Every finding on record at Smith Medical Nursing Care CTR

Based on observation, resident and staff interviews, and review of the facility's policy titled Grievance Policy, the facility failed to ensure information about the grievance process was posted and made available in visible areas of the facility. In addition, the facility failed to ensure three of 20 sampled residents (R) (R1, R38, and R3) were informed of the grievance process. The deficient practices had the potential to place the 44 residents residing in the facility at risk of not having the knowledge to file a grievance. Findings include:Review of the facility's undated policy titled Grievance Policy revealed the Procedure section included, 1. We will notify residents individually or through posting in prominent location throughout the facility of the right to file a grievance orally (spoken) or in writing: the right to file grievance anonymously; the contact information of the grievance official with whom a grievance can be filed, his or her grievances; and the contact information of the independent entities with whom grievances may be filed, that the pertinent State agency, Quality improvement Organization, State Survey Agency and the state Ombudsman program and advocacy system included. 3. If the grievance is anonymous; a written grievance; to the resident and coordinating with state and federal agencies is necessary of special allegations.1. An initial tour of the facility on 8/5/2025 at 9:00 am revealed no visible posting of information on how to file a grievance, information on who the Grievance Official was, or accessible grievance forms. 2. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 6/20/2025, for R1 revealed a Brief Interview of Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). During an interview on 8/7/2025 at 10:00 am, R1 stated she was unaware of who the Grievance Official was, the facility had not explained how to file a grievance, and she was not familiar with a grievance form. Review of the Quarterly MDS assessment, dated 5/10/2025, for R38 revealed a BIMS score of 14 (indicating little to no cognitive impairment). During an interview on 8/7/2025 at 10:05 am, R38 stated she was unaware of who the Grievance Official was, the facility had not explained how to file a grievance, and she was not familiar with a grievance form. Review of the Significant Change MDS assessment, dated 5/13/2025, for R3 revealed a BIMS score of 14 (indicating little to no cognitive impairment). During an interview on 8/7/2025 at 10:05 am, R3 stated she was unaware of who the Grievance Official was, the facility had not explained how to file a grievance, and she was not familiar with a grievance form. During an interview on 8/7/2025 at 10:21 am, Certified Nurse Assistant (CNA) AA stated she was aware of what grievances are, but she did not know who the Grievance Official was for the facility or how the process works. She stated that if a resident had a complaint, she would inform the Director of Nursing (DON).During an interview on 8/7/2025 at 10:24 am, Charge Nurse (CN) HH stated that if a resident had a grievance, she would go to the DON because she was the Grievance Official. She further stated she was unaware of the process for filing a grievance for the residents and was unaware of a grievance form.During an interview on 8/7/2025 at 10:31 am, the DON stated the Administrator was the Grievance Official and she handled and processed all the reports. She stated that if a resident wanted to file a grievance anonymously, she would not disclose the resident's name to the Administrator. She confirmed the grievance forms were not available to the residents, and there were no postings in the facility with grievance information or the name of the Grievance Official.During an interview on 8/7/2025 at 10:45 am, the Administrator stated she was the Grievance Official and completed the forms for the residents. The Administrator stated she completed the grievance form when a resident wanted to file a complaint. The Administrator further stated that the facility previously had an area with grievance forms available to the residents, but the forms were no longer available to residents. She confirmed there were no postings in the facility to provide residents with information on grievances.

Based on staff interviews and record review, the facility failed to ensure 14 of 14 Certified Nurse Aides (CNA) reviewed received an annual performance evaluation. This deficient practice had the potential to place the 44 residents residing in the facility at risk of receiving care from incompetent staff. Findings include: Review of the facility's education and training records dated 8/23/2024 through 7/17/2025 revealed no record of annual performance review for CNAs.During an interview on 8/7/25 at 9:45 am, CNA AA stated evaluations were done verbally and with observations, and she cannot recall having a written evaluation since her hire date of 3/29/2024.During an interview on 8/7/2025 at 10:06 am, CNA KK reports not having had a written performance evaluation since her start date of 10/23/2023, and that the Director of Nursing (DON) observes her and gives feedback while she is completing care for a resident.During an interview on 8/7/2025 at 10:03 am, Charge Nurse (CN) HH reported having completed training courses since she had been on staff, but could not say when she had received a formal evaluation, but thought she had.During an interview on 8/6/2025 at 4:45 pm, the DON stated that the facility does not do yearly CNA performance reviews or skills check-offs. She reports that annual performance reviews were not done prior to her employment, and she planned to implement the practice going forward.

