Every finding on record at Seven Hills Rehabilitation and Nursing

Based on staff interviews, resident interviews, observations and facility documentation, the facility staff failed to ensure adequate linen to meet the needs of the residents and provide a homelike environment for four of four nursing units. The findings included:The facility staff failed to provide adequate linen on all four nursing units. On 6/15/26 at 10:27 AM, an interview was conducted with a licensed practical nurse, LPN1. During the interview, LPN1 said, aides complain that they don't have enough linen and they are not washed in time in the morning. Aides have been stocking the linen carts the best they can. On 6/15/26 at 10:40 AM, an interview was conducted with a resident, Resident #100 (R100). R100 said, sometimes they have linen and sometimes they don't and they don't have those green pads anymore to put under me.On 6/15/26 at 10:45 am, an interview was conducted with a certified nursing assistant (CNA), CNA1. CNA1 stated that linen was stocked twice daily. She stated that lines shortage was daily. CNA1 stated that the linen carts on the floor were always without linen and the linen closet has no linen to restock the carts during the day.On 6/15/26 at 10:55 AM, an observation was made of the linen closet and linen carts on unit one and unit two nursing units. The linen cart and linen closet had no towels, no washcloths, no sheets, no green pads, no blankets or bedspreads available for staff to use for resident care.On 6/15/26 at 11:00 AM, an interview was conducted with CNA2. During the interview, CNA2 said, that I run out of linen when caring for the residents. Lines were brought up this morning, and closet and cart were stocked but we don't have enough washcloths or towels. I mainly run out of those every day.On 6/15/26 at 11:10 AM, an observation made of the linen closet and linen carts on nursing unit two and three. There were no towels, washcloths, green pads, blankets, bedspreads or sheets available in the linen closet or on the linen carts to provide care for the residents.On 6/15/26 at 11:15 AM, an interview was conducted with Resident #101, (R101). During the interview, R101 said, they are short on linen often.On 6/15/26 at 11:25 AM, an interview was conducted with Resident #102 (R102). R102 said, I have most of my own linens in the closet I keep hidden so I will have it when I need it. On 6/15/26 at 11:35 AM, an interview was conducted with a laundry aide, other staff #1 (OS1). She said, We do run out of laundry and then they will order some, but we don't have enough. I do the best I can with getting it washed and taken back up there. She stated that she stocks in the mornings, after lunch and that she documented the linen, she supplies on the units. OS1 documented that on 7-3 dayshift she supplied 30 fitted sheets, 24 flat sheets, 25 towels, 30 washcloths, 15 green pads and no bedspreads were supplied for the four units to take care 72 residents. She said, that is what I had to take upstairs for all these residents.On 6/16/26 at 9:00 AM, an interview was conducted with CNA3. She stated that there was a shortage of linen and said, we will use pillowcases to wash residents, and they can have a shower without washcloths or towels we just use the soap and our hands.On 6/16/26 at 9:05 AM, an interview was conducted with CNA4. She said, upon arrival this morning we have no towels or washcloths this morning I feel bad for the residents we use what we have to, to bathe the residents and sometimes it is wipes to hit the hot spots, under arms and private areas. CNA4 opened the linen closet and said, You can see what is in the closed for us to use.On 6/16/26 at 9:08 AM, an observation was made of the linen closet and linen carts on units three and four. There were no towels, washcloths, blankets, bedspreads or pillowcases available for the aides to use and provide care for the residents.On 6/16/26 at 12:37 PM, an observation was made of all linen closets and all linen carts on units one, two, three and four. There were no towels, washcloths, sheets or bedspreads available to provide care for the residents.On 6/16/26, a review of facility documentation was conducted. The facility document titled, Safe and Homelike Environment, read in part, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. The facility will provide and maintain bed and bath linens that are clean and in good condition.On 6/16/26 at 3:10 PM, an end of day meeting was held with the Regional Director of Operations, Regional Director of Clinical Services, and the director of nursing. They were informed of the above concerns. They provided receipts for linen purchased from 12/25 to present. They were informed that the concern was that linen was not available for the floor staff to take care of the residents daily.No additional information provided prior to the exit conference.

Based on staff interviews, and facility documentation reviews, the facility staff failed to ensure that residents were protected during an allegation of abuse investigation and failed to investigate an allegation of verbal abuse involving one resident (Resident #1) in a survey sample of 10 residents. Resident #1 (R1) was the victim of two different abuse allegations and during the investigations on 5/30/25 and 10/30/25 the perpetrator was allowed to work to the end of their shift and worked their schedule days following, and while the investigation was being conducted. By allowing the perpetrator to continue to work, the facility did not protect the victim, and the perpertrator had unrestricted access to other residents; this noncompliance resulted in the identification of immediate jeopardy (IJ), and subsequent substandard quality of care. Following the removal of the IJ, the scope and severity was lowered to a level two, isolated. The findings included: The facility staff failed to ensure that the residents were protected during an abuse allegation investigation. The perpetrators were allowed to complete their shifts and work their scheduled days while the investigation was being conducted. This placed all the residents without protection from the perpetrator, which resulted in the identification of immediate jeopardy.On 4/28/26 at 2:00 pm, an interview was conducted with the administrator concerning the abuse policy. She said, abuse is to be reported to her immediately, the person is to be removed and sent home, the employee was suspended while we investigate, staff removed immediately from building, notify agencies-ombudsman, police if needed, adult protective services and OLC [Office of Licensure and Certification- state survey agency]. License is reported if abuse is founded. Findings are validated by witness, talking to other people in area, documentation including resident's statement. If it is new or history in past we try to see if it has been addressed. Follow up with education may need some counseling about abuse [sic]. On 4/28/26 at 3:30 pm, a review of the facility incident reports that involved R1 was conducted. There were two incident reports that involved R1. The first incident report was dated 5/30/25 and the second one was dated 10/30/25. The incidents were for allegations of abuse made by R1 against two staff members that had provided care for him.The first incident report dated 5/30/25 was reviewed. R1 reported an abuse allegation on certified nursing assistant, CNA1. The facility's report read, Resident alleges that the C.N.A. cleaning him up on the evening shift of 5/29/25 pushed him over so the fuxx hard that he hit his head on the siderail. R1 alleged she [CNA1] did it on purpose. R1 was assessed by the DON [director of nursing] with no injury noted. Resident contacted 911 on 5/29/25 who responded on site. The allegation reports required to notify state agencies were faxed on 5/30/25.During the review of the incident report there were four staff interviews conducted. The first interview was with the perpetrator, CNA1. The interview read, while assisting two other CNA's [certified nursing assistants] change a resident in room [room number redacted] B bed. The resident became very verbally and physically abusive because we had to turn him on his side to wipe him. While turning the resident on his side he reached over scratched a one of the CNA's arms and reached back and scratched and grabbed my arm all while being verbally abusive calling us dumb bitches and whores. After changing the resident, the verbal abuse only continued. The resident would shout out into the hallway saying he would beat our asses and how we were worthless whores. He also said he would get someone to f--k us up.The second interview was by a CNA5 that was in the room assisting with care. Her interview read in part, [name redacted] started to cuss us out calling us bitches and saying that he wanted to know who was coming to the room before we came in. We told him that we were about to roll him over to change so pull yourself over to the middle of the bed and he did. When we turned him, he did tap his head on the rail, but it was not hard or on purpose.The third interview was by another CNA6 hat was assisting with R1's care. This interview was R1 reporting what happened on 5/29/26. This aide was in the room assisting R1's roommate and R1 said to her, that bitch [name redacted] CNA1 rolled me too hard my eye hit the rail and my legs came out the bed. He also told me his mother told him to call the police and that's what he did [sic]. The fourth interview was from the director of nursing at that time, she interviewed R1 about the incident. R1 stated, CNA4 [name redacted] was my aid last night. She brought CNA1 [name redacted] in the room who came in with an attitude saying it don't matter who has you you need to let her clean you! CNA1 [name redacted] rolled me extra hard where I hit my right eye on the bed rail and my feet flew off the bed and CNA4 caught my legs.There were 12 resident's interviews included in the investigation report. Four of the residents stated that they did not know CNA1 in their interview, five of the residents had no issues with CNA1, and there were four interviews that stated, she pulls me over so hard she is too rough, she is a little rough almost throw you in the floor when she turn you over in bed, has a bad attitude and was rough with her one night. Resident does not want CNA in her room.On 4/28/26 a review of CNA1 timecard was reviewed. The timecard showed that CNA1 worked on 5/29/25, she clocked in at 12:02am and clocked out for the shift at 6:04am. On 5/29/26 she clocked in at 3:15pm and clocked out at 10:45pm. On 5/30/25 she clocked in at 11:54pm and clocked out at 4:29am. On 5/31/25 she clocked in at 11:37pm and clocked out at 11:44pm. The timecard shows that CNA1 was paid for the hours on her timecard.On 4/29/26 a notice of suspension pending investigation was provided for review. It was dated 5/30/25 and acknowledgment of receipt section was blank, no employee signature was present on the form, the administrator signature was dated 6/3/25 and there was a note written by the director of nursing at the time of the incident that read, presented verbally by DON [name redacted] dated 5/30/25. A note was on the front page of notice of suspension that read, mailed 6/4/25. There was a form titled, Employee Master, reviewed and read in part, .Termination involuntary policy violations termination date 5/31/25.On 4/29/26 the incident summary as reviewed. The notice was dated 6/4/25, and the date was the final notice of the findings for the incident on 5/30/25. There was a section in the final notice that read in part, .Actions VDH-OLC, Ombudsman and APS notified [notified on 5/30/25], MD Notified, RP notified, C.N.A. was suspended pending outcome of the investigation, alert residents interviewed regarding care and treatment of them [dated 6/3/25].The second incident report dated 10/30/25 was reviewed. R1 reported an allegation of abuse on CNA2. The incident report read, R1 [name redacted] called 911 to report that a staff member pushed his leg. Four staff members were present in the room at the time and all provide the same statement that no one harmed him. He became combative with staff and yelled and cursed staff members while they were providing ADL [activity of daily living] care. All were interviewed by police officer [name redacted] and provided written statements. The officer concluded that no harm was done to resident.The first interview reviewed was R1's interview of the incident. R1 was interviewed by a nurse about the incident that happened with CNA2. He stated he was calling the cops. He stated in the interview that CNA2 got a smirk and pushed left leg down harder. Also, stated CNA2 said, I want to fuck with you now. The verbal abuse that was reported by R1 in this interview, was never addressed in the facility's investigation.The second interview was by one of the staff assisting with R1's care and her interview stated that CNA2 lifted R1's leg to remove a pillow and some dirty sheets then sat his leg back down softly. After that R1 started yelling saying she cracked his leg and she replied with, I didn't crack nothing, then R1 started yelling and arguing and we left the room.The third interview with a staff member assisting with R1's care stated that he went in to help give a bed bath and change the sheets. R1 called CNA2 a bitch for moving his pillow from under his leg. When they went to turn R1 over he started to dig his fingernails in the staff's arm, so he walked out of the room.The fourth interview was CNA2's interview. Interview read in part, .to bathe him and wash him up. Off the gate he was already rude and calling people out of their name. He [R1] told me and another coworker to not pull on his leg, we stated that we have to move his leg to remove the pillow and fully clean him up. He [R1] stated that I [CNA2] cracked his leg and hip which I stated I didn't crack nothing went to get the unit manager or ADON to help us.The fifth interview was with another staff assisting with R1's care. The interview read in part, .walked in the room and explained what we were doing we then proceed to all pick up his leg to move the pillow and as we did that he[R1] screamed. We all proceeded to leave the room because he started swinging on [name redacted] [coworker].There were 11 resident interviews conducted titled, Safety. One resident interviewed stated he does not feel safe on 2nd and 3rd shift and his reason was staff. The other residents did not have any concerns.A review of CNA2's timecard was conducted. She was allowed to complete her shift on 10/30/25 (clocked out at 2:59pm), reported to work on 10/31/25 (dayshift), 11/3/25 (day shift), and 11/4/25 (dayshift).A review of the incident summary that was submitted was dated 11/4/25. The notice stated this will serve as the final report of a facility reported incident regarding R1 on 10/30/25. The final report had a section labeled, Actions, and some of the actions were notifying state agencies, physicians, responsible party, resident's interviews, some of the interviews were completed on 10/30/25 and some were completed on 11/03/25. On 4/30/26 at 8:30 am, an interview was conducted with the administrator concerning the two incidents/allegations of abuse involving R1 that were reviewed.During the interview, the incident on 5/30/25, which happened on 5/29/25 was discussed. The administrator stated that she reported the incident when she was notified. She said, I think I was notified on the 30th. One of the staff interviews was discussed with the administrator. In the interview it was read in part, .that when we turned him, he did tap his head on the rail, but it was not hard or on purpose. The administrator said, I felt it was not done on purpose, but he may have tapped it. The administrator stated that the director of nursing interviewed R1, and the DON did not think it was anything intentional. When the administrator was questioned about the resident's interviews, several interviews were stating that the CNA1 was rough and when she turned you over in the bed, she was rough and felt like she was going to roll them on the floor. The administrator said, follow up with the person was done, I think the director of nursing did that to clarify it wasn't abuse.The facility reported incident that the facility provided for review had that R1 called 911 the evening of 5/29/26 and the police came to the facility. So, the allegation of abuse was made aware to staff the evening of the incident as evidenced by the police coming to the facility.The administrator was interviewed about the second incident dated 10/30/25. She stated that she looked at the interviews, that she was present during the police being at the facility and during the staff statements. CNA1 was in the building but she could not remember if she was interviewed first. The administrator said, I felt this was the investigation. I don't remember if she [CNA2] left the unit, but I did not say go home cause everyone stayed kinda together.These failures by the facility put all residents residing in the facility in immediate danger by not removing the perpetrator during an open investigation with allegations of abuse. The consequence could cause serious injury, serious harm, serious impairments up to and including death for residents the alleged perpetrator continues to have access to. On 4/29/26 at 9:51 am, a meeting was held with the administrator, the director of nursing, and the regional director of clinical services. They were informed that immediate jeopardy had been identified and a copy of the IJ template was provided. On 4/29/26 at 3:38 pm, the facility submitted a removal plan that read as follows: Plan Corrective Action for those residents found to be affected by the deficient practice: C.N.A. 1 was terminated from employment 05/31/2025C.N.A. 2 was terminated from employment 01/24/2026Resident # 1 was discharged from the facility 02/19/2026Corrective Actions taken for residents with potential to be affected by deficient practice:All FRI's from 05/29/2025 will be reviewed by the Administrator or Designee to determine if any staff members who had abuse allegations were allowed to work during an investigation. If staff were allowed to work during an investigation, Administrator or designee will further review the FRI to determine if a complete investigation occurred. Skin sweeps will be conducted by the DON or designee residents with BIMs below 12 to assess any indicators of abuse and family members will be interviewed. Residents with BIMS above 12 or above will be interviewed for any concerns of abuse.Systemic Changes put in place to ensure the deficient practice does not recur: Education will be provided to all staff by the Administrator or designee on the abuse policy and process prior to their next scheduled shift. Education will be provided by Corporate HR to the Administration on the abuse policy and process.Completion of the removal plan at12:00 am on 04/30/2026. On 4/30/26 at 8:45 am, the survey team completed the following:1. Verified CNA #1 and #2 were terminated from employment, verified Resident # 1 was discharged from facility2. -reviewed the audit performed of facility reported incidents -reviewed head to toe skin assessments of residents with a BIMS below 12 - reviewed family interviews for residents with a BIMS below 12 -reviewed interviews for residents with a BIMS of 12 or above3. Interviewed staff for education regarding the abuse policy and procedures to follow. The IJ was determined to have been removed as of 12:00 am on 4/30/26, at which time the scope and severity was lowered to level two, isolated.On 4/30/26, the facility policy titled, Abuse, Neglect and Exploitation, read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. 2. The facility will designate an Abuse Coordinator in the facility who is responsible for reporting allegations or law. suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.On 4/30/26 at10:35 am, the vice president of clinical services and the administrator was wanting to discuss their creditable evidence, dispute of Immediate Jeopardy Determination that they had presented earlier. The information provided was reviewed and it did not provide credible evidence that residents were protected from an alleged perpetrator during an abuse allegation.No additional information was provided prior to exit conference.

Based on staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure resident #2 (R2) was free from significant medication error, which resulted in harm for one of ten residents in the survey sample.The findings included:The facility staff failed to ensure that R2 was administered the correct dosage of his medication daily. On 4/27/26 at 10:15 AM, a clinical record review was conducted. On 6/9/25 the nurse practitioner/Doctor of Nursing Practice (DNP) wrote a progress note that read in part, . the reason for visit was resident was having muscle weakness. A different nurse practitioner (NP) wrote a progress note dated 6/18/25 and 6/19/25 that the reason for the visit was that R2 was having weakness. On 6/9/25 Doctor of Nursing Practice (DNP) wrote in progress note the reason for visit was resident was having muscle weakness. The NP progress note dated 6/23/25, read in part. it was found to be due to an incorrect medication dose being dispensed (500mg vs 250). On 4/27/26 at 2:34 PM, a telephone interview was conducted with pharmacist #1. She stated on 5/18/25 R2 was dispensed 150 tablets of Divalproex DR 500mg and was delivered to the facility. The label on the medication card reads to give two in the morning and three in the evening, but the physicians order was to administer Divalproex DR 250mg tablets. On 4/27/26 at 3:24 PM, an interview was conducted with a Licensed Practical Nurse, LPN #3 (LPN3). During the interview, LPN3 stated that she would find out the dosage that R2 was being administered prior to going to the hospital on 6/20/25. LPN3 stated that she was the unit manager during this time and that she was not the nurse that assessed him that day.On 4/27/26 at 4:36 PM, LPN3 stated that R2 was being administered Divalproex DR 250mg and provided a copy of the physician's order. LPN3 stated that she was the nurse that assessed R2 on 6/20/25 prior to him being transported to the hospital. LPN3 stated that she did not observe any changes in condition with R2. LPN3 said, resident stays up late at night, his vital signs were within normal range, and that he knew where he was. During the interview, LPN3 stated, R2[name redacted] was given the wrong dose of medication and it was too much. LPN3 completed a change in condition assessment on 6/20/25 and documented that R2 had altered mental status. She stated his mother request for him to go to the hospital and that is the reason he was sent out.4/28/26 12:34 PM, a clinical record review was conducted. The hospital's discharge summary was reviewed and read in part, . motor weakness was possibly medication induced. R2'S lab work was reviewed on the hospital discharge summary, and R2 had a valproic acid lab level of 115. Normal range for a valproic acid level was 50-100, so R2's level was noted to be high. On 4/28/26 at 11:46 AM, an interview was conducted with physician's assistant (PA). PA stated that the side effects of receiving increased dosage of Divalproex DR could be drowsiness, muscle weakness, skin reactions, somnolence, nausea and vomiting. On 4/28/26 at 12:21 AM, an interview was conducted with the director of nursing (DON). The DON stated she expects the nurses to do the six rights of medication administration. The DON stated, right dosage, right resident, right route and if pharmacy sends the wrong medication, the nurses should be doing the rights of medication and catch it. DON stated, the facility has received medications from the pharmacy with the incorrect label several times. On 4/28/26 at 2:09 PM, a review of the facility's documentation was conducted. The facility's policy titled, Medication Administration, read in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review MAR to identify medication to be administered. Compare medication source (bubble pack, vial, etc) with MAR [medical administration record] to verify resident name, medication name, form, dose, route, and time.On 4/28/26 at 4:52 PM, an interview was conducted with LPN1. LPN1 stated, when giving medications, you should make sure that it's the right patient, right medication, right dose and the MAR matches the card of medications. She stated, sometimes they do not match, especially with milligrams and if they do not match, you are supposed to correct it. On 4/28/26 at 5:01 PM, an interview was conducted with LPN5. LPN5 stated, when giving medications you make sure it's the right resident, look at order and make sure card matches the order, make sure it is the right dose. LPN5 stated I click off medications as I give them and if something is wrong and does not match, I call the doctor and notify the pharmacy.On 4/28/26 at 5:15 PM, an end of day meeting was conducted with Administrator, DON and Regional Director of Clinical Services (RDCS) and the above concerns were discussed. On 4/29/26 at 10:08 AM, a telephone interview was conducted with pharmacist #2. She stated that it was an error by the pharmacy that Divalproex DR 500 was dispensed on 5/18/25, which was not the correct dosage.On 4/30/26 at 9:30AM, The facility identified the significant medication error on 6/23/25 and the facility implemented a plan of correction. The RDCS presented the plan of correction and it was reviewed. During the review there was a pharmacy label that read Divalproex DR 500mg. Take two in the morning and three at bedtime. The action plan the facility presented was as follows: Quality Assurance Committee oversight.Medication cards were removed from the medication cartsMedication ordered with correct dosePharmacy was notified of error. NP [nurse practitioner] reviewed that orders and clarified that Divalproex DR should be sent for 250mgA MAR [medication administration record] to card audit was completedMedication administration education given to nursing staffNew medication cards sent for this resident were checked for accuracyThe completion date was 6/23/25 and the audits being conducted were MAR to card audit was completed on 8/25/25. The completion audit for accuracy of medication cards dispensed from the pharmacy was completed on 9/2025. The facility achived past non-compliance for this deficient practice. No other additional information was provided prior to exit conference. Past non-compliance was achieved.

Based on staff interviews, resident interviews, observations and facility documentation, the facility staff failed to ensure adequate linen to meet the needs of the residents and provide a homelike envornment for four of four nursing units. The findings included: The facility staff failed to provide adequate linen on all four nursing units. On 6/15/26 at 10:27 AM, an interview was conducted with a licensed practical nurse, LPN1. During the interview, LPN1 said, aides complain that they don't have enough linen and they are not washed in time in the morning. Aides have been stocking the linen carts the best they can. On 6/15/26 at 10:40 AM, an interview was conducted with a resident, Resident #100 (R100). R100 said, sometimes they have linen and sometimes they don't and they don't have those green pads anymore to put under me.On 6/15/26 at 10:45 am, an interview was conducted with a certified nursing assistant (CNA), CNA1. CNA1 stated that linen was stocked twice daily. She stated that lines shortage was daily. CNA1 stated that the linen carts on the floor were always without linen and the linen closet has no linen to restock the carts during the day.On 6/15/26 at 10:55 AM, an observation was made of the linen closet and linen carts on unit one and unit two nursing units. The linen cart and linen closet had no towels, no washcloths, no sheets, no green pads, no blankets or bedspreads available for staff to use for resident care.On 6/15/26 at 11:00 AM, an interview was conducted with CNA2. During the interview, CNA2 said, that I run out of linen when caring for the residents. Lines were brought up this morning, and closet and cart were stocked but we don't have enough washcloths or towels. I mainly run out of those every day.On 6/15/26 at 11:10 AM, an observation made of the linen closet and linen carts on nursing unit two and three. There were no towels, washcloths, green pads, blankets, bedspreads or sheets available in the linen closet or on the linen carts to provide care for the residents.On 6/15/26 at 11:15 AM, an interview was conducted with Resident #101, (R101). During the interview, R101 said, they are short on linen often.On 6/15/26 at 11:25 AM, an interview was conducted with Resident #102 (R102). R102 said, I have most of my own linens in the closet I keep hidden so I will have it when I need it. On 6/15/26 at 11:35 AM, an interview was conducted with a laundry aide, other staff #1 (OS1). She said, We do run out of laundry and then they will order some, but we don't have enough. I do the best I can with getting it washed and taken back up there. She stated that she stocks in the mornings, after lunch and that she documented the linen, she supplies on the units. OS1 documented that on 7-3 dayshift she supplied 30 fitted sheets, 24 flat sheets, 25 towels, 30 washcloths, 15 green pads and no bedspreads were supplied for the four units to take care 72 residents. She said, that is what I had to take upstairs for all these residents.On 6/16/26 at 9:00 AM, an interview was conducted with CNA3. She stated that there was a shortage of linen and said, we will use pillowcases to wash residents, and they can have a shower without washcloths or towels we just use the soap and our hands.On 6/16/26 at 9:05 AM, an interview was conducted with CNA4. She said, upon arrival this morning we have no towels or washcloths this morning I feel bad for the residents we use what we have to, to bathe the residents and sometimes it is wipes to hit the hot spots, under arms and private areas. CNA4 opened the linen closet and said, You can see what is in the closed for us to use.On 6/16/26 at 9:08 AM, an observation was made of the linen closet and linen carts on units three and four. There were no towels, washcloths, blankets, bedspreads or pillowcases available for the aides to use and provide care for the residents.On 6/16/26 at 12:37 PM, an observation was made of all linen closets and all linen carts on units one, two, three and four. There were no towels, washcloths, sheets or bedspreads available to provide care for the residents.On 6/16/26, a review of facility documentation was conducted. The facility document titled, Safe and Homelike Environment, read in part, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. The facility will provide and maintain bed and bath linens that are clean and in good condition.On 6/16/26 at 3:10 PM, an end of day meeting was held with the Regional Director of Operations, Regional Director of Clinical Services, and the director of nursing. They were informed of the above concerns. They provided receipts for linen purchased from 12/25 to present. They were informed that the concern was that linen was not available for the floor staff to take care of the residents daily.No additional information provided prior to the exit conference.

