between his/her legs. The CNA yelled for the nurse and the other CNA that was on duty. The nurse and the CNA on duty came into the room right away. Resident #23 was escorted out of Resident #22's room. An interview on 4/10/2019 at approximately 3:10 PM with CNA #3 confirmed the witnessed resident to resident sexual abuse between Resident #22 and #23. The facility admitted Resident #8 on 2/10/2017 with [DIAGNOSES REDACTED]. The facility admitted Resident #10 on 8/3/2017 with [DIAGNOSES REDACTED]. Review on 4/10/2019 at approximately 10:52 AM of a incident reported by the facility in which Resident #8 had an altercation with Resident #10. Resident #8 was observed kicking Resident #10 while he/she was ambulating down the hallway with the use of a walker. Resident #10 was documented as being involved in previous resident to resident altercations. Review on 4/10/2019 at approximately 11:00 AM of the statement dated 12/13/2019 from Licensed Practical Nurse (LPN) #6 witnessed and confirmed that Resident #8 had kicked Resident #10 while ambulating down the hall using a walker. The facility admitted Resident #9 on 8/22/2018 with [DIAGNOSES REDACTED]. Review on 4/11/2019 at approximately 12:20 PM of an incident of resident to resident abuse which was reported by the facility revealed Resident #9 in his/her room and was heard yelling. When staff responded, Resident #9 was upset because Resident #8 was agitated and was throwing things at him/her causing a skin tear to his/her lower leg. Review on 4/11/2019 at approximately 12:30 PM of the statement from CNA #8 states, I was making rounds in the room with another resident when I heard objects being thrown and loud voices in this resident's room. So the nurse and I went into Resident #8 and #9's room and Resident #8 was throwing things at Resident #9 and Resident #9 had a big gash in his/her leg. Review on 4/11/2019 at approximately 2:40 PM of the facility policy on Abuse stated, All residents have the right to be free from Abuse. The facility reported an allegation of resident to resident sexual abuse involving Resident #11 and Resident #12 to the State Agency. Review of the Five-day report revealed Resident #12 ambulated with his/her walker into Resident #11's room and with the walker in between them he had his/her hands on the resident's shoulders and kissed him/her on the lips. The kiss was observed by a CNA when s/he went into Resident #11's room after s/he saw Resident #12 go into Resident #11's room. The facility report to the State Agency had one witness listed on the report, CNA #8. Resident #12's Progress Note dated 12/18/18 at 3:59 PM indicated at 3:15 PM a resident was noted by the CNA to be kissing another resident. The resident was removed from the Resident #11's room and explained this is not appropriate behavior. Resident will be placed on 15 minute checks. Review of Resident #11's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score of 4. Review of Resident #12's Significant Change Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score of 11. The Unit Manager's facility-obtained witness statement dated 12/18/18 indicated it was reported by the CNA that when s/he and the oncoming CNA were rounding for report Resident #12 was seen kissing Resident #11 on the lips. The Unit Manger was told that Resident #12 was standing in Resident #11's room in front of the resident with his/her walker between them. The CNA stated that Resident #12 had his/her hands on Resident #11's shoulders and had leaned over his/her walker and kissed Resident #11's lips. The CNA reported that otherwise their bodies were not touching. When observed, Resident #12 was redirected out of resident's room and Resident #11 was redirected up to the nurses' desk. CNA #8's facility-obtained statement dated 12/18/18 indicated s/he was making rounds with another aide to give him/her report and they saw Resident #12 in Resident #11's room kissing him/her. They were in standing position with Resident #12's walker in between them. CNA #8 had Resident #12 stop and s/he went to his/her room. Resident #11 went to the nurses' desk and CNA #8 went and got the nurse and told him/her. While reviewing Resident #11 and Resident #12's medical records related to the incident reported on 12/18/18, a second incident between Resident #11 and Resident #12 was noted as occurring on 12/31/18. Review of Resident #11's and Resident #12's Progress Notes dated 12/31/18 revealed at approximately 12:15 PM the unit manger was sitting at the nurses' desk and heard a CNA talking to residents. When the unit manager looked up s/he saw Resident #11 standing next to Resident #12. The unit manager asked the CNA what happened if anything and s/he said that they were just standing in the hall talking and Resident #11 kissed Resident #12 on the cheek and then Resident #12 kissed Resident #11 on the lips. Intervention was to do 15 minute checks for 24 hours and ask the physician for a medication review. Review of the Resident Incident Reports revealed the incident occurred on 12/31/18 at 12:15 PM. In an interview with the surveyor on 4/10/19 at approximately 11:00 AM, R. LPN #6 stated Resident #12 was moved to his/her hall about 2 weeks ago. LPN #6 stated Resident #12 has had occurrences of sexual behaviors, when s/he comes out of his room s/he will follow residents around. S/he will tell them they are beautiful. LPN #6 stated s/he has not seen Resident #12 do anything with a resident, s/he has seen him/her tell a resident s/he is beautiful. Resident #12 will look at residents like s/he is obsessing. LPN #6 stated s/he will redirect Resident #12. LPN #6 stated s/he has had reports Resident #12 will follow residents around, but s/he has not seen him. LPN #6 stated Resident #12 will stay in the bed most of the day, but will get up around dinner time. Resident #12 will walk around a lap at night and then go back to his room. LPN #6 stated s/he has not witnessed Resident #12 touch another resident, s/he knows to watch him/her when s/he is up. If s/he sees him/her go up to a resident, s/he will go ahead and separate the residents. In an interview with the surveyor on 4/10/19 at approximately 11:55 AM, CNA #8 stated s/he was giving report when s/he witnessed the incident on 12/18/18 but does not remember who the CNA was that was with him/her. They were walking by Resident #11's room and looked in to see Resident #12 giving Resident #11 a kiss. CNA #8 pulled Resident #11 out of the room and told the nurse what happened. CNA #8 stated staff have to keep a good eye on Resident #11 because s/he will go into other residents' rooms. In an interview with the surveyor on 4/10/19 at approximately 3:30 PM, the Unit Manager stated the incidents on 12/18/18 and 12/31/18 with Resident #11 and Resident #12 were both kissing incidents. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 04/09/19 at 12:09 PM, review of the monthly cumulative orders for (MONTH) (YEAR) revealed an order dated 07/23/18 to Give HS (bedtime) snack Dx (diagnosis): Diabetes Mellitus document % taken. On 04/09/19 at 01:58 PM, review of the care plan revealed impaired communication with unclear speech, does not make self clear and is rarely to never understood and difficulty understanding others at times secondary to intellect (sic) disabilities was identified as a problem area. Socially inappropriate behaviors such as taking food items off other residents' trays and episodes of inappropriate outburst of demanding snacks among other things, were also identified as problem areas and both included the intervention not to argue with the resident. Inappropriate behaviors such as temper tantrums, taking foods and paperwork from staff offices and making accusations of staff taking his/her belongings and of pinching him/her was also identified and also included the intervention, Do not argue with resident. At 02:39 PM, review of the reportable file revealed a facility-obtained statement dated 11/26/18 at 11:00 AM from CNA #8 stating CNA #9 asked LPN #6 if the resident could have another sandwich and the nurse told her/him no, that resident #6 was limited to food. CNA #9 told the nurse that a sandwich might keep the resident from crying and waking up the other residents. LPN #6 told CNA #9 that Resident #6 would be okay just don't pay (the resident) no mind. CNA #8 told CNA #9 that it really upset CNA #8 that the nurse treated the resident that way and was going in the room picking with the resident and that s/he was already eating a sandwich and the nurse went into the room and took the other half and threw it in the trash. CNA #9's facility-obtained statement dated 11/26/18 stated Resident #6 came to the nurse's station and took 2 peanut butter and jelly sandwiches and started eating them. LPN #6 took the sandwiches away from the resident and the resident began yelling at the top of (his/her) lungs. The statement further indicated CNA #9 asked the nurse why the resident couldn't have the sandwich and the nurse (said) the resident was restricted to what s/he could have. CNA #9's statement indicated s/he told the nurse that the resident had the right to those sandwiches and s/he didn't feel it was right that the nurse took them away from the resident. LPN #6's facility-obtained statement dated 11/26/18 indicated the nurse came out of a resident's room and saw the resident grab a sandwich from behind the nurses desk. The statement further stated s/he took the sandwich away from the resident and that the resident was upset. The nurse further indicated that s/he understood now that if a resident wants something they can have it and that in the future s/he would not refuse a resident what they request. A Nursing Home Administrator's note dated 11/23/18 at approximately 11:30 PM indicated that CNA #9 reported that Resident #6 asked for something to eat. CNA #9 asked LPN #6 to give the resident a sandwich and that the nurse said no and that the resident was on limited food and couldn't have another sandwich. The Administrator's note also indicated the CNA stated the Resident kept crying and crying and that the LPN sat at the nursing station and never paid (the resident) no mind. The LPN reportedly went in and took the sandwich away from the resident and threw it away. During an interview on 04/09/19, the Nursing Home Administrator confirmed the incident constituted abuse and stated the nurse had been terminated.

Based on review of facility files and interview, the facility failed to thoroughly investigate all allegations of abuse for 8 of 26 residents reviewed for abuse and neglect (Residents #5, #11, #12, #17, #22, #23, #24, and #25). The findings included: The facility reported an allegation of resident to resident sexual abuse involving Resident #11 and Resident #12 to the South [NAME]ina (SC) State Agency. Review of the Five-day report revealed Resident #12 ambulated with his/her walker into Resident #11's room and with the walker in between them s/he had his/her hands on the resident's shoulders and kissed him/her on the lips. The kiss was observed by a Certified Nursing Assistant (CNA) when s/he went into Resident #11's room after s/he saw Resident #12 go into Resident #11's room. The facility report to the SC State Agency had one witness listed on the report, CNA #8. Resident #12's Progress Note dated 12/18/18 at 3:59 PM indicated at 3:15 PM resident was noted by CNA to be kissing another resident. The resident was removed from the Resident #11's room and explained this is not appropriate behavior. Resident will be placed on 15 minute checks. The Unit Manager's facility-obtained witness statement dated 12/18/18 indicated it was reported by the CNA that when s/he and the oncoming CNA were rounding for report Resident #12 was seen kissing Resident #11 on the lips. The Unit Manger was told that Resident #12 was standing in Resident #11's room in front of the resident with his/her walker between them. The CNA stated that Resident #12 had his/her hands on Resident #11's shoulders and had leaned over his/her walker and kissed Resident #11's lips. The CNA reported that otherwise their bodies were not touching. When observed, Resident #12 was redirected out of the resident's room and Resident #11 was redirected up to the nurses' desk. CNA #8's facility-obtained statement dated 12/18/18 indicated s/he was making rounds with another aide to give him/her report and they saw Resident #12 in Resident #11's room kissing him/her. They were in a standing position with Resident #12's walker in between them. CNA #8 had Resident #12 stop and s/he went to his/her room. Resident #11 went to the nurses' desk and CNA #8 went and got the nurse and told him/her. Review of the facility's investigative file for the incident on 12/18/18 revealed CNA #8's statement indicated another CNA, coming on for 2nd shift, was with him/her at the time of the incident. Review of the facility's investigation revealed there was no statement in the facility's investigation from a CNA on 2nd shift. The facility's investigation contained statements from the Unit Manager, the two day shift nurses, and CNA #9 (worked 1st shift per Daily Staffing Sheet). CNA #9's facility-obtained statement indicated s/he did not witness the incident. The surveyor requested the Daily Staffing Sheet for 2nd shift on 12/18/18 during the survey but the facility was unable to provide the documentation as requested. In an interview with the surveyor on 4/10/19 at approximately 11:55 AM, CNA #8 stated s/he was giving report when s/he witnessed the incident on 12/18/18 but does not remember who the CNA was that was with him/her. They were walking by Resident #11's room and looked in to see Resident #12 giving Resident #11 a kiss. CNA #8 pulled Resident #11 out of the room and told the nurse what happened. CNA #8 stated staff have to keep a good eye on Resident #11 because s/he will go into other residents' rooms. The facility reported an allegation of resident to resident sexual abuse involving Resident #5 and Resident #11 to the SC State Agency on 2/7/19. The surveyor requested the facility's investigative file while at the facility. Review of the initial report dated 2/7/19 revealed a CNA was walking down the hall and saw Resident #5 with his/her arms wrapped around Resident #11 from behind him/her and s/he was fondling his/her breast. Review of the Resident Incident Report revealed the incident occurred on 2/7/19 at 11:30 AM. Review of the facility's investigative file revealed there was only one Incident Witness Statement completed. Review of the Daily Staffing Sheet dated 2/7/19 revealed there were seven staff members assigned to the unit on the 7:00 AM-3:00 PM shift. The facility failed to interview staff members (on all shifts) who had contact with the resident during the period of the alleged incident per their Abuse Investigation and Reporting policy. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 04/10/2019 10:17 AM, review of the 24-Hour Report and Five-Day Follow-Up Report revealed no documentation of the time the incident occurred. A facility-obtained statement from Resident #25 indicated the incident occurred around lunch time. The Five-Day Follow-Up Report indicated an in-service was done but there was no documentation of an investigation included in the Reportable File. The file was requested from facility but no additional information was provided. The investigation in the file did not include a statement from the accused Licensed Practical Nurse (LPN) or any other staff members that may have observed the resident take the medications. The SSD (Social Services Director) typed a statement from Resident #25. The Director of Nursing (DON) who spoke to the resident and retrieved the medications also did not write a statement. Review of the disciplinary action for the other LPN on duty indicated s/he saw the medications in the resident's room during the 02:00 PM FSBS (finger stick blood sugar). S/he asked the resident who admitted s/he got them off the other nurse's cart. The LPN stated s/he was approached by the DON approximately 20 minutes later about the meds. A notation on the bottom of the LPN's statement signed by the DON indicated the incident was brought to her attention at 03:00 PM and that the nurse failed to report the incident or take the medications from the resident. During an interview on 04/10/19 at 12:45 PM, the NHA (Nursing Home Administrator) stated the CNAs were talking among themselves about Resident #25 having medications in his room which was overheard by medical records staff. The medical records staff member told another LPN on duty. The NHA stated the medical records staff then informed the DON. Per the NHA, the other LPN on duty confirmed s/he had seen the medications in the resident's room when s/he gave his/her 02:00 PM medications. During an interview on 04/10/19 at approximately 4:00 PM, the NHA confirmed a 24 hour report was sent to the State Agency at 5:35 PM on 03/26/19 because that was approximately when the management became aware. The NHA further confirmed the other LPN on duty, CNAs, and the Medical Records clerk were aware but stated that the management was not informed. The NHA confirmed statements were not obtained from the accused LPN, the CNAs or the Medical records clerk but would not confirm or deny whether it was a thorough investigation. Resident #25 also filed an allegation on 12/14/18 related to a staff member posting information on Facebook including the resident's name sometime in (MONTH) (YEAR). Review of the 24-Hour facsimile transmission log revealed it was sent to the SC State Agency on 12/15/18 at 11:43 AM. Review of the investigation file revealed a statement from the resident and from one of the CNAs involved in the incident. No statements were obtained from the other involved CNA or other staff members who were named in the statement as having information. During an interview on 04/11/19 at 09:51 AM, the NHA confirmed s/he had attempted to obtain a statement from the CNAs boyfriend/girlfriend who allegedly reported the post, the other CNA, and the resident's spouse without success but that no statements were obtained from other staff who might have had knowledge of the incident. The facility admitted Resident #22 originally on 1/24/2014 and readmitted on [DATE] with [DIAGNOSES REDACTED]. The facility admitted Resident #23 on 1/18/2019 with [DIAGNOSES REDACTED]. Review on 4/9/2019 at approximately 11:30 AM of an incident of resident to resident abuse between Resident #22 and Resident #23 in which a CNA left a residents room and went to take out the trash and the soiled linen. The CNA went down the hall to put some wipes in the resident's rooms. Resident #23 was observed in Resident #22's room. Resident #23 was leaning over Resident #22 with his/her hand in Resident #22's brief. Resident #23 was moving his/her hand back and forth between his/her legs. The CNA yelled for the nurse and the other CNA that was on duty. The nurse and the CNA on duty came into the room right away. Resident #23 was escorted out of Resident #22's room. Resident #22 was safeguarded, by the facility, against sexual abuse. During an interview on 4/10/2019 at approximately 3:10 PM with CNA #3 he/she stated, I yelled for the nurse and the other CNA that was on duty that night to come into Resident #22's room and both the nurse and the CNA came into the resident's room right away. The facility failed to interview CNA #4 and other pertinent staff concerning the incident with Residents #22 and #23. Record review of a facility incident report and facility investigation reporting file, and interview with the Administrator revealed the facility failed to complete a thorough investigation of a fall with injury on 1/27/2019 for Resident #17. The facility failed to obtain written statements by all witnesses at the time of the incident. Specifically, the facility's investigation did not include statements from CNA #7 and CNA #8. This was confirmed by multiple interviews with the Administrator on 04/11/2019. On 3/19/19 at approximately 6:15 PM, Resident #24 was found to be restrained in bed by his/her bedsheets and blanket. Review of the facility's investigative file and the medical record on 4/9/2019 at 1:15 PM revealed there was not an incident report related to the occurrence completed, neither was there any additional documentation or investigation completed. During an interview with the DON on 4/10/19 at 4:19 PM, s/he confirmed a thorough investigation had not been completed and that an incident report had not been filled out at the time of the occurrence.