Based on observations and staff interviews, the facility failed to ensure expired medications and medical supplies were not stored in the medication storage room. This deficient practice had the potential to place the 44 residents residing in the facility at risk of receiving expired medications or having expired medical supplies being used for them. Findings Include:Observation of the medication storage room on 8/6/2025 at 10:45 am with the Office Manager and Licensed Practical Nurse (LPN) JJ revealed the room contained supplies sitting on the floor and included: One box of 10 cubic centimeters (cc) syringes with expiration date 11/03/2024. Three boxes of skin prep with expiration date 4/1/2025. Two bottles of bisacodyl 5 milligram (mg) with expiration date of 8/2024. Bisacodyl suppositories with an expiration date of 6/2025. One box of Metamucil with an expiration date of 1/2025. Three bottles of Hibiclens with an expiration date of 10/2024. Intermittent male catheters with expiration dates of 7/24/2025 and 3/31/2025.In an interview, the Office Manager confirmed the identified expired medications and medical supplies. In an interview on 8/6/2025 at 11:00 am, the Office Manager revealed that she was responsible for managing the stock medications and supply room. She said that some of the items in the room were no longer in use. In an interview on 8/7/2025 at 11:41 am, the Director of Nursing (DON) revealed the Office Manager was responsible for the medication storage room. She stated that the Office Manager and the Administrator were the only ones with a key to the room. She further stated that if the medication cart was low in stock of an item, either the Administrator or the Office Manager would retrieve the items from the medication storage room. In an interview on 8/7/2025 at 11:58 am, LPN DD revealed that if they run out of a floor stock medication, the DON will get the key and retrieve the item for them.

Based on observations and staff interviews, the facility failed to ensure kitchen equipment was stored in a sanitary manner and failed to ensure the ice machine was clean and free from residue. These deficient practices had the potential to place the 44 residents who received hydration from the kitchen at increased risk of illness. Findings include:The initial walk-through observation of the kitchen on 8/5/2025 at 9:15 am, with the Dietary Manager (DM), revealed one slicer sitting on a prep table, and located near the hand-washing sink without a cover. Further observation revealed one industrial-sized mixer sitting on a prep table without a cover.Observation and interview on 8/5/2025 at 9:15 am with the Dietary Manager (DM) in the Dining Hall, of the industrial ice machine, revealed a red-brown residue on the interior of the ice machine when wiped with a paper towel. The DM confirmed the findings. Observation on 8/7/2025 at 10:30 am in the kitchen revealed that the industrial-sized mixer and slicer remained uncovered. Interview with the DM on 8/5/2025 at 9:15 am revealed that the ice machine was cleaned daily by the dietary staff, and Maintenance oversaw the overall upkeep of the ice machine.Interview with the DM on 8/7/2025 at 10:30 am revealed that neither the slicer nor the mixer had had a cover on them since she had worked there.

Based on observations, staff interviews, and review of the facility's policy titled Smoking Policy, the facility failed to ensure proper and effective ventilation, specifically in the indoor designated smoking area and hallways near the area. This deficient practice had the potential to place the 44 residents residing in the facility at risk of medical complications related to exposure to poor air quality. Findings include:Review of the facility's undated policy titled Smoking Policy revealed the Procedure section included, . 6. Smoking occurs in designated locations that are environmentally separate from all residents' care areas. These designated locations may be outdoors. The Documentation section included, .3. Smoking will occur in a designated area at a designated time only. Currently, the area is the back porch and the front area outside area. Times and location are subject to change.During the initial tour of the facility on 8/5/2025 at 9:00 am, the smell of cigarette smoke was noted in the hallway that was connected to the designated indoor smoking area. Observations on 8/5/2025 at 2:00 pm and 8/7/2025 at 9:29 am revealed the smell of cigarette smoke lingering in the hallways connected to the designated indoor smoking area.During an interview on 8/6/2025 at 4:00 pm, Certified Nurse Assistant (CNA) CC revealed there was an air filter in the indoor smoking room to help keep the smoke down, but she was unsure who was responsible for maintaining the air filter. She continued to state that when the residents were finished with smoking, the smoke and the smell of cigarette smoke lingered into the hallways, and could be smelled at the end of the hall.During an interview on 8/7/2025 at 9:30 am, CNA AA confirmed she smelled cigarette smoke in that hallway, and stated it usually smelled like that because they open the door from the indoor smoking area, and the smell gets out.During an interview on 8/7/2025 at 10:34 am, the Director of Nursing (DON) confirmed she noticed the smell of cigarette smoke and stated this could be an issue for other residents who don't smoke. She continued to state that the residents who smoke would leave the designated smoking area, and the smoke would linger in the hallways. The DON further stated that they try to get the residents who smoke out fast to help with the smell, but there was no ventilation system in the designated smoking area.During an interview on 8/7/2025 at 10:41 am, the Administrator stated that the closed indoor designated smoking areas have an air purifier, fans, and windows open to help reduce smoke. She continued to state she expected the staff to leave the door closed during the smoking time.