Based on staff interviews, clinical reviews, and facility documentation the facility staff failed to ensure medications were administered according to professional standards of nursing practice. Specifically, nursing staff administered an incorrect medication dose over an extended period of time for one resident (Resident #2-R2) out of a survey sample of 10 residents. The findings included: For R2, the facility staff failed to follow professional standards of practice during medication administration that would have prevented R2 from receiving the wrong dose of medications. On 4/27/26 at 1:00 PM, a review of the clinical record was conducted. The progress notes were reviewed and R2's medications included Divalproex DR [delayed release] 250 mg (Divalproex is an anticonvulsant medication used to treat seizures) with the order/instructions to give two tablets in the morning and three tablets at bedtime. The medication administration record (MAR) was reviewed for the months of May 2025 and June 2025 and was signed off daily, indicating the medication Divalproex DR 250 mg give two tablets in the morning and three tablets in the evening, was administered.The SBAR (situation, background, assessment and recommendation) dated 6/20/25 was reviewed and R2's change in condition was altered mental status. An evaluation note was reviewed dated 6/20/25 and read in part .mother stated that mental status and demeanor is off and wants patient sent to the ER [emergency room] now for evaluation.The nurse practitioner had a progress note dated 6/23/25, explaining R2's hospitalization, and noted that R2 was receiving the incorrect dose of Divalproex DR (anticonvulsant medication) R2 was receiving 500 mg (milligrams) daily and not the ordered dose of 250 mg prescribed by the physician.On 4/27/26 at 2:34 PM, a telephone interview was conducted with a pharmacist at the facility's contracted pharmacy. The pharmacist stated that on 5/18/25, the pharmacy filled Divalproex DR 500 mg and dispensed 150 tablets to the facility. On 4/27/26 at 4:36 PM, conducted an interview with License Practical Nurse #3 (LPN3). During the interview she stated that she did not want to give the wrong information about R2's medication, so she wanted to meet with the Director of Nursing (DON) to obtain the information requested. LPN3 returned with a physician's order for Divalproex DR 250mg and stated that was the dosage R2 was receiving; however, with further discussion, LPN3 said, [R2's name redacted] was given the wrong dose of medication and that it was too much.On 4/28/26 at 12:21 PM, an interview conducted with the director of nursing (DON). The DON stated I expect the nurses to do the rights of medication administration, right dosage, right resident, right route and that if pharmacy sends the wrong medication, the nurses should be doing the rights of medication and catch it. On 4/28/26 at 2:09PM, a review of the facility's policy titled, Medication Administration, was conducted. The policy read in part, . Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review MAR [medication administration record to identify medication to be administered. Compare medication source (bubble pack, vial, etc) with MAR to verify resident name, medication name, form, dose, route and time.On 4/28/26 at 4:52PM, an interview was conducted with licensed practical nurse #1 (LPN1). LPN1 stated, when giving medications, you make sure that it's the right patient, right medication, right dose and the MAR matches the card of medications and if they do not match, you are supposed to correct it.On 4/28/26 at 5:01PM, an interview was conducted with licensed practical nurse #5 (LPN5). LPN5 stated, when giving medications you make sure it's the right resident, look at order to make sure card matches the order, make sure it is the right dose. LPN5 stated, I click off medications as I give them and if something is wrong and does not match, I call the doctor and notify the pharmacy. On 4/28/26 at 5:15PM, an end of day meeting was conducted with Administrator, DON, and Regional Director of Clinical Services (RDCS). RDCS stated the [NAME] standard of practice was the reference the facility used. During review of [NAME], [NAME] reads in part, .compare the medication label to the order in the patient's medical record,On 4/29/26 at 10:08 AM, a telephone interview was conducted with a second pharmacist (Pharmacist #2). Pharmacist #2 stated that it was an error by the pharmacy that Divalproex DR 500 was sent 5/18/25 instead of Divalproex DR 250mg. There was no order change by the physician for Divalproex DR 500 mg medication in R2's medical record. On 4/30/26 at 9:30AM, The facility identified the significant medication error on 6/23/25 and the facility implemented a plan of correction which included following the standards of practice with medication administration. The RDCS presented the plan of correction and it was reviewed. During the review there was a pharmacy label that read Divalproex DR 500mg. Take two in the morning and three at bedtime. The action plan the facility presented was as follows: Quality Assurance Committee oversight.Medication cards were removed from the medication cartsMedication ordered with correct dosePharmacy was notified of error. NP [nurse practitioner] reviewed that orders and clarified that Divalproex DR should be sent for 250mgA MAR [medication administration record] to card audit was completedMedication administration education given to nursing staffNew medication cards sent for this resident were checked for accuracyThe completion date was 6/23/25 and the audits being conducted were MAR to card audit was completed on 8/25/25. The completion audit for accuracy of medication cards dispensed from the pharmacy was completed on 9/2025. The facility achived past non-compliance for this deficient practice. No other additional information was provided prior to exit conference.

Based on staff interviews, clinical record review, and facility documentation review the facility staff failed to ensure effective pain management on multiple occassions, for one resident (Resident #1-R1) in a survey sample of 10 residents. The findings included:For R1 who had chronic pain syndrome related to degenerative disc disease of the lumbar spine and avascular necrosis of the left hip, the facility staff failed to provide non-pharmacological interventions and failed to ensure the resident's pain was controlled. On 4/27/26 at 1:19 pm, an interview was conducted with a licensed practical nurse, LPN#1 (LPN1). LPN1 stated, he [R1] was rude and disrespectful at times with the staff. LPN1 stated, staff ignored him at times and avoided going in his room because R1[name redacted] doesn't know how to talk to people.On 4/28/26 at 11:25 am, an interview with the physician assistant (PA) was conducted. The PA stated he began working at the facility in early February. The PA stated R1 had pain and several medical conditions that was painful. However, the PA stated R1 demonstrated drug-seeking behaviors, including requesting additional narcotic medication and attempting to negotiate care, such as stating he would agree to showering if given more narcotics. The PA stated he attempted to adjust R1's pain medication regimen to adequately manage pain while avoiding addiction related behaviors. The PA stated he was not aware of R1 obtaining outside medications from anyone.On 4/28/26 at 2:40 pm, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she began working at the facility in January and attempted to establish a good rapport with R1. She stated R1 refused care daily due to pain and wanted interventions to decrease his pain. The ADON stated that if R1 was sleepy, he appeared comfortable, but when care was provided, especially movement of his left leg, he would scream out in pain. The ADON stated R1 hated his left leg being moved and pain was the reason he declined care, refused staff assistance, and refused appointments. The ADON stated that on the day of a scheduled appointment, staff attempted to prepare R1 by washing him, limb by limb. She stated R1 refused to have linens changed and refused to attend the appointment due to pain. The ADON said, that pain was his reason he declined care and refused staff to do things. She stated he wanted to go to a facility closer to family and where he could use recreational drugs. The ADON stated R1 was asking the provider to increase his pain medications dosage and requested medical marijuana to help with his pain management.On 4/28/26 at 4:43 pm, an interview was conducted with a registered nurse, RN#1 (R1), who was the Minimum Data Set (MDS) coordinator. R1 stated care plans were reviewed and updated quarterly, annually, with MDS assessments, and with changes in physician orders or resident condition. RN1 stated that if an interventions was not effective, it should be changed. RN1 stated she reviewed the 24-hour report daily and discussed changes during morning meetings. RN1 stated that prior to her employment, floor nurses updated the care plans. She further said, changes discussed during interdisciplinary team (IDT) meetings were updated by her if they were reported to her. On 4/28/26 at 5:08 pm, an end of day meeting was held with the administrator, the director of nursing, and the regional director of clinical services and the above concerns were discussed. No additional information was provided at this time. On 4/29/26 at 10:00 am, a clinical record review was conducted. R1's care plan was reviewed. Review of R1's care plan identified bilateral hip pain and neuropathic pain. The care plan included goals for the resident to verbalize relief of pain, demonstrate the ability to cope with and complete activities with pain relief, remain free from interruption in normal activities due to pain. Interventions included administering analgesics as ordered anticipating the resident's need for pain relief and responding promptly to complaints of pain, and evaluating the effectiveness of pain interventions. The care plan also directed staff to review compliance with pain management interventions, alleviation of symptoms, dosing schedules, resident satisfaction with results, impact on functional ability, and impact on cognition. Review of the care plan failed to identify any non-pharmacological interventions to assist with alleviating the resident's pain. The care plan was initiated on 4/24/24 and was last revised on 12/22/2025. Further review of the clinical record was completed, including progress notes. On 2/13/26, a nursing note indicated the resident was seen for increased, uncontrolled pain with a reported pain score of 10/10. Staff were called to the resident's room for uncontrolled pain. The physician assistant evaluated the resident and provided a one-time order for hydrocodone/acetaminophen 10-325 mg. Additional documentation dated 2/16/26 noted chronic pain syndrome related to degenerative disc disease of the lumbar spine and avascular necrosis of the left hip. The resident was followed for pain management with ongoing symptom review, with pain reported as partially controlled throughout subsequent progress notes. The resident continued to report episodes of uncontrolled pain, with pain ratings up to 10/10, and analgesic dosages were adjusted according. However, there was no evidence of non-pharmacological interventions or other alternative pain management approaches being implemented or documented to assist in alleviating the resident's pain. On 4/29/26 a review was conducted of facility documentation that was provided. The policy titled, Pain Management, was reviewed and read in part, .The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences. 1. c. manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. On 4/30/26 at 10:00 am, a meeting was held with the administrator, the director of nursing, and the regional nurse of clinical services and the above findings were discussed. No additional information was obtained prior to exit conference.

Based on staff interviews and facility documentation review, the facility staff failed to effectively administer the facility by failure of the administrator, who was the abuse coordinator to effectively implement the facility's abuse policy to ensure measures were taken to protect residents when an allegation of abuse and/or neglect is being investigated and failure to conduct thorough investigations into allegations for one resident, Resident #1 (R1) out of a survey sample of 10 residents.The findings included:The facility's Abuse Coordinator, who was the administrator, failed to follow the abuse policy, protect the residents when an allegations of abuse was alleged, and initiate a thorough investigation into the allegations. On 4/28/26 during a review of facility incidents and investigation documentation revealed that R1 made allegations of abuse on two separate occassions (5/30/25 and 10/30/25) involving two different staff members, certified nursing assistant CNA1 and CNA2.Documentation showed that in both incidents, the alleged perpetrators were not removed from the facility and were allowed to continue working during the investigation period, which permitted them continued access to many residents within the facility.On 4/28/26 an interview was conducted with the administrator. During the interview, the administrator confirmed she was the Abuse Coordinator. She stated that when an allegation of abuse was made, she reported it immediately to the required state agencies, initiated an investigation, and removal and suspension of the alleged perpetrator from the facility pending the outcome of the investigation. The administrator confirmed this was the facility's policy for abuse allegations.Facility documentation confirmed that both perpetrators were allowed to remain in the facility and continued to work their schedules during the investigations. CNA1 was involved in the incident on 5/30/25 and her timecard revealed that she completed her shift on 5/29/25, the day the incident happened and was allowed to work on 5/30/25 and clocked in at the facility on 5/31/25 at 11:37 pm to 11:44 pm. CNA2 was involved in the second incident with R1 on 10/30/25. CNA2's timecard revealed that she completed her schedule shift on 10/30/25, worked her schedule shift on 10/31/25, 11/3/25, and on 11/4/25.R1 also made an allegation of verbal abuse which was not investigated by the facility. On 4/28/26 a review of the facility policy titled, Abuse, Neglect, and Exploitation, and read in part, 2. The facility will designate an Abuse Coordinator in the facility who is responsible for reporting allegations or law. suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.Failure to remove the perpetrators, by the abuse coordinator during the investigations did not ensure the safety and protection of Resident #1 and other residents from potential abuse.On 4/28/25 an end of day meeting was conducted with the administrator, the director of nursing and the regional nursing consultant. No additional information was provided prior to exit

Based on staff interviews, employee record review, and facility documentation review the facility staff failed to implement their abuse policy by failure to ensure that one employee, CNA #3 (CNA3) was trained on the Abuse, Neglect, and Exploitation training out of a survey sample of five employee records. The findings included:The facility failed to implement their abuse policy with regards to the annual requirement for staff to receive abuse trianing for certified nursing assistant #3 (CNA3).On 4/30/26 at 8:30 am, an interview was conducted with CNA3. CNA's yearly training was discussed. CNA3 stated she was done with her training that was due, she said, I am good on all of my training.On 4/30/26 at 9:00 am, a review of CNA3's yearly training record was conducted. During the review, the training on CNA3's transcript had that her training on Cultural Competence Inservice, Abuse, Neglect, and Exploitation, and Abuse, Neglect, and Exploitation HIPAA for Long-Term Care Employees were overdue. The training was assigned on February 2, 2026, and was to be completed by the employee on February 28, 2026.On 4/30/26 at 9:00 am, The administrator provided the employee records to be reviewed and stated, this was the yearly training records for the employees. The administrator stated the employees were required to complete these training courses yearly and by the due date.On 4/30/26 a review of the facility policy titled, Abuse, Neglect, and Exploitation, read in part, Employee Training A. New employees will be educated on abuse, neglect, exploitation, and misappropriation of resident property during initial orientation. B. Existing staff will receive annual education through planned in-services and as needed. Training topics will include: C. 1. Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. 2. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property. 3. Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, such as physical or psychosocial indicators. 4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources. 5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: a. Aggressive and/or catastrophic reactions of residents. b. Wandering or elopement-type behaviors. c. Resistance to care. d. Outbursts or yelling out; and e. Difficulty in adjusting to new routines or staff.On 4/30/26 at approximately 10:30 am, a meeting was held with the director of nursing (DON), the administrator, and the regional director of clinical services. During the meeting the DON stated she was a new hire, and the training should have been completed. No additional information was provided.No additional information was provided prior to exit conference

Based on staff interview, clinical record review, and facility documentation review the facility staff failed to ensure that pharmacy regimen reviews were completed and implemented timely for one resident, Resident #1 (R1) out of a survey sample of 10 residents. The findings included:R1's pharmacy regimen reviews were not completed or implemented timely.On 4/30/26 at 8:45 am, an interview was conducted with the director of nursing (DON). The DON explained the facility process of the drug regimen reviews. The DON stated that the coordinator from the pharmacy will let me know when she is coming and when reviews were ready . She stated that she will review and give to the doctor to review and sign. Once signed by the physician, the DON stated she gives the reviews to the unit managers to check and to make sure the suggestions was implemented. The DON said she makes a copy of all the reviews, place copies in a binder, and it was kept in her office. She stated she takes the original review to the medical records department and the review was scanned into the residents medical chart. On 4/30/26. a review of R1's clinical recorded was conducted. R1's pharmacy consultations were reviewed. R1 had a review that was completed on 2/18/2025 for a gradual dose reduction of his antipsychotic medication Quetiapine 100 mg was reduced to 75 mg, and this recommendation was not reviewed and completed until 3/25/25 with the physician's signature. On 2/18/26 a recommendation was completed for a current AIMS and this recommendation was not signed and completed until 3/27/25. On 7/29/25 a recommendation was requested for a gradual dose reduction for R1's antidepressant (Duloxetine 60 mg twice daily); however, this recommendation was not addressed until 9/5/25 by the physician. On 11/26/25 a recommendation for a dose reduction was made on R1's pantoprazole 40 mg everyday to 20 mg; however, the recommendation was not reviewed and signed by the physician until 12/24/25. On 4/30/26, a review of the facility policy was reviewed. The policy titled, Medication Regimen Review, read in part, .the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. On 4/30/26 at 10:00 am, a meeting was held with the administrator, the director of nursing, and the regional director of clinical services and were made aware of the above concerns. No additional information was obtained prior to exit conference.

Based on facility document review, clinical record review, and staff interviews the facility failed to develop a complete and thorough comprehensive care plan to ensure person-centered interventions were present for one of 10 residents in the sample, Resident #1 (R1).The findings include:For R1, the facility failed to update the Comprehensive Care Plan to include personalized interventions that addressed R1's reasons for refusing care (pain) and measures to attempt to provide Activities of Daily Living (ADL) care in the presence of R1's refusals. According to R1's diagnoses recorded in the clinical record, diagnosis included but were not limited to: history of stroke secondary to carotid artery dissection, status post craniectomy, with residual left-sided hemiparesis, neuropathic pain, left hip avascular necrosis, degenerative disc disease of lower spine with chronic lower back pain, adult failure to thrive, and lower extremity weakness. On R1's most recent Minimum Data Set (MDS), a quarterly assessment with an assessment reference date (ARD) of 12/27/25, R1 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment indicating that R1 was cognitively intact. In section GG of this MDS, R1 was noted to be dependent on staff or require maximum assistance from staff for all ADLs except oral hygiene (supervision assist) and eating (set up assist). R1 had a care plan to address activities of daily living (ADL) created on 4/10/2024 with most recent revision on 9/29/2025. This care plan had a focus statement ADL self-care performance deficit r/t [related to] Hemiplegia, Stroke indicating that R1 required assistance from staff to perform ADLs. This care plan included only one intervention that was initiated on 4/10/2024 stating Resident will receive ADL assistance as needed. No additional interventions were added to the care plan after 4/10/2024, and no revisions were made to the existing intervention. During the clinical record review, it was noted that R1 refused ADL care almost daily. R1 frequently cited pain as the reason for refusing ADL care.R1 had a care plan for behaviors created on 3/22/2024 and revised on 1/20/2026. The focus statement of this care plan was The resident has a behavior problem, refusal of medications, weights and Showers, turn and repositioning, appointments, meals, change of bed linens, and refuses to get up in chair. Resident with inappropriate request with foul abusive language to staff. The following interventions were present on the care plan: Administer medications as ordered. Monitor/document for side effects and effectiveness created/initiated on 3/22/2024. If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident created/initiated on 3/22/2024. Resident to be evaluated by Psych Provider created/initiated on 4/23/2024.The care plan failed to include personalized interventions that specifically addressed R1's refusal of care. Clinical record review demonstrated a physician's order on 12/5/2025 to give additional pain medication one hour prior to showering on shower days. The care plan was not updated to include this intervention.An interview was conducted with the Assistant Director of Nursing (ADON) on 4/28/2026 at 2:51 PM. The ADON stated that R1 refused care every day. An interview was conducted with the MDS coordinator, Registered Nurse (RN) #1 on 4/28/2026 at 3:44 PM. RN #1 stated that care plans are revised/updated quarterly and annually with MDS assessments and daily as needed for changes or new orders. RN #1 stated that they would be notified by staff if something needs updated or changed in their daily care meetings. RN #1 stated that if behaviors are not documented in the clinical record, RN #1 would be notified in the morning meeting of issues.A facility policy titled Comprehensive Care Plans implemented on 11/1/2021 and most recently revised on 12/1/2022 states that It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. At a minimum, the comprehensive care plan with describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well- being and Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. The policy further states The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment and that Alternative interventions will be documented, as needed.On 4/30/2026 the above findings were presented to the Director of Nursing (DON) and administrator.No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive plan of care for one of two residents in the survey sample (Resident #1). The findings include: Resident #1's plan of care was not updated with problems, goals, and interventions regarding a pressure ulcer. R1's clinical record documented the resident was assessed on 12/30/24 with a stage 2 pressure injury on the sacrum. R1's clinical record documented treatment orders dated 12/30/24 for daily dressing changes with wound cleanser, medical grade honey and bordered gauze. R1's clinical record documented current physician orders for pressure ulcer treatment/prevention that included heel protectors, elevation of heels as tolerated when in bed, a pillow between knees at all times in addition to skin barrier cream, and Pro-stat supplement to assist with wound healing. R1's plan of care revised on 12/6/24, documented the resident was at risk of pressure ulcer development. Care plan interventions included protective ointment to buttocks, prompt incontinence care, and skin assessments. R1's care plan had not been updated indicating the resident had a pressure ulcer and included no goals and/or interventions implemented for care/treatment of the ulcer. On 1/8/25 at 10:40 a.m., the registered nurse responsible for care plan updates (RN #1) was interviewed about R1's plan of care. RN #1 stated R1's care plan had not been updated since the pressure ulcer was assessed and treatment initiated. RN #1 stated she was responsible for care plan updates and usually updated plans based upon new treatment orders and wound reports. RN #1 stated R1's plan of care should have been updated to include the pressure ulcer and reflect goals and interventions in place for care of the ulcer. This finding was reviewed with the administrator and director of nursing on 1/8/25 at 12:15 p.m. with no further information presented prior to the end of the survey.