Based on review of facility files and interview, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents. Resident #1, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12 were noted to having smoking materials and/or smoke unsupervised on facility grounds. Staff failed to intervene and/or document the incidents so that behavior could be monitored. 7 of 11 residents reviewed for accidents/incidents. The findings included: Review of Resident #1's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] indicated the resident was an unsafe smoker. The degree of supervision needed while smoking was not checked, with choices being occasional, frequent, and constant. There was no additional Safe Smoking Assessment completed when the resident started smoking at the facility. Review of Resident #1's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #1's Progress Notes, including Nursing and Social Services, from 11/1/17-3/7/18. The Nurses' Note dated 11/9/17 indicated the resident was seen by the physician and order was written that Resident #1 may smoke 2-3 cigarettes daily with supervision. There were no additional Nurses' Notes related to the resident smoking. On 1/24/18 social services documented nursing reported Resident #1 was increasingly verbally aggressive and using profanity directed at nurses when they speak to him/her about building policies and rules s/he is not complying with. There was no documentation of what policies the resident was not complying with. On 2/28/18 social services documented the resident leaves the building for social leaves almost every day. Discharge plan but in 30 day discharge notice period now and seeking alternative arrangements for living. There was no Safe Smoking Practices policy signed by Resident #1. The resident's Release of Responsibility for Leave Of Absence forms were signed with no indication of time out or time in 54 times. Review of the Notice of Resident Transfer or Discharge form revealed Resident #1 was issued a notice and the date of notice was not completed. The facility administrator and resident signed the notice on 2/21/18. The notice indicated Resident #1 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility. The resident's health had also improved sufficiently that the resident no longer needs the services provided by this facility. Review of Resident #7's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 12/14/17. The assessment indicated the resident was an unsafe smoker related to being forgetful at times. The degree of supervision needed while smoking was noted as constant. Review of Resident #7's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #7's Progress Notes, including Nursing and Social Services, from 11/28/17-3/4/18. There was no documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's name on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #8's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 9/5/17 indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of the resident's Release of Responsibility for Leave of Absence revealed the resident signed him/herself out on 2/4/18 and 2/9/18. The time in was not completed for the leave of absence on 2/9/18. Review of Resident #8's care plan revealed resident has episodes of physical/verbal aggression toward staff and has episodes of being noncompliant with care and also smoking during non-regulation times to smoke and also having lighters and cigarettes without informing staff. Interventions and approaches were noted on the care plan and included give resident limited amount of cigarettes and provide lighter, encourage resident to return lighter. Review of Resident #8's care plan also revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #8's Progress Notes, including Nursing and Social Services, from 11/9/17-2/27/18. The social services note dated 12/7/17 indicated the resident had increased episodes of physical and verbal aggression, as well as resistiveness to care and smoking cigarettes and lighters s/he gets into the facility without telling anyone and smoking outside of regulated times. There was no other documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #9's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 11/8/17 indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of the physician progress notes [REDACTED]. Resident #9 was of course not happy about this. Review of the Release of Responsibility for Leave of Absence form revealed Resident #9 signed him/herself out on 2/9/18, 2/17/18, and 2/21/18. The time out was not indicated on 2/17/18 and the time in was not indicated on any of the dates. There were no receiving nurse initials noted on those dates. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #9's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, remind resident to return cigarettes and lighter back to nurses station when not in use. Resident #9's Progress Notes, including Nursing and Social Service, were reviewed from 11/2/17-2/21/18. The Social Services note dated 1/2/18 indicated the resident went to the store over the weekend in his/her motorized wheelchair. Resident is not safe to go by him/herself but s/he is very strong willed. Resident stated that s/he told the nurse but s/he does not know who the nurse was. The social worker told the resident whenever s/he leaves the facility s/he has to sign out. The Social Services note dated 2/21/18 indicated Resident #9 was issued a 30 day discharge letter. S/he has been leaving the facility and not signing out as s/he has been told many times, s/he has cigarettes and lighter on him/her as evidenced of him/her smoking outside. It is a danger to the facility and other residents if s/he decides to light up in his/her room. There was no other documentation in the resident's Progress Notes related to the resident smoking or having smoking materials. Review of the Notice of Resident Transfer or Discharge form revealed Resident #9 was issued a notice and the date of notice was not completed. The facility administrator and resident signed the notice on 2/21/18. The notice indicated Resident #9 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility and the resident's health had improved sufficiently that the resident no longer needs the services provided by the facility. Review of Resident #10's medical revealed the resident's most current Safe Smoking assessment dated [DATE] indicated the resident was assessed as an unsafe smoker. The degree of supervision needed while smoking was constant. Social Services staff provided a Safe Smoking Policy with the resident's name written on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. The form indicated the resident does not smoke. Review of the Notice of Resident Transfer or Discharge form revealed Resident #10 was issued and the date of notice was 2/21/18. The facility administrator signed the notice on 2/21/18. The resident refused to sign the form. The notice indicated Resident #10 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility and the resident's health had improved sufficiently that the resident no longer needs the services provided by the facility. Review of Resident #10's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, and smoking materials will be kept in locked areas when not in use. Review of Resident #10's medical record revealed the resident signed him/herself out 27 times between 2/6/18- 3/12/18. The documentation indicated only one time and did not note if it was when the resident signed in or out. Reviewed Resident #10's Progress Notes, including Nursing and Social Service, from 11/17/17-3/8/18. A nursing note dated 2/22/18 indicated the resident signed him/herself out several times this PM to go off property to smoke. A social services note dated 3/8/18 indicated Resident #10 continues to have smoking items on him/her after many times of advising him/her about the smoking policy. Resident goes outside several times a day to smoke at one point s/he told me that s/he has his/her cigarettes and lighter hidden somewhere off the property. Review of Resident #11's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE]. The assessment indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of Resident #11's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, remind resident to return cigarettes and lighter back to nurses station when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #11's Progress Notes, including Nursing and Social Services, from 11/1/17-3/13/18. There was no documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #12's medical record revealed the resident's had a Safe Smoking Assessment that was not dated. The assessment indicated the resident was a safe smoker. The degree of supervision needed while smoking was not indicated, with the choices being occasional, frequent, or constant. Review of Resident #12's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, remind resident to return cigarettes and lighter back to nurses station when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #12's Progress Notes, including Nursing and Social Services, from 11/2/17-3/9/18. There was a Nurses' Note dated 3/7/18 at 6:09 PM that indicated the resident left the facility without letting the nurses or any other staff know about him/her leaving and did not sign him/herself out. Review of the Nurses' Note dated 2/18/18 at 6:14 PM reveled at approximately 4:10 PM a staff member witnessed Resident #12 leaving the facility without signing out. Resident went to the store in his/her wheelchair as witnessed by a staff member using the busy street as a route. Resident returned at 4:30 PM. The Social Services note dated 3/8/18 indicated resident continues to not follow the rules of the facility. Resident #12 leaves the premises to smoke and s/he does not sign out and s/he has smoking item on him/her. Social worker, unit manager, and Director of Nursing have spoken with him/her on many occasions on these issues but s/he has decided that s/he is going to do what s/he wants to do. Social Services staff provided a Safe Smoking Policy with the resident's signature on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #12's Release of Responsibility for Leave of Absence form revealed the resident signed him/herself out 21 times between 2/15/18-3/12/18. There were 19 times the time out or time in was not documented on the form. The receiving nurse did not initial the form 12 times when the resident went on a leave of absence from the facility. Review of the Notice of Resident Transfer or Discharge form revealed Resident #12 was issued a notice and the date of notice was 2/21/18. The facility administrator and resident signed the notice on 2/21/18. The notice indicated Resident #10 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility. The surveyor observed the facility parking lot and route to the store next door. There is no curb with no wheelchair access around the parking lot of the facility that goes from the building to the four lane road where the building sits. There is an abandoned building beside the facility and the store is next to that building. There is no access to the abandoned building with the location of the curb and trees around the facility. There is no sidewalk along the road between the facility and the store. In an interview with the surveyor on 3/14/18 at approximately 11:35 AM, the activities director stated s/he has been at the facility over [AGE] years. The activities director stated s/he knows there have been some lighters confiscated by social services. The smoking policy was discussed at a meeting recently with residents, s/he thinks January. The residents felt they should be able to smoke whenever they want. In an interview with the surveyor on 3/13/18 at approximately 12:20 PM, social services stated there were 2 smoking residents that do not have a signed/initialed smoking policy. Those residents were not smoking when they were admitted to the facility. If they decide to start smoking while at the facility, nursing does an assessment and notifies social services so s/he can educate the resident on the smoking policy. Social services goes and talks with the resident but does not have them sign the form that they have been educated on the smoking policy. The resident does have to sign the policy on admission if they smoke when they come in. In an interview with the surveyor on 3/12/18 at approximately 2:35 PM, CNA (Certified Nursing Aide) #1 stated s/he worked with Resident #1 from time to time. The resident signed out a lot and would go to the grocery store. CNA #1 stated s/he has seen Resident #1 outside smoking in the smoking area when it wasn't scheduled smoking times. Resident #8 would also be out there with the resident. Resident #1 and Resident #8 would be smoking. There would be no staff with them, they would not tell anyone they were going out there. Staff would have to go searching for them. They would go out to the smoking area, but by themselves. The smoking area is off the back of unit 4. CNA #1 stated s/he would assume Resident #1 and Resident #8 had the cigarettes and lighters since there was no staff with them. In an interview with the surveyor on 3/12/18 at approximately 2:50 PM, CNA #2 stated sometime you could smell smoke in the room and s/he would ask Resident #1 where s/he was smoking at, and the resident would get mad at him/her. CNA #1 tried to not ask Resident #1 about things because of how s/he would act. CNA #1 never caught the resident smoking in his/her room. CNA #1 would see Resident #1, Resident #8, and sometimes Resident #9 would go outside to the smoking area unsupervised. They would say they were going to catch air. CNA #2 would not follow them outside, Resident #1 could be so rude. In an interview with the surveyor on 3/12/18 at approximately 3:10 PM, LPN (Licensed Practical Nurse) #2 stated s/he was normally assigned to Resident #1. Resident #1 has had words and cussed LPN #2 out. Somebody reported to LPN #2 that Resident #1 was going out back smoking by him/herself. LPN #2 asked the resident about it and s/he cussed him/her out. It was reported to LPN #2 that the resident was out there at night. LPN #2 doesn't work nights so s/he never saw Resident #1 out there without staff. Resident #1 would sign him/herself out every day when s/he found out s/he could. S/he would ask the resident where s/he had been all that time. The resident would say walking around talking to people. S/he would be gone for an hour or so, a lot of times s/he would leave again on the same shift. LPN #2 stated it was about a month ago when Resident #1 found out s/he could sign him/herself out. That is when other residents found out about being able to sign themselves out too. They had a meeting with the residents and told them they were thinking about changing the smoking policy. That's when the residents found out they could sign themselves out. LPN #2 stated s/he guessed so they would know they could sign out and go smoke off the premises. A housekeeper usually takes the residents out for smoke breaks. That staff if responsible for keeping smoking materials. In an interview with the surveyor on 3/12/18 at approximately 3:40 PM, social services stated Resident #10, Resident #12, and Resident #1 claimed they were hiding their cigarettes and lighter. Social services stated they found cigarettes and lighters in Resident #8, Resident #12, Resident #7, and Resident #13's rooms. Staff would come tell social services or the housekeeping supervisor what they found. Housekeeping is in charge of smoke breaks and smoking materials. Social services would go and talk to the residents and remind them of the smoking policy. Social services was trying to get the residents to go to assisted living so they could smoke as they please. Social services stated there were multiple times they found smoking materials with Resident #8. The resident is [MEDICAL CONDITION] and will try to hide them from staff but s/he finds them. Social services saw Resident #11 through the window of another resident's room come outside to the courtyard area by therapy and pull out a cigarette and lighter and start to smoke. Staff tells social services that Resident #10, Resident #11, and Resident #8 will go outside at night to the smoking area or the facility parking lot and smoke unsupervised. Social services stated the administrator wanted the discharge letters given to the residents because they were not following the smoking policy. The residents told social services they had a meeting with the administrator and s/he told them if they wanted to smoke they could sign themselves out and go smoke off facility grounds. In an interview with the surveyor on 3/13/18 at approximately 12:40 PM, assistant director of environmental services stated smoke breaks are 10:30-11:30, 1:30-2:30, and 4:00-4:30. Those are the hours that have been in place for a while. Housekeeping or laundry usually go outside with the residents on smoke break. The smoking materials are kept in the storage closet, they are in a lock box. Surveyor observed area where smoking materials are kept. The key is hanging on the wall of the unit hallway between two doors near the storage room. The materials are kept in a cardboard box that has a note attached with the smoking times. In an interview with the surveyor on 3/13/18 at approximately 1:45 PM, social services stated s/he does not date or sign behind residents when s/he reviews the smoking policy with them. S/he has them initial or sign and keeps them in a folder in his/her office. Social services stated s/he issued four discharge notices, the ones provided. Social services stated that most of the time s/he does not document when s/he reeducates the residents on the smoking policy when they are found with smoking materials. Social services does not provide a copy of the smoking policy to the residents or responsible parties. In an interview with the surveyor on 3/13/18 at approximately 3:15 PM, the ADON (Assistant Director of Nurse) stated all of a sudden, several residents started signing themselves out so they would not be restricted to the scheduled smoke breaks. The ADON stated if staff suspects a resident has smoking materials, they get social services. Social services gets another administrative person to check with them. The nurse or social services should document if a resident has smoking materials. They don't complete incident reports if they find smoking materials. S/he knows residents have had smoking materials and it has been confiscated. The ADON does not remember who or when. They will ask residents if they have anything, ask if they can look in a drawer maybe. They don't search the whole room. There are no time limits for signing out. The residents should be signed out and back in by the nurse. The ADON stated s/he was not sure the residents were educated that they need to sign back in and let the nurse know. Whoever told them about being able to sign out should have also told them they need to let the nurse know they are back. The ADON stated s/he is not sure who told the residents about signing out and not sure they educated them on signing back in. Review of the facility's Safe Smoking Policy revealed that all residents who smoke will receive supervision while smoking and practice safe smoking habits. All residents who smoke are required to wear a protective smoking apron and are supervised while smoking. Staff members maintain all smoking material for residents who smoke; e.g., cigarettes, pipes, lighters, lighter fluid, etc. Staff members will distribute smoking materials to residents at smoking times. Smoking occurs in designated locations that are environmentally separate from all resident care areas. Violation of the smoking policy is an endangerment to the health and safety of residents. First infractions will consist of a verbal warning to both the resident and their responsible party. A second infraction of the smoking policy will result in a notice of discharge. Documentation included the progress notes reflect any warning issued for an infraction of the smoking policy. Review of the facility's policy on Signing Residents Out revealed all residents leaving the premises must be signed out. Staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once. Residents must be signed in upon return to the facility. On 3/14/18 at approximately 12:30 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0689 at a scope and severity of K. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on December, 7, 2017.