Based on staff and resident interviews, record review, and review of the facility's policy titled Medication Administration General Guidelines, the facility failed to ensure a significant medication error did not occur for one of 20 sampled residents (R) (R32). This deficient practice had the potential to place R32 at risk of medical complications and a reduced quality of life. Findings include:Review of the facility policy titled Medication Administration General Guidelines, dated 2007, revealed the Procedures: Medication Preparation section included, . 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record [MAR]. Compare the medication and dosage schedule on the resident's MAR with the medication label. The Medication Administration section included, . 9. Verify medication is correct three (3) times before administering the medication. a. When pulling the medication package from the med cart. b. When dose is prepared. c. Before dose is administered. 10. Residents are identified before medication is administered using at least two resident identifiers.Review of the clinical record for R32 revealed diagnoses including, but not limited to, hypertension, brainstem stroke, dysphagia, and [NAME] syndrome.Further review of the clinical record revealed that R32 was allergic to penicillin.Review of the facility-provided document titled Incident/Accident Report for R32 revealed an entry dated 4/6/2025 at 10:00 pm and signed by Registered Nurse (RN) GG, documented medication error; pt. [patient] given oral dose Amoxil [amoxicillin, a penicillin-type of antibiotic]. No signs/symptoms of reaction. No actual physical injury. Pt. notified and RP [responsible part] notified. Administration notified. The physician was notified, and the physician, Director of Nursing, and Administrator signed the document. Review of Nurses Notes for R32 revealed: 4/7/2025 at 2:20 am, documented no rash or signs of adverse reactions. 4/72025 at 4:00 am, documented no signs of a reaction. 4/7/2025 at 6:00 am, documented R32 denied having any symptoms during the night. 4/7/2025 at 1:40 am, documented R32 in his room, sitting in his wheelchair, and no reaction noted. 4/7/2025 for 7:00 pm to 7:00 am, documented no visible signs of reaction or rash. 4/8/2025 at 2:20 pm, documented no adverse reaction. 4/9/2025 for 7:00 am to 7:00 pm, documented no signs of rash, hives, itching, or swelling. 4/10/2025 for 7:00 am to 7:00 pm, documented no skin rashes noticed, and no difficulty breathing. In an interview on 8/7/2025 at 10:03 am, Charge Nurse (CN) HH stated new medication orders were documented on a 24-hour report and communicated at shift change. She further stated physician orders were placed on the MAR, and if the medication was not on the MAR, the nurse should not administer it. In a telephone interview on 8/7/2025 at 1:23 pm, Registered Nurse (RN) GG stated that on 4/6/2025, he prepared medication for R32 and R2 before administering the medications. He stated he always prepared medications for both residents residing in the same room at the same time. He further stated that after he administered medication to R32, he realized he had administered Amoxil, which was ordered for R2, to R32 in error. He stated that after review of the MAR for R32, he verified that R32 was allergic to penicillin, and he notified the physician, received an order to administer Benadryl, and to monitor R32. In an interview on 8/7/2025 at 1:10 pm, the Director of Nursing (DON) stated RN GG realized the medication error as soon as it occurred, notified the physician, administered the prescribed Benadryl, and staff monitored R32 accordingly. She confirmed that an incident report was filed, but there was no re-education with RN GG after the incident.