Based on observation, staff interview, and clinical record review, the facility staff failed to implement physician ordered interventions for pressure ulcer prevention for one of two residents in the survey sample (Resident #1). The findings include: Resident #1 (R1) was admitted to the facility with diagnoses that included osteoporosis, vascular dementia, psychotic disturbance, mood disorder, anxiety, atherosclerosis, depression, neuropathy, glaucoma and osteoarthritis. The minimum data set (MDS) dated [DATE] assessed R1 with severely impaired cognitive skills. R1's clinical record documented a physician's order dated 5/18/22, which read, Elevate bilateral heels, as tolerated, when Resident is in bed on pillows to assist w/ [with] skin breakdown prevention. R1's record also documented a physician's order dated 5/19/22 for bilateral heel protectors and a physician's order dated 10/26/22 to keep a pillow between the knees at all times for pressure prevention. On 1/7/25 at 2:15 p.m., accompanied by licensed practical nurse (LPN) #3 and the unit manager (LPN #4), R1 was observed prior to a pressure ulcer dressing change. R1 was in bed with no heel protectors in use. The resident's heels were resting directly on the sheet-covered mattress. There was no pillow between the resident's legs. The heels and legs were observed with no skin breakdown noted. LPN #4 was interviewed at this time about the heel protectors and positioning pillow. LPN #4 stated she was not sure about the heel protectors or pillows. On 1/7/25 at 2:35 p.m., the certified nurses' aide (CNA #1) caring for R1 was interviewed. CNA #1 stated that R1's feet were sometimes elevated on pillows. CNA #1 stated she had not seen the heel protectors today and was not sure where the heel protectors were located. On 1/7/25 at 2:50 p.m., LPN #2 who was caring for R1 was interviewed about the heel protectors and pillows. LPN #2 stated that R1 previously had the pillow placed between the legs, but she had found the pillow soiled and sent it to laundry. LPN #2 stated she had not seen the heel protectors in use today and was not sure why they were not in place. On 1/7/25 at 4:00 p.m., the director of nursing (DON) was interviewed about R1 observed without use of heel protectors or positioning pillows. The DON stated R1 was at high risk of pressure ulcer development and the heel protectors and pillows should have been in use as ordered. The DON stated the pillow between the knees was to prevent skin breakdown as R1 had impaired leg positioning. This finding was reviewed with the administrator and DON on 1/7/25 at 4:15 p.m., with no further information presented prior to the end of the survey.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure misappropriation of medications did not occur for one of nine residents, resident # 7 (R7). The findings included: On 5/14/24, licensed practical nurse #2 (LPN #2) was observed removed medications belonging to R7 from the facility med cart and gave them to certified nursing assistant #2, (CNA#2) for personal use. A review of the clinical record revealed that R7 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, dementia, cerebral infarction, major depressive disorder, chronic pain, generalized anxiety disorder, and hypertension. The most recent minimum data set (MDS) assessment was a quarterly assessment, dated 3/3/24, which assessed R7 as cognitively intact. On 6/11/24 at 8:38 AM, other staff #1 (OS#1), who was the director of rehabilitation, was interviewed. OS #1 stated that on 5/14/24 she was in the facility gym when she observed 2 facility employees in the parking lot talking. OS#1 stated that LPN #2 was observed running into the facility, so OS#1 stated that she went to .see what was wrong. OS #1 stated that when she reached the med cart where LPN #2 had been, she noticed a medication supply card lying on the med cart. OS #1 stated that she then went to the door, she watched LPN #2 hand CNA #2 .a baggie. OS#1 stated that CNA #2 left the parking lot and LPN #2 returned to the facility. OS #1 then stated that she reported what she had observed to the director of nursing (DON) and to human resources, then provided a written statement of her observations. On 6/11/24 at 8:45 AM, OS #3 (Speech Therapist) was interviewed. OS #3 stated that she had observed CNA # 2 in tears as she walked down the hall, after speaking to LPN #2. OS #3 then stated that she observed LPN #2 .open the med cart drawer, remove a pill pack, and start popping pills, at least six, into a plastic baggie. OS #3 then stated that LPN #2 placed the baggie into her pocket and left the med cart. OS #3 stated that she noted the medication on the label of the pill pack to be Zofran. OS #3 stated that she reported her observations to her manager, who was OS #1, and provided a written statement. On 6/11/24 at 8:57 AM, R7 was interviewed. R7 stated that she was not aware of the incident and that she always received her medications when she asked for them. On 6/11/24 at 9:00 AM, OS #2, who was the admissions coordinator, was interviewed. OS #2 stated that he was outside talking to CNA #2 .because she was upset and that he .wanted to make sure she was ok. OS #2 stated that while he and CNA #2 were talking, LPN #2 also came outside, then went back inside the facility. He stated that LPN #2 returned to the parking lot, holding a plastic bag, and handed it to CNA #2. OS #2 stated that he did not observe the contents of the bag, that CNA #2 left the parking lot, and that he returned to the facility. OS #2 stated that he also had provided a written statement. On 6/11/24 at 9:06 AM, the administrator was interviewed. The administrator stated that both LPN #2 and CNA #2 were terminated immediately following the reported observations. The administrator also stated that the incident was due to the .actions of 2 employees, and that no one else was re-educated about the abuse policy since they were not involved. On 6/11/24, the facility event summary for the incident was reviewed. The summary included the witness statements from LPN #2 and CNA #2, evidence that both employees had been terminated, and that the event had been reported to all entities. On 6/11/24 at 10:06 AM, the DON was interviewed regarding conflicting written statements in the event summary that had been obtained from LPN #2. The DON stated that LPN #2 had first reported that the medication she gave to CNA #2 was famotidine which she obtained from the floor stock supply, then later reported it as being Zofran from R7's discontinued medication supply. According to R7's clinical record, Zofran was a current medication she received on an as needed basis. On 6/11/24, the facility policy for Abuse, Neglect, and Exploitation was reviewed. Per the policy, It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy defines misappropriation as .deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Per the policy, New employees will be educated on abuse, neglect, exploitation, and misappropriation of resident property during new orientation and existing staff will receive annual education through planned in-services and as needed. Review of LPN #2's employee file did not indicate any occurrences or allegations of misappropriation of medication prior to this incident. On 6/11/24 at 11:04 AM, the DON and administrator were made aware of the above concerns. No further information was provided.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to assess and implement behavioral health interventions following statements of suicidal intent for three of seven residents in the survey sample (Residents #2, #6 and #7), resulting in the identification of immediate jeopardy. The findings include: 1. Facility staff failed to identify and implement interventions to address Resident #2's behavioral health needs following statements of self-harm reported to staff on 12/26/23. Resident #2 attempted self-harm on 1/19/24 by wrapping the bed remote cord around her neck. After an emergency department visit/assessment, Resident #2 was readmitted to the facility with no updated plan of care implemented for suicide prevention. Five days later (1/24/24), Resident #2 was found again with the bed remote cord wrapped around her neck along with continued suicidal statements. Resident #2 was hospitalized for five days following this suicide attempt and was readmitted to the facility on [DATE] with a recommendation for restricted access to cords/ligatures. Resident #2 was observed on 2/12/24 with the bed remote/cord accessible on the resident's bed rail and no plan of care addressing the recent suicide attempts with the cord. Resident #2 (R2) was admitted to the facility with diagnoses that included bipolar disorder, major depression disorder, affective mood disorder, borderline personality disorder, dementia with agitation, psychotic disturbance, generalized anxiety disorder, cognitive communication deficit, cerebral infarction, hypertension, diabetes, atrial fibrillation, ischemic heart disease, urinary tract infection, COPD (chronic obstructive pulmonary disease) and asthma. The MDS (minimum data set - an assessment tool) dated 12/12/23 assessed R2 with severely impaired cognitive skills and as being dependent on staff for bed mobility and transfers. R2's clinical record documented on 12/21/23 that R2 had been verbally abusive to staff, using racial slurs, in addition to refusing blood sugar checks and meals. A social services (SS) note dated 12/26/23 documented, .Resident came to Social Services on 12/26/23 around noon and stated that she wanted to go 'home to live with her mom at her house' .Then [R2] proceeded to state that if SS didn't get her out of the building soon she would harm herself. She was descriptive. SS notified the nurse on duty and the nurse notified the NP on duty. The nurse practitioner (NP) assessed R2 on 12/27/23 but documented no assessment or mention of the resident's statement on 12/26/23 of self-harm. The NP progress note dated 12/27/23, .patient is being seen today for mood disorder. Patient is refusing care and medications. Nursing reports patient is combative at times and hitting at staff. She is not easily redirected. She has a diagnosis of dementia, which is likelyprogressing [likely progressing] .Mood euthymic .Start Hydroxyzine 25 mg [milligrams] .every 8 hours as needed X 7 days for anxiety . Nursing notes documented on 1/11/24 that R2 continued to refuse medications & meals and made verbally aggressive statements toward staff. The NP assessed R2 again on 1/12/24 in reference to mood disorder, refusing medications and verbal aggression. On 1/12/24, the NP ordered the Hydroxyzine 25 mg every 8 hours as needed for an additional 14 days. The NP documented no assessment or mention of the resident's statements of self-harm. A social services note dated 1/12/24 documented a conversation with R2 about the verbally aggressive behaviors but made no mention of the resident's status regarding the expression of suicidal intent or self-harm. The SS note dated 1/12/24 documented, .spoke to resident [R2] today about the inappropriate language .She was asked to please use kind words when speaking to staff . R2's Nursing notes on 1/13/24 and 1/14/24 documented incidents in which R2 refused care, refused medications, made multiple verbal threats to staff that included wanting to blow this Nurses brains out, threatened to get a machine gun and kill, and demonstrated physical aggression by grabbing a nurse's arm saying she was going to break it, and throwing a cup of water on a nurse. The Nursing notes documented that after some time, R2 settled down and went to sleep. There was no notification to a provider about the aggressive behaviors, threats, or care refusals on 1/13/24 and 1/14/24. R2's medication administration record (MAR) documented no administration or refusal of the Hydroxyzine 25 mg that was ordered every 8 hours as needed for anxiety. There was no psychiatric referral or assessment in response to these behaviors. R2's last psychiatric evaluation was documented on 5/5/23. R2's Nursing note dated 1/19/24 documented, .Around 4pm today resident stated that she wanted to kill herself. Patient was caught in her room with the cord from her bed remote controller around her neck. Unit manager was notified .instructed nurse to send resident out to the hospital for further evaluation. R2's emergency department (ED) note dated 1/19/24 documented, .Patient arrives by ems [emergency medical services] from [nursing facility] with thoughts of SI [suicidal ideation], patient denies HI [homicidal ideation] but per ems stated 'I am going to burn this place down' .presents to the emergency department with suicidal thoughts .states she has been depressed for 'a good while' .over the last several weeks, she has had thoughts of not wanting to live. She reports that she prays she will die. She has been suicidal with several plans to harm herself. She has thought of buying a gun and shooting herself. She has also considered running off a mountain ledge. She is currently at a skilled care nursing facility and states that today, she wrapped a cord around her neck to try to suffocate herself .does have a distant history of a mental health admission . The hospital documentation revealed that Mental Health evaluated R2 in the hospital's ED on 1/19/24 and recommended admission since the resident had suicidal thoughts with plans. The hospital's ED disposition note dated 1/20/24 documented, presents to the emergency department with suicidal thoughts .has been increasingly depressed with worsening suicidal thoughts over the last several weeks. She has several plans to harm herself . she wrapped a cord around her neck . head and neck exam is unremarkable . I do not suspect traumatic injury from her actions . I do not suspect an acute medical process . Mental health has evaluated her and is recommending admission. Disposition pending bed placement . According to the hospital documentation, R2 was discharged to the nursing facility on 1/20/24, with orders to start the antipsychotic medication Seroquel 12.5 mg at each bedtime and an antibiotic for 7 days for treatment of a urinary tract infection. Upon readmission to the facility on [DATE], R2's chart revealed that there were no other physician orders or any care plan interventions implemented to address the attempted suicide or suicide prevention. According to the progress notes, the physician assessed R2 on 1/22/24 but documented no assessment of and/or reference to the suicide attempt of 1/19/24 or the status of the R2's intent for self-harm. The physician's progress note dated 1/22/24 listed no changes regarding R2's bipolar affective disorder or generalized anxiety diagnoses and no changes in treatment. There were no physician orders for any safety monitoring or preventative measures in response to R2's suicide attempt with the bed remote cord. Progress notes reveal that the NP assessed R2 again on 1/24/24 regarding follow up for the treatment of the urinary tract infection. The NP's note dated 1/24/24 documented review of R2's medication and a physical examination, but made made no mention or reference to the resident's mental state, status of self-harm intent, or interventions in place for suicide prevention. On 1/24/24, R2 was found again with the bed remote cord wrapped around her neck. A nursing note dated 1/24/24 at 6:54 p.m. documented, .Resident observed lying in bed with bed remote cord wrapped around her neck. Resident verbally voiced that she does want to kill herself and she plans to do so using the bed remote cord. On call physc [psych] contacted and made aware that resident has suicidal ideations, has plan, and this is her 2nd attempt within this month. Verbal order given to send patient to hospital . The hospital's ED report dated 1/24/24 documented, .pt [patient] from facility for trying to wrap telephone cord around her neck; pt stated 'if i wanted to hurt myself, then i should have that right to do so . Mental health evaluated R2 and recommended psychiatric admission with pending bed placement with assessment listed as suicidal ideation, Alzheimer's dementia and affective mood disorder. The ED discharge summary dated 1/29/24 documented, .Patient has been in the emergency department over 120 hours at this point and has been declined from most acute inpatient psychiatric units due to medical needs .today she denies all SI and HI .We are approaching 6 days in the emergency department .remaining in the emergency department indefinitely pursuing an unlikely bed search would be detrimental to patient's overall mental health and wellbeing given this prolonged length of stay .increased frequency of Seroquel to 12.5 mg with meals and at bedtime .Imminent risk for suicide is low at this point .recommend nursing facility restrict access to ligature risks such as phone cords given she has attempted this in the past . R2 was readmitted to the nursing facility on 1/29/24 with orders for the increased frequency of Seroquel and referral for psych services. R2's clinical record documented that the Seroquel dose was increased as ordered upon readmission on 1/29/24, but there were no orders or updated care plan interventions addressing the repeated suicide attempt, safety monitoring, or the restricted access to ligatures/cords as recommended by the ED physician. According to the chart, R2 was assessed by psychiatry on 1/31/24 and 2/7/24, which documented R2 as denying thoughts of self-harm. Psychiatry recommended non-pharmacological interventions in addition to medication that included a quiet environment, gentle redirection/reassurance, reinforcement of self-efficacy, identify/address/eliminate underlying causes of distress, approach in way the does not increase distress, safety monitoring for falls, and redirection as needed. R2's comprehensive care plan included no updates regarding the statement of suicidal intent on 12/26/23, the suicide attempts with the bed remote cord on 1/19/24 and 1/24/24, or the restricted access to cords for suicide prevention. R2's care plan documented the diagnosis of depression and a history of suicidal ideation that was listed as being resolved on 5/22/23. Interventions to minimize depression, anxiety, and sad mood were last updated on 5/22/23 and included, Arrange for psych consult, follow up as indicated . Discuss with resident/family caregiver any concerns, fears, issues . Monitor/document/report PRN [as needed] any risk for harm to self; suicidal plan, past attempt at suicide, risk actions . intentionally harmed or tried to harm self, refusing to eat or drink, refusing med [medication] or therapies, senses of hopelessness or helplessness, impaired judgement or safety awareness . Monitor/document/report PRN any s/sx [signs/symptoms] of depression .pharmacy review monthly R2's plan of care had been updated on 1/29/24 noting, Touch call bell at bedside for use when assistance is needed . The touch bell was not associated with any care plan problem/concern and there was no explanation listed as to why R2 needed/used a touch call bell. On 2/12/24 at 10:50 a.m., R2 was observed in bed with eyes closed. There were quarter length bed rails raised on each side of the bed near the head/upper portion of the bed. The bed remote with a coiled cord was observed mounted on R2's right bed rail, near R2's side. A manual tap bell was observed on the over-bed table. On 2/12/24 at 2:30 p.m., R2's physician/medical director (administration staff #6) was interviewed. The physician stated that R2 had been assessed on 12/22/23 concerning blood pressures and insomnia, but was aware the resident had behaviors as she called him a quack during the visit. When questioned about the R2's ED visits, the physician reviewed the clinical record and stated that R2 was seen in the ED on 1/19/24 due to an attempt to self-harm and returned to the facility because there was no psych bed available. When questioned further, the physician stated that he had assessed R2 on 1/22/24 and that there was nothing in his note speaking to the suicide attempt because he was unaware of the event at that time. The physician stated that he had not been notified of R2's statement of self-harm of 12/26/23 or the 1/19/24 suicide attempt. The physician stated the ED notes from the 1/19/24 visit had not been scanned for his review when he saw the resident on 1/22/24. The physician R2 went to the ED again on 1/24/24 with another suicide attempt and was kept for five days because inpatient psych care was not available. The physician stated that he saw R2 after the readmission to the facility on [DATE], along with the director of nursing (DON) and assistant director of nursing (ADON) and anything with a cord was removed. The physician stated psych services were available whenever needed and could be provided at the request of a provider and/or nursing at any time. On 2/12/24 at 2:10 p.m., R2 was observed in bed. The bed remote with coiled cord was hanging from the bed rail with the remote portion laying on the floor. R2 was interviewed at this time about why she had a tap bell. R2 stated that she had tried to choke herself with a cord a couple of times. When asked about her access to the cords, R2 stated that staff did not get rid of the cords right away but later removed the call light cord and gave her the tap bell. R2 did not know why the bed remote with cord was not removed. On 2/12/24 at 2:20 p.m., the social worker (administration staff #5) was interviewed about R2. The social worker stated on 12/26/23, R2 came to her and voiced that she did not want to be in the facility and threatened to harm herself. The social worker stated she reported this to the ADON, who she thought told the nurse practitioner. The social worker stated she thought R2's name was put in the book for a NP visit. The social worker stated R2 was found with the bed control cord wrapped around her neck on 1/19/24. When questioned further, the social worker stated that the cords were not removed from R2's room until after the second suicide attempt on 1/24/24. The social worker did not know why the cords were not removed after the first attempt on 1/19/24. The social worker stated that she thought nursing had taken measures to protect R2 and prevent self-harm. On 2/12/24 at 3:20 p.m., R2 was observed in bed with the bed rails in the up position. The bed remote with cord was mounted on R2's right bed rail near the resident's side. When asked if able to reach/use the bed remote, R2 stated, I can reach it but barely. On 2/12/24 at 3:22 p.m., the licensed practical nurse unit manager (LPN #8) was interviewed about R2 and interventions to prevent self-harm. LPN #8 reviewed R2's plan of care and stated that the interventions for attempts of suicide included arranging for psych services, psych medications, and documenting any reports of self-harm. When questioned why the interventions had not been implemented, LPN #8 stated that nobody had reported any recent issues to her about R2. On 2/12/24 at 3:30 p.m., LPN #9, a nurse who routinely cared for R2, was interviewed. LPN #9 stated that bR2 had frequent behaviors of refusing medicines, refusing meals, and verbal threats/racial slurs. LPN #9 stated that he found R2 on 1/24/24 with the bed cord wrapped around her neck. LPN #9 stated that the cord had been wrapped around the neck several times, as tight as she could get it, and that R2 made statements that she wanted to die. LPN #9 stated that he was not working the first time R2 wrapped the cord around the neck (1/19/24). When questioned about safety interventions, LPN #9 stated that the call light cord was replaced with a tap bell, but this was done after the second suicide attempt on 1/29/24. LPN #9 stated he did not know why the cords were not removed after the first suicide attempt. When questioned about the which cords had been removed, LPN #9 stated that R2 still had the bed remote/cord, but that staff were supposed to keep the bed remote/cord out of the R2's reach. On 2/13/24 at 8:00 a.m., the DON was interviewed about R2 and any interventions or care plan updates following R2's expressing suicidal intent on 12/26/23. The DON stated that she started working as the DON on 12/27/23 and was not aware of behavioral issues with R2 until January 2024. The DON stated R2 was found with the bed remote cord wrapped around her neck on 1/19/24 and was sent for emergency evaluation. When questioned about interventions implemented, the DON stated that R2 returned to the facility on [DATE] with orders for Seroquel. The DON stated that the interdisciplinary team had a discussion upon R2's return, and that someone on the team had stated that R2 usually exhibited behaviors (verbal, aggressive, self-harm) with a UTI (urinary tract infection), but did not remember who had made that statement. The DON stated R2 was scheduled to be evaluated by psychiatry on 1/24/24 but had wrapped a cord around her neck again and was sent to the hospital prior to being seen. When questioned further, the DON stated that she did not remember what interventions were implemented after the 12/26/23 expression of suicidal intent or after the 1/19/23 suicide attempt. The DON stated, My recollection was there was discussion in the morning meeting and the team thought the behaviors were related to the UTI as that had been her history. The DON stated that regarding R2's access to cords, the call bell cord was removed following the second suicide attempt on 1/29/24 and that the bed remote cord was supposed to be positioned out of reach. When questioned further, the DON stated that the out of reach location had been on the bottom of the bed rail. When notified that the bed control cord had been observed within reach of the resident, the DON stated that the bed remote cord was moved yesterday (2/12/24) to the headboard of the bed. When asked why the bed remote was moved, the DON stated that there were concerns that the bed remote/cord on the bed rail was not far enough out of the R2's reach. When asked why the plan of care had not been updated in response to the self-harm statements, suicide attempts or cord access, the DON stated that the MDS coordinator was responsible for care plan updates. On 2/13/24 at 8:45 a.m., the administrator was interviewed about any behavioral care services provided to R2 in response to statements of suicidal intent and two suicide attempts. The administrator stated that R2 had been discussed in morning meetings. The administrator stated the protocol was that any thoughts/attempts of suicide were immediately elevated to the DON and medical provider with the expectation that once notified, actions were implemented immediately to care for/protect the resident. When questioned further, the administrator stated that he had no other information to provide regarding R2's interventions for suicide prevention. On 2/13/24 at 8:55 a.m., the Assisted Director of Nursing (ADON - RN #4) was interviewed about R2. The ADON stated that she notified the NP after the report on 12/26/23 the expression of self-harm and that R2 had not attempted to use a cord at that point. The ADON stated the NP assessed R2 prior to the 1/19/24 incident. When questioned further, the ADON stated R2 was scheduled to see psych on 1/24/24 but went out to the emergency room due to the second suicide attempt prior to the visit. The ADON stated she was not involved with interventions implemented after the 1/19/24 incident but that when R2 returned on 1/29/24, that staff removed anything that she could use for self-harm. The ADON stated that it had been discussed in the morning meeting that the call bell/cord was removed and replaced with a tap bell. The ADON stated that the bed remote cord was not removed but was supposed to be where R2 could not reach it. When questioned further, the ADON stated that she thought that location was on the headboard of the bed. On 2/13/24 at 9:45 a.m., the registered nurse MDS coordinator (RN #2), who was responsible for care plan updates, was interviewed. RN #2 stated the care plan was updated on 1/29/24 indicating that R2 used a tap bell. When questioned further, RN #2 stated that he added the tap bell because he was told to, and did not recall anything else being added to the care plan. When questioned specifically, RN #2 stated that there were no updates regarding the expressions of suicide, and that nothing had been added about the suicide attempts or the relocations of the bed remote/cord. On 2/13/24 at 10:00 a.m., the social worker (administration staff #5) was interviewed again about R2's expressions of suicidal intent on 12/26/23. The social worker stated that R2 gave details of how she would hurt herself. The social worker stated that R2 had said that she was going to drive a truck out of here and said, something about a cord. The social worker stated R2 voiced that she wanted to harm herself and again stated that she reported this to the ADON. On 12/13/24 at 10:15 a.m., the nurse practitioner (NP - other staff #7) was interviewed about R2 and care/services provided regarding expressions of suicidal intent and suicide prevention. The NP stated that R2 was in the book on 12/26/23 regarding refusing medications. The NP stated that it was not communicated to her that R2 had made a statement of self-harm on 12/26/23 and that self-harm was not listed in the book as the reason for the visit. The NP stated that R2 had been assessed on 12/27/23 but reviewed the resident for behaviors that included refusal of medications/care, prescribing a medication as needed for anxiety. The NP stated that if the expressions of self-harm had been reported to her, she would have assessed the resident's risk, addressed the issue in her notes, and most likely obtained a psychiatric evaluation. The NP stated she had no notifications about R2 until 1/19/24 when the resident was found with a cord around her neck. The NP stated the resident returned to the facility on [DATE] with orders for Seroquel at bedtime. The NP stated she checked the resident on 1/24/23 but this was a follow up about the UTI. The NP stated the resident was scheduled for a psychiatric assessment on 1/24/24 but had the second suicide attempt and was sent out prior to the visit. The NP stated that she had been informed by nursing that R2 had demonstrated behaviors when diagnosed with a UTI. When asked about any interventions for expressions of suicidal intent and suicide prevention, the NP stated urgent psychiatric care could have been provided. The NP stated if she had known about the statement of self-harm on 12/26/23, she would have initiated urgent psychiatric assessment/care, as those services were available 24 hours each day. The NP stated that psychiatry visited the facility each week and that a provider or nursing could request immediate services for urgent and/or crisis situations. The NP stated that R2 currently needed to continue with psychiatric services, medications, and should not have cords due to recent history of using cords for attempted suicide. After consulting with the state agency supervisory staff, the facility administrator was notified on 2/13/24 at 3:20 p.m. that immediate jeopardy was identified related to the failure to provide behavioral health services/care in response to R2's statements and acts of self-harm. A plan of removal for the immediate jeopardy was requested. A plan of removal for the immediate jeopardy was presented and approved by the survey team, in consultation with the state agency, on 2/14/24 at 8:50 a.m. The removal plan included the following. -Call light cord removed from the room on 1/30/24, tap bell provided. -Bed controller with cord attached to bed headboard out of R2's reach on 2/12/24. -Nurse practitioner (NP) assessed R2, R6, & R7 on 2/13/24 with an order for follow-up psych visits scheduled for 2/14/24. -R2 was placed on 1:1 supervision on 2/13/24 until seen by psych services. -Director of nursing (DON) held ad-hoc safety meeting on 2/13/24 to discuss immediate jeopardy findings, created plan of removal, notified medical director with medical director involvement in plan. -Audits conducted of current residents to identify any resident with like concerns of self-harm via an updated mood assessment (PHQ9 interviews); Findings reviewed/discussed in QAPI ad-hoc meeting on 2/13/24. -Care plans of residents expressing self-harm or PHQ9 responses of better off dead or self-harm were reviewed and updated as indicated. -Administrator educated the MDS team and the director of rehab on yes responses to the PHQ9 interview regarding self-harm; any yes response to the question regarding self-harm or better off dead will be immediately communicated to the DON or administrator. DON/administrator/designee will immediately notify the on-call psych provider and medical provider. If unable to contact, will send resident out to the hospital for psychological evaluation. The resident will be placed on 1:1 until EMS is on scene to transport resident. Following implementation of the removal plan, the survey team observe/verified the plan was implemented as written. The survey team performed the following. Observed R2 with no accessible cords. Bed remote/cord was attached to the headboard out of resident's reach. R2 had a tap bell in use with no call light cord in place. NP progress notes documented assessment of R2, R6, and R7 on 2/13/24. Meeting minutes documented ad-hoc safety meeting on 2/13/24 with facility administration including medical director. Audits were documented of mood assessments for all residents assessed as having self-harm or suicidal intent, using the PHQ9 interview. R2's care plan was revised on 2/14/23 to include the self-harm statements, suicide attempts, and interventions that included restricted cord access. R2 was observed with 1:1 supervision by facility staff on 2/14/24. Inservice education was documented as listed above, with staff signatures starting on 2/13/24. Staff members were interviewed to verify understanding of training on 2/14/24. Staff on R2's unit including those assigned to care for R2, were interviewed to verify knowledge about the resident's self-harm risks and interventions in place for prevention of self-harm. R2 was assessed by psychiatry on 2/14/24. After verification of the immediate jeopardy removal plan and consultation with state agency supervision, the survey team removed the immediate jeopardy status on 2/14/24 at 11:55 a.m. and advised facility administration accordingly at that time. After removal of the immediate jeopardy status, the scope/severity of this deficiency was lowered to level three, isolated. The survey team audited the most recent MDS mood assessments of all current residents and identified two residents that answered yes to having thoughts of being better off dead, or of hurting self in some way. These residents (Residents #6 and #7) were added to the survey sample for review of behavioral health care/services. 41449 2. For Resident #6 (R6), who verbalized having feelings/thoughts of self-harm and/or being better off dead, the facility staff failed to respond and implement interventions to address the resident's behavioral health needs. On 2/12/24 at approximately 4:30 p.m., a review of R6's clinical record was conducted. R6's most recent MDS (minimum data set - an assessment tool) with an ARD (assessment reference date) of 12/20/23, was a quarterly assessment. R6 was coded in section D0150, question I, which asked if the resident has Thoughts that you would be better off dead, or of hurting yourself in some way. R6 reported having these feelings 2-6 days (several days), out of 14 days. There was no evidence within the clinical record that the facility responded to or implemented any interventions to address R6's mental/behavioral health needs. According to the clinical record, R6's diagnosis included but were not limited to major depressive disorder, mood disorder, and anxiety disorder. On 1/29/24, R6 was seen by the doctor who documented Chronic MDD [major depressive disorder]. Not optimal control. Sertraline was increased to 100 mg daily 1/22/2024. F/u [follow-up] psychiatry team provider as well There was no evidence that R6 was seen by psychiatry following this order. According to the clinical record, R6's feelings of depression and suicidal ideation were not noted in the progress notes indicating that any facility staff had any further conversation with the resident about their feelings. The care plan did not mention the event nor any interventions. On 2/12/24 at 4:55 p.m., an interview was conducted with RN #2, who was a MDS coordinator. RN #2 confirmed conducting the interview on 12/20/23, during which R6 had expressed suicidal ideation. Following , RN #2 stated that R2's response had been reported to the director of nursing (DON) and facility Administrator. When asked what is done when a resident verbalizes feelings of depression and/or suicidal ideation, RN #2 said, It is left up to them [Administrator and DON], but we need to get some type of psychiatric services that day, either in-house or at the ER [emergency room ]. When questioned about the provision of psychiatric services, RN #2 reviewed R6's clinical chart and confirmed that R6 was last seen by psychiatric services in December 2022. RN #2 also confirmed that there was no evidence of any facility response to R6's verbalizations of feelings that he/she would be better off dead and/or self-harm once facility leadership had been made aware. RN #2 provided the survey team with a copy of an email where RN #2 had notified the facility administrator and director of nursing of R6's response to the MDS question/suicidal ideation. On 2/13/24 at 8:30 a.m., during an interview, the Director of Nursing (DON) stated that psychiatric services have continued to be available at the facility with on-site visits and 24-hour telehealth visits. On 2/13/24 at 8:44 a.m., an interview was conducted with the facility administrator. The administrator stated that when a resident verbalizes such feelings of depression and suicidal ideation that It should be escalated to the DON and provider, and they will handle it and implement interventions. When asked about the timing of such interventions, the administrator said, It should be addressed immediately. On 2/13/24 at 10:03 a.m., an interview was conducted with the facility's social worker (SW - Administrative Staff #5 - AS#5). The SW stated that when a resident verbalizes suicidal ideation, she usually hears about it in morning meeting. When asked about R6's expressions of suicidal ideation on 12/20/23, the SW stated that she was unaware of this. On 2/13/24 at 10:19 a.m., an interview was conducted with the nurse practitioner (NP). When asked about the availability of psychiatric services, the NP stated, psychiatric services are available and if urgent, we can do telehealth. The NP was asked about when orders are placed for psychiatry is ordered when she would expect this to be implemented, the NP said, Typically psych services rounds once a week or every other week, I would expect them to be seen on the next visit, unless it is urgent. When asked about R6's feelings of depression and expressions of suicidal ideation shared with facility staff on 12/20/23, the NP said, This is the first I'm hearing of this. On 2/13/24, in the afternoon, R [TRUNCATED]