Based on review of facility files and interview, the facility failed to provide services that meet professional standards of quality. Resident #1, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12 were noted to not follow the facility's safe smoking policy. There was no documentation related to the incidents with the residents in their medical records. 7 of 12 residents reviewed for professional standards. The findings included: Review of Resident #1's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] indicated the resident was an unsafe smoker. The degree of supervision needed while smoking was not checked, with choices being occasional, frequent, and constant. There was no additional Safe Smoking Assessment completed when the resident started smoking at the facility. Review of Resident #1's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #1's Progress Notes, including Nursing and Social Services, from 11/1/17-3/7/18. The Nurses' Note dated 11/9/17 indicated the resident was seen by the physician and order was written that Resident #1 may smoke 2-3 cigarettes daily with supervision. There were no additional Nurses' Notes related to the resident smoking. On 1/24/18 social services documented nursing reported Resident #1 was increasingly verbally aggressive and using profanity directed at nurses when they speak to him/her about building policies and rules s/he is not complying with. There was no documentation of what policies the resident was not complying with. On 2/28/18 social services documented the resident leaves the building for social leaves almost every day. Discharge plan but in 30 day discharge notice period now and seeking alternative arrangements for living. There was no Safe Smoking Practices policy signed by Resident #1. The resident's Release of Responsibility for Leave Of Absence forms were signed with no indication of time out or time in 54 times. Review of the Notice of Resident Transfer or Discharge form revealed Resident #1 was issued a notice and the date of notice was not completed. The facility administrator and resident signed the notice on 2/21/18. The notice indicated Resident #1 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility. The resident's health had also improved sufficiently that the resident no longer needs the services provided by this facility. Review of Resident #7's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 12/14/17. The assessment indicated the resident was an unsafe smoker related to being forgetful at times. The degree of supervision needed while smoking was noted as constant. Review of Resident #7's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #7's Progress Notes, including Nursing and Social Services, from 11/28/17-3/4/18. There was no documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's name on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #8's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 9/5/17 indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of the resident's Release of Responsibility for Leave of Absence revealed the resident signed him/herself out on 2/4/18 and 2/9/18. The time in was not completed for the leave of absence on 2/9/18. Review of Resident #8's care plan revealed resident has episodes of physical/verbal aggression toward staff and has episodes of being noncompliant with care and also smoking during non-regulation times to smoke and also having lighters and cigarettes without informing staff. Interventions and approaches were noted on the care plan and included give resident limited amount of cigarettes and provide lighter, encourage resident to return lighter. Review of Resident #8's care plan also revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #8's Progress Notes, including Nursing and Social Services, from 11/9/17-2/27/18. The social services note dated 12/7/17 indicated the resident had increased episodes of physical and verbal aggression, as well as resistiveness to care and smoking cigarettes and lighters s/he gets into the facility without telling anyone and smoking outside of regulated times. There was no other documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #9's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 11/8/17 indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of the physician progress notes [REDACTED]. Resident #9 was of course not happy about this. Review of the Release of Responsibility for Leave of Absence form revealed Resident #9 signed him/herself out on 2/9/18, 2/17/18, and 2/21/18. The time out was not indicated on 2/17/18 and the time in was not indicated on any of the dates. There were no receiving nurse initials noted on those dates. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #9's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, remind resident to return cigarettes and lighter back to nurses station when not in use. Resident #9's Progress Notes, including Nursing and Social Service, were reviewed from 11/2/17-2/21/18. The Social Services note dated 1/2/18 indicated the resident went to the store over the weekend in his/her motorized wheelchair. Resident is not safe to go by him/herself but s/he is very strong willed. Resident stated that s/he told the nurse but s/he does not know who the nurse was. The social worker told the resident whenever s/he leaves the facility s/he has to sign out. The Social Services note dated 2/21/18 indicated Resident #9 was issued a 30 day discharge letter. S/he has been leaving the facility and not signing out as s/he has been told many times, s/he has cigarettes and lighter on him/her as evidenced of him/her smoking outside. It is a danger to the facility and other residents if s/he decides to light up in his/her room. There was no other documentation in the resident's Progress Notes related to the resident smoking or having smoking materials. Review of the Notice of Resident Transfer or Discharge form revealed Resident #9 was issued a notice and the date of notice was not completed. The facility administrator and resident signed the notice on 2/21/18. The notice indicated Resident #9 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility and the resident's health had improved sufficiently that the resident no longer needs the services provided by the facility. Review of Resident #10's medical revealed the resident's most current Safe Smoking assessment dated [DATE] indicated the resident was assessed as an unsafe smoker. The degree of supervision needed while smoking was constant. Social Services staff provided a Safe Smoking Policy with the resident's name written on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. The form indicated the resident does not smoke. Review of the Notice of Resident Transfer or Discharge form revealed Resident #10 was issued and the date of notice was 2/21/18. The facility administrator signed the notice on 2/21/18. The resident refused to sign the form. The notice indicated Resident #10 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility and the resident's health had improved sufficiently that the resident no longer needs the services provided by the facility. Review of Resident #10's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, and smoking materials will be kept in locked areas when not in use. Review of Resident #10's medical record revealed the resident signed him/herself out 27 times between 2/6/18- 3/12/18. The documentation indicated only one time and did not note if it was when the resident signed in or out. Reviewed Resident #10's Progress Notes, including Nursing and Social Service, from 11/17/17-3/8/18. A nursing note dated 2/22/18 indicated the resident signed him/herself out several times this PM to go off property to smoke. A social services note dated 3/8/18 indicated Resident #10 continues to have smoking items on him/her after many times of advising him/her about the smoking policy. Resident goes outside several times a day to smoke at one point s/he told me that s/he has his/her cigarettes and lighter hidden somewhere off the property. Review of Resident #11's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE]. The assessment indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of Resident #11's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, remind resident to return cigarettes and lighter back to nurses station when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #11's Progress Notes, including Nursing and Social Services, from 11/1/17-3/13/18. There was no documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #12's medical record revealed the resident's had a Safe Smoking Assessment that was not dated. The assessment indicated the resident was a safe smoker. The degree of supervision needed while smoking was not indicated, with the choices being occasional, frequent, or constant. Review of Resident #12's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, remind resident to return cigarettes and lighter back to nurses station when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #12's Progress Notes, including Nursing and Social Services, from 11/2/17-3/9/18. There was a Nurses' Note dated 3/7/18 at 6:09 PM that indicated the resident left the facility without letting the nurses or any other staff know about him/her leaving and did not sign him/herself out. Review of the Nurses' Note dated 2/18/18 at 6:14 PM reveled at approximately 4:10 PM a staff member witnessed Resident #12 leaving the facility without signing out. Resident went to the store in his/her wheelchair as witnessed by a staff member using the busy street as a route. Resident returned at 4:30 PM. The Social Services note dated 3/8/18 indicated resident continues to not follow the rules of the facility. Resident #12 leaves the premises to smoke and s/he does not sign out and s/he has smoking item on him/her. Social worker, unit manager, and Director of Nursing have spoken with him/her on many occasions on these issues but s/he has decided that s/he is going to do what s/he wants to do. Social Services staff provided a Safe Smoking Policy with the resident's signature on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #12's Release of Responsibility for Leave of Absence form revealed the resident signed him/herself out 21 times between 2/15/18-3/12/18. There were 19 times the time out or time in was not documented on the form. The receiving nurse did not initial the form 12 times when the resident went on a leave of absence from the facility. Review of the Notice of Resident Transfer or Discharge form revealed Resident #12 was issued a notice and the date of notice was 2/21/18. The facility administrator and resident signed the notice on 2/21/18. The notice indicated Resident #10 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility. The surveyor observed the facility parking lot and route to the store next door. There is no curb with no wheelchair access around the parking lot of the facility that goes from the building to the four lane road where the building sits. There is an abandoned building beside the facility and the store is next to that building. There is no access to the abandoned building with the location of the curb and trees around the facility. There is no sidewalk along the road between the facility and the store. In an interview with the surveyor on 3/14/18 at approximately 11:35 AM, the activities director stated s/he has been at the facility over [AGE] years. The activities director stated s/he knows there have been some lighters confiscated by social services. The smoking policy was discussed at a meeting recently with residents, s/he thinks January. The residents felt they should be able to smoke whenever they want. In an interview with the surveyor on 3/13/18 at approximately 12:20 PM, social services stated there were 2 smoking residents that do not have a signed/initialed smoking policy. Those residents were not smoking when they were admitted to the facility. If they decide to start smoking while at the facility, nursing does an assessment and notifies social services so s/he can educate the resident on the smoking policy. Social services goes and talks with the resident but does not have them sign the form that they have been educated on the smoking policy. The resident does have to sign the policy on admission if they smoke when they come in. In an interview with the surveyor on 3/12/18 at approximately 2:35 PM, CNA (Certified Nursing Aide) #1 stated s/he worked with Resident #1 from time to time. The resident signed out a lot and would go to the grocery store. CNA #1 stated s/he has seen Resident #1 outside smoking in the smoking area when it wasn't scheduled smoking times. Resident #8 would also be out there with the resident. Resident #1 and Resident #8 would be smoking. There would be no staff with them, they would not tell anyone they were going out there. Staff would have to go searching for them. They would go out to the smoking area, but by themselves. The smoking area is off the back of unit 4. CNA #1 stated s/he would assume Resident #1 and Resident #8 had the cigarettes and lighters since there was no staff with them. In an interview with the surveyor on 3/12/18 at approximately 2:50 PM, CNA #2 stated sometime you could smell smoke in the room and s/he would ask Resident #1 where s/he was smoking at, and the resident would get mad at him/her. CNA #1 tried to not ask Resident #1 about things because of how s/he would act. CNA #1 never caught the resident smoking in his/her room. CNA #1 would see Resident #1, Resident #8, and sometimes Resident #9 would go outside to the smoking area unsupervised. They would say they were going to catch air. CNA #2 would not follow them outside, Resident #1 could be so rude. In an interview with the surveyor on 3/12/18 at approximately 3:10 PM, LPN (Licensed Practical Nurse) #2 stated s/he was normally assigned to Resident #1. Resident #1 has had words and cussed LPN #2 out. Somebody reported to LPN #2 that Resident #1 was going out back smoking by him/herself. LPN #2 asked the resident about it and s/he cussed him/her out. It was reported to LPN #2 that the resident was out there at night. LPN #2 doesn't work nights so s/he never saw Resident #1 out there without staff. Resident #1 would sign him/herself out every day when s/he found out s/he could. S/he would ask the resident where s/he had been all that time. The resident would say walking around talking to people. S/he would be gone for an hour or so, a lot of times s/he would leave again on the same shift. LPN #2 stated it was about a month ago when Resident #1 found out s/he could sign him/herself out. That is when other residents found out about being able to sign themselves out too. They had a meeting with the residents and told them they were thinking about changing the smoking policy. That's when the residents found out they could sign themselves out. LPN #2 stated s/he guessed so they would know they could sign out and go smoke off the premises. A housekeeper usually takes the residents out for smoke breaks. That staff if responsible for keeping smoking materials. In an interview with the surveyor on 3/12/18 at approximately 3:40 PM, social services stated Resident #10, Resident #12, and Resident #1 claimed they were hiding their cigarettes and lighter. Social services stated they found cigarettes and lighters in Resident #8, Resident #12, Resident #7, and Resident #13's rooms. Staff would come tell social services or the housekeeping supervisor what they found. Housekeeping is in charge of smoke breaks and smoking materials. Social services would go and talk to the residents and remind them of the smoking policy. Social services was trying to get the residents to go to assisted living so they could smoke as they please. Social services stated there were multiple times they found smoking materials with Resident #8. The resident is [MEDICAL CONDITION] and will try to hide them from staff but s/he finds them. Social services saw Resident #11 through the window of another resident's room come outside to the courtyard area by therapy and pull out a cigarette and lighter and start to smoke. Staff tells social services that Resident #10, Resident #11, and Resident #8 will go outside at night to the smoking area or the facility parking lot and smoke unsupervised. Social services stated the administrator wanted the discharge letters given to the residents because they were not following the smoking policy. The residents told social services they had a meeting with the administrator and s/he told them if they wanted to smoke they could sign themselves out and go smoke off facility grounds. In an interview with the surveyor on 3/13/18 at approximately 12:40 PM, assistant director of environmental services stated smoke breaks are 10:30-11:30, 1:30-2:30, and 4:00-4:30. Those are the hours that have been in place for a while. Housekeeping or laundry usually go outside with the residents on smoke break. The smoking materials are kept in the storage closet, they are in a lock box. Surveyor observed area where smoking materials are kept. The key is hanging on the wall of the unit hallway between two doors near the storage room. The materials are kept in a cardboard box that has a note attached with the smoking times. In an interview with the surveyor on 3/13/18 at approximately 1:45 PM, social services stated s/he does not date or sign behind residents when s/he reviews the smoking policy with them. S/he has them initial or sign and keeps them in a folder in his/her office. Social services stated s/he issued four discharge notices, the ones provided. Social services stated that most of the time s/he does not document when s/he reeducates the residents on the smoking policy when they are found with smoking materials. Social services does not provide a copy of the smoking policy to the residents or responsible parties. In an interview with the surveyor on 3/13/18 at approximately 3:15 PM, the ADON (Assistant Director of Nursing) stated all of a sudden, several residents started signing themselves out so they would not be restricted to the scheduled smoke breaks. The ADON stated if staff suspects a resident has smoking materials, they get social services. Social services gets another administrative person to check with them. The nurse or social services should document if a resident has smoking materials. They don't complete incident reports if they find smoking materials. S/he knows residents have had smoking materials and it has been confiscated. The ADON does not remember who or when. They will ask residents if they have anything, ask if they can look in a drawer maybe. They don't search the whole room. There are no time limits for signing out. The residents should be signed out and back in by the nurse. The ADON stated s/he was not sure the residents were educated that they need to sign back in and let the nurse know. Whoever told them about being able to sign out should have also told them they need to let the nurse know they are back. The ADON stated s/he is not sure who told the residents about signing out and not sure they educated them on signing back in. Review of the facility's Safe Smoking Policy revealed that all residents who smoke will receive supervision while smoking and practice safe smoking habits. All residents who smoke are required to wear a protective smoking apron and are supervised while smoking. Staff members maintain all smoking material for residents who smoke; e.g., cigarettes, pipes, lighters, lighter fluid, etc. Staff members will distribute smoking materials to residents at smoking times. Smoking occurs in designated locations that are environmentally separate from all resident care areas. Violation of the smoking policy is an endangerment to the health and safety of residents. First infractions will consist of a verbal warning to both the resident and their responsible party. A second infraction of the smoking policy will result in a notice of discharge. Documentation included the progress notes reflect any warning issued for an infraction of the smoking policy. Review of the facility's policy on Signing Residents Out revealed all residents leaving the premises must be signed out. Staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once. Residents must be signed in upon return to the facility. On 3/14/18 at approximately 12:30 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0658 at a scope and severity of K. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on December, 7, 2017.