Based on staff interviews, record review, and review of the facility's policy titled [Facility's Name] Fall Management Guide, the facility failed to identify a fall, investigate the fall to determine a root cause, and implement interventions to ensure protection from future potential falls for one of four residents (R) (R3) reviewed for falls. Findings included: Review of the facility's policy titled, [Facility's Name] Fall Management Guide, updated 06/21/2024, revealed, If a fall occurs: Incident report/staff education will be completed by the investigating nurse along with a nursing note. DON [Director of Nursing] completes fall investigation once investigating nurse has completed these steps. The policy also indicated, Determine the cause of the fall and decide how a similar fall could be prevented for each resident. Review of a Nursing Home Summary Sheet indicated the facility admitted R3 on 7/9/2012. Diagnoses included muscle weakness. Review of a Fall Risk Assessment Form, dated 3/25/2024, indicated R3 had a total score of 15. The Fall Risk Assessment Form revealed a total score of 10 or more indicated a resident was at risk for falls. Review of a Fall Risk Assessment Form, dated 4/14/2024, indicated R3 had a total score of 15, which indicated the resident was at risk for falls. Review of a Fall Risk Assessment Form, dated 7/13/2024, indicated R3 had a total score of 15, which indicated the resident was at risk for falls. The Fall Risk Assessment Form indicated R3 experienced no falls in the prior three months. Review of the Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/13/2024, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 5 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented R3 had impairment on both sides of the lower extremities and required substantial to maximal assistance with walking. Section I (Active Diagnoses) documented diagnoses including dementia, arthritis, and hypertension. Section J (Health Conditions) documented R3 had one fall since admission with no injury. Review of R3's Care Plan revealed a problem area for falls, revised 3/5/2025, that indicated that the resident was at risk for falls related to a diagnosis of dementia, multiple sclerosis (MS), degenerative joint disease of the spine, a shuffling gait, and psychotropic medication use. Interventions directed to staff to Provide safe, clutter free environment/uncluttered pathways and Safety training and education as needed for staff. The care plan indicated that, for 5/3/2024 and 8/3/2024, there were No falls this review period. Review of a Nursing Notes For Heavy Nursing Care Except Medication note, dated 5/22/2024 at 5:45 pm, indicated that while R3 was ambulating to the dining room, the resident was noted to start sliding to the floor. The note indicated, lowered resident [R3] to the floor, then assisted to chair, and started to slide out of the chair. Writer assisted resident to floor. Review of the hospital General Instructions, dated 5/22/2024, indicated R3 was admitted on [DATE] at 6:45 am and was evaluated for acute bilateral sacral pain. The General Instructions indicated R3 was discharged to a nursing home with fall prevention warnings. Review of R3's Falls Intervention Plan (FIP), dated from the timeframe of 2017 through 2025, revealed no dated entry for an intervention related to the resident's fall on 5/22/2024. During an interview on 3/19/2025 at 10:45 am, the DON stated she was not aware R3 experienced a fall in May of the prior year, as she did not have an incident report for a fall in May of 2024. The DON reviewed the nurse's note dated 5/22/2024 and confirmed that she did not have an incident report for the 5/22/2024 incident. The DON stated perhaps the nurse did not consider the incident to be a fall, as R3 was assisted to the ground. The DON stated that if the resident did not fall to the ground, she would not consider that a fall. The DON further stated the team did not review R3 for a fall on 5/22/2024. The DON stated she expected an incident report be completed for all falls and the care plan and fall interventions to be updated after a resident had a fall. During an interview on 3/19/2025 at 10:55 am, the Administrator stated when a resident fell , she expected staff to ensure the resident was safe and that there were no injuries. The Administrator stated she expected the nurses to do assessments, call the doctor, call the family, notify the DON, notify the Administrator, and fill out an incident report for the fall. The Administrator further stated that she expected the DON to investigate the fall, get staff statements, do a timeline, and complete a root cause analysis to find out why the resident fell and how they could prevent another fall. The Administrator stated she was aware of the 5/22/2024 incident where staff lowered R3 to the ground. The Administrator stated R3 did not fall because staff caught the resident and lowered the resident to the floor. The Administrator stated she was not aware that easing a resident to the ground (an episode where a resident lost their balance and would have fallen, if not for another person or if they had not caught themselves) was considered a fall. The Administrator stated she expected when there was a fall, an incident report and an investigation were completed that would show how and why the resident fell so that new interventions could be put in place to prevent future falls.