Based on clinical record review, staff interview, and review of facility documents, the facility failed to ensure adequate supervision and implement interventions for non-compliance with smoking materials for one of seven residents (Resident #3). Multiple occurences of non-compliance with smoking materials, designated smoking times, designated smoking areas, and smoking supervision was revealed in Resident #3's clinical record, as well as through staff interviews. No evidence was found that the facility implemented interventions to address the unsecured smoking materials repeatedly observed in R3's possession. While R3 was in therapy on 2/1/24, a fire occurred in R3's room and unsecured smoking materials were again retrieved from the room, which had been accessible to other residents. On 2/13/24, the survey team determined that no focused interventions or the additional measures indicated per facility policy had been implemented to address R3's ongoing noncompliance, putting all residents at risk for serious injury, harm, impairment, or death. This resulted in the identification of immediate jeopardy (IJ), as well as substandard quality of care. Once the facility's removal plan was approved and verified on 2/14/24, the IJ was removed, and the scope and severity were lowered to a level 2, isolated. The Findings include: On 2/12/24, a review was conducted of the 2/2/24 facility synopsis of a fire that occurred in R3's room on 2/1/24. The facility synopsis of the fire event did not evidence that R3 had caused the fire in his room. However, the result of the investigation did lead to deficient practice. Diagnoses for R3 included: Chronic obstructive pulmonary disease, bipolar, schizoaffective disorder, anxiety, epilepsy with partial seizures, and tobacco use. The most current MDS (minimum data set - assessment tool) was a quarterly assessment, with an ARD (assessment reference date) of 1/15/24, which assessed R3 as being cognitively intact for daily decision making, with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. Review of R3's current care plan for smoking, created on 2/2/23 and revised on 8/22/23, documented R3 as being a supervised smoker. The care plan did not indicate that R3 was non-compliant with smoking policies or that any interventions had been implemented to address R3's non-compliance. Review of R3's progress notes revealed the following exerpts: 1/20/24 at 10:20 PM: resident went out side door to smoke outside of smoking hours, resident stated he knows hes [SIC] not supposed to but is going to do it anyway, resident did not sign himself out. 1/20/24 at 10:43 PM: writer caught resident smoking vape with O2 [oxygen] in his nose in his room, contacted on call supervisor made her aware. 1/26/24 2:32 AM: per CNA [certified nursing assistant] resident went to front lobby and asked to be let out to smoke, she stated she wasn't allowed to then resident became verbally abusive with the CNA. it has been explained to resident on numerous occasions that it is a safety concern for him to be out at night by himself and he was only allowed to smoke at designated times in designated areas per policy he stated he doesn't care and proceeded to let himself out. Review of R3's notes written by the nurse practitioner included the following exerpts: 1/31/24: Patient found vaping in his room per nursing. 2/1/24 at 12:41 PM: Smoking materials were found in the resident's room. He had a multicolored vape and a black lighter. These items were turned in to Social Services. Social Services turned the items over to the Director of Nursing. On 2/12/24 at 4:45 PM, certified nursing assistant (CNA #5) was interviewed. CNA #5 verbalized working with R3 a few days prior to the fire and verbalized catching R3 vaping (e-cigarette) in his room, while handing out meal trays. CNA #5 stated that she had reported it to the nurse (identified as license practical nurse (LPN #6), who she thought had taken the vape away and stored it in the med cart. When questioned further, CNA #5 verbalized, [R3] is non-compliant with smoking and does what he wants to do. On 2/12/24 at 5:00 PM, R3 was interviewed. When questioned about smoking, R3 verbalized that he was noncompliant with the smoking/vaping policy and has kept smoking materials in his room (a vape pipe). Questioned further, R3 verbalized finding a lighter while at dialysis, picked it up, and had put it in his room because it looked to be in good condition. R3 stated that he had never used the lighter, as he no longer smokes. When questioned about the types of smoking materials used, R3 verbalized only vaping. When questioned about noncompliance, R3 admitted to going outside at night to vape, .even when staff tells me I'm not supposed to . but it helps me with my anxiety. On 2/12/24 at 7:20 PM, LPN #6 (working on unit where R3 resided) was interviewed. LPN #6 verbalized catching R3 vaping in his room on 1/20/24, collecting the vape, and putting it in the med cart at that time. When questioned further, LPN #6 said that R3 goes out at night unsupervised and vapes, has been caught multiple times vaping in his room. When asked what happens when R3 was caught, LPN #6 stated that the smoking materials are confiscated and re-education attempted, but that R3 continues to vape and hide smoking materials in his room. On 2/13/24 at 8:50 AM, CNA #6 (working on unit where R3 resided) was interviewed regarding compliance with smoking materials. CNA #6 verbalized that R3 had been caught several times with smoking items in his room and vaping unsupervised in and out of the facility. On 2/13/24 at 9:00 AM, LPN #7 (working on the unit where R3 resided) was interviewed. LPN #7 denied personally catching R3 smoking but was aware of R3's non-compliance and that R3 had previously asked LPN #7 to order vape products off the Internet. On 2/13/24 at 9:55 AM, LPN #1 (assigned to R3 at this time) was interviewed. LPN #1 denied personally catching R3 vaping in a room or smoking at non-smoke times, but stated knowing of R3's non-compliance with smoking. LPN#1 said that R3 could be manipulative and demanding when wanting to smoke. LPN#1 stated that after it was given to him when leaving for dialysis, LPN #1 suspected that R3 did not turn the vape back in when returning from dialysis. On 2/13/24 at 10:40 AM, the nurse practitioner (Other Staff, OS #7) was interviewed regarding a progress note dated 1/31/24. OS #7 verbalized being aware that R3 had been caught vaping the night of 1/30/24 or the early morning of 1/31/24. OS #7 verbalized knowing of R3's non-compliance and that R3 had been educated several times regarding his health, but continues to smoke. On 2/13/24 at 11:15 AM, R3 was interviewed again. When asked how the smoking materials are kept, R3 verbalized, When I go to dialysis, I don't turn in my vape or if I go to the scheduled smoking breaks, I just smuggle it back to my room with me . I'm slick like that and very observant. The survey team extended the sample to include three additional residents that smoke (Resident #'s 1, 4, and 5) and had the potential to keep lighters and smoking materials. Rooms of all residents that smoked were observed and did not evidence unsecured smoking materials. Resident smoke breaks were observed throughout the survey process and did not evidence concern. The facility had a total of 7 smokers at the time of the survey. Review of the facility Smoking Policy with a revision date of 8/1/23 included these excerpts: 1. Smoking in the facility is prohibited in all areas except the designated smoking area. 2. e. Prohibition of oxygen use in or near the smoking area. 3. Electronic cigarettes will be treated the same as any other smoking product 6. Residents who desire to continue smoking will be assessed to determine recommendations for safe smoking safety interventions. Residents will be educated on and must agree to the terms outlined in the facility resident smoking agreement 8. If a resident contributes to an unsafe environment related to smoking the plan of care may be revised to include additional measures up to and including: room searches, increased supervision, or appropriate discharge proceedings 11. For the safety of all residents, those residents who have agreed to the smoking terms must have their materials to include cigarettes, e-cigarettes, vaping pens and all devices secured in a locked system that is not accessible to other residents and in an area that is supervised by the facility staff. On 2/13/24 at 3:20 PM, the administrator was made aware in a meeting with the survey team of the above findings and serious concerns regarding Resident #3, which had been discussed with the state agency. Thus, the administrator was notified that the survey team had identified IJ (Immediate Jeopardy) and substandard quality of care (SQC) findings, based on the facility's failure to ensure adequate supervision of a non-compliant smoker and failure to implement interventions for non-compliance with smoking materials, putting all residents and staff in danger. When a written plan of removal regarding adequate supervision and interventions to address the non-compliance with the facilities smoking policy by R3 was requested, the administrator verbalized that it would be hard to come up with a plan of removal involving R3, as R3 is non-compliant with smoking. On 2/13/24 at 7:30 PM, LPN #5 was interviewed (via telephone) regarding a progress note written by LPN #5. LPN #5 verbalized documenting an incident based on what a CNA had reported. LPN #5 said that R3 had demanded to go outside to smoke and had smoking material with him. When the CNA refused to allow R3 to go outside to smoke, R3 proceeded to enter the door code to the outside, and let himself out. On 2/14/24 at 8:20 AM, LPN #4 (assigned to R3 on the day of the fire) was interviewed. LPN #4 verbalized at the time of the fire R3 had been in therapy for close to an hour before the staff began to smell smoke and realized the smoke was coming from R3's room. LPN #4 stated feeling certain that R3 had not started the fire but verbalized that R3 was non-compliant with keeping smoking materials in his room and had been caught multiple times vaping in the room. On 2/14/24 at 8:50 AM, the survey team was presented with a plan of removal for failure to ensure hazardous smoking materials were secured and failure to address R3's repeated non-compliance with smoking policies, which put all residents and staff in danger, related to the risk of fire. The facility's plan of removal included the following interventions: Resident #3 was issued a discharge notice on 2/13/24. Resident #3 will sign out for his vape when going to appointments and will be required to sign it back in after each trip. Resident educated on this on 2/13/24. Resident #3 will have random room searches completed as he permits following appointments. Should resident refuse, he will be placed on 1:1 supervision. Resident educated on this 2/13/24. Resident #3's plan of care has been reviewed and updated to reflect non-compliance. Resident updated smoking assessment completed 2/13/24. DON immediately secured the found smoking material in a lock box on 2/1/24. Room rounds conducted starting on 2/1/24 for 7 days to ensure the absence of cigarettes and other fire-starting materials. Identified like residents of current residents in facility by auditing current smokers. All smoking residents had updated smoking assessments completed on 2/13/24. All smokers had their smoking contracts reviewed with them and re-educated to the smoking process on 2/1/24. All smokers found to be non-compliant with smoking by: smoking off times, locations, or by not following the smoking contract will be issued a 30-day discharge from facility and placed on increased supervision checks until no longer in the facility. DON held ad-hoc safety meeting on 2/13/24 to discuss survey IJ findings and create removal plan. DON notified medical director of IJ findings and action plan on 2/13/24. Findings of like resident reviews discussed at QAPI ad-hoc meeting on 2/13/24. Care plans of smokers reviewed and updated 2/13/24. AIT (Administrator in Training) educated all staff present in the building on 2/13/24, regarding locked safety box process and what to do if violation. Education will remain ongoing for any staff that did not attend prior to working their next assigned shift. Staff will be required to sign out and in for resident vape pens. Staff on duty were educated on 2/13/24 and others educated prior to their next worked shift. Education regarding assessment of smoking, monitoring unsafe behaviors and smokers' safety lock box will be added to new hire orientation. DON/administrator will educate the interdisciplinary team, other department heads and receptionists on the facility smoking material safety box lock process upon entry to the center on 2/13/24. Education will remain ongoing for any facility staff that did not attend prior to their next shift. Data obtained during the audit process will be analyzed for patterns and trends and reported to QAPI by the administrator/DON for 3 months. QAPI committee will determine effectiveness of interventions and determine need for continued auditing to maintain compliance. On 2/14/24 at 9:40am, the facility administrator was again interviewed. The administrator acknowledged that R3's non-compliance with the smoking policy began in December 2023. When asked about the facility's QA program, the administrator identified the purpose of QA is to identify concerns and trends, review operations, systems and quality improvement. The administrator stated that the QA team meets on a monthly basis. When asked to identify how items are identified for the QA committee to work to improve, he said, we use a standard format, look at quality measures, survey issues, and anything of that nature. When asked about the QA's involvement to ensure ongoing compliance once R3's was known to be non-compliant with the use and storage of smoking materials, the administrator stated, When we had issues, we did room sweeps. For the most part we haven't had issues until the [R3's name redacted] issue. When asked what the QA team did to ensure the safety of all residents, once R3's non-compliance became known in December 2023, the administrator looked through the QA meeting minutes from December 28, 2023 through January 29, 2024, and stated, There is nothing in there. When asked if R3's noncompliance would have been an opportunity for the QA committee to identify and monitor ongoing compliance with the smoking policy and storage of smoking materials, the administrator stated, Yes, I can't disagree with that. On 2/14/24, the survey team verified the plan of removal through observations of resident rooms for smoking materials, ensuring smoking lock box materials were secured and accounted for, and the review of newly implemented tool used to sign out E-cigarettes. The survey team also verified the removal plan through staff interviews regarding education on smoking policy and what to do if smoking materials were found unsecured. The survey team also reviewed inservices, as well signatures of staff receiving education, and all other documentation indicated in the plan of removal. No concerns were identified. The IJ was removed by the survey team on 2/14/23 at 11:55 PM.