Based on review of facility files and interview, the facility failed to develop and implement a comprehensive person centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Care plans related to safe smoking were not followed for Resident #1, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12. These residents were noted with smoking materials on facility grounds and/or smoke unsupervised on facility grounds. 7 of 12 residents reviewed for care plans. The findings included: Review of Resident #1's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] indicated the resident was an unsafe smoker. The degree of supervision needed while smoking was not checked, with choices being occasional, frequent, and constant. There was no additional Safe Smoking Assessment completed when the resident started smoking at the facility. Review of Resident #1's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #1's Progress Notes, including Nursing and Social Services, from 11/1/17-3/7/18. The Nurses' Note dated 11/9/17 indicated the resident was seen by the physician and order was written that Resident #1 may smoke 2-3 cigarettes daily with supervision. There were no additional Nurses' Notes related to the resident smoking. On 1/24/18 social services documented nursing reported Resident #1 was increasingly verbally aggressive and using profanity directed at nurses when they speak to him/her about building policies and rules s/he is not complying with. There was no documentation of what policies the resident was not complying with. On 2/28/18 social services documented the resident leaves the building for social leaves almost every day. Discharge plan but in 30 day discharge notice period now and seeking alternative arrangements for living. Review of Resident #7's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 12/14/17. The assessment indicated the resident was an unsafe smoker related to being forgetful at times. The degree of supervision needed while smoking was noted as constant. Review of Resident #7's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #7's Progress Notes, including Nursing and Social Services, from 11/28/17-3/4/18. There was no documentation related to the resident smoking. Review of Resident #8's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 9/5/17 indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of the resident's Release of Responsibility for Leave of Absence revealed the resident signed him/herself out on 2/4/18 and 2/9/18. The time in was not completed for the leave of absence on 2/9/18. Review of Resident #8's care plan revealed resident has episodes of physical/verbal aggression toward staff and has episodes of being noncompliant with care and also smoking during non-regulation times to smoke and also having lighters and cigarettes without informing staff. Interventions and approaches were noted on the care plan and included give resident limited amount of cigarettes and provide lighter, encourage resident to return lighter. Review of Resident #8's care plan also revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #8's Progress Notes, including Nursing and Social Services, from 11/9/17-2/27/18. The social services note dated 12/7/17 indicated the resident had increased episodes of physical and verbal aggression, as well as resistiveness to care and smoking cigarettes and lighters s/he gets into the facility without telling anyone and smoking outside of regulated times. There was no other documentation related to the resident smoking. Review of Resident #9's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 11/8/17 indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of Resident #9's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, remind resident to return cigarettes and lighter back to nurses station when not in use. Resident #9's Progress Notes, including Nursing and Social Service, were reviewed from 11/2/17-2/21/18. The Social Services note dated 1/2/18 indicated the resident went to the store over the weekend in his/her motorized wheelchair. Resident is not safe to go by him/herself but s/he is very strong willed. Resident stated that s/he told the nurse but s/he does not know who the nurse was. The social worker told the resident whenever s/he leaves the facility s/he has to sign out. The Social Services note dated 2/21/18 indicated Resident #9 was issued a 30 day discharge letter. S/he has been leaving the facility and not signing out as s/he has been told many times, s/he has cigarettes and lighter on him/her as evidenced of him/her smoking outside. It is a danger to the facility and other residents if s/he decides to light up in his/her room. There was no other documentation in the resident's Progress Notes related to the resident smoking or having smoking materials. Review of Resident #10's medical revealed the resident's most current Safe Smoking assessment dated [DATE] indicated the resident was assessed as an unsafe smoker. The degree of supervision needed while smoking was constant. Review of Resident #10's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, and smoking materials will be kept in locked areas when not in use. Reviewed Resident #10's Progress Notes, including Nursing and Social Service, from 11/17/17-3/8/18. A nursing note dated 2/22/18 indicated the resident signed him/herself out several times this PM to go off property to smoke. A social services note dated 3/8/18 indicated Resident #10 continues to have smoking items on him/her after many times of advising him/her about the smoking policy. Resident goes outside several times a day to smoke at one point s/he told me that s/he has his/her cigarettes and lighter hidden somewhere off the property. Review of Resident #11's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE]. The assessment indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of Resident #11's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, remind resident to return cigarettes and lighter back to nurses station when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #11's Progress Notes, including Nursing and Social Services, from 11/1/17-3/13/18. There was no documentation related to the resident smoking. Review of Resident #12's medical record revealed the resident's had a Safe Smoking Assessment that was not dated. The assessment indicated the resident was a safe smoker. The degree of supervision needed while smoking was not indicated, with the choices being occasional, frequent, or constant. Review of Resident #12's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, remind resident to return cigarettes and lighter back to nurses station when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #12's Progress Notes, including Nursing and Social Services, from 11/2/17-3/9/18. There was a Nurses' Note dated 3/7/18 at 6:09 PM that indicated the resident left the facility without letting the nurses or any other staff know about him/her leaving and did not sign him/herself out. Review of the Nurses' Note dated 2/18/18 at 6:14 PM reveled at approximately 4:10 PM a staff member witnessed Resident #12 leaving the facility without signing out. Resident went to the store in his/her wheelchair as witnessed by a staff member using the busy street as a route. Resident returned at 4:30 PM. The Social Services note dated 3/8/18 indicated resident continues to not follow the rules of the facility. Resident #12 leaves the premises to smoke and s/he does not sign out and s/he has smoking item on him/her. Social worker, unit manager, and Director of Nursing have spoken with him/her on many occasions on these issues but s/he has decided that s/he is going to do what s/he wants to do. In an interview with the surveyor on 3/14/18 at approximately 11:35 AM, the activities director stated s/he has been at the facility over [AGE] years. The activities director stated s/he knows there have been some lighters confiscated by social services. The smoking policy was discussed at a meeting recently with residents, s/he thinks January. The residents felt they should be able to smoke whenever they want. In an interview with the surveyor on 3/12/18 at approximately 2:35 PM, CNA (Certified Nursing Aide) #1 stated s/he worked with Resident #1 from time to time. The resident signed out a lot and would go to the grocery store. CNA #1 stated s/he has seen Resident #1 outside smoking in the smoking area when it wasn't scheduled smoking times. Resident #8 would also be out there with the resident. Resident #1 and Resident #8 would be smoking. There would be no staff with them, they would not tell anyone they were going out there. Staff would have to go searching for them. They would go out to the smoking area, but by themselves. The smoking area is off the back of unit 4. CNA #1 stated s/he would assume Resident #1 and Resident #8 had the cigarettes and lighters since there was no staff with them. In an interview with the surveyor on 3/12/18 at approximately 2:50 PM, CNA #2 stated sometime you could smell smoke in the room and s/he would ask Resident #1 where s/he was smoking at, and the resident would get mad at him/her. CNA #1 tried to not ask Resident #1 about things because of how s/he would act. CNA #1 never caught the resident smoking in his/her room. CNA #1 would see Resident #1, Resident #8, and sometimes Resident #9 would go outside to the smoking area unsupervised. They would say they were going to catch air. CNA #2 would not follow them outside, Resident #1 could be so rude. In an interview with the surveyor on 3/12/18 at approximately 3:10 PM, LPN (Licensed Practical Nurse) #2 stated s/he was normally assigned to Resident #1. Resident #1 has had words and cussed LPN #2 out. Somebody reported to LPN #2 that Resident #1 was going out back smoking by him/herself. LPN #2 asked the resident about it and s/he cussed him/her out. It was reported to LPN #2 that the resident was out there at night. LPN #2 doesn't work nights so s/he never saw Resident #1 out there without staff. Resident #1 would sign him/herself out every day when s/he found out s/he could. S/he would ask the resident where s/he had been all that time. The resident would say walking around talking to people. S/he would be gone for an hour or so, a lot of times s/he would leave again on the same shift. LPN #2 stated it was about a month ago when Resident #1 found out s/he could sign him/herself out. That is when other residents found out about being able to sign themselves out too. They had a meeting with the residents and told them they were thinking about changing the smoking policy. That's when the residents found out they could sign themselves out. LPN #2 stated s/he guessed so they would know they could sign out and go smoke off the premises. A housekeeper usually takes the residents out for smoke breaks. That staff if responsible for keeping smoking materials. In an interview with the surveyor on 3/12/18 at approximately 3:40 PM, social services stated Resident #10, Resident #12, and Resident #1 claimed they were hiding their cigarettes and lighter. Social services stated they found cigarettes and lighters in Resident #8, Resident #12, Resident #7, and Resident #13's rooms. Staff would come tell social services or the housekeeping supervisor what they found. Housekeeping is in charge of smoke breaks and smoking materials. Social services would go and talk to the residents and remind them of the smoking policy. Social services was trying to get the residents to go to assisted living so they could smoke as they please. Social services stated there were multiple times they found smoking materials with Resident #8. The resident is [MEDICAL CONDITION] and will try to hide them from staff but s/he finds them. Social services saw Resident #11 through the window of another resident's room come outside to the courtyard area by therapy and pull out a cigarette and lighter and start to smoke. Staff tells social services that Resident #10, Resident #11, and Resident #8 will go outside at night to the smoking area or the facility parking lot and smoke unsupervised. Social services stated the administrator wanted the discharge letters given to the residents because they were not following the smoking policy. The residents told social services they had a meeting with the administrator and s/he told them if they wanted to smoke they could sign themselves out and go smoke off facility grounds. On 3/14/18 at approximately 12:30 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0656 at a scope and severity of K. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on December, 7, 2017.