Based on observations, staff interviews, and a review of the dietary menu cycle and recipes, the facility failed to ensure staff followed food recipes for preparing pureed foods for eight of eight residents who received a puree diet. This failure had the potential to compromise the nutritive value of the pureed meal served to eight of the eight residents who received a pureed diet. Findings include: A review of the menu for lunch on 3/23/2024 revealed the meal included baked chicken, red potatoes, and green beans. Observation revealed a stack of papers on the table near the pureeing table that had the recipe for Pureed Chicken and Pureed Green Beans. The recipe for chicken required chicken, bread, and chicken broth. The recipe for green beans required green beans, vegetable broth, thickener, and salt and pepper. There was no recipe observed for the red potatoes. A kitchen visit was conducted on 3/23/2024 at 11:20 am with Cook EE to observe the puree process. Cook EE weighed the chicken and then used 2 cups of chicken broth to get her desired consistency, bread was not added. Cook EE then pureed green beans, without adding thickener, salt, or pepper to the beans. The green beans were noted to be somewhat loose with a mild holding of shape. Cook EE then used 6 1/2 scoops of peeled potatoes and 2 scoops of red potatoes with skins to make the pureed potatoes. There were 2 cups of water used as the liquid in the potatoes and the potatoes were noted to be runny and gummy. When questioned about not following the recipe the Dietary Manager (DM) reported that thickener does not have to be used nor the bread if the product is thick enough. During preparation of a puree plate on the food service line on 3/23/2024 at 12:50 pm the DM confirmed that the pureed potatoes did not hold their shape and were spread across the plate. During an interview on 3/24/2024 at 1:20 pm with the Registered Dietitian (RD) it was reported that a liquid with nutritional value should be used when pureeing items and it is best to not use water. The RD reported that if thickener was on the recipe, then it should have been used but it should not be used in such a way to change the quality of the food. It was further reported that the pureed foods should never be runny, and she would need to provide some education to the staff regarding this issue.

Based on observation, staff interviews, and review of the facility policy titled Food Labeling Policy, the facility failed to ensure items in the reach-in freezer, reach-in cooler, and dry food storage area were labeled and dated, food items in dry storage were not expired, and the proper use of the three-compartment sink. The deficient practices had the potential to place 36 of 38 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings include: A review of the undated facility policy titled Food Labeling Policy, revealed It is the policy of (facility name) to use peel and stick date marking labels. The date the food item is placed in the refrigerator will be legibly written on the food item and discarded seven days after the date. The initial kitchen tour began on [DATE] at 8:00 am and revealed the following: In the reach-in freezer: 1. Hamburgers in a bag were not labeled and dated. 2. Two bags of meatballs were not labeled and dated. 3. Three bags of frozen sandwich meat were not labeled and dated. 4. One bag of biscuits was not labeled and dated. 5. Rolls on two trays in a plastic bag that was not labeled and dated. 6. One bag of nuggets that was not labeled and dated. 7. One bag of hushpuppies that was not labeled and dated. In the reach-in cooler: 1. One pack of bologna in a bag without an expiration date or label with an open or discard date. During an observation and interview on [DATE] at 8:20 am Cook DD explained the process of using the three-compartment sink. Upon checking the solution in the sanitizer sink with the chemical solution test strip, the sanitizer was not registering on the strip. Cook DD then pressed for more of the sanitizing solution to be added to the sink and tested a second time, but the test strip continued to not change color, indicating a failure to register at 200 parts per million (ppm), after 45 seconds. Cook DD expressed that there is no specific time that she should put the test strip in the water, and she puts the test strip into the water until it changes colors. She again tried to add more of the sanitizing solution, but nothing would come out of the dispenser. On [DATE] at 8:30 am the Dietary Manager (DM) entered the