Based on facility documentation and staff interviews, the facility staff failed to review and update a facility-wide assessment to care for the resident population during day-to-day operations and emergencies, which had the potential to affect all 82 residents residing in the facility. The findings included: On 2/13/24, the facility administrator was asked to provide the survey team with the facility assessment. On 2/14/24, a three-ring binder was provided to the survey team which included the most recent facility assessment which indicated the following, Date of facility assessment: 5/12/22, Date reviewed with QAPI Committee: 5/26/2021 . It was noted that the facility name did not reflect the current name the facility was operating under, nor updates to reflect the current facility administration staff. On 2/14/24 at 9:40 a.m., an interview was conducted with the facility administrator. When asked what the facility assessment is and the purpose of it, the administrator said, It is done to look to overall view of the facility. When asked how often it is reviewed and by whom, the administrator said, It is reviewed annually by the Administrator and IDT [interdisciplinary team]. When it was discussed that the last review was performed in May 2022, he said, It's one of those items with the changes, I've only been here since August and we've been trying but I can only do so much, it's not an easy building. The administrator confirmed that the ownership change took place the beginning of February with a new ownership. During the above meeting with the facility administrator, the surveyor shared the concerns that the facility assessment had not been revised annually as required and was not up to date. The administrator verbalized understanding. On 2/14/24, the administrator provided a facility policy titled, Facility Assessment with a reviewed/revised date of 12/1/22. The policy in part read, . 3. The administrator is responsible for ensuring the completion of the facility assessment and maintaining all documents that pertain to the assessment. He/she serves as the leader of the facility assessment process or may designate someone to lead the process . 10. The facility assessment will be reviewed and updated whenever there is, or the facility plans for, any change that would require a substantial modification to any part of the assessment or at a minimum annually. Any changes to the assessment will be documented, along with a revision history. No further information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain an effective quality assurance program with regards to smoking safety, which had the potential to affect many residents on one of three nursing units. The findings included: The facility staff failed to maintain an effective quality assurance (QA) program to address smoking safety. On 7/21/23, the facility experienced a fire event that was related to unsecured smoking materials. This incident was investigated during a standard survey conducted 7/30/23 through 8/2/23, which resulted in immediate jeopardy being identified during that survey. As part of the facility's plan of correction, the facility stated, The smoking policy was revised to indicate that smoking material, including any incendiary device would be secured and supervised by facility staff. All smokers were educated to the process with particular attention to storage of smoking materials . The administrator/designee will conduct a random quality monitoring audit of 10 rooms per week to ensure smoking materials are secured as per the new process . On 2/12/24, during this abbreviated survey, it was noted that the facility failed to adhere to the smoking policy/protocol to address serial noncompliance of Resident #3 (R3). The facility policy requires that hazardous smoking material be secured and inaccessible to residents. According to R3's clinical record, unsecured smoking material and an incendiary device were retrieved and/or observed in R3's possession on 1/20/24, 1/26/24, 1/27/24, 1/31/24, and 2/1/24. There was no credible evidence that any of the measures to address resident noncompliance were implemented. Following the identification and documentation of R3 having unsecured smoking devices and failure of interventions, while R3 was in therapy, a fire was started in R3's room on 2/1/24. Residents on the unit had to be evacuated and the fire department was called and responded and extinguished the fire. Immediately following the fire, an unsecured electronic cigarette and a cigarette lighter was removed from R3's. The facility's Resident Smoking policy with a revision date of 8/1/23, had provisions on how non-compliance would be handled. The policy read in part, . 8. All safe smoking intervention recommendations will be documented on each resident's care plan. If a resident contributes to an unsafe environment related to smoking the plan of care may be revised to include additional measures up to and including room searches, increased supervision, or appropriate discharge proceedings . Review of R3's care plan revealed that the non-compliance with the storage of smoking devices was not addressed, nor were any interventions implemented with regards to the non-compliance. The above resulted in immediate jeopardy (IJ) being identified and called on 2/13/24 at 3:20 p.m., for the second time in a 6-month period. When the facility administrator was made aware of the IJ, he stated that R3 was going to be problematic because of his ongoing non-compliance and he didn't know how they were going to address this. On 2/14/24 at 9:40 a.m., an interview was conducted with the facility administrator. The administrator acknowledged that R3's non-compliance with the smoking policy began in December 2023. When asked about the facility's QA program, the administrator identified the purpose of QA is to identify concerns and trends, review operations, systems and quality improvement. The administrator stated that the QA team meets on a monthly basis. When asked to identify how items are identified for the QA committee to work to improve, he said, we use a standard format, look at quality measures, survey issues, and anything of that nature. The administrator was shown the survey report (form CMS-2567) from the standard survey conducted 7/30/23 through 8/2/23, which resulted in immediate jeopardy being identified in the area of Quality of Care with regards to accident hazards. As part of the facility's plan of correction, the facility had stated, The smoking policy was revised to indicate that smoking material, including any incendiary device, would be secured and supervised by facility staff. All smokers were educated to the process with particular attention to storage of smoking materials . The administrator/designee will conduct a random quality monitoring audit of 10 rooms per week to ensure smoking materials are secured as per the new process . Review of the facility's plan of correction from the deficient practice cited in August 2023 was conducted, which included a statement from the administrator that indicated . as of 8/22/23 smoking policy was changed related to noncompliance of smokers. All resident smoking materials are secured, and smoking is supervised. Also included in the plan of correction were audits of 10 rooms to monitor for on-going compliance. Those audits were conducted on 8/25/23, 9/1/23, 9/5/23, 9/14/23, 9/19/23 and 9/24/23, additionally there was one page of an audit that was undated. When asked about the QA's involvement to ensure ongoing compliance once R3 was identified and known to be non-compliant with the storage and use of smoking materials, the administrator stated, When we had issues, we did room sweeps. For the most part we haven't had issues until the [R3's name redacted] issue. When asked what the QA team did to ensure the safety of all residents once R3's non-compliance was identified and known in December 2023, the administrator looked through the QA meeting minutes from December 28, 2023 through January 29, 2024, and stated, There is nothing in there. When asked if R3's noncompliance would have been an opportunity for the QA committee to identify and monitor ongoing compliance with the smoking policy and storage of smoking materials, the administrator stated, Yes, I can't disagree with that. A review was conducted of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) with a revision date of 12/1/22. The policy read in part, It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life . 2. The QAA Committee shall be interdisciplinary and shall: c. Develop and implement appropriate plans of action to correct identified quality deficiencies . 3. The QAPI plan will address the following elements: . c. Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following: i. tracking and measuring performance . iii. Identifying and prioritizing quality deficiencies. iv. Systematically analyzing underlying causes of systemic quality deficiencies. v. Developing and implementing corrective action or performance improvement activities. vi. Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed . On 2/14/24 during the meeting at 9:40 a.m., the facility Administrator was made aware of the above concerns with regards to an effective Quality Assurance program. No further information was provided.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide medically related social services in response to statements of self-harm for three of seven residents in the survey sample (Residents #2, #6 and #7). The findings include: 1. Facility staff failed to provide a social services assessment and initiate and/or advocate for interventions for suicide prevention and emotional support for Resident #2 following statements of self-harm and two suicide attempts involving the resident wrapping the bed remote cord around her neck. Resident #2 (R2) was admitted to the facility with diagnoses that included bipolar disorder, major depression disorder, affective mood disorder, borderline personality disorder, dementia with agitation, psychotic disturbance, generalized anxiety disorder, cognitive communication deficit, cerebral infarction, hypertension, diabetes, atrial fibrillation, ischemic heart disease, urinary tract infection, COPD (chronic obstructive pulmonary disease) and asthma. The minimum data set (MDS) dated [DATE] assessed R2 with severely impaired cognitive skills and as dependent on staff for bed mobility and transfers. A social services (SS) note dated 12/26/23 documented, .Resident came to Social Services on 12/26/23 around noon and stated that she wanted to go 'home to live with her mom at her house' .Then she [R2] proceeded to state that if SS didn't get her out of the building soon she would harm herself. She was descriptive. SS notified the nurse on duty and the nurse notified the NP on duty. The nurse practitioner (NP) assessed R2 on 12/27/23 and documented no assessment or mention of the resident's statement on 12/26/23 of wanting to self-harm. The NP progress note dated 12/27/23, .patient is being seen today for mood disorder. Patient is refusing care and medications. Nursing reports patient is combative at times and hitting at staff. She is not easily redirected. She has a diagnosis of dementia, which is likelyprogressing [likely progressing] .Mood euthymic .Start Hydroxyzine 25 mg [milligrams] .every 8 hours as needed X 7 days for anxiety . A social services note dated 1/12/24 documented a conversation with R2 about the verbally aggressive behaviors but made no mention of the resident's status regarding a desire for self-harm. The SS note dated 1/12/24 documented, .spoke to resident today about the inappropriate language .She was asked to please use kind words when speaking to staff . Nursing notes on 1/13/24 and 1/14/24 documented R2 refused care, refused medications, made multiple verbal threats to staff that included wanting to blow this Nurses brains out, getting a machine gun and kill, demonstrated physical aggression by grabbing a nurse's arm saying she was going to break it and throwing a cup of water on a nurse. Nursing notes documented after some time the resident settled down and went to sleep. There was no notification to a provider about the aggressive behaviors on 1/13/24 and 1/14/24. There was no psychiatric referral or assessment in response to these behaviors. R2's last psychiatric evaluation was documented on 5/5/23. A nursing note dated 1/19/24 documented, .Around 4pm today resident stated that she wanted to kill herself. Patient was caught in her room with the cord from her bed remote controller around her neck. Unit manager was notified .instructed nurse to send resident out to the hospital for further evaluation. R2 was sent to the emergency room . The emergency department (ED) note dated 1/19/24 documented, .Patient arrives by ems [emergency medical services] from [nursing facility] with thought of SI [suicidal ideation], patient denies HI [homicidal ideation] but per ems stated 'I am going to burn this place down' .presents to the emergency department with suicidal thoughts .states she has been depressed for 'a good while' .over the last several weeks, she has had thoughts of not wanting to live. She reports that she prays she will die. She has been suicidal with several plans to harm herself. She has thought of buying a gun and shooting herself. She has also considered running off a mountain ledge. She is currently at a skilled care nursing facility and states that today, she wrapped a cord around her neck to try to suffocate herself .does have a distant history of a mental health admission . Mental health evaluated R2 in the emergency department on 1/19/24 and recommended admission since the resident had suicidal thoughts with plans. The ED disposition note dated 1/20/24 documented, presents to the emergency department with suicidal thoughts .has been increasingly depressed with worsening suicidal thoughts over the last several weeks. She has several plans to harm herself .she wrapped a cord around her neck .head and neck exam is unremarkable .I do not suspect traumatic injury from her actions .I do not suspect an acute medical process .Mental health has evaluated her and is recommending admission. Disposition pending bed placement . R2 was discharged from the hospital and readmitted to the nursing facility on 1/20/24 with orders to start the antipsychotic medication Seroquel 12.5 mg at each bedtime and an antibiotic for 7 days for treatment of a urinary tract infection. Upon readmission on 1/20/24, there were no other orders or care plan interventions implemented regarding the suicide prevention. There was no assessment or notes from social services about any needed behavioral support or services in response to the attempted suicide. On 1/24/24, R2 was found again with the bed remote cord wrapped around her neck. A nursing note dated 1/24/24 at 6:54 p.m. documented, .Resident observed lying in bed with bed remote cord wrapped around her neck. Resident verbally voiced that she does want to kill herself and she plans to do so using the bed remote cord. On call physc [psych] contacted and made aware that resident has suicidal ideations, has plan, and this is her 2nd attempt within this month. Verbal order given to send patient to hospital . The ED report dated 1/24/24 documented, .pt [patient] from facility for trying to wrap telephone cord around her neck; pt stated 'if i wanted to hurt myself, then i should have that right to do so . Mental health evaluated R2 and recommended psychiatric admission with pending bed placement with assessment listed as suicidal ideation, Alzheimer's dementia and affective mood disorder. The ED discharge summary dated 1/29/24 documented, .Patient has been in the emergency department over 120 hours at this point and has been declined from most acute inpatient psychiatric units due to medical needs .today she denies all SI and HI .We are approaching 6 days in the emergency department .remaining in the emergency department indefinitely pursuing an unlikely bed search would be detrimental to patient's overall mental health and wellbeing given this prolonged length of stay .increased frequency of Seroquel to 12.5 mg with meals and at bedtime .Imminent risk for suicide is low at this point .recommend nursing facility restrict access to ligature risks such as phone cords given she has attempted this in the past . R2 was readmitted to the nursing facility on 1/29/24 with orders for the increased frequency of Seroquel and referral for psych services. There were no orders or updated care plan interventions addressing the restricted access to ligatures/cords as recommended by the ED physician. A social services note dated 2/1/24 documented an additional conversation with R2 about inappropriate language but made no mention of the resident's status regarding the desire for self-harm or any interventions in place for suicide prevention. The social services note of 2/1/24 documented, .spoke to the resident about yelling .She [R2] was reminded that this language is not appropriate and will not be used . There were no other documented interactions by the social worker with R2. R2's care plan (revised 2/2/24) include no problems, goals and/or interventions regarding the self-harm statements, recent suicidal ideation and suicide attempts with the bed remote cord. The clinical record included no assessments by the social worker following the self-harm statements and suicide attempts other than telling the resident not to use inappropriate language. On 2/12/24 at 2:20 p.m., the social worker (administration staff #5) was interviewed about services provided for R2 in response to suicide attempts and ideation. The social worker stated R2 came to her office and reported the thoughts of self-harm on 12/26/23 and that she reported those statements to the assistant director of nursing (ADON). The social worker stated she thought the ADON contacted the NP and that the resident was put in the book for psychiatric services. When asked about any support services or follow up concerning the self-harm statement, the social worker stated she checked on the resident and had talked with the resident about not using inappropriate language. The social worker stated she thought nursing had taken measures about suicide prevention. On 2/14/24 at 9:40 a.m., the administrator was interviewed about the social worker's role regarding residents' behavioral health needs. The administrator stated, She [social worker] is the residents go to person for any psychosocial needs. When asked to explain the social worker's role when a resident was having an acute change such as verbalizing suicidal ideation, the administrator stated, The social worker should be reaching out to the provider with assistance with nursing and working to get whatever that resident needs. The administrator confirmed that the social worker should be notified and working with any resident with thoughts of self-harm. Regarding R2's suicidal ideation and attempts of self-harm, the administrator stated he would have expected there to be documentation and involvement from the social worker. On 2/13/24 at 10:00 a.m., the social worker (administration staff #5) was interviewed again about follow-up, interventions or support services provided for R2 following the statements/attempts of suicide. The social worker stated, I pop in and out checking on her (R2). When asked if she inquired about any psychiatric services for R2, the social worker stated she was told the resident was put in the book to see psychiatry. When asked about her role if a resident expressed self-harm, the social worker stated she would notify nursing or the provider, that she was still learning her job and would document in notes if there were concerns. The facility's social services director job description (dated December 2018) documented under essential duties and responsibilities, .Participate in resident care planning by identifying the social and emotional needs of the residents in accordance with the medical assessment .Make referrals to support agencies when the need for such services is determined by the interdisciplinary team, keeping records of such referrals .Work closely with the facility mental health provider to ensure that all resident psychosocial needs are identified, referrals are made, and services are provided . This finding was reviewed with the administrator, director of nursing and regional nurse consultant on 2/14/24 at 11:30 a.m. with no further information provided prior to the end of the survey. 41449 2. For Resident #6 (R6), who verbalized feelings/thoughts of self-harm and/or being better off dead, the facility staff failed to provide medically related social services for the resident to maintain their highest practicable mental and psychosocial well-being. On 2/12/24 at approximately 4:30 p.m., a review of R6's clinical record was conducted. R6's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 12/20/23, was a quarterly assessment. R6 was coded in section D0150, question I, which asked Thoughts that you would be better off dead, or of hurting yourself in some way. R6 reported having these feelings 2-6 days (several days). There was no evidence within the clinical record that the facility responded to or implemented any interventions to address R6's behavioral health needs. According to the clinical record, R6 has diagnosis included but were not limited to major depressive disorder, mood disorder and anxiety disorder. According to the clinical record, R6's feelings of depression and suicidal ideation were not noted in the progress notes indicating that any social services involvement was made about the resident's suicidal ideation. The most recent social services progress notes and/or assessments were as follows: a. On 9/27/23, a late entry was made to indicate a quarterly care conference was held on 9/27/23. b. On 2/3/23 a note indicated that R6's responsible party came in and needed POA [power of attorney] documentation. There were no social services notes or assessments noted for 2022, or 2024. On 2/13/24 at 10:03 a.m., an interview was conducted with the facility's social worker (SW) (Administrative Staff #5- AS#5). The SW stated that when a resident verbalizes suicidal ideation, she usually hears about it in morning meeting. The SW was asked about R6's report of suicidal ideation on 12/20/23. The SW stated she was unaware of this. When asked about her role and involvement with residents, the SW said she visits residents and will speak to them but was not able to give any clear indication about the frequency of her visits with residents or level of involvement when someone verbalizes suicidal ideation or has a mental health diagnosis. On 2/14/24 at 9:40 a.m., an interview was conducted with the facility administrator. When asked to explain the role of the social worker, the administrator said, She is the resident's go to person for any psychosocial needs. When asked to explain her role when a resident is having an acute change such as verbalizing suicidal ideation, the administrator said, The social worker should be reaching out to the provider with assistance with nursing and working to get whatever that resident needs. When asked if the social worker would be notified if a resident is verbalizing thoughts of suicidal ideation and any assessment of the resident, the administrator confirmed that the social worker should be notified and working with that resident. When notified that there was no evidence of involvement from the social worker when R6 verbalized feelings of suicidal ideation, the administrator stated he would have expected there to be documentation and involvement from the social worker. The administrator also stated, nursing was handling a lot of the normal social services things because that was not a stable position and she [the social worker] is still learning and growing in her role. During the above meeting, the facility administrator was made aware that the survey team had concerns regarding the lack of medically related social services for R6, he verbalized understanding. On 2/14/24, a review was conducted of the Social Worker's job description. This document read in part, Summary: Identify and provide for each resident's social, emotional and psychological needs, and the continuing development of the resident's full potential during his/her stay at the facility . Essential Duties & Responsibilities: . Assist residents and families with social, emotional, and family issues ., maintain progress notes for each resident as required by company policy and state and federal regulations, indicating response to the treatment plan and adjustment to facility life . make referrals to support agencies when the need for such services is determined by the interdisciplinary team, keeping records of such referrals, . work closely with the facility mental health provider to ensure that all resident psychosocial needs are identified, referrals are made and services are provided . No further information was provided. 3. For Resident #7 (R7), who reported suicidal ideation, the facility staff failed to provide medically related social services for the resident to maintain their highest practicable mental and psychosocial well-being. On the afternoon of 2/12/24, a review of R7's clinical record was conducted. R7's had a current MDS (minimum data set) (an assessment tool) in progress, with an ARD (assessment reference date) of 2/12/24, which was a quarterly assessment. R7 was coded in section D0150, question I, which asked Thoughts that you would be better off dead, or of hurting yourself in some way. R7 reported having these feelings 12-14 days (nearly every day). There was no evidence within the clinical record that the facility implemented any interventions to address R7's suicidal ideation. According to the clinical record, R7 has diagnosis included but were not limited to vascular dementia, major depressive disorder, and generalized anxiety disorder. According to the clinical record, a progress note entry was made on 2/12/24 at 4:13 p.m., that read, Resident scored a 24 on PHQ9, answered yes to question concerning thoughts of hurting herself, resident does not have a plan in place. Administrator aware, Director of clinical services aware. There was no social services documentation within R7's chart for 2024. The only documentation with regards to social services was as follows: a. The last social services assessment documented under the assessment tab of the clinical record was dated 4/13/22. b. The most recent progress note entry was dated 9/29/2023, and read, Quarterly Care Conference held on 9/11/2023 and attended by [R7's name redacted], her POA [Power of attorney name redacted], SS [social services], Dietary, Activities Dir. PT/OT rep, and Nursing: Discussed goals, requests, preferences, concerns, medications, current treatments, current therapy plans, current diet. Concerns relayed to appropriate disciplines. c. The only other note for 2023 was dated 1/11/2023, and read, Resident will move from 24B to 39B. Responsible party has been made aware and is receptive to the change. On 2/13/24 at 10:03 a.m., an interview was conducted with the facility's social worker (SW) (Administrative Staff #5- AS#5). The SW stated that when a resident verbalizes suicidal ideation, she usually hears about it in morning meeting. The SW was asked about R7's report of suicidal ideation on 2/12/24. The SW stated she was unaware of this. When asked about her role and involvement with residents, the SW said she visits residents and will speak to them but was not able to give any clear indication about the frequency of her visits with residents or level of involvement when someone verbalizes suicidal ideation or has a mental health diagnosis. On 2/14/24 at 9:40 a.m., an interview was conducted with the facility administrator. When asked to explain the role of the social worker, the administrator said, She is the resident's go to person for any psychosocial needs. When asked to explain her role when a resident is having an acute change such as verbalizing suicidal ideation, the administrator said, The social worker should be reaching out to the provider with assistance with nursing and working to get whatever that resident needs. When asked if the social worker would be notified if a resident is verbalizing thoughts of suicidal ideation and any assessment of the resident, the administrator confirmed that the social worker should be notified and working with that resident. When notified that there was no evidence of involvement from the social worker when R7 verbalized feelings of suicidal ideation, the administrator stated he would have expected there to be documentation and involvement from the social worker. The administrator also stated, nursing was handling a lot of the normal social services things because that was not a stable position and she [the social worker] is still learning and growing in her role. During the above meeting, the facility administrator was made aware that the survey team had concerns regarding the lack of medically related social services for R7, he verbalized understanding. On 2/14/24, a review was conducted of the Social Worker's job description. This document read in part, Summary: Identify and provide for each resident's social, emotional and psychological needs, and the continuing development of the resident's full potential during his/her stay at the facility . Essential Duties & Responsibilities: . Assist residents and families with social, emotional, and family issues ., maintain progress notes for each resident as required by company policy and state and federal regulations, indicating response to the treatment plan and adjustment to facility life . make referrals to support agencies when the need for such services is determined by the interdisciplinary team, keeping records of such referrals, . work closely with the facility mental health provider to ensure that all resident psychosocial needs are identified, referrals are made and services are provided . No further information was provided.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for three of seven residents in the survey sample (Residents #2, #3 and #6). The findings include: 1. a) Resident #2's plan of care was not revised following statements of self-harm and before/after two suicide attempts by the resident when the bed remote cord was found wrapped around the resident's neck. Resident #2 (R2) was admitted to the facility with diagnoses that included bipolar disorder, major depression disorder, affective mood disorder, borderline personality disorder, dementia with agitation, psychotic disturbance, generalized anxiety disorder, cognitive communication deficit, cerebral infarction, hypertension, diabetes, atrial fibrillation, ischemic heart disease, urinary tract infection, COPD (chronic obstructive pulmonary disease) and asthma. The minimum data set (MDS) dated [DATE] assessed R2 with severely impaired cognitive skills and as dependent on staff for bed mobility and transfers. R2's clinical record documented on 12/21/23 that the resident was verbally abusive to staff, using racial slurs in addition to refusing blood sugar checks and meals. A social services (SS) note dated 12/26/23 documented, .Resident came to Social Services on 12/26/23 around noon and stated that she wanted to go 'home to live with her mom at her house' .Then she [R2] proceeded to state that if SS didn't get her out of the building soon she would harm herself. She was descriptive. SS notified the nurse on duty and the nurse notified the NP [nurse practitioner] on duty. A nursing note dated 1/19/24 documented, Around 4pm today resident stated that she wanted to kill herself. Patient was caught in her room with the cord from her bed remote controller around her neck. Unit manager was notified .instructed nurse to send resident out to the hospital for further evaluation. R2 was sent to the emergency room . The emergency department (ED) note dated 1/19/24 documented, .Patient arrives by ems [emergency medical services] from [nursing facility] with thought of SI [suicidal ideation], patient denies HI [homicidal ideation] but per ems stated 'I am going to burn this place down' .presents to the emergency department with suicidal thoughts .states she has been depressed for 'a good while' .over the last several weeks, she has had thoughts of not wanting to live. She reports that she prays she will die. She has been suicidal with several plans to harm herself. She has thought of buying a gun and shooting herself. She has also considered running off a mountain ledge. She is currently at a skilled care nursing facility and states that today, she wrapped a cord around her neck to try to suffocate herself .does have a distant history of a mental health admission . The emergency documentation noted that Mental health evaluated R2 in the emergency department on 1/19/24 and recommended admission since the resident had suicidal thoughts with plans. The ED disposition note dated 1/20/24 documented, Presents to the emergency department with suicidal thoughts .has been increasingly depressed with worsening suicidal thoughts over the last several weeks. She has several plans to harm herself .she wrapped a cord around her neck .head and neck exam is unremarkable .I do not suspect traumatic injury from her actions .I do not suspect an acute medical process .Mental health has seen her and is recommending admission. Disposition pending bed placement R2 was discharged from the hospital and readmitted to the nursing facility on 1/20/24 with orders to start the antipsychotic medication Seroquel 12.5 mg at each bedtime and an antibiotic for 7 days for treatment of a urinary tract infection. On 1/24/24, R2 was found again with the bed remote cord wrapped around her neck. A nursing note dated 1/24/24 at 6:54 p.m. documented, Resident observed lying in bed with bed remote cord wrapped around her neck. Resident verbally voiced that she does want to kill herself and she plans to do so using the bed remote cord. On call physc [psych] contacted and made aware that resident has suicidal ideations, has plan, and this is her 2nd attempt within this month. Verbal order given to send patient to hospital . The ED report dated 1/24/24 documented, .pt [patient] from facility for trying to wrap telephone cord around her neck; pt stated 'if i wanted to hurt myself, then i should have that right to do so Mental health evaluated R2 and recommended psychiatric admission with pending bed placement with assessment listed as suicidal ideation, Alzheimer's dementia and affective mood disorder. The ED discharge summary dated 1/29/24 documented, .Patient has been in the emergency department over 120 hours at this point and has been declined from most acute inpatient psychiatric units due to medical needs .today she denies all SI and HI .We are approaching 6 days in the emergency department .remaining in the emergency department indefinitely pursuing an unlikely bed search would be detrimental to patient's overall mental health and wellbeing given this prolonged length of stay .increased frequency of Seroquel to 12.5 mg with meals and at bedtime .Imminent risk for suicide is low at this point .recommend nursing facility restrict access to ligature risks such as phone cords given she has attempted this in the past . R2 was readmitted to the nursing facility on 1/29/24 with orders for the increased frequency of Seroquel and referral for psych services. R2's plan of care (revised 2/2/24) included no updates regarding the expressions of self-harm on 12/26/23 or the suicide attempts with the bed remote cord on 1/19/24 and 1/24/24. R2's plan of care documented a diagnosis of depression and a history of suicidal ideation that was listed as resolved on 5/22/23. Interventions to minimize depression, anxiety, and sad mood were last updated on 5/22/23 and included, Arrange for psych consult, follow up as indicated . Discuss with resident/family caregiver any concerns, fears, issues . Monitor/document/report PRN [as needed] any risk for harm to self; suicidal plan, past attempt at suicide, risk actions .intentionally harmed or tried to harm self, refusing to eat or drink, refusing med [medication] or therapies, sense of hopelessness or helplessness, impaired judgement or safety awareness .Monitor/document/report PRN any s/sx [signs/symptoms] of depression . pharmacy review monthly . R2's plan of care was revised on 1/29/24 stating, Touch call bell at bedside for use when assistance is needed . The intervention was not associated with any care plan problem/concern and there was no explanation listed as to why the resident needed/used a touch bell. The care plan included no mention of the restricted access to cords following the two suicide attempts when the resident was found the with bed remote cord wrapped around her neck. On 2/13/24 at 8:00 a.m., the director of nursing (DON) was interviewed about R2's care plan regarding self-harm. When asked why the plan of care had not been updated in response to the expressions of self-harm, suicide attempts, or need for restricted cord access, the DON stated that the MDS coordinator was responsible for care plan updates. On 2/13/24 at 9:45 a.m., the registered nurse MDS coordinator (RN #2) responsible for care plan updates was interviewed. RN #2 stated R2's care plan was updated on 1/29/24 indicating the resident used a tap bell. RN #2 stated that the tap bell was added because he was told to add it by the assistant director of nursing. RN #2 stated he did not recall anything else being added to the plan. When questioned further, RN #2 stated that there were no updates regarding the expressions of self-harm statements and nothing had been added about the suicide attempts or about restricting access to cords. When asked further, RN #2 stated resident concerns and changes in condition were discussed each Monday through Friday during morning meetings with the interdisciplinary and clinical team. RN #2 stated care plans were supposed to be revised/updated based up discussions with the clinical team in response to changes in condition or care needs. The facility's policy titled Behavioral Health Services (revised 12/1/22) documented, .Behavioral health care plan shall be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition . 1. b) Resident #2's plan of care was not revised to accurately reflect the resident's resuscitation status. R2's clinical record documented a Durable Do Not Resuscitate form dated 4/18/17 signed by the resident and physician, indicating the decision to withhold cardiopulmonary resuscitation in case of cardiac arrest. R2's clinical record documented a physician's order for Do Not Resuscitate - DNR, dated 4/16/23. R2's plan of care (revised 2/2/24) documented the resident's resuscitation status as full code. The advanced directives section of the care plan had not been updated since 1/21/23 and the plan of care did not reflect the resident's DNR order. On 2/13/24 at 9:45 a.m., the registered nurse MDS coordinator (RN #2) responsible for care plan updates was interviewed about R2's resuscitation status. RN #2 stated nobody had informed him that R2's code status needed to be changed to DNR. On 2/14/23 at 8:00 a.m., the director of nursing (DON) was interviewed about R2's resuscitation status. The DON reviewed the clinical record and stated the resident had a DNR order. When questioned further, the DON stated that the care plan had not been updated to indicate the DNR status. This finding was reviewed with the administrator, DON, and regional nurse consultant on 2/14/24 at 11:30 a.m., with no further information presented prior to the end of the survey. 28106 2. Resident #3's (R3) smoking care plan was not revised related to non-compliance with smoking materials. Diagnoses for R3 included: Chronic obstructive pulmonary disease, bipolar, schizoaffective disorder, anxiety, and tobacco use. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/15/23, which assessed R3 as being cognitively intact with a BIMS score of 15 out of 15. Review of R3's progress notes revealed the following: 1/20/24 at 10:20 PM: resident went out side door to smoke outside of smoking hours, resident stated he knows hes [SIC] not supposed to but is going to do it anyway, resident did not sign himself out. 1/20/24 at 10:43 PM: writer caught resident smoking vape with O2 [oxygen] in his nose in his room, contacted on call supervisor made her aware. 1/26/24 2:32 AM: per CNA [certified nursing assistant] resident went to front lobby and asked to be let out to smoke, she stated she wasn't allowed to then resident became verbally abusive with the CNA. it has been explained to resident on numerous occasions that it is a safety concern for him to be out at night by himself and he was only allowed to smoke at designated times in designated areas per policy he stated he doesn't care and proceeded to let himself out. Review of a nurse practitioner note dated 1/31/24 read in part: Patient found vaping in his room per nursing. 2/1/24 at 12:41 PM: Smoking materials were found in the resident's room. He had a multicolored vape and a black lighter. These items were turned in to Social Services. Social Services turned the items over to the Director of Nursing. Review of R3's current care plan for smoking created on 2/2/23 and revised on 8/22/23 did not indicate that R3 was non-compliant with smoking policies nor interventions to address R3's non-compliance. On 2/13/24, a registered nurse (RN #2, MDS coordinator) was interviewed. RN #2 verbalized being aware of R3's non-compliance to smoking through the daily stand-up meetings. When questioned further, RN #2 said that nursing is supposed to notify the MDS coordinators of what to care plan, adding that the MDS coordinators just couldn't put in what was needed. RN #2 reviewed R3's care plan for smoking and agreed that non-compliance to smoking should be added to the care plan. On 2/14/24 at 11:30 AM, the above information was presented to the director of nursing, administrator, and nurse consultant. No other information was presented prior to the exit conference on 2/14/24. 41449 3. For Resident #6 (R6), who verbalized suicidal ideation, the facility staff failed to review and revise the care plan to include implementation of interventions. On 2/12/24 at approximately 4:30 p.m., a review of R6's clinical record was conducted. R6's most recent MDS (minimum data set - an assessment tool) was a quarterly assessment, with an ARD (assessment reference date) of 12/20/23. Section D0150, question I, asked Thoughts that you would be better off dead, or of hurting yourself in some way and coded that R6 had reported having these feelings 2-6 days (several days). There was no evidence within the clinical record that the facility responded to or implemented any interventions to address R6's behavioral health needs. According to the clinical record, R6 had diagnoses that included but were not limited to major depressive disorder, mood disorder and anxiety disorder. According to the clinical record, R6's expression of having feelings of depression and suicidal ideation were not documented in the progress notes. The care plan for R6, which was revised on 1/18/24, did not mention the suicidal ideation nor any related interventions. On 2/12/24 at 4:55 p.m., an interview was conducted with RN #2, who was an MDS coordinator. RN #2 confirmed having conducted the interview on 12/20/23, during which R6 expressed suicidal ideation. RN #2 stated that he had reported R6's response to the director of nursing (DON) and facility Administrator. When asked what happens when a resident verbalizes feelings of depression and/or suicidal ideation, RN #2 said, It is left up to them [Administrator and DON], but we need to get some type of psychiatric services that day, either in-house or at the ER [emergency room ]. During this interview, RN #2 reviewed R6's clinical chart and confirmed that R6 was last seen by psychiatric services in December 2022. RN #2 also confirmed that there was no evidence of the physician being notified of the suicidal ideation. On 2/13/24 at 9:45 a.m., another interview was conducted with RN #2 - MDS Coordinator, who stated that he was responsible for care plan development and updates. RN #2 stated any updates or changes were discussed in daily meetings (Monday through Friday) with department heads and the clinical team. RN #2 stated that based upon those discussions, he was responsible for updating care plans accordingly. On 2/14/24, the facility administrator and corporate nurse consultant both explained that each day the facility holds a morning meeting with the department managers and IDT (interdisciplinary team) to review items and areas of concern that need to be addressed, including a review of the 24-hour report, new physician orders, and risk areas. On 2/14/24, the facility staff provided the survey team with the 24-hour report and documentation of the morning meetings. According to these documents, there was no evidence that R6 was a topic of discussion since expressing suicidal ideation on 12/20/23. On 2/14/24, the facility provided evidence that R6 was seen by the NP on 2/13/24. The NP noted that during her assessment, R6 denied feelings of depression and denied suicidal ideation. The NP orders included, consult psych. On 2/14/24, the facility administration reported that R6 had been seen by psychiatry that morning. The notes from this visit were not available prior to the conclusion of the survey. The facility policy titled, Behavioral Health Services was received and reviewed. The policy read, in part, . 9. Behavioral health care plans shall be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition . No further information was provided.