Based on review of facility files and interview, administration failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Resident #1, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12 were noted to having smoking materials and/or smoke unsupervised on facility grounds. Staff failed to intervene and/or document the incidents so that behavior could be monitored. Administration failed to document the smoking policy was enforced for the residents found not to follow the policy. 7 of 12 residents reviewed for administration. The findings included: Review of Resident #1's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] indicated the resident was an unsafe smoker. The degree of supervision needed while smoking was noted checked, with choices being occasional, frequent, and constant. There was no additional Safe Smoking Assessment completed when the resident started smoking at the facility. Review of Resident #1's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #1's Progress Notes, including Nursing and Social Services, from 11/1/17-3/7/18. The Nurses' Note dated 11/9/17 indicated the resident was seen by the physician and order was written that Resident #1 may smoke 2-3 cigarettes daily with supervision. There were no additional Nurses' Notes related to the resident smoking. On 1/24/18 social services documented nursing reported Resident #1 was increasingly verbally aggressive and using profanity directed at nurses when they speak to him/her about building policies and rules s/he is not complying with. There was no documentation of what policies the resident was not complying with. On 2/28/18 social services documented the resident leaves the building for social leaves almost every day. Discharge plan but in 30 day discharge notice period now and seeking alternative arrangements for living. There was no Safe Smoking Practices policy signed by Resident #1. The resident's Release of Responsibility for Leave Of Absence forms were signed with no indication of time out or time in 54 times. Review of the Notice of Resident Transfer or Discharge form revealed Resident #1 was issued a notice and the date of notice was not completed. The facility administrator and resident signed the notice on 2/21/18. The notice indicated Resident #1 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility. The resident's health had also improved sufficiently that the resident no longer needs the services provided by this facility. Review of Resident #7's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 12/14/17. The assessment indicated the resident was an unsafe smoker related to being forgetful at times. The degree of supervision needed while smoking was noted as constant. Review of Resident #7's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #7's Progress Notes, including Nursing and Social Services, from 11/28/17-3/4/18. There was no documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's name on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #8's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 9/5/17 indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of the resident's Release of Responsibility for Leave of Absence revealed the resident signed him/herself out on 2/4/18 and 2/9/18. The time in was not completed for the leave of absence on 2/9/18. Review of Resident #8's care plan revealed resident has episodes of physical/verbal aggression toward staff and has episodes of being noncompliant with care and also smoking during non-regulation times to smoke and also having lighters and cigarettes without informing staff. Interventions and approaches were noted on the care plan and included give resident limited amount of cigarettes and provide lighter, encourage resident to return lighter. Review of Resident #8's care plan also revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #8's Progress Notes, including Nursing and Social Services, from 11/9/17-2/27/18. The social services note dated 12/7/17 indicated the resident had increased episodes of physical and verbal aggression, as well as resistiveness to care and smoking cigarettes and lighters s/he gets into the facility without telling anyone and smoking outside of regulated times. There was no other documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #9's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 11/8/17 indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of the physician progress notes [REDACTED]. Resident #9 was of course not happy about this. Review of the Release of Responsibility for Leave of Absence form revealed Resident #9 signed him/herself out on 2/9/18, 2/17/18, and 2/21/18. The time out was not indicated on 2/17/18 and the time in was not indicated on any of the dates. There were no receiving nurse initials noted on those dates. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #9's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, remind resident to return cigarettes and lighter back to nurses station when not in use. Resident #9's Progress Notes, including Nursing and Social Service, were reviewed from 11/2/17-2/21/18. The Social Services note dated 1/2/18 indicated the resident went to the store over the weekend in his/her motorized wheelchair. Resident is not safe to go by him/herself but s/he is very strong willed. Resident stated that s/he told the nurse but s/he does not know who the nurse was. The social worker told the resident whenever s/he leaves the facility s/he has to sign out. The Social Services note dated 2/21/18 indicated Resident #9 was issued a 30 day discharge letter. S/he has been leaving the facility and not signing out as s/he has been told many times, s/he has cigarettes and lighter on him/her as evidenced of him/her smoking outside. It is a danger to the facility and other residents if s/he decides to light up in his/her room. There was no other documentation in the resident's Progress Notes related to the resident smoking or having smoking materials. Review of the Notice of Resident Transfer or Discharge form revealed Resident #9 was issued a notice and the date of notice was not completed. The facility administrator and resident signed the notice on 2/21/18. The notice indicated Resident #9 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility and the resident's health had improved sufficiently that the resident no longer needs the services provided by the facility. Review of Resident #10's medical revealed the resident's most current Safe Smoking assessment dated [DATE] indicated the resident was assessed as an unsafe smoker. The degree of supervision needed while smoking was constant. Social Services staff provided a Safe Smoking Policy with the resident's name written on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. The form indicated the resident does not smoke. Review of the Notice of Resident Transfer or Discharge form revealed Resident #10 was issued and the date of notice was 2/21/18. The facility administrator signed the notice on 2/21/18. The resident refused to sign the form. The notice indicated Resident #10 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility and the resident's health had improved sufficiently that the resident no longer needs the services provided by the facility. Review of Resident #10's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, and smoking materials will be kept in locked areas when not in use. Review of Resident #10's medical record revealed the resident signed him/herself out 27 times between 2/6/18- 3/12/18. The documentation indicated only one time and did not note if it was when the resident signed in or out. Reviewed Resident #10's Progress Notes, including Nursing and Social Service, from 11/17/17-3/8/18. A nursing note dated 2/22/18 indicated the resident signed him/herself out several times this PM to go off property to smoke. A social services note dated 3/8/18 indicated Resident #10 continues to have smoking items on him/her after many times of advising him/her about the smoking policy. Resident goes outside several times a day to smoke at one point s/he told me that s/he has his/her cigarettes and lighter hidden somewhere off the property. Review of Resident #11's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE]. The assessment indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of Resident #11's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, remind resident to return cigarettes and lighter back to nurses station when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #11's Progress Notes, including Nursing and Social Services, from 11/1/17-3/13/18. There was no documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #12's medical record revealed the resident's had a Safe Smoking Assessment that was not dated. The assessment indicated the resident was a safe smoker. The degree of supervision needed while smoking was not indicated, with the choices being occasional, frequent, or constant. Review of Resident #12's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, remind resident to return cigarettes and lighter back to nurses station when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #12's Progress Notes, including Nursing and Social Services, from 11/2/17-3/9/18. There was a Nurses' Note dated 3/7/18 at 6:09 PM that indicated the resident left the facility without letting the nurses or any other staff know about him/her leaving and did not sign him/herself out. Review of the Nurses' Note dated 2/18/18 at 6:14 PM reveled at approximately 4:10 PM a staff member witnessed Resident #12 leaving the facility without signing out. Resident went to the store in his/her wheelchair as witnessed by a staff member using the busy street as a route. Resident returned at 4:30 PM. The Social Services note dated 3/8/18 indicated resident continues to not follow the rules of the facility. Resident #12 leaves the premises to smoke and s/he does not sign out and s/he has smoking item on him/her. Social worker, unit manager, and Director of Nursing have spoken with him/her on many occasions on these issues but s/he has decided that s/he is going to do what s/he wants to do. Social Services staff provided a Safe Smoking Policy with the resident's signature on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #12's Release of Responsibility for Leave of Absence form revealed the resident signed him/herself out 21 times between 2/15/18-3/12/18. There were 19 times the time out or time in was not documented on the form. The receiving nurse did not initial the form 12 times when the resident went on a leave of absence from the facility. Review of the Notice of Resident Transfer or Discharge form revealed Resident #12 was issued a notice and the date of notice was 2/21/18. The facility administrator and resident signed the notice on 2/21/18. The notice indicated Resident #10 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility. The surveyor observed the facility parking lot and route to the store next door. There is no curb with no wheelchair access around the parking lot of the facility that goes from the building to the four lane road where the building sits. There is an abandoned building beside the facility and the store is next to that building. There is no access to the abandoned building with the location of the curb and trees around the facility. There is no sidewalk along the road between the facility and the store. In an interview with the surveyor on 3/14/18 at approximately 11:35 AM, the activities director stated s/he has been at the facility over [AGE] years. The activities director stated s/he knows there have been some lighters confiscated by social services. The smoking policy was discussed at a meeting recently with residents, s/he thinks January. The residents felt they should be able to smoke whenever they want. In an interview with the surveyor on 3/13/18 at approximately 12:20 PM, social services stated there were 2 smoking residents that do not have a signed/initialed smoking policy. Those residents were not smoking when they were admitted to the facility. If they decide to start smoking while at the facility, nursing does an assessment and notifies social services so s/he can educate the resident on the smoking policy. Social services goes and talks with the resident but does not have them sign the form that they have been educated on the smoking policy. The resident does have to sign the policy on admission if they smoke when they come in. In an interview with the surveyor on 3/12/18 at approximately 2:35 PM, CNA (Certified Nursing Aide) #1 stated s/he worked with Resident #1 from time to time. The resident signed out a lot and would go to the grocery store. CNA #1 stated s/he has seen Resident #1 outside smoking in the smoking area when it wasn't scheduled smoking times. Resident #8 would also be out there with the resident. Resident #1 and Resident #8 would be smoking. There would be no staff with them, they would not tell anyone they were going out there. Staff would have to go searching for them. They would go out to the smoking area, but by themselves. The smoking area is off the back of unit 4. CNA #1 stated s/he would assume Resident #1 and Resident #8 had the cigarettes and lighters since there was no staff with them. In an interview with the surveyor on 3/12/18 at approximately 2:50 PM, CNA #2 stated sometime you could smell smoke in the room and s/he would ask Resident #1 where s/he was smoking at, and the resident would get mad at him/her. CNA #1 tried to not ask Resident #1 about things because of how s/he would act. CNA #1 never caught the resident smoking in his/her room. CNA #1 would see Resident #1, Resident #8, and sometimes Resident #9 would go outside to the smoking area unsupervised. They would say they were going to catch air. CNA #2 would not follow them outside, Resident #1 could be so rude. In an interview with the surveyor on 3/12/18 at approximately 3:10 PM, LPN (Licensed Practical Nurse) #2 stated s/he was normally assigned to Resident #1. Resident #1 has had words and cussed LPN #2 out. Somebody reported to LPN #2 that Resident #1 was going out back smoking by him/herself. LPN #2 asked the resident about it and s/he cussed him/her out. It was reported to LPN #2 that the resident was out there at night. LPN #2 doesn't work nights so s/he never saw Resident #1 out there without staff. Resident #1 would sign him/herself out every day when s/he found out s/he could. S/he would ask the resident where s/he had been all that time. The resident would say walking around talking to people. S/he would be gone for an hour or so, a lot of times s/he would leave again on the same shift. LPN #2 stated it was about a month ago when Resident #1 found out s/he could sign him/herself out. That is when other residents found out about being able to sign themselves out too. They had a meeting with the residents and told them they were thinking about changing the smoking policy. That's when the residents found out they could sign themselves out. LPN #2 stated s/he guessed so they would know they could sign out and go smoke off the premises. A housekeeper usually takes the residents out for smoke breaks. That staff if responsible for keeping smoking materials. In an interview with the surveyor on 3/12/18 at approximately 3:40 PM, social services stated Resident #10, Resident #12, and Resident #1 claimed they were hiding their cigarettes and lighter. Social services stated they found cigarettes and lighters in Resident #8, Resident #12, Resident #7, and Resident #13's rooms. Staff would come tell social services or the housekeeping supervisor what they found. Housekeeping is in charge of smoke breaks and smoking materials. Social services would go and talk to the residents and remind them of the smoking policy. Social services was trying to get the residents to go to assisted living so they could smoke as they please. Social services stated there were multiple times they found smoking materials with Resident #8. The resident is [MEDICAL CONDITION] and will try to hide them from staff but s/he finds them. Social services saw Resident #11 through the window of another resident's room come outside to the courtyard area by therapy and pull out a cigarette and lighter and start to smoke. Staff tells social services that Resident #10, Resident #11, and Resident #8 will go outside at night to the smoking area or the facility parking lot and smoke unsupervised. Social services stated the administrator wanted the discharge letters given to the residents because they were not following the smoking policy. The residents told social services they had a meeting with the administrator and s/he told them if they wanted to smoke they could sign themselves out and go smoke off facility grounds. In an interview with the surveyor on 3/13/18 at approximately 12:40 PM, assistant director of environmental services stated smoke breaks are 10:30-11:30, 1:30-2:30, and 4:00-4:30. Those are the hours that have been in place for a while. Housekeeping or laundry usually go outside with the residents on smoke break. The smoking materials are kept in the storage closet, they are in a lock box. Surveyor observed area where smoking materials are kept. The key is hanging on the wall of the unit hallway between two doors near the storage room. The materials are kept in a cardboard box that has a note attached with the smoking times. In an interview with the surveyor on 3/13/18 at approximately 1:45 PM, social services stated s/he does not date or sign behind residents when s/he reviews the smoking policy with them. S/he has them initial or sign and keeps them in a folder in his/her office. Social services stated s/he issued four discharge notices, the ones provided. Social services stated that most of the time s/he does not document when s/he reeducates the residents on the smoking policy when they are found with smoking materials. Social services does not provide a copy of the smoking policy to the residents or responsible parties. In an interview with the surveyor on 3/13/18 at approximately 3:15 PM, the ADON (Assistant Director of Nursing) stated all of a sudden, several residents started signing themselves out so they would not be restricted to the scheduled smoke breaks. The ADON stated if staff suspects a resident has smoking materials, they get social services. Social services gets another administrative person to check with them. The nurse or social services should document if a resident has smoking materials. They don't complete incident reports if they find smoking materials. S/he knows residents have had smoking materials and it has been confiscated. The ADON does not remember who or when. They will ask residents if they have anything, ask if they can look in a drawer maybe. They don't search the whole room. There are no time limits for signing out. The residents should be signed out and back in by the nurse. The ADON stated s/he was not sure the residents were educated that they need to sign back in and let the nurse know. Whoever told them about being able to sign out should have also told them they need to let the nurse know they are back. The ADON stated s/he is not sure who told the residents about signing out and not sure they educated them on signing back in. Review of the facility's Safe Smoking Policy revealed that all residents who smoke will receive supervision while smoking and practice safe smoking habits. All residents who smoke are required to wear a protective smoking apron and are supervised while smoking. Staff members maintain all smoking material for residents who smoke; e.g., cigarettes, pipes, lighters, lighter fluid, etc. Staff members will distribute smoking materials to residents at smoking times. Smoking occurs in designated locations that are environmentally separate from all resident care areas. Violation of the smoking policy is an endangerment to the health and safety of residents. First infractions will consist of a verbal warning to both the resident and their responsible party. A second infraction of the smoking policy will result in a notice of discharge. Documentation included the progress notes reflect any warning issued for an infraction of the smoking policy. On 3/14/18 at approximately 12:30 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0[AGE]5 at a scope and severity of K. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on December, 7, 2017.