kitchen and reported that once the sanitizing solution had been dispersed it would not disperse again for another 20 minutes. A further tour of the kitchen was then conducted, and observations revealed the following: In the reach-in freezer, there were open containers of turkey deli meat, hush puppies, fish, pizza, meatballs, Salisbury steak, and a bag of pork chops with no open dates or use-by dates. In the reach-in cooler, there were opened and undated containers of salmon patties, onion, and sliced cheese. There was also an open package of bologna with a use-by date of [DATE], and a bag of breadcrumbs dated [DATE] - [DATE]. The DM confirmed the findings in the reach-in freezer and reach-in cooler. Observation of the dry food storage area revealed the following: 1. Two containers of sweet roll mix with an expiration date of February 8, 2024. 2. A container of grape jelly without an in-date or use-by date. 3. 10 cans of condensed mushroom soup without an in-date or use-by date. 4. Seven cans of applesauce without an in-date or use-by date. 5. 10 cans of fruit cocktail without an in-date or use-by date. 6. Three cans of sliced apples without an in-date or use-by date. 7. Three cans of pineapples with no in-date or use-by date. 8. One can of mandarin oranges without an in-date or use-by date. 9. Individual packets of ketchup, mustard, saltines, and graham crackers were found in clear plastic containers without an in-date or use-by date. 10. Eight cans of mixed vegetables without an in-date or use-by date. 11. One plastic container with an open bag of elbow macaroni with no open date or expiration date. 12. One 10-pound bag of spaghetti without an in-date or use-by date. 13. One bag of dry spaghetti without an in-date or use-by date. The DM reported that the items did not have dates, but she ordered in such a way that orders do not overlap. The DM reported that the breadcrumbs were taken out of the freezer yesterday. When questioned if the breadcrumbs should have been marked to indicate when they were taken out of the freezer, the DM reported that she would discard the item. The DM acknowledged that the items in the reach-in freezer, reach-in cooler, and the dry storage area were not labeled and dated and expired items should not have been in the dry food storage area. During an observation on [DATE] at 11:32 am of Cook FF using the three-compartment sink, the sanitizer sink water still did not register at 200 ppm when tested using the test strip. Observation revealed the puree mixer bowl and blades were washed in the sink and placed in the sanitizing solution for less than 30 seconds. The puree mixer bowl, lid, and blades were washed again in the sanitizing sink and the solution again failed to register at 200 ppm. The items were then washed using a high-temperature dishwasher.

Based on staff interviews, record review, and review of the PBJ (Payroll Based Journal) [NAME] Report for the First Quarter (Q1) of Fiscal Year 2024, the facility failed to accurately report direct care staffing data to the Centers for Medicare and Medicaid (CMS). The facility census was 38 residents. Findings include: A review of the PBJ [NAME] Report for Q1 2024, October 1 through December 31, revealed the Staffing Data Report triggered for excessively low weekend staffing and a one-star staffing rating. A review of the facility's documents titled Daily Staff Posting, and PBJ Time, from October 2023 through December 2023, revealed discrepancies between the total number of hours nursing staff worked on the weekends and the total number of nursing hours worked reported to CMS for the following dates: Saturday 10/7/2023: The Daily Staff Posting indicated there were two Registered Nurses (RN), three Licensed Practical Nurses (LPN), and six Certified Nurse Aides (CNA). Total nursing hours worked was 108 hours, Census was 34, Per Patient Day (PPD) was 3.18, and the submitted PBJ time was 117.5 hours. Sunday 10/8/2023: The Daily Staff Posting documented there were two RNs, three LPNs, and seven CNAs. Total nursing hours worked was 108 hours, Census was 34, PPD was 3.18, and the submitted PBJ Time was 97.75 hours. Saturday 10/14/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 35, PPD was 2.86, and the submitted PBJ Time was 92 hours. Sunday 10/15/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 34, PPD was 2.94, and the submitted PBJ Time was 94.5 hours. Saturday 10/21/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 34, PPD was 2.94, and the submitted PBJ Time was 94.5 hours. Sunday 