Based on observation, staff and resident interviews, clinical record reviews and facility documentation reviews, the facility staff failed to provide effective administration regarding behavioral health services and smoking safety, resulting in the identification of two immediate jeopardy situations and substandard quality of care being identified, which had the potential to affect multiple residents on all 3 of the nursing units. The findings included: 1. The facility administration failed to administer the facility in an effective manner to address the behavioral health needs of 3 Residents who verbalized suicidal ideation, one of which had 2 attempts of suicide. On 2/12/24, during observations and clinical record reviews, the following was noted: 1A. On 12/26/23, Resident #2 (R2) reported to facility staff statements of suicidal ideation and was noted with increased verbal/physical behaviors. The facility staff failed to respond to the suicidal ideation and implemented no interventions to protect the resident or address the behavioral health needs of the resident. On 1/19/24, R2 attempted self-harm by wrapping the bed controller cord around her neck. After an emergency department visit/assessment, R2 was readmitted to the facility with no updated plan of care implemented for suicide prevention or ideation. On 1/24/24, five days later, R2 was found again with the bed controller cord wrapped around their neck, along with expressing suicidal ideation. R2 was hospitalized for 6 days following this suicide attempt and was readmitted to the facility on [DATE] with a recommendation for restricted access to cords/ligatures. On 2/12/24, observations by the survey team noted that R2 was in bed with the bed controller cord accessible, on the resident's bed rail. Chart review on 2/12/24 revealed no plan of care addressing suicidal ideation or the recent suicide attempts with the bed controller cord. Resident #2 made two attempts of self-harm resulting in emergency transfers to the hospital for treatment. Failure to implement a plan of care for suicidal ideation, including the recommended restricted access to cords/ligatures, allowed Resident #2 with means for additional attempts of self-harm. 1B. During a clinical record review on 2/12/24, it was noted that on 12/20/23, during an interview for mood status, Resident #6 (R6) verbalized feelings to facility staff of being better off dead or thoughts of harming self. The facility failed to respond and failed to implement measures to address the suicidal ideation for R6. On 2/12/24 at 4:55 p.m., an interview was conducted with RN #2, who was an MDS coordinator. RN #2 confirmed that he had interviewed R6 on 12/20/23, when the resident expressed suicidal ideation. Following the Resident's response, RN #2, reported the event to the director of nursing (DON) and facility Administrator. When asked what is done following a Resident verbalizing feelings of depression and/or suicidal ideation, RN #2 said, It is left up to them [Administrator and DON], but we need to get some type of psychiatric services that day, either in-house or at the ER [emergency room ]. During the above interview with RN #2, the nurse accessed R6's clinical chart. RN #2 confirmed that R6 was last seen by psychiatric services in December 2022. RN #2 also confirmed there was no evidence of any facility response to R6's verbalizations of feelings that he/she would be better off dead and/or self-harm once facility leadership was made aware. RN #2 provided the survey team with a copy of an email where RN #2 had notified the facility administrator and director of nursing of R6's response to the MDS question/suicidal ideation. On 2/14/24, the facility administrator and corporate nurse consultant both explained that each day the facility holds a morning meeting with the department managers and IDT (interdisciplinary team) to review items and areas of concern that need addressing. During this meeting, the 24-hour report is reviewed, new physician orders, and risk areas. On 2/14/24, the facility staff provided the survey team with the 24-hour report and documentation of the morning meetings. According to these documents, there was no evidence that R6 was a topic of discussion following his verbalization of suicidal ideation on 12/20/23. 1C. On 2/12/24, during a clinical record review and staff interview with RN #1 and RN #2, it was noted that Resident #7 (R7) during an interview for mood status, conducted that day, R7 verbalized having almost daily thoughts of being better off dead or of self-harm. The facility failed to notify the doctor and implement safety interventions to ensure R7's suicidal ideation was addressed. According to the clinical record, a progress note entry was made on 2/12/24 at 4:13 p.m., that read, Resident scored a 24 on PHQ9, answered yes to question concerning thoughts of hurting herself, resident does not have a plan in place. Administrator aware, Director of clinical services aware. There was no further documentation to address R7's suicidal ideation. During each of the above instances of resident's expressing suicidal ideation, the facility administrator and director of nursing were aware. Despite the knowledge, no interventions were implemented to protect the resident and address their behavioral health needs. On 2/13/24 at 9 a.m., an interview was conducted with LPN #1, who was assigned to care for R7 on 2/12/24 and 2/13/24. When asked about R7's report of suicidal ideation on 2/12/24, LPN #1 said, That was new to me. Yesterday about 3:20 p.m., the MDS lady [RN #3] came to me and had to do an assessment and wanted to know where the resident was. Then at about 4 p.m., the unit manager came to me and said I'm doing 15 min checks on the resident. I went to see her [R7] in the tv room and she was ok. LPN #1 went on to say she called the on-call psych provider, but it went to voicemail, so I left a message and put it in the book. When asked if she had received a return call, LPN #1 said, No. LPN #1 was asked if she had attempted to notify the medical provider, LPN #1 said, no. On 2/14/24, the facility administrator and corporate nurse consultant both explained that each day the facility holds a morning meeting with the department managers and IDT (interdisciplinary team) to review items and areas of concern that need addressing. During this meeting, the 24-hour report is reviewed, new physician orders, and risk areas. On 2/14/24, the facility staff provided the survey team with the 24-hour report and documentation of the morning meetings but reported due to the survey team being on-site the meeting was not held on 2/13/24. 2. The facility administration failed to administer the facility in an effective manner to address smoking safety. On 7/21/23, the facility experienced a fire event that was related to unsecured smoking materials. This incident was investigated during a standard survey conducted 7/30/23 through 8/2/23, which resulted in immediate jeopardy being identified during that survey. As part of the facility's plan of correction, the facility stated, The smoking policy was revised to indicate that smoking material, including any incendiary device would be secured and supervised by facility staff. All smokers were educated to the process with particular attention to storage of smoking materials . The administrator/designee will conduct a random quality monitoring audit of 10 rooms per week to ensure smoking materials are secured as per the new process . On 2/12/24, during this abbreviated survey, it was noted that the facility failed to adhere to the smoking policy/protocol to address serial noncompliance of Resident #3 (R3). Although policy requires that hazardous smoking material be secured and inaccessible to residents, unsecured smoking material and an incendiary device were retrieved and/or observed from Resident #3's possession on 1/20/24, 1/26/24, 1/27/24, 1/31/24, and 2/1/24. No evidence was found that any of the measures to address resident noncompliance were implemented. Following the identification and documentation of R3 having unsecured smoking devices and failure of interventions, while R3 was in therapy, a fire was started in R3's room on 2/1/24. Residents on the unit had to be evacuated and the fire department was called and responded and extinguished the fire. Immediately following the fire, an unsecured electronic cigarette and a cigarette lighter was removed from R3's. The facility's Resident Smoking policy with a revision date of 8/1/23, had provisions on how non-compliance would be handled. The policy read in part, . 8. All safe smoking intervention recommendations will be documented on each resident's care plan. If a resident contributes to an unsafe environment related to smoking the plan of care may be revised to include additional measures up to and including room searches, increased supervision, or appropriate discharge proceedings . Review of R3's care plan revealed that the non-compliance with the storage of smoking devices was not addressed, nor any interventions with regards to the non-compliance. The above resulted in immediate jeopardy (IJ) being identified and called on 2/13/24 at 3:20 p.m. When the facility administrator was made aware of the IJ, he stated that R3 was going to be problematic because of his ongoing non-compliance and he didn't know how they were going to address this. On 2/14/24 at 9:40 a.m., an interview was conducted with the facility administrator. The administrator acknowledged that R3's non-compliance with the smoking policy began in December 2023. Therefore, the administration knew of the non-compliance and failed to implement their smoking policy and measures to address the serial non-compliance, which put the safety of everyone in the facility in jeopardy. Review of the job description for the administrator was conducted. The document read in part, . Essential Duties & Responsibilities: .Verify that the building and grounds are maintained appropriately, and that equipment and work areas are clean, safe and orderly, and any hazardous conditions are addressed . Oversee regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility; morale of the staff; and ensure resident needs are being addressed . Consult with department managers concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services . On 2/14/24, the facility Administrator was made aware of the above concerns. No further information was provided.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure hazardous smoking materials were secured for three of forty residents in the survey sample (Residents #43, #24 and #75). The facility experienced a centrally located fire on [DATE] with heavy smoke requiring evacuation of the facility with three of forty residents in the survey sample hospitalized for assessment/treatment related to the smoke/evacuation event (Residents #19, #23 and #239). Resident #43 was found with a lighter immediately after the [DATE] fire that started in her room. There was no protocol implemented after finding the lighter, to ensure all smoking materials including lighters, were securely stored. Two residents (Resident #24 and #75) were observed on [DATE] with smoking materials unsecured and accessible to other residents. This resulted in the identification of immediate jeopardy and substandard quality of care related to unsecured, hazardous smoking materials creating a risk of fire to all residents. The findings include: A facility reported incident form dated [DATE] documented the facility experienced a fire on [DATE] at approximately 7:45 p.m. This report to the state agency documented, At approximately 745 pm a resident came out into the hall and began yelling that it was flooding near her room. When staff began to investigate, they discovered there was flames in [Resident #43's room] and smoke was coming out of the room. The facility was evacuated . (Sic) This report documented the local fire department and fire marshal responded promptly with the fire and smoke contained assisted by the activated sprinkler system. This report documented the fire marshal identified that the fire started in Resident #43's wardrobe located in her room. The facility's investigation of the [DATE] fire incident included interviews with residents and staff working on the evening of the fire. The investigation documented, .Staff responded and were able to determine that the fire was coming from [Resident #43's] room .All residents were evacuated except for twenty-six residents which the local fire department would not allow to be evacuated but rather would shelter in place due to their safety protocol .It was at this time, two residents [Residents #19 and #23] exhibited signs/symptoms potentially related to smoke inhalation and were transferred to the local hospital .staff identified that [Resident #43] had a lighter in her gown pocket. When asked for it she refused. When asked how the fire started in her room and she denied knowing any details .When [Resident #43] was brought back into the building, the Fire Marshall, and the Regional Director of Clinical Services .went directly to interview her. She [Resident #43] was asked if she had smoked in her room, and she responded no. The Fire Marshall informed her that the fire had started in her wardrobe, and did she have any knowledge as to how this occurred, she responded no. When asked to search her, she responded no. When confronted with information of staff seeing her with a lighter .she reported she had one but had thrown it down outside. When asked where she got it, she would not respond. When asked by the Fire Marshall where she threw the lighter down, she described the area outside where she had been sitting during the evacuation. The Fire Marshall went outside and did in fact find the lighter. [Resident #43] was placed on direct line of sight 1:1 supervision at this point .[Resident #43] requested the Fire Marshall speak with her [family member] regarding the event. The Fire Marshall did so and reported to him [family member] that while he did not believe she was smoking, he did believe she started the fire . This investigation documented the fire marshal inspected Resident #43's room after the fire and reported no evidence of smoking but identified that the fire initiated in R43's wardrobe and believed this was the result of someone potentially lighting something in the space . Resident #43 (R43) was transferred to the hospital on [DATE] after the family called 911 for transport of the resident for psychiatric evaluation. The investigation documented, .All resident rooms assessed for fire starting material to ensure all were safely stored . (Sic) Written statements from staff working on the evening of [DATE] documented that Resident #43 was upset by recent changes in the smoking protocol that no longer allowed her to smoke. Written statements from staff included the following and were dated [DATE]. Certified nurses' aide (CNA) #7 - When I had gone into room to complete care, resident [#43] began asking to be pushed to the front. I explained I couldn't she yelled and said 'this is bullshit' I talked to the nurse and another aide came up to explain to resident the policy on smoking again. Resident left room was in hallway right outside her room .10 minutes later was alarted [alerted] there was a fire in the residents room. (Sic) Licensed practical nurse (LPN) #7 - Resident [#43] .was yelling at CNA about her smoking privileges and became increasingly upset. resident was cursing at CNA and yelling more as myself and another CNA were trying to explain policy. Shortly after leaving out of resident's room as I rounded the corner entering Pondside unit I heard the fire alarm sound. As I approached the fire panel, I could see smoke filling Riverside end of hall entering Twin Lakes . CNA #8 - I went to [R43's] room and explain smoking policy. I then went to help another aide within 10 minutes .[LPN #2] ran up the hall for help. When I approached the hall the room had water and black smoke flowing out. I then called 911 . (Sic) Resident #54 - .states roommate said she smelled smoke. Resident went to the door and saw smoke and yelled it's a fire. Resident states, 'I saw [R43] roll herself out of the room fast' . LPN #2 unit manager - On [DATE] I was coming out of my office .when [Resident #54] started screaming and yelling its a fire. I immediately ran down there and pulled the fire alarm. I attempted to open the door to check to see if [R43] was in her room but due to the amount of smoke and water I couldn't see. The CNA said don't go in [R43] is in the hallway . A survey team entered the facility on [DATE] at 10:30 a.m. and obtained a list of current smokers. The fire incident of [DATE] was also reviewed. Investigation revealed the facility implemented a new smoking policy on [DATE]. The previous policy required staff supervision of all smoking at designated times with staff responsible for locking/security of all smoking materials in a central location not accessible to residents. The new policy (revised [DATE]) implemented by the facility on [DATE], no longer allowed residents requiring supervision and/or transport to the smoking area to smoke and placed the responsibility for locking/securing smoking materials with the residents that smoked rather than staff. The new policy documented, For the safety of all residents, those residents who desire to smoke must have their materials secured at all times in an area that is not accessible to other residents . Identified smokers were provided a personal, metal lock box with key for storage of their smoking materials. Resident #43 was admitted to the facility with diagnoses that included history of alcohol dependence, obesity, congestive heart failure, insomnia, tobacco use, depression, hypertension, edema, COPD (chronic obstructive pulmonary disease), atrial fibrillation, asthma, and anxiety. The minimum data set (MDS) dated [DATE] assessed R43 as cognitively intact. R43's smoking assessment dated [DATE] documented the resident required supervision, a smoking apron and was not deemed eligible to smoke because she was unable to wheel own self to go smoke. R43's plan of care (revised [DATE]) documented prior to [DATE], the resident was an active smoker in the facility with supervision. The plan of care was revised on [DATE] following the change in the facility's smoking policy stating, The resident was an active smoker who failed the smoking assessment and is not safe to smoke independently therefore a smoking cessation program will be offered. Interventions added on [DATE] included, Instruct resident about smoking risks and hazards and about smoking cessation aids that are available .Quarterly smoking assessments . A nursing note dated [DATE] at 6:26 p.m. documented, Resident [#43] was observed outside smoking. Resident was educated on the smoking policy and offered a nicotine patch. Resident is non compliance with the smoking policy and stated she was going to continue to smoke. Resident educated on the policy. (Sic) On [DATE] at 11:55 a.m., the assistant director of nursing (LPN #1) was interviewed about the fire incident, smoking policy and Resident #43's history with smoking materials. LPN #1 stated she was called on the evening of [DATE] about the fire and she came to the facility. LPN #1 stated the fire marshal reported to her that evening that the fire started in Resident #43's room. LPN #1 stated Resident #43 had been a smoker but with the new policy implemented on [DATE], the resident was deemed unsafe to smoke. LPN #1 stated the new policy required that the smokers be independent and able to get to and from the smoking area on their own. LPN #1 stated as a result of the fire, there were two residents sent to the hospital due to smoke exposure (Residents #19 and #23) and another resident (Resident #239) became unresponsive after evacuation while in the holding area. LPN #1 stated EMS, monitoring residents in the holding areas, initiated resuscitation to Resident #239 (R239) prior to transferring him to the hospital for possible cardiac arrest. On [DATE] at 1:53 p.m., Resident #24 (R24), assessed as a current and independent smoker, was observed in his room. R24 stated he currently had no cigarettes, but had a lighter. R24 displayed his smoking lock box which was empty. A lighter was observed in the drawer beside the box unlocked/unsecured. On [DATE] at 2:27 p.m., the director of nursing (DON) and LPN #1 were interviewed again about the fire investigation and any actions taken in response to the incident. LPN #1 stated a lighter was seen in R43's gown pocket immediately after the fire but the resident refused to turn in the lighter. LPN #1 stated R43 later acknowledged she had a lighter and she threw it on the ground in the holding area during the evacuation. LPN #1 stated the fire marshal located the lighter in the area reported by the resident. LPN #1 stated R43 was placed on one-to-one supervision until she left the facility. The DON stated Resident #43 was a previous smoker and she did not say where she obtained the lighter. On [DATE] at 2:36 p.m., the unit manager (LPN #2) working on the evening of [DATE], the DON and LPN #1 were interviewed. LPN #2 stated R43 was a previous smoker when all smoking was supervised by staff members. LPN #1 stated the new policy required residents to secure their own smoking materials and was implemented on [DATE]. LPN #2 stated with the new policy, R43 was no longer eligible to smoke because she required supervision and was unable to get to and from the designated smoking area independently. When asked about R43's reaction to the new policy, LPN #2 stated, She was not happy about it. LPN #2 stated she was not happy that staff were not going to transport her to/from the smoking area. When asked about R43's smoking materials when the policy changed, the DON stated, We did not search her belongings. The DON stated prior to the policy change, all smoking materials were locked in a central location by staff. LPN #2 stated she wrote the note and witnessed R43 smoking on [DATE] and she informed the resident on that date she was not eligible to smoke. LPN #2 stated R43 told her she got a cigarette from another resident. LPN #2 stated she did not see a lighter on the resident at that time. LPN #2 stated she educated R43 again about the new policy. LPN #2 stated R43 finished her cigarette and stated she was going to continue to smoke. LPN #2 stated she did not know where R43 got the lighter because previously, all lighters were supposed to be locked by staff. The DON stated all the current smokers were provided a lock box and key. When asked how the facility ensured that residents were locking their supplies since the new policy was implemented, the DON stated, We don't really know. We have to trust them [residents]. LPN #1 stated, That's a good question. During an interview and observation on [DATE] at 4:06 PM, R75 stated he was a current smoker but did not smoke on the facility premises, additionally R75 displayed how he kept his lighter and three packs of cigarettes in a black bag with a zipper on the table next to his bed. When questioned further, R75 confirmed that he did not have a lock box to keep his cigarettes, nor did the facility offer a lock box upon readmission. Review of R75's undated Admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed R75 was originally admitted on [DATE] and readmitted on [DATE] with a primary diagnosis of cellulitis of left lower limb and co-morbidity of tobacco use. Review of R75's Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of [DATE], revealed R75 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating he was cognitively intact. Review of R75's Care Plan, located in the EMR under the Care Plan tab and initiated on [DATE]. revealed . R75 smokes unsupervised per smoking assessment .R75 will be educated on safe smoking recommendations to include, use of smoking apron, designated smoking area, use of locked box . Notify charge nurse immediately if it is suspected resident has violated facility smoking policy . Review of R75's Resident Smoking Agreement, located in the EMR under the Miscellaneous tab and dated [DATE], revealed R75 signed the agreement that indicated residents were allowed to smoke on the premises as long as the activity did not endanger staff, families, or other residents at the facility. The facility indicated it did not provide supervised or assisted smoking and . I understand that if I am observed engaging in any of the following activities that I voluntarily agree to the enhanced enforcement measures including, but no limited to, unannounced room searches, monitoring of all mail and visitor traffic, and/or immediate discharge from the facility: .Leaving smoking materials unsecure in an area that is easily accessible to other residents . Review of R75's Safe Smoking Screening, located in the EMR under the Assessments tab and dated [DATE], revealed . Resident has no plans to smoke at this time . Review of R75's Progress Note, located in the EMR under the Progress Notes tab and dated [DATE], indicated the resident was a former smoker. There was no identified protocol in place since the [DATE] fire to ensure that hazardous smoking materials were secured from unauthorized access. R43 was found with an unsecured lighter immediately after the fire incident on [DATE]. Two additional residents were observed on [DATE] with lighters/cigarettes unsecured, which was not according to the smoking policy. After consulting with state agency supervision, immediate jeopardy was identified on [DATE] at 4:45 p.m. related to unsecured smoking materials and lack of protocol to ensure hazardous smoking materials remained locked when not in use. The DON and assistant director of nursing (LPN #1) were notified of the immediate jeopardy status on [DATE] at 4:45 p.m. Staff members searched all resident rooms on the evening of [DATE], educated staff and all residents on the smoking policy, and removed/secured all smoking materials found during the search. The survey team verified initial audits were completed and residents/staff were educated about the policy while the plan of immediate jeopardy removal was in development. On [DATE] at 10:55 a.m., the regional director of clinical services (RDCS - administration staff #4) was interviewed. The RDCS stated the thought process behind the new policy was because smokers had complained about scheduled times to smoke. The RDCS stated the new policy was thought to give residents more autonomy by allowing them to smoke at their leisure instead of at specified times. The RDCS stated all residents assessed as safe to smoke were given a lock box and key and signed an agreement stating the items would remain locked when not in use. The RDCS stated for residents not following the policy, residents knew their smoking rights could be revoked. When asked about a plan to ensure that residents locked their smoking materials as required, the RDCS stated she had not been notified about problems with the security of lighters/cigarettes. The RDCS stated she and the interim administrator performed a sweep after the fire incident on [DATE] and did not find any unlocked materials. The RDCS stated that since unsecured lighters/cigarettes were found by the survey team on [DATE], that locking of all smoking materials was obviously not maintained. On [DATE] at 8:37 a.m., the interim administrator (administration staff #1) was interviewed about the fire incident. The interim administrator stated she was out of town on [DATE] but came to the facility on [DATE]. The administrator stated a room sweep was conducted on [DATE] with no unlocked smoking materials found. When asked if there was any protocol or process from that moment forward to ensure smoking materials remained locked, the interim administrator stated, No. The interim administrator stated the plan was to follow up about the new smoking policy implementation during quality assurance meetings but that the fire incident happened prior to any quality assurance meeting about smoking. The facility presented a revised plan of immediate jeopardy removal dated [DATE] that documented, .The facility took immediate action to resolve the Immediate Jeopardy related to failure to ensure hazardous smoking materials (cigarettes, lighters) were secured to prevent access to other residents as unsecured smoking material was identified in the unlocked room of 2 residents in an accessible location . The plan included the following. -Care plans of smokers reviewed for any documented unsafe behaviors [DATE]. -DON immediately secured the found smoking materials and locked them in the DON office - completed [DATE]. -DON educated all staff present in the building regarding locked safety box process with education remaining for any staff not present prior to their next scheduled shift - initiated on [DATE]. -Room rounds were conducted on [DATE] that included a room search to locate/remove any smoking materials not locked. -Second room inspected by the DON and ADON on [DATE] to ensure security of any smoking paraphernalia. -DON educated the interdisciplinary team, other department heads and receptionists about lock box process on [DATE]. -QAPI (quality assurance/process improvement) meeting was held on [DATE] and the smoking policy revised with changes to the security process for smoking materials. This new policy implemented on [DATE] required all smoking lock boxes locked in central location and supervised by staff ,d+[DATE]. Resident will obtain smoking material from staff when desired and return to designated staff person upon completion. A responsible staff member will log smoking devices out when obtained and log back in upon return. Notification will be made to the DON and/or administrator of any smoking materials not returned to the staff person for security. Violations by any resident that contributes to an unsafe environment, including smokers and non-smokers may result in additional measures that include room searches, increased supervision or appropriate discharge proceedings. Visitors that threaten the safety of the environment and the facility may be subject to modified visitation. -Inservice/education of all staff members and residents (smokers and non-smokers) on the new smoking policy starting on [DATE]. This plan of immediate jeopardy removal was presented and approved by the survey team and state agency supervision on [DATE] at 5:00 p.m. Following implementation of the plan of removal, the survey team observed/verified that the plan was implemented as written. The survey team performed the following: Observed the lock boxes in central location and all materials locked in supervised container. Process observed - residents requesting and signing out cigarettes, lighters with documentation on sign in/out sheet. Observed receptionist providing supplies, verifying that residents return supplies. Sampled smokers and non-smokers that verified education had been done and knowledge of the new policy. Sampled staff working and verified education had been done and was ongoing as staff report to work regarding new smoking protocol/policy. Education was documented on in-service sheets with resident/staff signatures. After verification of the plan of immediate jeopardy removal and consultation with state agency supervision, the survey team abated the immediate jeopardy status on [DATE] at 12:20 p.m. and advised facility administration at this time. The three residents transferred to the hospital for assessment/treatment following the [DATE] fire were Residents #19, #23 and #239. Resident #19 (R19) was admitted to the facility with diagnoses that included cerebral infarction with left-side hemiplegia, insomnia, depression, diabetes, chronic pain, cognitive communication deficit, muscle contractures, obesity, atrial fibrillation, history of pneumonia, dementia with behaviors and mood disorder. The MDS dated [DATE] assessed R19 as cognitively intact. R19's clinical record documented on [DATE], Resident sent to [hospital] due to smoke inhalation . Resident #19 was admitted on [DATE] and discharged back to the facility on [DATE]. The hospital discharge summary dated [DATE] documented, .presented to the hospital from .her nursing facility after a fire broke out there. Patient was exposed to a small amount of smoke but is feeling fine .denies any shortness of breath, headache, chest pain. Her O2 sat [oxygen saturation] remains stable .is returning to SNF [skilled nursing facility] today in stable condition. Resident #23 (R23) was admitted to the facility with diagnoses that included cerebral infarction, glaucoma, depression, insomnia, hemiplegia, osteoarthritis, gastroesophageal reflux disease, epilepsy, hypertension and schizoaffective disorder. The MDS dated [DATE] assessed Resident #23 as cognitively intact. R23's clinical record documented a nursing note dated [DATE] stating, Resident transported to [hospital] due to smoke inhalation. The resident was hospitalized and returned to the facility on [DATE]. The hospital discharge summary dated [DATE] documented, .brought to hospital from .nursing facility .there was fire in the building, and concern of inhalation of smoke, patient without any acute issues in the ED [emergency department], but could not return to her nursing facility due to fire damage in the building .Clinically stable, has very minimal sore throat, no trouble breathing, eating and drinking well. No concerns per nursing. Patient discharging in a stable condition today back to her nursing facility . Resident #239 (R239) was admitted to the facility with diagnoses that included kidney failure, urine retention, pharynx cancer with tracheostomy, anemia, hypertension, urinary tract infection, protein-calorie malnutrition, anxiety, dysphagia, emphysema, COPD, and tracheo-esophageal fistula. The MDS dated [DATE] assessed Resident #239 with short and long-term memory problems and severely impaired cognitive skills. Resident #239 was admitted to the hospital after becoming unresponsive in the holding area after evacuation on [DATE] due to the facility fire. The hospital discharge summary dated [DATE] documented, .to the ED on ,d+[DATE] after there was report of a fire at his nursing facility .It was reported that he was taken to holding area for safety. While he was sitting in a wheelchair in the holding area, it was reported that he became unresponsive and was thought to be in cardiac arrest .He received CPR less than 5 minutes .The patient awakened and did not require any ongoing treatment, but was transferred to the ED. It is thought that the episode of unresponsiveness could have very well been secondary to position with sitting in a wheelchair causing his trach to become obstructed . The resident was discharged back to the nursing facility in stable condition on [DATE]. No further information was presented regarding the fire incident and/or unsecured smoking materials prior to the end of the survey. 40824 Findings include: Review of R75's undated Admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed R75 was originally admitted on [DATE] and readmitted on [DATE] with a primary diagnosis of cellulitis of left lower limb and co-morbidity of tobacco use. Review of R75's Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of [DATE], revealed R75 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating he was cognitively intact. Review of R75's Care Plan, located in the EMR under the Care Plan tab and initiated on [DATE]. revealed . R75 smokes unsupervised per smoking assessment .R75 will be educated on safe smoking recommendations to include, use of smoking apron, designated smoking area, use of locked box . Notify charge nurse immediately if it is suspected resident has violated facility smoking policy . Review of R75's Resident Smoking Agreement, located in the EMR under the Miscellaneous tab and dated [DATE], revealed R75 signed the agreement that indicated residents were allowed to smoke on the premises as long as the activity did not endanger staff, families, or other residents at the facility. The facility indicated it did not provide supervised or assisted smoking and . I understand that if I am observed engaging in any of the following activities that I voluntarily agree to the enhanced enforcement measures including, but no limited to, unannounced room searches, monitoring of all mail and visitor traffic, and/or immediate discharge from the facility: .Leaving smoking materials unsecure in an area that is easily accessible to other residents . Review of R75's Safe Smoking Screening, located in the EMR under the Assessments tab and dated [DATE], revealed . Resident has no plans to smoke at this time . Review of R75's Progress Note, located in the EMR under the Progress Notes tab and dated [DATE], indicated the resident was a former smoker. During an interview and observation on [DATE] at 4:06 PM, R75 stated he was a current smoker but did not smoke on the facility premises, additionally R75 showed this surveyor he kept his lighter and three packs of cigarettes in a black bag with a zipper on the table next to his bed. Additionally, R75 confirmed that he did not have a lock box to keep his cigarettes, nor did the facility offer a lock box upon readmission.

Based on record review, interviews, and facility policy review, the facility failed to provide transportation to the hemodialysis center for two consecutive appointments for one of one (Resident (R)59) reviewed for dialysis out of a total sample of 41 residents. This failure caused harm when R59 required emergent dialysis and hospital admission for chest pain, fluid overload and critically high blood potassium levels. Findings include: Review of the facility's Policy titled, Care Planning Special Needs - Dialysis, revised on 12/1/2022, revealed as follows This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving dialysis .Policy Explanation and Compliance Guidelines: 3. Interventions will include, but not limited to: .h. Transportation Arrangements .4. Nursing staff will provide a report to the dialysis provider regarding the resident's condition and treatment provisions each dialysis treatment day, and as needed. 5. If no written report is received upon return from dialysis, nursing staff will call the dialysis provider to receive a report. 6. Changes in condition following a dialysis treatment will be reported immediately to the physician . Review of R59's Admission Record, located under the Profile tab of the Electronic Medical Record (EMR), revealed R59 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (ESRD) and dependence on renal dialysis. Review of R59's discharge assessment Minimum Data Set (MDS), located in the Electronic Medical Record (EMR) under the MDS tab with an Assessment Reference Date (ARD) of 06/05/23, revealed R59 was admitted to the facility on [DATE] with diagnoses that included ESRD and dependence on dialysis. Review of the quarterly MDS with an ARD of 04/12/23 revealed a Brief Interview for Mental Status BIMS score of 12 out of 15 indicating the resident was moderately cognitively impaired. Review of R59's Care Plan, located under the Care Plan tab of the EMR and initiated on 02/21/23, revealed R59, receives Hemodialysis due to diagnosis of ESRD (End Stage Renal Disease). Resident goes to dialysis on Tuesday/Thursday/Saturday. Review of R59's hospital discharge notes, dated 03/01/23 and located under the Miscellaneous tab of the EMR, revealed as follows .Spoke to his sister who said that the reason they [facility] did not take him to dialysis is because he was positive for COVID the week before and confusion over who could transport him causing him to miss 2 sessions. He was negative on his COVID test here so that should not be a problem in the future .Discharge Diagnoses 1. Hyperkalemia [elevated blood potassium level] Resolved after he received a session of dialysis last night. 2. Volume overload (as above) [retention of fluid resulting in increased burden on the heart] .Summary of Hospital Course .He was brought to the emergency department because of transportation issues he missed his 2 previous dialysis sessions. Patient complains of shortness of breath and anxiety/nervousness, but otherwise full 12-point review of systems was negative. In the emergency department he was found to be tachypneic [rapid breathing], satting [oxygen saturations] well on room air, labs notable for elevated potassium of 6.6 [normal range between 3.5 and 5.0 Elevated potassium levels can cause heart problems that require immediate medical attention]. He was admitted for dialysis. He underwent dialysis emergently on the evening of 28 February and was fine easily after. He did well overnight, and his labs showed significant improvement as well and he was sent back to [Facility Name] nursing home with instructions to insist that he go to dialysis and not be allowed to refuse. The patient lacks capacity and should not be allowed to make that decision. Review of the progress notes for R59, located under the Progress Notes tab of the EMR, revealed a note by Assistant Director of Nursing/ License Practical Nurse (ADON/ LPN)1 dated 03/01/23 at 8:28 AM as follows: - LATE ENTRY: Resident missed dialysis appointments on 2/25. Transportation trips were canceled by transportation company due to resident being Covid positive. Further review of the progress notes failed to reveal that R59 had also missed a dialysis appointment on 02/28/23 and had been transferred to the hospital. Telephone interview with the complainant on 08/01/23 at 11:40 AM revealed she was the social worker at the dialysis clinic where R59 received treatment. Complainant stated as follows: - She recalled R59 had a high potassium level in February 2023 and the dialysis clinic was trying to coordinate with the facility to start a medication to treat that and they were unable to get through to anyone in the nursing home to coordinate R59's treatment. Complainant stated she called R59's sister who went to the facility and reported finding R59 in bed, lethargic with slurred speech. R59's sister insisted that he be sent to the hospital. R59 had missed a couple of treatments and his potassium was high. The complainant stated she left messages for the Administrator, Director of Nursing, and the Unit Manager, and none returned her calls to coordinate care for R59. It was R59's sister who informed the dialysis clinic that R59 had been admitted to the hospital. The complainant stated that she found out after the fact that R59 missed his appointments because he was COVID positive; however, part of that process that COVID patients who had Medicaid could be transported by ambulance. The dialysis clinic was equipped to receive COVID patients. The complainant stated it was the facility's obligation to make alternative arrangements via basic life support ambulance transport and COVID should not have kept R59 from receiving critical dialysis treatment. During an interview on 08/02/23 at 10:29 AM LPN1 stated she had written the note dated 03/01/23 because she had just been informed at that time that R59 was in the hospital. LPN1 stated she could not recall all the events at the time. LPN1 stated she was the unit manager in February 2023. She could recall that R59 was sent to the hospital at some point. LPN1 stated R59 tested positive for COVID after a rapid test on the night of 02/21/23 during the third shift. Review of the Progress Notes located under the Progress Notes tab of the EMR revealed no progress notes documenting that R59 had missed his dialysis appointments on 2/25/23 and 2/28/23. LPN1 stated she did not know what happened regarding the two missed dialysis appointments. LPN1 stated she talked to Medical Records, who told her that the transport company canceled the trip because resident was COVID positive. When asked what she did about R59 missing two dialysis appointments, she stated she did not send R59 to the ER and she did not know who sent R59 to the ER or why he was sent to the ER. LPN 1 stated she noted on the Progress Notes as follows: 03/01/23 at 8:31 AM: - Writer called hospital to get an update on resident. Writer informed that resident has been admitted with an admitting diagnosis of chest pain, volume overload and increased potassium. LPN1 stated R59 was admitted on [DATE] and returned to the facility on [DATE]. LPN1 confirmed that the progress notes on 03/01/23 failed to reveal any nursing notes about R59's return from the hospital, any assessment, and whether the physician had been notified of his status. When asked if R59 was not getting dialysis at all because he was COVID positive, LPN1 stated she was not sure. When asked if a transport company rejected R59 for being COVID positive, what was the backup plan to ensure the resident got to dialysis, LPN1 stated she did not know. During an interview with the Medical Records Coordinator (MRC) on 08/02/23 at 11:03 AM she stated that she recalled the situation with R59. The transport company was scheduled to take him to dialysis but refused to take him due to his COVID positive status. She stated she called the insurance company who informed her that the driver would not pick up a COVID positive patient. The MRC further stated that in such circumstances, when transportation failed, she would call the insurance company to see if they can arrange alternative transport for the resident. The MRC stated she called another transport company that also refused to transport R59 secondary to being COVID positive. If not, the dialysis would be rescheduled. The MRC stated it would be the nurses who informed her when a resident was not picked up. When asked if the facility made any effort on 02/28/23 to send R59 to dialysis after he missed the appointment on 02/25/23, the MRC stated she did not know. When asked if she reported the transport challenges to nursing, she stated they were aware. When asked if she had documentation of her transport arrangements, she stated she did not keep a log. Review of email sent to MRC on 02/28/23 at 1:08 PM by LPN1, provided by MRC revealed LPN1 requested for transport to dialysis and stated R59 was COVID free. Neither LPN1 nor MRC could explain why R59 was not transported to dialysis on 02/28/23. During an interview on 08/02/23 at 11:49 AM the Director of Nursing (DON) stated she was not employed at the facility when R59 missed two dialysis appointments in February 2023 requiring R59 to be transported to the ER for emergent dialysis and admitted to the hospital for chest pain, fluid overload, and high potassium.