Based on review of facility files and interview, the facility failed to maintain medical records on each resident that are accurately documented and complete. Resident #1, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12 were noted to having smoking materials and/or smoke unsupervised on facility grounds. Staff failed to document the incidents so that the residents' behavior could be monitored. The surveyor noted that the resident leave of absence forms where not completed with time out and time in for all residents who signed themselves out. 7 of 12 residents reviewed for medical records. The findings included: Review of Resident #1's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] indicated the resident was an unsafe smoker. The degree of supervision needed while smoking was not checked, with choices being occasional, frequent, and constant. There was no additional Safe Smoking Assessment completed when the resident started smoking at the facility. Review of Resident #1's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #1's Progress Notes, including Nursing and Social Services, from 11/1/17-3/7/18. The Nurses' Note dated 11/9/17 indicated the resident was seen by the physician and order was written that Resident #1 may smoke 2-3 cigarettes daily with supervision. There were no additional Nurses' Notes related to the resident smoking. On 1/24/18 social services documented nursing reported Resident #1 was increasingly verbally aggressive and using profanity directed at nurses when they speak to him/her about building policies and rules s/he is not complying with. There was no documentation of what policies the resident was not complying with. On 2/28/18 social services documented the resident leaves the building for social leaves almost every day. Discharge plan but in 30 day discharge notice period now and seeking alternative arrangements for living. There was no Safe Smoking Practices policy signed by Resident #1. The resident's Release of Responsibility for Leave Of Absence forms were signed with no indication of time out or time in 54 times. Review of Resident #7's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 12/14/17. The assessment indicated the resident was an unsafe smoker related to being forgetful at times. The degree of supervision needed while smoking was noted as constant. Review of Resident #7's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #7's Progress Notes, including Nursing and Social Services, from 11/28/17-3/4/18. There was no documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's name on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #8's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 9/5/17 indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of the resident's Release of Responsibility for Leave of Absence revealed the resident signed him/herself out on 2/4/18 and 2/9/18. The time in was not completed for the leave of absence on 2/9/18. Review of Resident #8's care plan revealed resident has episodes of physical/verbal aggression toward staff and has episodes of being noncompliant with care and also smoking during non-regulation times to smoke and also having lighters and cigarettes without informing staff. Interventions and approaches were noted on the care plan and included give resident limited amount of cigarettes and provide lighter, encourage resident to return lighter. Review of Resident #8's care plan also revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #8's Progress Notes, including Nursing and Social Services, from 11/9/17-2/27/18. The social services note dated 12/7/17 indicated the resident had increased episodes of physical and verbal aggression, as well as resistiveness to care and smoking cigarettes and lighters s/he gets into the facility without telling anyone and smoking outside of regulated times. There was no other documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #9's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 11/8/17 indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of the physician progress notes [REDACTED]. Resident #9 was of course not happy about this. Review of the Release of Responsibility for Leave of Absence form revealed Resident #9 signed him/herself out on 2/9/18, 2/17/18, and 2/21/18. The time out was not indicated on 2/17/18 and the time in was not indicated on any of the dates. There were no receiving nurse initials noted on those dates. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #9's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, remind resident to return cigarettes and lighter back to nurses station when not in use. Resident #9's Progress Notes, including Nursing and Social Service, were reviewed from 11/2/17-2/21/18. The Social Services note dated 1/2/18 indicated the resident went to the store over the weekend in his/her motorized wheelchair. Resident is not safe to go by him/herself but s/he is very strong willed. Resident stated that s/he told the nurse but s/he does not know who the nurse was. The social worker told the resident whenever s/he leaves the facility s/he has to sign out. The Social Services note dated 2/21/18 indicated Resident #9 was issued a 30 day discharge letter. S/he has been leaving the facility and not signing out as s/he has been told many times, s/he has cigarettes and lighter on him/her as evidenced of him/her smoking outside. It is a danger to the facility and other residents if s/he decides to light up in his/her room. There was no other documentation in the resident's Progress Notes related to the resident smoking or having smoking materials. Review of Resident #10's medical revealed the resident's most current Safe Smoking assessment dated [DATE] indicated the resident was assessed as an unsafe smoker. The degree of supervision needed while smoking was constant. Social Services staff provided a Safe Smoking Policy with the resident's name written on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. The form indicated the resident does not smoke. Review of Resident #10's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, and smoking materials will be kept in locked areas when not in use. Review of Resident #10's medical record revealed the resident signed him/herself out 27 times between 2/6/18- 3/12/18. The documentation indicated only one time and did not note if it was when the resident signed in or out. Reviewed Resident #10's Progress Notes, including Nursing and Social Service, from 11/17/17-3/8/18. A nursing note dated 2/22/18 indicated the resident signed him/herself out several times this PM to go off property to smoke. A social services note dated 3/8/18 indicated Resident #10 continues to have smoking items on him/her after many times of advising him/her about the smoking policy. Resident goes outside several times a day to smoke at one point s/he told me that s/he has his/her cigarettes and lighter hidden somewhere off the property. Review of Resident #11's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE]. The assessment indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of Resident #11's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, remind resident to return cigarettes and lighter back to nurses station when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #11's Progress Notes, including Nursing and Social Services, from 11/1/17-3/13/18. There was no documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #12's medical record revealed the resident's had a Safe Smoking Assessment that was not dated. The assessment indicated the resident was a safe smoker. The degree of supervision needed while smoking was not indicated, with the choices being occasional, frequent, or constant. Review of Resident #12's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, remind resident to return cigarettes and lighter back to nurses station when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #12's Progress Notes, including Nursing and Social Services, from 11/2/17-3/9/18. There was a Nurses' Note dated 3/7/18 at 6:09 PM that indicated the resident left the facility without letting the nurses or any other staff know about him/her leaving and did not sign him/herself out. Review of the Nurses' Note dated 2/18/18 at 6:14 PM reveled at approximately 4:10 PM a staff member witnessed Resident #12 leaving the facility without signing out. Resident went to the store in his/her wheelchair as witnessed by a staff member using the busy street as a route. Resident returned at 4:30 PM. The Social Services note dated 3/8/18 indicated resident continues to not follow the rules of the facility. Resident #12 leaves the premises to smoke and s/he does not sign out and s/he has smoking item on him/her. Social worker, unit manager, and Director of Nursing have spoken with him/her on many occasions on these issues but s/he has decided that s/he is going to do what s/he wants to do. Social Services staff provided a Safe Smoking Policy with the resident's signature on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #12's Release of Responsibility for Leave of Absence form revealed the resident signed him/herself out 21 times between 2/15/18-3/12/18. There were 19 times the time out or time in was not documented on the form. The receiving nurse did not initial the form 12 times when the resident went on a leave of absence from the facility. In an interview with the surveyor on 3/14/18 at approximately 11:35 AM, the activities director stated s/he has been at the facility over [AGE] years. The activities director stated s/he knows there have been some lighters confiscated by social services. The smoking policy was discussed at a meeting recently with residents, s/he thinks January. The residents felt they should be able to smoke whenever they want. In an interview with the surveyor on 3/13/18 at approximately 12:20 PM, social services stated there were 2 smoking residents that do not have a signed/initialed smoking policy. Those residents were not smoking when they were admitted to the facility. If they decide to start smoking while at the facility, nursing does an assessment and notifies social services so s/he can educate the resident on the smoking policy. Social services goes and talks with the resident but does not have them sign the form that they have been educated on the smoking policy. The resident does have to sign the policy on admission if they smoke when they come in. In an interview with the surveyor on 3/12/18 at approximately 2:35 PM, CNA (Certified Nursing Aide) #1 stated s/he worked with Resident #1 from time to time. The resident signed out a lot and would go to the grocery store. CNA #1 stated s/he has seen Resident #1 outside smoking in the smoking area when it wasn't scheduled smoking times. Resident #8 would also be out there with the resident. Resident #1 and Resident #8 would be smoking. There would be no staff with them, they would not tell anyone they were going out there. Staff would have to go searching for them. They would go out to the smoking area, but by themselves. The smoking area is off the back of unit 4. CNA #1 stated s/he would assume Resident #1 and Resident #8 had the cigarettes and lighters since there was no staff with them. In an interview with the surveyor on 3/12/18 at approximately 2:50 PM, CNA #2 stated sometime you could smell smoke in the room and s/he would ask Resident #1 where s/he was smoking at, and the resident would get mad at him/her. CNA #1 tried to not ask Resident #1 about things because of how s/he would act. CNA #1 never caught the resident smoking in his/her room. CNA #1 would see Resident #1, Resident #8, and sometimes Resident #9 would go outside to the smoking area unsupervised. They would say they were going to catch air. CNA #2 would not follow them outside, Resident #1 could be so rude. In an interview with the surveyor on 3/12/18 at approximately 3:10 PM, LPN (Licensed Practical Nurse) #2 stated s/he was normally assigned to Resident #1. Resident #1 has had words and cussed LPN #2 out. Somebody reported to LPN #2 that Resident #1 was going out back smoking by him/herself. LPN #2 asked the resident about it and s/he cussed him/her out. It was reported to LPN #2 that the resident was out there at night. LPN #2 doesn't work nights so s/he never saw Resident #1 out there without staff. Resident #1 would sign him/herself out every day when s/he found out s/he could. S/he would ask the resident where s/he had been all that time. The resident would say walking around talking to people. S/he would be gone for an hour or so, a lot of times s/he would leave again on the same shift. LPN #2 stated it was about a month ago when Resident #1 found out s/he could sign him/herself out. That is when other residents found out about being able to sign themselves out too. They had a meeting with the residents and told them they were thinking about changing the smoking policy. That's when the residents found out they could sign themselves out. LPN #2 stated s/he guessed so they would know they could sign out and go smoke off the premises. A housekeeper usually takes the residents out for smoke breaks. That staff if responsible for keeping smoking materials. In an interview with the surveyor on 3/12/18 at approximately 3:40 PM, social services stated Resident #10, Resident #12, and Resident #1 claimed they were hiding their cigarettes and lighter. Social services stated they found cigarettes and lighters in Resident #8, Resident #12, Resident #7, and Resident #13's rooms. Staff would come tell social services or the housekeeping supervisor what they found. Housekeeping is in charge of smoke breaks and smoking materials. Social services would go and talk to the residents and remind them of the smoking policy. Social services was trying to get the residents to go to assisted living so they could smoke as they please. Social services stated there were multiple times they found smoking materials with Resident #8. The resident is [MEDICAL CONDITION] and will try to hide them from staff but s/he finds them. Social services saw Resident #11 through the window of another resident's room come outside to the courtyard area by therapy and pull out a cigarette and lighter and start to smoke. Staff tells social services that Resident #10, Resident #11, and Resident #8 will go outside at night to the smoking area or the facility parking lot and smoke unsupervised. Social services stated the administrator wanted the discharge letters given to the residents because they were not following the smoking policy. The residents told social services they had a meeting with the administrator and s/he told them if they wanted to smoke they could sign themselves out and go smoke off facility grounds. In an interview with the surveyor on 3/13/18 at approximately 12:40 PM, assistant director of environmental services stated smoke breaks are 10:30-11:30, 1:30-2:30, and 4:00-4:30. Those are the hours that have been in place for a while. Housekeeping or laundry usually go outside with the residents on smoke break. The smoking materials are kept in the storage closet, they are in a lock box. Surveyor observed area where smoking materials are kept. The key is hanging on the wall of the unit hallway between two doors near the storage room. The materials are kept in a cardboard box that has a note attached with the smoking times. In an interview with the surveyor on 3/13/18 at approximately 1:45 PM, social services stated s/he does not date or sign behind residents when s/he reviews the smoking policy with them. S/he has them initial or sign and keeps them in a folder in his/her office. Social services stated s/he issued four discharge notices, the ones provided. Social services stated that most of the time s/he does not document when s/he reeducates the residents on the smoking policy when they are found with smoking materials. Social services does not provide a copy of the smoking policy to the residents or responsible parties. In an interview with the surveyor on 3/13/18 at approximately 3:15 PM, the ADON (Assistant Director of Nursing) stated all of a sudden, several residents started signing themselves out so they would not be restricted to the scheduled smoke breaks. The ADON stated if staff suspects a resident has smoking materials, they get social services. Social services gets another administrative person to check with them. The nurse or social services should document if a resident has smoking materials. They don't complete incident reports if they find smoking materials. S/he knows residents have had smoking materials and it has been confiscated. The ADON does not remember who or when. They will ask residents if they have anything, ask if they can look in a drawer maybe. They don't search the whole room. There are no time limits for signing out. The residents should be signed out and back in by the nurse. The ADON stated s/he was not sure the residents were educated that they need to sign back in and let the nurse know. Whoever told them about being able to sign out should have also told them they need to let the nurse know they are back. The ADON stated s/he is not sure who told the residents about signing out and not sure they educated them on signing back in. Review of the facility's Safe Smoking Policy revealed that all residents who smoke will receive supervision while smoking and practice safe smoking habits. All residents who smoke are required to wear a protective smoking apron and are supervised while smoking. Staff members maintain all smoking material for residents who smoke; e.g., cigarettes, pipes, lighters, lighter fluid, etc. Staff members will distribute smoking materials to residents at smoking times. Smoking occurs in designated locations that are environmentally separate from all resident care areas. Violation of the smoking policy is an endangerment to the health and safety of residents. First infractions will consist of a verbal warning to both the resident and their responsible party. A second infraction of the smoking policy will result in a notice of discharge. Documentation included the progress notes reflect any warning issued for an infraction of the smoking policy. Review of the facility's policy on Signing Residents Out revealed all residents leaving the premises must be signed out. Staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once. Residents must be signed in upon return to the facility. On 3/14/18 at approximately 12:30 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0[AGE]2 at a scope and severity of K. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on December, 7, 2017.