10/22/2023: The Daily Staff Posting documented there was one RN, three LPNs, and six CNAs. Total nursing hours worked was 100 hours, Census was 35, PPD was 2.86, and the submitted PBJ Time was 91.5hours Saturday 10/28/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 37, PPD was 2.70, and the submitted PBJ Time was 99 hours. Sunday 10/29/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 37, PPD was 2.70, and the submitted PBJ Time was 100 hours. Saturday 11/4/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 38, PPD was 2.63, and the submitted PBJ Time was 99.75 hours. Sunday 11/5/2023: The Daily Staff Posting documented there was one RN, two LPNs, and six CNAs. Total nursing hours worked was 100 hours, Census was 37, PPD was 2.63, and the submitted PBJ Time was 100.25 hours. Saturday 11/11/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 38, PPD was 2.63, and the submitted PBJ Time was 104.75 hours. Sunday 11/12/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 38, PPD was 2.63, and the submitted PBJ Time was 94.75 hours. Saturday 11/18/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 38, PPD was 2.63, and the submitted PBJ Time was 90.5 hours. Sunday 11/19/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 38, PPD was 2.63, and the submitted PBJ Time was 98.25 hours. Saturday 11/25/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 37, PPD was 2.70, and the submitted PBJ Time was 98.25 hours. Sunday 11/26/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 37, PPD was 2.70, and the submitted PBJ Time was 97.95 hours. Saturday 12/2/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 37, PPD was 2.70, and the submitted PBJ Time was 107 hours. Sunday 12/3/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 37, PPD was 2.70, and the submitted PBJ Time was 84.25 hours. Saturday 12/9/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 38, PPD was 2.63, and the submitted PBJ Time was 94.5 hours. Sunday 12/10/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 38, PPD was 2.63, and the submitted PBJ Time was 87.5 hours. Saturday 12/16/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 39, PPD was 2.56, and the submitted PBJ Time was 82 hours. Sunday 12/17/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 39, PPD was 2.56, and the submitted PBJ Time was 118 hours. Saturday 12/23/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 37, PPD was 2.70, and the submitted PBJ Time was 107.75 hours. Sunday 12/24/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 33, PPD was 3.03, and the submitted PBJ Time was 96.75 hours. Saturday 12/30/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 39, PPD was 2.56, and the submitted PBJ Time was 108 hours. Sunday 12/31/2023: The Daily Staff Posting documented there was one RN, three LPNs, and seven CNAs. Total nursing hours worked was 100 hours, Census was 39, PPD was 2.56, and the submitted PBJ Time was 92 hours. An interview on 3/24/2024 at 8:05 am with the Office Manager revealed the facility did not have an electronic time system. She stated the staff uses a timecard and places it under the time stamp machine that stamps the in and out date and time on the card. She stated she then calculated their time, wrote it on the timecard, and manually transferred those hours onto their PBJ Time log sheet used for PBJ reporting. An interview on 3/24/2024 at 11:30 am with the Office Manager revealed she had been instructed by the previous staff that did payroll to split the hours after midnight and carry them over to the next day. She confirmed the hours submitted to CMS were not accurate and did not reflect the actual hours worked for the reported dates. She verified all the staff listed on the PBJ Time were direct care staff. A policy was requested, however the Office Manager stated they did not have a policy related to PBJ reporting. An interview on 3/24/2024 at 11:33 am with the Administrator revealed she was unsure why the facility triggered low staffing on the PBJ report because they had adequate staff to care for the residents. She confirmed the Office Manager divided and carried over the hours the nursing staff worked on the night shift after midnight, which resulted in them not getting credit for the total hours worked on the begin date. She stated she educated the Office Manager on the correct way for reporting hours. She confirmed that the data submitted to CMS was inaccurate and that she would start completing and submitting the PBJ time herself to make sure it was submitted correctly.