Based on complaint investigation, clinical record review, staff interview, and review of facility documents, the facility failed for one of fifteen residents in the survey sample (Resident #1) to provide adequate supervision for the resident who was suspected of starting several fires in the facility. The resident was placed on 30-minute checks, but continued to move about the building, setting several more fires, before being transferred to the hospital. Upon review of the initial survey findings, further investigation was deemed necessary, and the survey was extended, subsequently finding that the facility failed to implement any interventions to prevent reoccurrence, after the first fire was discovered. In addition, the facility failed to ensure that smoking materials were secure and not accessible to residents. These combined findings were determined to have put all residents and staff at risk of serious injury/harm/impairment and/or death, which resulted in the identification of immediate jeopardy and substandard quality of care. The findings were: 1. Resident #1 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included wedge compression fracture of the second lumbar vertebra, acute osteomyelitis of the right ankle and foot, methicillin resistant staphylococcus aureus, chronic pain, hypertension, depressive disorder, legal blindness, chronic obstructive pulmonary disease, generalized muscle weakness, cognitive communication deficit, and anemia. According to the Admission Minimum Data Set (MDS) with an Assessment Reference Date of 12/6/2022, Resident #1 was assessed under Section B (Hearing, Speech, and Vision) as having clear speech, able to make self-understood, and able to understand others. Under Section C (Cognitive Patterns), Resident #1 was assessed as being cognitively intact for daily decision making, with a Summary Score of 15 out of 15. A Safe Smoking Screen, dated 3/31/2020, found Resident #1 was safe to smoke. The screen also noted the following: D. Other: 3. Level of supervision required for resident when smoking: b. Resident requires supervision while smoking. No other smoking screens were found. The facility's Resident Smoking policy included the following: 10. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan. 13. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. Review of the Progress Notes in the Resident #1's closed Electronic Health Record (EHR) revealed the following entries: 12/24/2022 - 11:05 a.m. - Writer and Housekeeper were in hallway talking with activities assistant. At this time writer smelled burning and housekeeper stated he smelled burning and saw smoke from the hallway. Nurse proceeded to walk down hallway and saw towels on resident's dresser on fire. Nurse immediately removed resident from the room, yelled fire and to activate the alarm. The CNA (Certified Nursing Assistant) brought the fire extinguisher to the room and the fire was put out. Fire department called, and DON (Director of Nursing) notified. [NOTE: The room in question was Resident # 1's room.] 12/24/2022 - 16:35 (4:35 p.m.) - Resident had a fire in his room this morning. Fire department was notified and came. Resident was moved to another room. Resident became verbally aggressive when questioned about what happened. Two more fires were discovered after, and resident displayed verbal aggressive behavior again. During this time another fire was discovered in the room resident was placed in when his initial room caught fire. Resident observed roaming throughout the building hallways in vicinity of fires. Writer contacted on-call spoke with [provider name redacted] got order to send resident out for mental eval[uation]. Resident is own rp [Responsible Party]. Spoke with [name redacted] ER nurse. Made her aware facility will not accept resident back per DON. An undated facility synopsis of the day's events (written by the director of nursing) noted the following: Resident sent to the ED [Emergency Department] for a Psych evaluation due to property damage in multiple sites and being a danger to himself, other residents, and staff. The resident started 4 fires in the building, all of which he was the only resident in the room/location. The initial fire was set in room [ROOM NUMBER], his original room, which was directly across from the oxygen room. After the fire department arrived, assessed the building, reset the alarms, and left, another fire was set in the bathroom of that room. The fire department returned made sure all fires were out in that room. The resident was then moved to room [ROOM NUMBER] where he started a fire in the bathroom. He exited the bathroom into the adjacent room [room [ROOM NUMBER]] setting the privacy curtains on fire. He then went to the front lobby and lit a box on fire and sat in the TV room across the hall from the fire .Staff and the fire department extinguished all fires. The fire department did a thorough search of the building for additional fires. At approximately 11:30 a.m. on 1/3/2023, the DON was interviewed concerning the facility's response to Resident # 1's actions. The DON confirmed that Resident # 1 was assessed for safe smoking, but with supervision. When asked about smoking and the management of smoking materials, the DON said smoking supplies are kept by staff in a locked box. The DON went on to say that there are three to four smoking breaks a day for residents, depending on the weather, which are supervised by staff. There was an incident several days ago when the resident had smoking materials in his room, the DON said. Continuing with the interview, the DON said that staff were unable to determine where the resident obtained the cigarette ends. Staff had been unable to determine if the resident had any other smoking supplies in his room. We are unable to search a resident's room, the DON said, so we didn't know what else he had in his room. Further review of the Progress Notes in Resident # 1's EHR revealed the following: 12/21/2022 - 19:16 (7:16 p.m.) - Nurse walked into the resident's room to a smell of cigarette smoke. The nurse educated the resident that it is against policy to have any type of cigarette in the room, and they are to be kept in the designated area of the facility. The resident denies having cigarettes in hos [sic] room but pulled out the ends of two cigarettes. The nurse educated the resident that he cannot bring them back to his room The DON provided the following written statement, dated 1/3/2023, from a staff member concerning the incidents of 12/24/2022: On Dec. 24, 2022, Mr. [redacted name of Resident # 1] never asked me to take him outside for a smoke break that morning at 9:30 a.m. nor 1:00 p.m. I had told all the smokers earlier that week that I wouldn't take them outside that day due to the weather being so cold. Mr. [redacted name of Resident # 1] never once asked me to take him outside that day. Asked if Resident # 1 was monitored between the time the fires were discovered and the time he was discharged to the hospital for a mental evaluation, the DON said, He was placed on 15 minutes checks. When the DON provided the requested documentation of the 15-minute checks, the DON said, He was on 30-minute checks. The DON went on to say that following the events of 12/24/2022, the staff was re-educated on the use of fire extinguishers. Following is a full transcript of the 30-minute checks on Resident # 1, beginning with the first entry at 11:15 a.m. on 12/24/2022, and ending with the last entry at 3:50 p.m. on 12/24/2022: 11:15 a.m. - Resident was sitting in the hallway on Brookside [nursing unit]. 12:30 p.m. - We started to smell smoke again, toilet paper roll was found in bathroom against the wall [Resident's bathroom]. Resident was then sitting in front TV room. 1:10 p.m. - Smoke was spotted again in the front lobby way. Resident was then placed in room # 11 til everything was cleared but resident left out the room. He refused to go back in (fire under the bed). 1:30 p.m. - Resident went out to smoke. 2:00 p.m. - Resident was sitting in TV room. 2:35 p.m. - Resident walked to his room. After that the hallway on Riverside [nursing unit] was filled with smoke at that point. The bathroom of [room] # 11 and curtain of [room] # 14 was on fire. fire. [Rooms # 11 and # 14 had a shared bathroom.] 3:15 p.m. - Resident was sitting in TV room. 3:50 p.m. - Resident was waiting in lobby for ambulance. Resident #1 was subsequently discharged to the hospital for a mental evaluation. At the end of the day conference, the management staff, including the DON, was asked why Resident # 1 was not placed on one-to-one supervision. There was no definitive response to that inquiry. The DON repeated earlier explanation that the focus was in getting Resident #1 out of the building It should be noted that no residents or staff sustained any injuries related to Resident # 1's actions. 28106 On 1/12/23 the abbreviated survey resumed. The above information was verified through documentation. On 1/12/23 at 12:50 PM LPN #1 (the nurse that wrote the progress note on 12/24/22 at 4:35 PM) was interviewed. LPN #1 said that he was not assigned to Resident #1 that day but was floating and helping out other nurses. Resident #1 seemed upset because the activities assistant director was not taking the resident's out to smoke due to very low temperatures that day. A fire was discovered in Resident #1's room (room [ROOM NUMBER]) and the fire department was called out. Resident #1 was moved to another room and seemed to be getting more agitated and began roaming throughout the facility. Another fire was started in the lobby around 2:30 PM and two other fires broke out in rooms [ROOM NUMBERS] where Resident #1 was moved to after the first fire. Resident #1 denied starting the fires and LPN #1 did not observe Resident #1 with a lighter. LPN #1 verbalized that the facility staff are not allowed to search a Resident or a Resident's room. According to LPN #1 the fire Marshal also did not search Resident #1 or his belongings, as there was no proof that Resident #1 had started the fires. LPN #1 was asked about supervision for Resident #1. LPN #1 said that Resident #1 was put on 30 or 60 minute time checks but he (LPN #1) did not document any time checks as he was not assigned to Resident #1. LPN #1 said that after the 4th fire, LPN #1 personally put Resident #1 on one to one supervision but Resident #1 was taken out of the facility shortly after. On 1/12/23 at 3:30 PM the activities assistant director (other staff, OS #1) was interviewed. OS #1 verbalized she is the primary person that takes residents out to smoke on day shift and on 12/24/22 had decided not to do smoke breaks due to the cold temperatures. OS #1 said that on the day of the fires, Resident #1 did not speak to her or ask to go outside to smoke but others were asking and she (OS #1) took other residents out to smoke at 1:00 PM and Resident #1 did not go. OS #1 was asked about the process of taking resident's out to smoke. OS #1 said that we have a box with packs of cigarettes and usually 2 lighters. The resident's are handed one or two cigarettes and she (OS #1) would light the cigarettes for the resident's. OS #1 was asked, how does she (OS #1) ensure lighters don't go missing. OS #1 said that she counts the lighters before and after the smoke breaks. OS #1 went on to say that every once in a while a staff member might take a lighter out of the box and forget to put it back. OS #1 was asked how could a resident get a lighter. OS #1 verbalized that sometimes family members or friends might bring cigarettes and lighters in and give them to the resident's and the resident's are supposed to turn them in to the facility but was not sure if that always happened. On 1/12/23 at 3:45 PM LPN #2 was interviewed (the nurse that wrote the progress note on 12/24/22 at 11:05 AM). LPN #2 said that she was not assigned to Resident #1 on 12/24/22, but was the nurse that discovered the first fire and called the fire department. LPN #2 verbalized Resident #1 was showing signs of behaviors due to not being allowed to go out and smoke so she (LPN #2) took Resident #1 out to smoke around 1:30 PM. LPN #2 said that she helped clean up Resident #1's room after the fire was put out and noticed 2 cigarettes in Resident #2's coat pocket but did not take them as the director of nursing (DON) said we could not take Resident's belongings. LPN #2 verbalized that there was no observation of a lighter, but she did ask Resident #1 to hand over the cigarettes to which Resident #1 refused. LPN #2 said that Resident #1 was placed on 30 or 60 minute checks by the maintenance director but due to not being assigned to Resident #1 she did not document checks and assumed the nurse assigned to Resident #1 would do the documentation of the checks. During the interviews of LPN #1, #2 and OS #1 all were asked if any education was provided after the incident regarding what to do if someone is suspected of starting fires and providing supervision. All three staff members verbalized that they did not receive education on high risk resident's starting fires or supervision, but was educated on extinguishing fires using the acronym RACE (remove, alert, confine, extinguish) and PASS (pull pin, aim, squeeze, sweep). On 1/12/23 at 4:10 PM the DON was interviewed via telephone. The DON verbalized that she was notified by the floor nurse that a fire had broke out in Resident #1's room and the fire department was called to extinguish the fire. The DON was also aware that the maintenance man had told the nurses to put Resident #1 on 30 minute checks. The DON was asked if there was anything she could have done differently regarding supervision. The DON verbalized looking back on things Resident #1 should have been placed on one to one supervision and the physician should have been notified. The DON was asked if there was any education that was provided after the incident. The DON verbalized that the facility did training in what to do in case of a fire and how to use the fire extinguishers. On 1/12/23 at 4:30 PM the previous administrator (AS #4) to the facility was interviewed via telephone in regards to staff not being allowed to search a resident's room. AS #4 verbalized based on new regulations we are not to search a resident's room and that's why we called 911, so that the Fire Marshal could search the room, but the Fire Marshal did not conduct a search as he could not prove Resident #1 started the fires. The current administrator was asked for a copy of the new regulation regarding searching rooms, but the survey team was not provided a copy of the regulation. Review of Resident #1's 30 minute checks were hand written on a piece of paper and not part of the electronic medical record. The documentation had no signature and entries made to the documentation were not consistent with 30 minute intervals, with the longest period between documentation was from 11:15 AM to 12:30 PM. In response to the request, the administrator was able to provide the staff member's name that documented the Resident #1's observation checks. The staff member [LPN #3] was not available for interview. The survey team extended the sample to include ten additional residents (#'s 6 through 15) and included all residents that smoked and had potential to keep lighters and smoking material. The survey team did not find concerns with the resident's in the extended sample. The Facility's Policy implemented on 12/01/22 read in part: 1. Smoking is prohibited in all areas except the designated smoking area. 12. If a resident or family member does not abide by the smoking policy or care plan (e.g. smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional measures such as room searches, prohibited smoking, or even discharge. On 1/12/23 at 5:35 PM, the administrator and regional director of clinical services (Administration Staff, AS #2) were made aware in a meeting with the survey team of the above information and serious concerns regarding Resident #1. The administrator and AS #2 were notified at this time that the survey team had consulted and discussed the above information with the state agency and the survey team had identified IJ (Immediate Jeopardy) and substandard quality of care (SQC) due to the facilities failure to ensure adequate supervision for Resident #1 suspected of starting fires in the facility and putting residents and staff in danger. At this time the survey team advised the administrator and AS #2 to develop and present a plan of removal regarding supervision for Resident's suspected of starting fires. On 1/12/23 at 7:20 PM , the administrator and AS #2 presented a plan of removal for review of the survey team. The facility's plan of removal for the immediate jeopardy for adequate supervision for resident's exhibiting behaviors of starting fires included the following interventions: 1). Resident #1 was discharged from the facility on 12/24/22. 2). 100% of in-house staff educated by nursing administration regarding protocol for staff in the event that residents exhibit fire starting behavior: Staff to immediately assure residents safety and safety of all residents in the affected area. Staff are to initiate 1:1 direct supervision with the resident exhibiting fire starting behavior. Staff to then call 911. MD (physician) and RP (responsible party) are to be notified. Any staff on leave will receive the required education prior to starting their next shift, this protocol will be added to new hire education for all staff. 3). In the event that residents exhibit fire starting behavior they will be placed on 1 on 1 direct supervision and 911 initiated. Resident will remain on 1:1 until either emergency services arrives, or higher level of care arrangements are made; Other residents will be removed from the affected area to safety; MD/RP will also be notified of the occurrence. 4). Once the facility is secured, room rounds will be conducted immediately to ensure absence of fire of fire starting materials. 5). Safety stand down will be conducted to review incident with all staff and provide education as necessary. The survey team reviewed and accepted the plan of removal for IJ status on 1/12/23 at 7:30 PM. On 1/13/23 the survey team observed and interviewed staff in regard to education, the team also reviewed inservices as well signatures of staff receiving education. The survey team abated the IJ on 1/13/23 at 12:35 PM. This is a complaint deficiency. 27353 3. The facility staff failed to ensure residents' smoking materials (cigarettes and lighters) were secured and inaccessible to residents; the residents' smoke box with materials (cigarettes and lighters) was left unlocked and unsecured at the nurse's station, readily accessible to residents, which resulted in IJ (Immediate Jeopardy) and SQC (Sub-Standard Quality of Care). On 01/12/23, a complaint investigation resumed from 01/03/23. The complaint alleged that the facility failed to maintain an environment for residents' safety and prevention of injury related to a resident, identified as Resident #1 (no longer a resident of the facility and discharged on [DATE]), who had started multiple fires in the facility on 12/24/22 prior to being discharged . On 01/12/23 at approximately 11:00 AM, a list of all residents who smoke was requested from the acting administrator. These residents were added to the survey sample. On 01/12/23 at approximately 11:45 AM, Resident #12 was interviewed in his room. Resident #12 was assessed as being cognitively intact for daily decision making (Cognitive score of 14 out of 15) on the most recent MDS (minimum data set), an admission assessment dated [DATE]. During the interview on 01/12/23 at 11:45 AM, Resident #12 was asked about smoking in the facility. Resident #12 acknowledged that he was a current smoker. When asked if he is allowed to go out to smoke or do staff take him out, Resident #12 stated, That's the only way you can go out to smoke, is if you have staff with you. Resident #12 further stated that the door is locked to the smoking area and that the designated staff member will open the door during smoke times. Resident #12 then stated that he had cigarettes and Black and Milds (cigars) stolen. When asked where the cigarettes were stolen from, Resident #12 stated that they were stolen from the box. This resident went on to explain that staff make the residents keep your cigarettes (and lighter if you have one) in the 'locker' box, but added, most of the time, they don't lock it up. This resident stated that the locker box is supposed to be kept locked and inside the medication room. The resident stated that the box had been left out at the nurse's station and it isn't locked. When asked how anything could be stolen from a locked box, Resident #12 stated that there isn't a lock on the box and that as far as he knew, there hadn't been a lock on the box for a long time. When asked if he keeps cigarettes and/or lighters on his person, Resident #12 stated that he did not, adding that smoking materials (cigarettes/lighters/cigars, etc.) are kept by staff and that the residents aren't allowed to keep the smoking supplies on them. When questioned further, Resident #12 stated that the smoking supplies are kept in the box that is supposed to be locked and kept in the medication room, which is also locked. When asked to explain the 'locker box', Resident #12 stated that the box is a small plastic type toolbox/lock box, which most of the time staff doesn't lock up, but is left at the nurse's station on a shelf. When asked why staff was not putting the smoke box in the medication room to secure it, Resident #12 stated that everyone doesn't have a key to the medication room. On 01/12/23 at approximately 12:50 PM, the smoking area was observed. The door giving access to the smoking area was locked and could not be opened without a key. A small poster with smoke times was observed and documented who was responsible for taking residents out to smoke at the designated times. According to this poster, Activities was responsible for two smoking breaks on day shift (9:30 AM to 9:50 AM and 1:00 PM to 1:20 PM) and Nursing was responsible for two smoke breaks on evenings (4:00 PM to 4:20 PM and 7:00 PM to 7:20 PM). On 01/12/23 at 1:00 PM, the Activity Assistant (OS #1) unlocked the door to the smoking area. The AA was holding a small plastic box (smoke box) that contained the residents' smoking materials. The residents went out to the smoking area. The AA opened the box (no lock seen) and passed out each individual resident a single cigarette and lit it, and then proceeded to the next resident, giving a single cigarette, and lighting it. The residents did not light their own cigarettes or handle the lighter at any time during the observation. When asked how the smoking process works, OS #1 stated that all resident smoking materials are kept in the smoke box, she opens it and gives out cigarettes and lights them for the residents. When asked if the smoke box was locked, as no lock was seen, the AA stated that there is no lock on the smoke box and further stated that someone had left the key inside of the box and the lock had to be cut off. The OS #1 stated that the smoke box has not had a lock since back in the summer. When asked where the smoke box is kept, OS #1 stated that it is kept at the nurse's station in a closet in the medication room. When questioned further, OS #1 stated that there is only one smoke box and that sometimes if it is not in the medication room, it is kept on the shelf at the nurse's station. OS #1 was asked if she had ever left the box at the nurse's station (not in medication room) without a lock on the box. When her past actions were questioned, OS #1 stated that she had left the unlocked smoke box at the nurse's station on a shelf. OS #1 was asked why the box would be left at the nurse's station if there a designated place to secure the box. OS #1 replied, Because you can't always find a nurse to get it out of the medication room or put it back. On 01/12/23 at 1:15 PM, LPN (Licensed Practical Nurse) # 1 was interviewed. LPN #1 was on duty the day the fires occurred (12/24/22). The LPN #1 confirmed awareness of the fires started on 12/24/22 and of Resident #1's involvement. When asked about the resident smoke box, LPN #1 stated that smoking materials stay behind the nurse's station, in the box, and is either on the shelf at the nurse's station (Riverside) or in the medication room. The LPN #1 stated that the key to the medication room is among the nurse's keys on Riverside. The LPN #1 stated that the smoke box itself has a 'snap lock', which doesn't have an actual lock to prevent access. When asked if the smoke box was ever left unlocked and accessible at the nurse's station, LPN #1 stated, Yes, I could get into it. LPN #1 added that the prior smoke box had a combination lock, but the facility got the current box approximately 6 months ago. LPN #1 explained, If a CNA [certified nursing assistant] takes them [residents] out, sometimes I have to pick it up [from the nurse's station] and put it in the med room. When questioned, LPN #1 stated that the normal routine is for the smoking assistant to ask the nurse to open the med room to get the box, make the smoke break announcement, and get the key to the outside smoking area out of the smoke box. After smoking, LPN #1 stated that the smoking area door is locked, and the box is returned to be locked up in the medication room. LPN #1 stated, I have seen the box on the counter, but if so, I get the nurse (who possesses the key) to put the box back in the med room. The LPN was asked about receiving any type of education and/or in-service after the fires on 12/24/22 that were started by Resident #1 or of any new processes that may have been initiated, because of the fires. LPN #1 stated, I don't recall, we may have, but I don't recall. I didn't get any information about smoking or the smoke box. On 01/12/23 at 3:15 PM, OS #1 was again interviewed. Asked if she had been in-serviced and/or received any education regarding fires being set (per the complaint) or on any supervision/fire safety/smoking/resident smoke box topics, OS #1 stated that she had not been in-serviced or received any education regarding that. OS #1 stated that it was so cold the day the fires occurred (12/24/22), but that she had let the DON (director of nursing) and the administrator know earlier that week that due to the severe cold temperatures being called for that day, that she was not going to take the residents out (12/24/22). OS #1 repeated, I wasn't going to take them to smoke because it was so cold, like 6 degrees. When questioned what the response had been to that plan, OS #1 stated that the administrator had said Ok. OS #1 stated that on that Saturday (12/24/22), Resident #1 did not ask her to go out to smoke. Stating that she routinely asked residents about having smoking materials on them, OS #1 specified that when Resident #1 was asked about having cigarettes or a lighter, Most of the time, he would give them to me. OS #1 stated that she had taken them out the day before (12/23/22) and that she didn't see any cigarettes or lighter on Resident #1 or any other residents. OS #1 again stated that no residents are supposed to have a lighter or cigarettes. OS #1 stated that she would open the door (smoking area) if they residents have cigarettes or lighter, they will give them to her when asked. The OS #1 stated she will give them a cigarette and she will light the cigarette for them. OS #1 was asked again about the smoke box and asked if she remembered the box being left unlocked at the nurses' station on 12/24/22 (the day of the fires). OS #1 stated that the box was on the shelf this morning (01/12/23 at 9:30 AM) and that it was left at the nurses' station unlocked on 12/24/22. OS #1 was asked how she knew that nothing was missing from the smoke box. OS #1 stated, I looked and didn't have any lighters missing. OS #1 was asked how many lighters are supposed to be kept in the smoke box and if there is an inventory sheet or check list to ensure all items are accounted for. Stating that there was no inventory sheet to account for the items in the smoke box, OS #1 added, I don't know how many lighters are supposed to be in the box. When questioned about where the smoke box was stored, OS #1 stated that she would bring the smoke box to the nursing station where smoke box is kept, sometimes sitting it on the shelf or under the desk, if she could not find a nurse. Asked how many times per week is the box not locked up in the medication room and left at the nurse's station, OS #1 stated that she could only speak for herself, but if she had to guess maybe two to three times per week. The OS #1 stated that whoever takes the residents out to smoke is responsible for them and for the smoke box security. On 01/12/23 at 3:40 PM, LPN #2 was interviewed via phone. LPN #2 confirmed that she was on duty on 12/24/22, when the fires were started in the facility. LPN #2 stated that the resident was agitated, repeatedly denying that he was trying to smoke and that he had set the room on fire. LPN #2 stated that his room was cleaned thoroughly after the fire and the resident returned to his room. The LPN stated that she didn't find any lighters when just looking around but stated that she did see two cigarettes in the resident's coat pocket that was sitting on the chair. LPN #2 was asked if she took the cigarettes. The LPN stated that she did not and further stated, We aren't allowed to search or take his stuff. He said he was allowed to smoke, and he said that he didn't have a lighter. LPN #2 stated that she reported the information to the DON via phone (who was not at the facility that day). LPN #2 stated that the DON reiterated, during that call, that staff cannot search the resident. LPN #2 stated that she did end up taking the resident out to smoke later that day (12/24/22), around 1:30 PM. LPN #2 stated that while outside smoking, Resident #1 said he didn't start the fire and complained about the facility being a smoking facility but that the staff wasn't taking the residents out to smoke. When questioned, LPN #2 stated that after the fires on 12/24/22, staff received education on fire extinguishers, but no education on resident's exhibiting high risk behaviors, smoking/smoke box security or supervision. On 01/12/23 at 4:10 PM, the DON was interviewed via phone (not in the building) by the survey team. When asked what education was provided, the DON stated that the education was on fire extinguishers, RACE and PASS. When asked if that was all of the education provided, the DON stated that, in hindsight, Resident #1's physician should have been called and Resident #1 on 1:1 (one to one observation) immediately. The facility's smoking policy was reviewed and included the following, but not limited to: 12/01/22 .all resident and family members will be notified of this policy during the admission process, and as needed .all residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment .Any resident who is deemed safe to smoke, WILL BE SUPERVISED and will be allowed to smoke in designated smoking areas (weather p [TRUNCATED]