Based on review of facility files and interview, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies. Resident #1, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12 were noted to having smoking materials and/or smoke unsupervised on facility grounds. The facility failed to document monitoring of the residents' behavior. The facility failed to develop a plan of action to correct the deficiency. 7 of 7 residents reviewed for smoking. The findings included: Review of Resident #1's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] indicated the resident was an unsafe smoker. The degree of supervision needed while smoking was noted checked, with choices being occasional, frequent, and constant. There was no additional Safe Smoking Assessment completed when the resident started smoking at the facility. Review of Resident #1's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #1's Progress Notes, including Nursing and Social Services, from 11/1/17-3/7/18. The Nurses' Note dated 11/9/17 indicated the resident was seen by the physician and order was written that Resident #1 may smoke 2-3 cigarettes daily with supervision. There were no additional Nurses' Notes related to the resident smoking. On 1/24/18 social services documented nursing reported Resident #1 was increasingly verbally aggressive and using profanity directed at nurses when they speak to him/her about building policies and rules s/he is not complying with. There was no documentation of what policies the resident was not complying with. On 2/28/18 social services documented the resident leaves the building for social leaves almost every day. Discharge plan but in 30 day discharge notice period now and seeking alternative arrangements for living. There was no Safe Smoking Practices policy signed by Resident #1. The resident's Release of Responsibility for Leave Of Absence forms were signed with no indication of time out or time in 54 times. Review of the Notice of Resident Transfer or Discharge form revealed Resident #1 was issued a notice and the date of notice was not completed. The facility administrator and resident signed the notice on 2/21/18. The notice indicated Resident #1 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility. The resident's health had also improved sufficiently that the resident no longer needs the services provided by this facility. Review of Resident #7's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 12/14/17. The assessment indicated the resident was an unsafe smoker related to being forgetful at times. The degree of supervision needed while smoking was noted as constant. Review of Resident #7's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #7's Progress Notes, including Nursing and Social Services, from 11/28/17-3/4/18. There was no documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's name on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #8's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 9/5/17 indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of the resident's Release of Responsibility for Leave of Absence revealed the resident signed him/herself out on 2/4/18 and 2/9/18. The time in was not completed for the leave of absence on 2/9/18. Review of Resident #8's care plan revealed resident has episodes of physical/verbal aggression toward staff and has episodes of being noncompliant with care and also smoking during non-regulation times to smoke and also having lighters and cigarettes without informing staff. Interventions and approaches were noted on the care plan and included give resident limited amount of cigarettes and provide lighter, encourage resident to return lighter. Review of Resident #8's care plan also revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #8's Progress Notes, including Nursing and Social Services, from 11/9/17-2/27/18. The social services note dated 12/7/17 indicated the resident had increased episodes of physical and verbal aggression, as well as resistiveness to care and smoking cigarettes and lighters s/he gets into the facility without telling anyone and smoking outside of regulated times. There was no other documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #9's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 11/8/17 indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of the physician progress notes [REDACTED]. Resident #9 was of course not happy about this. Review of the Release of Responsibility for Leave of Absence form revealed Resident #9 signed him/herself out on 2/9/18, 2/17/18, and 2/21/18. The time out was not indicated on 2/17/18 and the time in was not indicated on any of the dates. There were no receiving nurse initials noted on those dates. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #9's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, remind resident to return cigarettes and lighter back to nurses station when not in use. Resident #9's Progress Notes, including Nursing and Social Service, were reviewed from 11/2/17-2/21/18. The Social Services note dated 1/2/18 indicated the resident went to the store over the weekend in his/her motorized wheelchair. Resident is not safe to go by him/herself but s/he is very strong willed. Resident stated that s/he told the nurse but s/he does not know who the nurse was. The social worker told the resident whenever s/he leaves the facility s/he has to sign out. The Social Services note dated 2/21/18 indicated Resident #9 was issued a 30 day discharge letter. S/he has been leaving the facility and not signing out as s/he has been told many times, s/he has cigarettes and lighter on him/her as evidenced of him/her smoking outside. It is a danger to the facility and other residents if s/he decides to light up in his/her room. There was no other documentation in the resident's Progress Notes related to the resident smoking or having smoking materials. Review of the Notice of Resident Transfer or Discharge form revealed Resident #9 was issued a notice and the date of notice was not completed. The facility administrator and resident signed the notice on 2/21/18. The notice indicated Resident #9 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility and the resident's health had improved sufficiently that the resident no longer needs the services provided by the facility. Review of Resident #10's medical revealed the resident's most current Safe Smoking assessment dated [DATE] indicated the resident was assessed as an unsafe smoker. The degree of supervision needed while smoking was constant. Social Services staff provided a Safe Smoking Policy with the resident's name written on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. The form indicated the resident does not smoke. Review of the Notice of Resident Transfer or Discharge form revealed Resident #10 was issued and the date of notice was 2/21/18. The facility administrator signed the notice on 2/21/18. The resident refused to sign the form. The notice indicated Resident #10 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility and the resident's health had improved sufficiently that the resident no longer needs the services provided by the facility. Review of Resident #10's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, and smoking materials will be kept in locked areas when not in use. Review of Resident #10's medical record revealed the resident signed him/herself out 27 times between 2/6/18- 3/12/18. The documentation indicated only one time and did not note if it was when the resident signed in or out. Reviewed Resident #10's Progress Notes, including Nursing and Social Service, from 11/17/17-3/8/18. A nursing note dated 2/22/18 indicated the resident signed him/herself out several times this PM to go off property to smoke. A social services note dated 3/8/18 indicated Resident #10 continues to have smoking items on him/her after many times of advising him/her about the smoking policy. Resident goes outside several times a day to smoke at one point s/he told me that s/he has his/her cigarettes and lighter hidden somewhere off the property. Review of Resident #11's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE]. The assessment indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of Resident #11's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, remind resident to return cigarettes and lighter back to nurses station when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #11's Progress Notes, including Nursing and Social Services, from 11/1/17-3/13/18. There was no documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #12's medical record revealed the resident's had a Safe Smoking Assessment that was not dated. The assessment indicated the resident was a safe smoker. The degree of supervision needed while smoking was not indicated, with the choices being occasional, frequent, or constant. Review of Resident #12's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, remind resident to return cigarettes and lighter back to nurses station when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #12's Progress Notes, including Nursing and Social Services, from 11/2/17-3/9/18. There was a Nurses' Note dated 3/7/18 at 6:09 PM that indicated the resident left the facility without letting the nurses or any other staff know about him/her leaving and did not sign him/herself out. Review of the Nurses' Note dated 2/18/18 at 6:14 PM reveled at approximately 4:10 PM a staff member witnessed Resident #12 leaving the facility without signing out. Resident went to the store in his/her wheelchair as witnessed by a staff member using the busy street as a route. Resident returned at 4:30 PM. The Social Services note dated 3/8/18 indicated resident continues to not follow the rules of the facility. Resident #12 leaves the premises to smoke and s/he does not sign out and s/he has smoking item on him/her. Social worker, unit manager, and Director of Nursing have spoken with him/her on many occasions on these issues but s/he has decided that s/he is going to do what s/he wants to do. Social Services staff provided a Safe Smoking Policy with the resident's signature on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #12's Release of Responsibility for Leave of Absence form revealed the resident signed him/herself out 21 times between 2/15/18-3/12/18. There were 19 times the time out or time in was not documented on the form. The receiving nurse did not initial the form 12 times when the resident went on a leave of absence from the facility. Review of the Notice of Resident Transfer or Discharge form revealed Resident #12 was issued a notice and the date of notice was 2/21/18. The facility administrator and resident signed the notice on 2/21/18. The notice indicated Resident #10 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility. The surveyor observed the facility parking lot and route to the store next door. There is no curb with no wheelchair access around the parking lot of the facility that goes from the building to the four lane road where the building sits. There is an abandoned building beside the facility and the store is next to that building. There is no access to the abandoned building with the location of the curb and trees around the facility. There is no sidewalk along the road between the facility and the store. In an interview with the surveyor on 3/14/18 at approximately 11:35 AM, the activities director stated s/he has been at the facility over [AGE] years. The activities director stated s/he knows there have been some lighters confiscated by social services. The smoking policy was discussed at a meeting recently with residents, s/he thinks January. The residents felt they should be able to smoke whenever they want. In an interview with the surveyor on 3/13/18 at approximately 12:20 PM, social services stated there were 2 smoking residents that do not have a signed/initialed smoking policy. Those residents were not smoking when they were admitted to the facility. If they decide to start smoking while at the facility, nursing does an assessment and notifies social services so s/he can educate the resident on the smoking policy. Social services goes and talks with the resident but does not have them sign the form that they have been educated on the smoking policy. The resident does have to sign the policy on admission if they smoke when they come in. In an interview with the surveyor on 3/12/18 at approximately 2:35 PM, CNA (Certified Nursing Aide) #1 stated s/he worked with Resident #1 from time to time. The resident signed out a lot and would go to the grocery store. CNA #1 stated s/he has seen Resident #1 outside smoking in the smoking area when it wasn't scheduled smoking times. Resident #8 would also be out there with the resident. Resident #1 and Resident #8 would be smoking. There would be no staff with them, they would not tell anyone they were going out there. Staff would have to go searching for them. They would go out to the smoking area, but by themselves. The smoking area is off the back of unit 4. CNA #1 stated s/he would assume Resident #1 and Resident #8 had the cigarettes and lighters since there was no staff with them. In an interview with the surveyor on 3/12/18 at approximately 2:50 PM, CNA #2 stated sometime you could smell smoke in the room and s/he would ask Resident #1 where s/he was smoking at, and the resident would get mad at him/her. CNA #1 tried to not ask Resident #1 about things because of how s/he would act. CNA #1 never caught the resident smoking in his/her room. CNA #1 would see Resident #1, Resident #8, and sometimes Resident #9 would go outside to the smoking area unsupervised. They would say they were going to catch air. CNA #2 would not follow them outside, Resident #1 could be so rude. In an interview with the surveyor on 3/12/18 at approximately 3:10 PM, LPN (Licensed Practical Nurse) #2 stated s/he was normally assigned to Resident #1. Resident #1 has had words and cussed LPN #2 out. Somebody reported to LPN #2 that Resident #1 was going out back smoking by him/herself. LPN #2 asked the resident about it and s/he cussed him/her out. It was reported to LPN #2 that the resident was out there at night. LPN #2 doesn't work nights so s/he never saw Resident #1 out there without staff. Resident #1 would sign him/herself out every day when s/he found out s/he could. S/he would ask the resident where s/he had been all that time. The resident would say walking around talking to people. S/he would be gone for an hour or so, a lot of times s/he would leave again on the same shift. LPN #2 stated it was about a month ago when Resident #1 found out s/he could sign him/herself out. That is when other residents found out about being able to sign themselves out too. They had a meeting with the residents and told them they were thinking about changing the smoking policy. That's when the residents found out they could sign themselves out. LPN #2 stated s/he guessed so they would know they could sign out and go smoke off the premises. A housekeeper usually takes the residents out for smoke breaks. That staff if responsible for keeping smoking materials. In an interview with the surveyor on 3/12/18 at approximately 3:40 PM, social services stated Resident #10, Resident #12, and Resident #1 claimed they were hiding their cigarettes and lighter. Social services stated they found cigarettes and lighters in Resident #8, Resident #12, Resident #7, and Resident #13's rooms. Staff would come tell social services or the housekeeping supervisor what they found. Housekeeping is in charge of smoke breaks and smoking materials. Social services would go and talk to the residents and remind them of the smoking policy. Social services was trying to get the residents to go to assisted living so they could smoke as they please. Social services stated there were multiple times they found smoking materials with Resident #8. The resident is [MEDICAL CONDITION] and will try to hide them from staff but s/he finds them. Social services saw Resident #11 through the window of another resident's room come outside to the courtyard area by therapy and pull out a cigarette and lighter and start to smoke. Staff tells social services that Resident #10, Resident #11, and Resident #8 will go outside at night to the smoking area or the facility parking lot and smoke unsupervised. Social services stated the administrator wanted the discharge letters given to the residents because they were not following the smoking policy. The residents told social services they had a meeting with the administrator and s/he told them if they wanted to smoke they could sign themselves out and go smoke off facility grounds. In an interview with the surveyor on 3/13/18 at approximately 12:40 PM, assistant director of environmental services stated smoke breaks are 10:30-11:30, 1:30-2:30, and 4:00-4:30. Those are the hours that have been in place for a while. Housekeeping or laundry usually go outside with the residents on smoke break. The smoking materials are kept in the storage closet, they are in a lock box. Surveyor observed area where smoking materials are kept. The key is hanging on the wall of the unit hallway between two doors near the storage room. The materials are kept in a cardboard box that has a note attached with the smoking times. In an interview with the surveyor on 3/13/18 at approximately 1:45 PM, social services stated s/he does not date or sign behind residents when s/he reviews the smoking policy with them. S/he has them initial or sign and keeps them in a folder in his/her office. Social services stated s/he issued four discharge notices, the ones provided. Social services stated that most of the time s/he does not document when s/he reeducates the residents on the smoking policy when they are found with smoking materials. Social services does not provide a copy of the smoking policy to the residents or responsible parties. In an interview with the surveyor on 3/13/18 at approximately 3:15 PM, the ADON (Assistant Director of Nursing) stated all of a sudden, several residents started signing themselves out so they would not be restricted to the scheduled smoke breaks. The ADON stated if staff suspects a resident has smoking materials, they get social services. Social services gets another administrative person to check with them. The nurse or social services should document if a resident has smoking materials. They don't complete incident reports if they find smoking materials. S/he knows residents have had smoking materials and it has been confiscated. The ADON does not remember who or when. They will ask residents if they have anything, ask if they can look in a drawer maybe. They don't search the whole room. There are no time limits for signing out. The residents should be signed out and back in by the nurse. The ADON stated s/he was not sure the residents were educated that they need to sign back in and let the nurse know. Whoever told them about being able to sign out should have also told them they need to let the nurse know they are back. The ADON stated s/he is not sure who told the residents about signing out and not sure they educated them on signing back in. Review of the facility's Safe Smoking Policy revealed that all residents who smoke will receive supervision while smoking and practice safe smoking habits. All residents who smoke are required to wear a protective smoking apron and are supervised while smoking. Staff members maintain all smoking material for residents who smoke; e.g., cigarettes, pipes, lighters, lighter fluid, etc. Staff members will distribute smoking materials to residents at smoking times. Smoking occurs in designated locations that are environmentally separate from all resident care areas. Violation of the smoking policy is an endangerment to the health and safety of residents. First infractions will consist of a verbal warning to both the resident and their responsible party. A second infraction of the smoking policy will result in a notice of discharge. Documentation included the progress notes reflect any warning issued for an infraction of the smoking policy. Review of the facility's policy on Signing Residents Out revealed all residents leaving the premises must be signed out. Staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once. Residents must be signed in upon return to the facility. On 3/14/18 at approximately 12:30 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0[AGE]7 at a scope and severity of K. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on December, 7, 2017.

Based on review of facility files and interview, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Resident #1, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12 were noted to having smoking materials and/or smoke unsupervised on facility grounds. Staff failed to intervene and/or document the incidents so that the behavior could be monitored. Social services failed to document when residents were initially educated on the smoking policy. Social services failed to document when residents were found to not follow the facility smoking policy and what was done in response to those incidents. 7 of 12 residents reviewed for social services. The findings included: Review of Resident #1's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] indicated the resident was an unsafe smoker. The degree of supervision needed while smoking was noted checked, with choices being occasional, frequent, and constant. There was no additional Safe Smoking Assessment completed when the resident started smoking at the facility. Review of Resident #1's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #1's Progress Notes, including Nursing and Social Services, from 11/1/17-3/7/18. The Nurses' Note dated 11/9/17 indicated the resident was seen by the physician and order was written that Resident #1 may smoke 2-3 cigarettes daily with supervision. There were no additional Nurses' Notes related to the resident smoking. On 1/24/18 social services documented nursing reported Resident #1 was increasingly verbally aggressive and using profanity directed at nurses when they speak to him/her about building policies and rules s/he is not complying with. There was no documentation of what policies the resident was not complying with. On 2/28/18 social services documented the resident leaves the building for social leaves almost every day. Discharge plan but in 30 day discharge notice period now and seeking alternative arrangements for living. There was no Safe Smoking Practices policy signed by Resident #1. The resident's Release of Responsibility for Leave Of Absence forms were signed with no indication of time out or time in 54 times. Review of the Notice of Resident Transfer or Discharge form revealed Resident #1 was issued a notice and the date of notice was not completed. The facility administrator and resident signed the notice on 2/21/18. The notice indicated Resident #1 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility. The resident's health had also improved sufficiently that the resident no longer needs the services provided by this facility. Review of Resident #7's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 12/14/17. The assessment indicated the resident was an unsafe smoker related to being forgetful at times. The degree of supervision needed while smoking was noted as constant. Review of Resident #7's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #7's Progress Notes, including Nursing and Social Services, from 11/28/17-3/4/18. There was no documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's name on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #8's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 9/5/17 indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of the resident's Release of Responsibility for Leave of Absence revealed the resident signed him/herself out on 2/4/18 and 2/9/18. The time in was not completed for the leave of absence on 2/9/18. Review of Resident #8's care plan revealed resident has episodes of physical/verbal aggression toward staff and has episodes of being noncompliant with care and also smoking during non-regulation times to smoke and also having lighters and cigarettes without informing staff. Interventions and approaches were noted on the care plan and included give resident limited amount of cigarettes and provide lighter, encourage resident to return lighter. Review of Resident #8's care plan also revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #8's Progress Notes, including Nursing and Social Services, from 11/9/17-2/27/18. The social services note dated 12/7/17 indicated the resident had increased episodes of physical and verbal aggression, as well as resistiveness to care and smoking cigarettes and lighters s/he gets into the facility without telling anyone and smoking outside of regulated times. There was no other documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #9's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE] and updated 11/8/17 indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of the physician progress notes [REDACTED]. Resident #9 was of course not happy about this. Review of the Release of Responsibility for Leave of Absence form revealed Resident #9 signed him/herself out on 2/9/18, 2/17/18, and 2/21/18. The time out was not indicated on 2/17/18 and the time in was not indicated on any of the dates. There were no receiving nurse initials noted on those dates. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #9's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, staff will supervise resident while smoking, smoking materials will be kept in locked areas when not in use, remind resident to return cigarettes and lighter back to nurses station when not in use. Resident #9's Progress Notes, including Nursing and Social Service, were reviewed from 11/2/17-2/21/18. The Social Services note dated 1/2/18 indicated the resident went to the store over the weekend in his/her motorized wheelchair. Resident is not safe to go by him/herself but s/he is very strong willed. Resident stated that s/he told the nurse but s/he does not know who the nurse was. The social worker told the resident whenever s/he leaves the facility s/he has to sign out. The Social Services note dated 2/21/18 indicated Resident #9 was issued a 30 day discharge letter. S/he has been leaving the facility and not signing out as s/he has been told many times, s/he has cigarettes and lighter on him/her as evidenced of him/her smoking outside. It is a danger to the facility and other residents if s/he decides to light up in his/her room. There was no other documentation in the resident's Progress Notes related to the resident smoking or having smoking materials. Review of the Notice of Resident Transfer or Discharge form revealed Resident #9 was issued a notice and the date of notice was not completed. The facility administrator and resident signed the notice on 2/21/18. The notice indicated Resident #9 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility and the resident's health had improved sufficiently that the resident no longer needs the services provided by the facility. Review of Resident #10's medical revealed the resident's most current Safe Smoking assessment dated [DATE] indicated the resident was assessed as an unsafe smoker. The degree of supervision needed while smoking was constant. Social Services staff provided a Safe Smoking Policy with the resident's name written on it. There was no date to indicate when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. The form indicated the resident does not smoke. Review of the Notice of Resident Transfer or Discharge form revealed Resident #10 was issued and the date of notice was 2/21/18. The facility administrator signed the notice on 2/21/18. The resident refused to sign the form. The notice indicated Resident #10 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility and the resident's health had improved sufficiently that the resident no longer needs the services provided by the facility. Review of Resident #10's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, staff will supervise resident while smoking, and smoking materials will be kept in locked areas when not in use. Review of Resident #10's medical record revealed the resident signed him/herself out 27 times between 2/6/18- 3/12/18. The documentation indicated only one time and did not note if it was when the resident signed in or out. Reviewed Resident #10's Progress Notes, including Nursing and Social Service, from 11/17/17-3/8/18. A nursing note dated 2/22/18 indicated the resident signed him/herself out several times this PM to go off property to smoke. A social services note dated 3/8/18 indicated Resident #10 continues to have smoking items on him/her after many times of advising him/her about the smoking policy. Resident goes outside several times a day to smoke at one point s/he told me that s/he has his/her cigarettes and lighter hidden somewhere off the property. Review of Resident #11's medical record revealed the resident's most recent Safe Smoking assessment dated [DATE]. The assessment indicated the resident was a safe smoker. The degree of supervision needed while smoking was noted as constant. Review of Resident #11's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, no lighters or cigarettes to be kept in resident's room, remind resident to return cigarettes and lighter back to nurses station when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #11's Progress Notes, including Nursing and Social Services, from 11/1/17-3/13/18. There was no documentation related to the resident smoking. Social Services staff provided a Safe Smoking Policy with the resident's initials on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #12's medical record revealed the resident's had a Safe Smoking Assessment that was not dated. The assessment indicated the resident was a safe smoker. The degree of supervision needed while smoking was not indicated, with the choices being occasional, frequent, or constant. Review of Resident #12's care plan revealed resident exercises the right to smoke was identified as a problem area. Interventions and approaches were noted on the care plan and included to assist resident with smoking materials, remind resident to return cigarettes and lighter back to nurses station when not in use, and report any instance when resident is observed unsafe smoking practices. Reviewed Resident #12's Progress Notes, including Nursing and Social Services, from 11/2/17-3/9/18. There was a Nurses' Note dated 3/7/18 at 6:09 PM that indicated the resident left the facility without letting the nurses or any other staff know about him/her leaving and did not sign him/herself out. Review of the Nurses' Note dated 2/18/18 at 6:14 PM reveled at approximately 4:10 PM a staff member witnessed Resident #12 leaving the facility without signing out. Resident went to the store in his/her wheelchair as witnessed by a staff member using the busy street as a route. Resident returned at 4:30 PM. The Social Services note dated 3/8/18 indicated resident continues to not follow the rules of the facility. Resident #12 leaves the premises to smoke and s/he does not sign out and s/he has smoking item on him/her. Social worker, unit manager, and Director of Nursing have spoken with him/her on many occasions on these issues but s/he has decided that s/he is going to do what s/he wants to do. Social Services staff provided a Safe Smoking Policy with the resident's signature on it. There was no date to indicate of when the policy was reviewed with the resident and no staff signature to indicate who reviewed the policy with the resident. Review of Resident #12's Release of Responsibility for Leave of Absence form revealed the resident signed him/herself out 21 times between 2/15/18-3/12/18. There were 19 times the time out or time in was not documented on the form. The receiving nurse did not initial the form 12 times when the resident went on a leave of absence from the facility. Review of the Notice of Resident Transfer or Discharge form revealed Resident #12 was issued a notice and the date of notice was 2/21/18. The facility administrator and resident signed the notice on 2/21/18. The notice indicated Resident #10 would be transferred to an assisted living facility in [STATE] on [DATE]. The notice indicated the transfer was necessary for the resident's welfare and the resident's need could not be met in the facility. The surveyor observed the facility parking lot and route to the store next door. There is no curb with no wheelchair access around the parking lot of the facility that goes from the building to the four lane road where the building sits. There is an abandoned building beside the facility and the store is next to that building. There is no access to the abandoned building with the location of the curb and trees around the facility. There is no sidewalk along the road between the facility and the store. In an interview with the surveyor on 3/14/18 at approximately 11:35 AM, the activities director stated s/he has been at the facility over [AGE] years. The activities director stated s/he knows there have been some lighters confiscated by social services. The smoking policy was discussed at a meeting recently with residents, s/he thinks January. The residents felt they should be able to smoke whenever they want. In an interview with the surveyor on 3/13/18 at approximately 12:20 PM, social services stated there were 2 smoking residents that do not have a signed/initialed smoking policy. Those residents were not smoking when they were admitted to the facility. If they decide to start smoking while at the facility, nursing does an assessment and notifies social services so s/he can educate the resident on the smoking policy. Social services goes and talks with the resident but does not have them sign the form that they have been educated on the smoking policy. The resident does have to sign the policy on admission if they smoke when they come in. In an interview with the surveyor on 3/12/18 at approximately 2:35 PM, CNA (Certified Nursing Aide) #1 stated s/he worked with Resident #1 from time to time. The resident signed out a lot and would go to the grocery store. CNA #1 stated s/he has seen Resident #1 outside smoking in the smoking area when it wasn't scheduled smoking times. Resident #8 would also be out there with the resident. Resident #1 and Resident #8 would be smoking. There would be no staff with them, they would not tell anyone they were going out there. Staff would have to go searching for them. They would go out to the smoking area, but by themselves. The smoking area is off the back of unit 4. CNA #1 stated s/he would assume Resident #1 and Resident #8 had the cigarettes and lighters since there was no staff with them. In an interview with the surveyor on 3/12/18 at approximately 2:50 PM, CNA #2 stated sometime you could smell smoke in the room and s/he would ask Resident #1 where s/he was smoking at, and the resident would get mad at him/her. CNA #1 tried to not ask Resident #1 about things because of how s/he would act. CNA #1 never caught the resident smoking in his/her room. CNA #1 would see Resident #1, Resident #8, and sometimes Resident #9 would go outside to the smoking area unsupervised. They would say they were going to catch air. CNA #2 would not follow them outside, Resident #1 could be so rude. In an interview with the surveyor on 3/12/18 at approximately 3:10 PM, LPN (Licensed Practical Nurse) #2 stated s/he was normally assigned to Resident #1. Resident #1 has had words and cussed LPN #2 out. Somebody reported to LPN #2 that Resident #1 was going out back smoking by him/herself. LPN #2 asked the resident about it and s/he cussed him/her out. It was reported to LPN #2 that the resident was out there at night. LPN #2 doesn't work nights so s/he never saw Resident #1 out there without staff. Resident #1 would sign him/herself out every day when s/he found out s/he could. S/he would ask the resident where s/he had been all that time. The resident would say walking around talking to people. S/he would be gone for an hour or so, a lot of times s/he would leave again on the same shift. LPN #2 stated it was about a month ago when Resident #1 found out s/he could sign him/herself out. That is when other residents found out about being able to sign themselves out too. They had a meeting with the residents and told them they were thinking about changing the smoking policy. That's when the residents found out they could sign themselves out. LPN #2 stated s/he guessed so they would know they could sign out and go smoke off the premises. A housekeeper usually takes the residents out for smoke breaks. That staff if responsible for keeping smoking materials. In an interview with the surveyor on 3/12/18 at approximately 3:40 PM, social services stated Resident #10, Resident #12, and Resident #1 claimed they were hiding their cigarettes and lighter. Social services stated they found cigarettes and lighters in Resident #8, Resident #12, Resident #7, and Resident #13's rooms. Staff would come tell social services or the housekeeping supervisor what they found. Housekeeping is in charge of smoke breaks and smoking materials. Social services would go and talk to the residents and remind them of the smoking policy. Social services was trying to get the residents to go to assisted living so they could smoke as they please. Social services stated there were multiple times they found smoking materials with Resident #8. The resident is [MEDICAL CONDITION] and will try to hide them from staff but s/he finds them. Social services saw Resident #11 through the window of another resident's room come outside to the courtyard area by therapy and pull out a cigarette and lighter and start to smoke. Staff tells social services that Resident #10, Resident #11, and Resident #8 will go outside at night to the smoking area or the facility parking lot and smoke unsupervised. Social services stated the administrator wanted the discharge letters given to the residents because they were not following the smoking policy. The residents told social services they had a meeting with the administrator and s/he told them if they wanted to smoke they could sign themselves out and go smoke off facility grounds. In an interview with the surveyor on 3/13/18 at approximately 12:40 PM, assistant director of environmental services stated smoke breaks are 10:30-11:30, 1:30-2:30, and 4:00-4:30. Those are the hours that have been in place for a while. Housekeeping or laundry usually go outside with the residents on smoke break. The smoking materials are kept in the storage closet, they are in a lock box. Surveyor observed area where smoking materials are kept. The key is hanging on the wall of the unit hallway between two doors near the storage room. The materials are kept in a cardboard box that has a note attached with the smoking times. In an interview with the surveyor on 3/13/18 at approximately 1:45 PM, social services stated s/he does not date or sign behind residents when s/he reviews the smoking policy with them. S/he has them initial or sign and keeps them in a folder in his/her office. Social services stated s/he issued four discharge notices, the ones provided. Social services stated that most of the time s/he does not document when s/he reeducates the residents on the smoking policy when they are found with smoking materials. Social services does not provide a copy of the smoking policy to the residents or responsible parties. In an interview with the surveyor on 3/13/18 at approximately 3:15 PM, the ADON (Assistant Director of Nursing) stated all of a sudden, several residents started signing themselves out so they would not be restricted to the scheduled smoke breaks. The ADON stated if staff suspects a resident has smoking materials, they get social services. Social services gets another administrative person to check with them. The nurse or social services should document if a resident has smoking materials. They don't complete incident reports if they find smoking materials. S/he knows residents have had smoking materials and it has been confiscated. The ADON does not remember who or when. They will ask residents if they have anything, ask if they can look in a drawer maybe. They don't search the whole room. There are no time limits for signing out. The residents should be signed out and back in by the nurse. The ADON stated s/he was not sure the residents were educated that they need to sign back in and let the nurse know. Whoever told them about being able to sign out should have also told them they need to let the nurse know they are back. The ADON stated s/he is not sure who told the residents about signing out and not sure they educated them on signing back in. Review of the facility's Safe Smoking Policy revealed that all residents who smoke will receive supervision while smoking and practice safe smoking habits. All residents who smoke are required to wear a protective smoking apron and are supervised while smoking. Staff members maintain all smoking material for residents who smoke; e.g., cigarettes, pipes, lighters, lighter fluid, etc. Staff members will distribute smoking materials to residents at smoking times. Smoking occurs in designated locations that are environmentally separate from all resident care areas. Violation of the smoking policy is an endangerment to the health and safety of residents. First infractions will consist of a verbal warning to both the resident and their responsible party. A second infraction of the smoking policy will result in a notice of discharge. Documentation included the progress notes reflect any warning issued for an infraction of the smoking policy. On 3/14/18 at approximately 12:30 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0745 at a scope and severity of K. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on December, 7, 2017.