Based on observation, staff interview, resident interview, clinical record review, facility document review, and during a complaint investigation, the facility staff failed to ensure an environment free of accident hazards and failed to ensure adequate supervision to prevent accidents for three of 32 residents (Residents # 64, # 38, and # 88); failed to ensure adequate supervision for one of 32 resident (Resident # 145), which resulted in harm and failed to ensure for one of 32 residents that sunscreen was applied to the top of the foot area for the prevention of sunburn resulting in a blistering sunburn which had to be surgically debrided (procedure requiring local anesthetic and removal of dead skin tissue with a scalpel) resulting in harm for Resident # 347. 1. The facility staff failed to ensure safety and supervision for Resident # 145 for access to the smoking area, as a result the resident fell in koi pond and was found by another resident; Resident # 145 was sent to the hospital and treated for [REDACTED]. The resident returned to the facility 8 days later. This resulted in harm. 2. Resident # 347 sustained a blistering sunburn to the tops of both feet which had to be surgically debrided weekly in excess of 88 days resulting in harm. 3. The facility failed to ensure Resident # 64's Vape device and vaping liquids were properly stored at the Nurse's Station, and in accordance with the plan of care, when not in use. 4. Residents #38 had no pull cord on the emergency call light in the resident's restroom. 5. Residents #88 had no pull cord on the emergency call light in the resident's restroom. Findings include: 1. The facility staff failed to provide adequate supervision to Resident # 145 for access to the smoking area, which resulted in the resident falling into a koi pond. The resident was found by another resident and was sent to the hospital for treatment. This resulted in harm. Resident # 145 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident discharged out of the facility on 02/07/18, following a fall into the koi pond in the smoking area and was readmitted to the facility on [DATE]. The most current MDS (minimum data set) was a discharge return anticipated/14 day admission (completed on 02/13/18), the ARD (assessment reference date) was 02/08/18. Section C (Cognitive Patterns) of this MDS was blank. There was no cognitive information documented on this resident. This MDS assessed the resident as requiring supervision with one person physical assist for bed mobility/transfers and as requiring supervision with ambulation (no physical help), the resident was additionally assessed for locomotion on/off the unit as 7/0 (indicating that this activity only happened once or twice without support from staff), the resident was assessed for extensive assistance from staff for dressing, toileting and hygiene with one person physical assist. This MDS assessed the resident as 'not steady, but able to stabilize without human assistance for moving from a seated to standing position, walking, turning around, and surface to surface transfer. The resident was coded on this MDS as a current smoker and using a w/c for ambulation/mode of transportation. A complaint investigation was conducted on 02/20/18 through 02/23/18. An allegation within the complaint alleged that the resident fell into the koi pond, was unable to get out and was found by another resident and subsequently went to the hospital for treatment. On 02/20/18 at approximately 10:30 a.m., a brief entrance conference was conducted with the administrator who was made aware of follow up from FRIs (facility reported incidents) and that there were complaints. The administrator stated that he would provide information and follow up for FRIs and information related to the incident concerning Resident # 145. The administrator provided a list of smokers (supervised and unsupervised) and an 'updated' (as of 2/20/18) supervised smoking assignment document. Resident # 145 was observed multiple times during the survey process in his room in bed and in the hall area in his w/c (wheel chair), the resident was observed as slow for mobility and response when spoken to. On 02/22/18 at 8:40 a.m., the smoking area was observed, no residents were in the area at this time. The door leading to the outside courtyard was not locked and when opened, no alarms of any type were seen or heard to evidence notification to staff that the outside area had been accessed. On 02/22/18 at 9:40 a.m., the resident was observed in his w/c in the smoking with staff. Resident # 145's clinical record was reviewed. A smoking assessment dated [DATE] (timed 10:14) documented that the resident was able to call for help if a lit cigarette ash or cigarette falls on the person and was receiving medications with the potential to cause sedation, did participate in the education and care planning regarding smoking activities and was documented to smoke independently. The assessment additionally documented that the resident may smoke unsupervised in designated areas. An admission nursing assessment dated [DATE] documented, that the resident had slow comprehension and was oriented to person and was a current smoker and that the resident was oriented to the smoking rules. This assessment was signed completed on 02/08/18, the day after the resident's fall. The resident's Kardex dated (01/31/18) was reviewed and documented that the resident is 'dependent' upon staff for smoking. A fall risk assessment completed on 02/01/18 documented that the resident was a high risk for falls and had mild/moderate impairment in cognitive skills. This assessment also documented that the resident used a leg brace, w/c, walker and cane and that the resident wears glasses, but did not have them with him. An elopement assessment dated [DATE] gave the resident a score of 12 (total score of 10 or greater, the resident should be considered at risk). Resident # 145's physician's orders were reviewed, the resident did not have a physician's order to smoke, either assisted or unassisted. Progress notes were then reviewed and documented the following: 02/01/18 (12:49 a.m.) - ' .seemed to enjoy being at this facility .especially since he is able to smoke outside .' 02/01/18 (3:44 a.m.) - ' .Resident ambulates with cane .no behaviors .' 02/01/18 (10:24 a.m.) - .Initial admission data collection review .SW (social worker) .Resident was laying on top of the bed, fully dressed with hood of coat on his head with his feet and legs hanging down and drooling .full code .resident is single .his half brother .and sister .visit if I'm not drinking .comments on education .states he has a doctorate from (name of a university) and worked at (name of company) 'I was a supervisor' Resident stated he is an Admiral (military history) .Medical and Psychiatric History: 'I have a clean track record and I am accountable' .Resident stated he does well with change and likes being at this new place as long as he gets his cigarettes on time .During the resident interview he expressed, I want to retire and monitor at your residence 02/02/18 (4:18 p.m.) - 'SW (social worker) .met face to face with resident .alert yet presents with confusion and appears to need psychiatric evaluation based upon his responses which indicate need. Resident is a smoker and states everything will be fine as long as he gets his cigarettes on time .will monitor follow progress.' 02/04/18 (2:37 p.m.) - Behavior: PATIENT SEEN SMOKING IN HALLWAY BY STAFF, AND X 5 (five) CIGARETTE BUTTS FOUND UNDERNEATH HIS BED, AND X 2 (two) IN THE CLOSET .patient redirected cigarette put out, nurse along with other staff members stressed the importance of not smoking in the facility or bring (sic) cigarette butts from outside, patient has a lighter and will not allow it to be locked away .patient will be monitored Q (every) hour X (times) 24 HRS. The resident's MARs (medication administration record) were reviewed and revealed a behavior observation sheet that documented the resident was exhibiting 'wandering/pacing' type behaviors on the evening shift on 02/04/18. 02/05/18 (1:26 p.m.) A note by the SW documented, ' .referred to psychiatrist due to responses on initial admissions assessment.' No physician's orders were found for a psych consult and/or any documentation that the physician was made aware of any of the above information. 02/05/18 (5:19 p.m.) (Physician's Progress Note) documented by the NP (nurse practitioner) - ' .paranoid [MEDICAL CONDITION] .There are no notes that I could find about why patient is at (name of facility) .tobacco abuse .outside smoking used cigarettes (sic) .slow cognition .slow speech .oriented to self only .Plan: .Resident requires nursing facility services for safety .' None of the information regarding the resident smoking in the hall, found with cigarettes in his room, making inappropriate responses (per the SW) were addressed by the NP. 02/07/28 (7:34 p.m.) ' .found outside lying in pond, patient was lying on his back, his face was up .Patient non-compliant and has been going back and forth outside all day night and staff has redirected him X (times) 4 with effective results .difficulty talking and soak (sic) and wet from pond, dry clothing applied and wrapped with several blankets .send to ER (emergency room ) for further evaluation .' The resident was sent to the hospital on [DATE] between 7:15 p.m. and 7:30 p.m. According to the hospital H&P (history and physical) dated 02/08/18, the resident was admitted and treated at the hospital for, 'hypothermia, developed a fever during the night, found to have influenza (flu), and also now with concern of a partial complex [MEDICAL CONDITION] (sic) .apparently smokes a few cigarettes per day. He likes to be outside. He went outside apparently yesterday evening .ambulates with a cane as he has problems with the hip .suffered a fall and fell in the pond .apparently there .and could not get out, was there for, he says for about an hour or so .hypothermic .positive influenza B .he apparently became poorly responsive for a short time and there were twitching type moments of his right upper extremity .concerned, this could represent partial complex [MEDICAL CONDITION] . An addendum progress note from the hospital dated 02/08/18, documented that the patient was interviewed and examined and the resident stated he slipped into the pond and this was not an attempt to harm himself. The resident's CCP (comprehensive care plan) was reviewed and documented, .01/31/18 .Unsafe Smoking: At risk for injury related to unsafe smoking .Will safely smoke at designated times, in designated areas with supervision of staff and have no smoking injuries or incidents .assist (name of resident) as needed to designated smoking area at designated times and supervise smoking .ensure (name of resident) does not leave designated smoking area with smoking materials .facility smoking policy will be reviewed with resident .will be instructed, and reminded as indicated that any smoking materials (cigarettes, cigars, pipes, matches, lighters) are to be turned into staff for management and dispensing .Smoking assessment to be completed on admission, quarterly and with any significant change in condition . Resident # 145 only had one smoking assessment completed (02/01/18); the resident did not have another smoking assessment completed upon readmission to the facility on [DATE]. An initial/interim care plan could not be located for Resident 145 for Falls. A fall risk assessment was completed on 02/01/18 and identified the resident as high risk for falls. The resident's CCP did not address falls and/or safety related to falls at all and was not developed until 02/08/18, after the resident had fallen in the pond in the smoking area. The 'supervised smoking assignment' sheet presented by the administrator dated 12/11/17, with a hand written entry (update date) of 2/20/18 documented, .Supervised smokers are allowed two cigarettes per 15 minute time period. Smokers must return all lighters, matches, etc. to the lockbox when finished smoking .New residents must be supervised until assessed for unsupervised privileges .all supervised smokers must be accompanied by a family member or an employee .smoking location for residents will be in the courtyard . The facility's Smoking Protocol was presented and documented, While a resident at this facility, residents who wish to have smoking privileges may be allowed to do so subject to the following rules: 1. Prior to, or upon admission, resident shall be informed about any limitations on smoking .2. Residents who smoke will have a smoking assessment done to determine independent or dependent smoking privileges .assessment will review cognitive ability, manual dexterity, and mobility .all residents that desire to exercise smoking .will be assessed to determine their smoking safety awareness .smoking assessments will be done as part of the admission process, quarterly, or when reassessment is indicated .the staff shall consult with the Attending physician and the IDT (interdisciplinary team) to determine any restrictions on a resident's smoking privileges .any smoking related privileges, restrictions and concerns shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues .facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely .The staff will review the status of a resident's smoking privileges periodically, and consult as needed with the Director of Nursing Services, IDT or attending physician .All smoking materials (cigarettes, cigars, e-cigarettes, etc.) will be kept at the nurses station or a facility designated area. Smoking materials will only be given to residents that have been determined to be safe/independent smokers during the designated smoke times .Residents determined to be Supervised or Assisted Smokers will receive their smoking material .by the staff member assigned to monitor the smoking area and those materials will be returned by that staff member to the .area for storage .Violations of this protocol or the smoking contract will bring restrictions of smoking privileges or possible discharge from the facility if behaviors present a danger to self or others. Actions such as smoking in non-designated areas, allowing any other resident to use, borrow, buy or have access to smoking material, or any other behavior considered to exhibit poor safety awareness may result in revocation of smoking privileges .Smoking restrictions shall be strictly enforced in all nonsmoking areas .Smoking shall be prohibited at all times in any room, storage area, or any other area where oxygen, flammable liquids, materials, or combustible gases are in use or stored .Smoking is prohibited in public areas or where groups of people frequently gather .The facility will have designated smoking areas. Designated smoking areas may be outside weather permitting .Staff members and volunteer workers shall not purchase and/or provide any smoking articles for residents unless approved by the charge nurse .The facility may check periodically to determine if residents have any smoking articles in violation of smoking policies The administrator was interviewed on 02/22/18 at approximately 8:15 a.m. the administrator was asked for the investigation information for Resident # 145. The administrator presented a folder with information and statements regarding the incident. The investigation information was reviewed and the documentation included, but was not limited to the following: A statement by LPN (Licensed Practical Nurse) # 30 documented in summary, that Resident # 145 was observed just prior to supper being argumentative with the nurse at the nurse's station at around 7:00 p.m. on 02/07/18 and that it wasn't long after that a page came over for all nurses and CNA's to go to the courtyard. A statement by LPN # 12 documented that the resident was last seen around 6:00 p.m. the resident was seen ambulating using a walker around the facility and that the patient had been redirected four times prior to the incident, the resident kept going outside and continued to go back and forth outside in the rain and he would just sit at the table. At about 7:00 p.m., page overhead stated a patient is down in the courtyard. A statement by OS (other staff) # 7 documented that at 7:10 p.m. on 02/07/18 a resident came to the receptionist desk and stated that someone had fallen into the pond in the courtyard, it was pitch black dark outside and she (OS # 7) couldn't see anything, (she) took a few steps and saw something floating in the pond, (she) ran back inside and paged for immediate assistance from nurses and CNA's to the courtyard, Resident # 145 was pulled from the pond after that. A statement by a resident documented that it was dark and after dinner when the incident happened, this resident went outside via the courtyard door and kept hearing something, but didn't see anything because it was so dark, this resident made a loop around the pond to come in and that's when (this resident) saw someone in the pond on his back, (this resident) told him (Resident # 145) that he would go get help and went and told the person at the receptionist desk, everything got hectic and staff got him (Resident # 145) out of the pond and called 911. On 02/22/18 at 9:59 a.m., LPN (Licensed Practical Nurse) # 44 was interviewed regarding Resident # 145 and was asked if the resident was supposed to be supervised for smoking and/or going outside, the LPN stated, Always. An interview was attempted with Resident # 145 on several occasions, which the resident declined. 02/23/18 at 8:46 a.m., Resident # 19 was interviewed regarding Resident # 145 falling into the pond. Resident # 19 stated that it was around 7 or 8 at night when it happened. The resident was asked if this resident was supposed to be supervised in any way. Resident # 19 stated, he was supposed to. Resident # 19 was asked if he was supervised, the resident stated, No. Resident # 19 was asked how he knew that, Resident # 19 stated, Everybody knows that. Resident # 19 stated that when you come here you need to be assessed and stated that Resident # 145 snuck out and fell in the pond. Resident # 19 stated that it rained all that day (when the fall happened) and he (Resident # 145) sat right there (pointing to spot) in the pouring rain. This surveyor and Resident # 19 went to the courtyard area. The resident used the handicap accessible push button to open the door, the door opened giving access to the courtyard. No alarms/lighting or any type of notification and/or alerting system was seen or heard. It was cloudy, overcast with a light misting of rain and cool temperature. The table and chairs were wet, this surveyor wiped a chair off and sat down, the resident was in a w/c. Resident # 19 was asked if the door was locked to the outside the day the Resident # 145 fell , the resident stated, no-but they've been locking it at dusk now. Resident # 19 stated that he didn't like that because he has [MEDICAL CONDITION] and likes to go out to smoke when he can't sleep and was assessed to safely smoke alone, now he states that he can't do that because the guy fell in the fell in the pond. The resident stated, that he (Resident # 145) had been going in and out most of the evening, in and out of the rain. On 02/23/18 at approximately 10:45 a.m., the complaint allegations for Resident # 145 were reviewed with the administrator and DON (director of nursing) in a meeting with the survey team. The administrator and DON were made aware of the serious concerns regarding Resident # 145's fall into the pond, the lack of safety awareness on the resident's part, as evidenced by smoking in the hall way, keeping cigarette butts in his room and closed with failure to return a lighter to staff, the facility staff failing to implement interventions for Resident # 145 for violating the smoking policy and failing to implement interventions and provide supervision for Resident # 145 related to falls. The administrator stated in summary, 'Are you saying that a resident can't go out to the courtyard without being supervised even if they aren't smoking.' The administrator was made aware that is not what the survey team stated in any way. The administrator was again made aware that Resident # 145 was identified (by facility staff) as a risk in several care areas and that those identified concerns for this resident were not addressed or acted upon appropriately to ensure a safe environment and to prevent accidents for Resident #145, and all other residents. No further information and/or documentation was presented prior to the exit conference on 02/23/18 at 12:45 p.m., to evidence that the facility staff provided a safe environment and appropriate supervision for Resident # 145 for the prevention of accidents, which resulted in harm. This is a complaint deficiency. 2. Resident # 347 sustained a blistering sunburn to the tops of both feet which had to be surgically debrided weekly in excess of 88 days resulting in harm. Resident # 347, a closed record review, was admitted to the facility 10/11/12 with a readmission date of [DATE]. Resident # 347's [DIAGNOSES REDACTED]. An MDS (minimum data set) quarterly review dated 6/7/17 had assessed the resident with moderate impairment in cognition with a total summary score of 12 out of 15. The clinical record was reviewed 2/21/18 at 7:30 a.m. Nurses' notes were reviewed, and a note dated 5/18/17 documented Resident complained of feet itching and asked nurse to check her feet. I observed open areas (1 on each upper foot). Wound nurse checked both and put treatment in place. Small blisters noted above areas. Resident had legs crossed and was rubbing them against each other. 98.2-72-156/76 (sic). MD notified. Called RP (responsible party) and (family member) with RP number not in service. (Family member's) mailbox full. Areas cleansed with normal saline, xeroform gauze applied with cover dressing. Dressing will be changed every other day. Resident advised not to rub feet/legs together but to let staff know when she is itchy. The note was signed by LPN (licensed practical nurse) # 2. The clinical record did not include any other nurses' notes about the areas to the tops of the residents feet. The next documentation located was an acute visit by the facility nurse practitioner (NP) dated 5/23/17 which documented .I was asked to see (name of resident) today by nursing due to 2 wounds on top of her feet .she said they do hurt. She denies chest pain, shortness of breath She does have wounds on both tops of her feet. It looks like it blistered up from whatever has happened and then has opened up. They do have Vaseline gauze on there at the time and they are covered. No drainage noted PLAN: I have asked the wound nurse and wound doctor to please see her today The Wound Care Specialist Evaluation forms were then reviewed. The first evaluation form, dated 5/23/17 documented At the request of (name of physician), this [AGE] year old female was seen and evaluated today The evaluation form included documentation of surgical excisional debridement of the dorsal (top of foot) wounds of both feet. The treatment notes initially described the wound as an arterial wound; however, on the treatment evaluation form dated 6/20/17, an area marked Additional information documented After investigation of events prior to my first exam it was noted by CNA caring for patient and the patient's nurse (name of LPN # 2) that day that this patient appeared to have sunburn on both feet dorsal surface. Wounds were red with blistering that day then note of necrosis the following day. Discussed case with wound care nurse, interim DON (director of nursing), and NP. All are in agreement that wounds are secondary to sun exposure. The treatment notes, including weekly debridement, were reviewed to reveal the left foot healed 7/25/17, and the left foot healed 8/22/17. The wounds required treatment, including the weekly surgical debridement, in excess of 88 days. Further review of the clinical record revealed skin assessment sheets, dated 5/3/17, 5/10/17, 5/17/17 were blank, with the exception of an assessment dated [DATE] prior to the resident going to the hospital for an unrelated event. The assessment sheet(s) included A. Skin Conditions. a. Skin Condition (list all areas NEW or OLD (sic). Under this area were blocks where information was to be documented including site and description. Under site was documented Other (specify). Under description was documented Tops of both feet. Dressings present. Treatment was in place before patient went to hospital. Under b. New Areas Noted? was marked no. The rest of the assessment included c. List the areas noted above which are new. d. Physician notified and Treatment Ordered for new areas? d.1. Name of Family Member Notified and Date. e. Referral made to wound care nurse for new areas? All areas b through e had options of Yes or No to be marked, and the areas were not marked. Skin assessment sheets for (MONTH) (YEAR) were also reviewed and were also blank with no assessments completed. The care plan for (MONTH) (YEAR) and (MONTH) (YEAR) were reviewed, and a Focus area updated 5/22/17 documented Bilateral open areas on top of both feet (3 degree burns). Under Goals was documented (name of resident) will have no complications related to (SPECIFY skin injury type) (sic) of the (SPECIFY location) (sic) through the review date. The skin injury type and location was not documented. Interventions for the focus area included Educate resident/family/caregivers causative factors and measures to prevent skin injury . Follow facility protocols for the treatment of [REDACTED]. to MD On 2/21/18 at 10:45 a.m. LPN # 2 was interviewed about the nursing note dated 5/18/17. LPN # 2 stated I looked at her feet when she complained of them itching. We had a picnic here at the facility that day and we had put sunscreen on all the residents going outside to the picnic. We made sure faces, arms, etc. had sunscreen on them; I guess we didn't think about her feet. She had on slipper type shoes, and that was the pattern of the sunburn; the very tops of her feet had been exposed. We got her seen right away by the nurse practitioner and wound nurse; they started treatment. On 2/21/18 at 4:00 p.m. an interview with the DON, who was identified as the interim DON when the incident occurred, and the regional nurse consultant was conducted. The DON and regional nurse consultant were asked about the lack of nursing documentation, and lack of documentation on the skin assessment sheets. The regional nurse consultant stated I believe the computer system was down that day, which is why there was no skin assessment sheets for that day. It would have been entered as a nursing note scanned into the system. The regional consultant was then asked how long the system was down, as there were no skin assessments or nurses' notes regarding the wounds with the exception of 5/18/17, and a skin assessment form dated 5/31/17. The regional nurse consultant stated she was not sure how long the system was down, but thought it was down for about a day. The DON was asked about the lack of documentation, and she stated There should have been nursing notes. And we have identified the skin assessment forms as an area needing improvement; those should have been filled out as well. The DON further stated the facility had done a QAPI (quality assurance program improvement) since the incident to include orders for staff to apply sunscreen as needed for all residents going outside during the months a sunburn could be acquired. She also stated an education on skin assessment sheets was ongoing. The DON was also asked about the reference to a third degree burn on the care plan. She was asked if there was a definition of third degree burn, and if the resident had been diagnosed with [REDACTED]. On 2/22/18 at 7:44 a.m. the administrator and DON were informed of the above findings, and the possibility of a harm level citation. The administrator and DON had no comment. On 2/23/18 at 8:00 a.m. the DON informed this surveyor it was not clear why the sunburn was referred to as a third degree burn; there were no physician notes or [DIAGNOSES REDACTED]. No further information was provided prior to the exit conference. THIS IS A COMPLAINT DEFICIENCY. 3. The facility failed to ensure Resident # 64's Vape device and vaping liquids were properly stored at the Nurse's Station, and in accordance with the plan of care, when not in use. Resident # 64 in the survey sample, a [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Annual Minimum Data Set, with an Assessment Reference Date of 1/27/18, the resident was assessed under Section C (Cognitive Patterns), as being cognitively intact, with a Summary Score of 15 out of 15. During the orientation tour at 10:30 a.m. on 2/20/18, the resident was observed just inside the door of his room, seated in his wheelchair. While the surveyor engaged the resident in conversation, a Vape device was observed on the resident's night stand, located next to the door of the room. Asked if he vaped, Resident # 64 said, Yes. I never smoked, but I do vape. At 10:15 a.m. on 2/23/18, Resident # 64 was observed in the facility's Court Yard, seated in his wheelchair. At the time of the observation, the resident was engaged in vaping. When asked how much nicotine he used in his vape mixture, he said, I use 3 milligrams. When he finished vaping, the resident placed the Vape device in his lap, wheeled himself out of the Court Yard, through the Day Room, and into the hallway where he joined other residents waiting to enter the Dining Room to play Bingo. When the Dining Room door was opened, Resident # 64 entered along with other residents to play Bingo. At approximately 10:20 a.m. on 2/23/18, the surveyor went to the resident's room where two containers of vaping liquids were observed on a small table next to his night stand. The first container was labeled KEEP IT 100 KRUNCHY SQUARES, 3 mg (milligrams) (0.3%), 100 ml (milliliters) (3.38 FL OZ) (fluid ounces). The following warning also appeared on the label, WARNING: This product contains nicotine. Nicotine is an addictive chemical. The second container was labeled, Gorilla Vapes. There was a space on the label for the flavor of the liquid, but the writing was smudged and unreadable. The label also included the following entry, This product may contain nicotine, as addictive substance known to the State of California to cause birth defects [MEDICAL CONDITION]. At 10:25 a.m. on 2/23/18, LPN # 3 (Licensed Practical Nurse), the Charge Nurse on the unit where Resident # 64's room was located, was asked about the storage of his vaping supplies. He keeps them in his room, LPN # 3 said. We (the nurses) have questioned why he is allowed t (TRUNCATED)