Based on observations, resident interview, staff interviews, and a review of the facility policy titled Preventive Maintenance, the facility failed to ensure that it maintained a safe, clean, and comfortable home-like environment in 10 of 29 resident rooms related to dust and grime build-up and vegetation growth on resident room air conditioner/heater units, grime buildup on medical equipment in resident rooms, dusty ceiling vents in resident bathroom, rusty equipment and furniture in resident rooms, and missing paint in a resident room. These failures placed the residents at risk from the use of unsanitary equipment and the potential for a diminished quality of life. Findings include: A review of the undated facility policy titled Preventive Maintenance, revealed: It is the policy of (the facility) to check the premises, temperature of the facility, the grounds and equipment to ensure the premises, temperature, grounds and equipment remain in perfect working order and is clean, safe and sanitary. It is the direct responsibility of the Administration to insure {sic} that all equipment, facility temperature, the premises and the grounds remain safe, operational, clean, and sanitary. Observations made on 3/22/2024 between 8:00 am and 12:00 pm of resident rooms during initial rounds revealed rooms 117, 118, 143, 144, and 147 had dust and dark-colored grime build-up on the air-conditioner/heater unit grates and vents. Further observations on 3/23/2024 at 10:00 am and on 3/24/2024 at 11:14 am revealed resident rooms 117, 118, 143,144, and 147 had dust and dark-colored grime build-up on the air-conditioner/heater unit grates and vents. 35062 Observations on 3/22/2024 at 10:16 am and 3/24/2024 at 9:36 am revealed a thick layer of dust on the ceiling vent in the bathroom of room [ROOM NUMBER]. 36200 Observation 3/22/2024 at 10:29 am, in the bathroom for room [ROOM NUMBER] revealed a rusty grab bar by the toilet, black streaking on the bathroom wall. Observations in room [ROOM NUMBER] revealed streaking and missing paint throughout the room, black buildup in the air conditioner/heater unit vent, a rusty base on the overbed table for bed A, and a tube feeding pole with a buildup of grime on the pole and base of the pole. Observation on 3/22/2024 at 10:46 am, in the bathroom for room [ROOM NUMBER], revealed there were rusty railings in the bathroom. Observation of room [ROOM NUMBER] revealed a rusty base on the overbed table. Observation on 3/22/2024 at 11:08 and 3/23/2024 at 11:14 am in room [ROOM NUMBER] revealed the air conditioner/heater unit vent cover was missing, loose baseboard under the sink in the room, scuffed and missing paint by the door near the entry to the room and peeling paint on the door. Observation of the bathroom for room [ROOM NUMBER] revealed a rusty grab bar in the bathroom. Observation on 3/22/2024 at 11:14 am in room [ROOM NUMBER] revealed the top of the soap dispenser was missing and a green sprig was growing out of the air conditioner/heater unit vent. Observation on 3/23/2024 at 4:19 pm in room [ROOM NUMBER] revealed the tube feeding pole with buildup on the pole and base of the pole. Observation revealed dust build-up in the air conditioner/heater unit vent and green vegetation that appeared to be growing out of the floor in the room at the base of the air conditioner/heater unit. An environmental tour was conducted on 3/24/2024 at 11:52 am with the Administrator and all environmental concerns were observed and confirmed by the Administrator. The Administrator reported that the air conditioner/heater unit vents should be cleaned monthly. She stated she would expect the air-conditioner/heater unit grates and vents to be clean and free from dust and grime buildup. The Maintenance Director was not available for an interview.

Based on record review, staff interviews, and review of the facility policies titled Completion of Minimum Data Set (MDS) and Comprehensive Care Plan, and Patient's Plan of Care, the facility failed to develop a care plan for one resident (R) (R28) with a diagnosis of Post Traumatic Stress Disorder (PTSD). This failure had the potential for R28 to not receive treatment and/or care according to their needs and place the resident at risk for adverse consequences. The sample size was 22. Findings include: A review of the facility policy titled Completion of MDS and Comprehensive Care Plan, last revised 3/15/2005 revealed: Procedural Guidelines: 7) Comprehensive Care Plans: The center should develop a comprehensive care plan for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment. The care plan will describe the services that are to be furnished to attain or maintain the patient's highest practicable physical, mental and psychosocial well-being or services that are not provided due to the patient's exercise of her rights to refuse treatment. A review of the facility policy Patient's Plan of Care, last revised 3/15/2005 revealed: Procedural Guidelines: 1) An interdisciplinary team, in coordination with other patient care services, develops and maintains a care plan for each resident. R28 was admitted on [DATE] with diagnoses that include but are not limited to hallucinations and PTSD. A review of R28 quarterly MDS dated [DATE] documented that Section I (Active Diagnoses) did not include PTSD. A review of R28's care plan revealed the care plan did not include a care plan area for PTSD, R28's PTSD triggers, monitoring for symptoms of PTSD, or interventions related to PTSD. A review of a telepsychiatry note dated 12/15/2023 revealed: Diagnoses included bipolar disorder, hallucinations, PTSD, major depression disorder, and alcohol abuse. Delusional and demanding at times. The resident reports a long psych history. Hallucinates since she was young. Has seen dead people. Now have crawling sensations. Sees bugs and snakes in bed at night. An interview on 3/24/2024 at 9:25 am with the Administrator revealed the resident has not had any behaviors since admission and has not had any symptoms related to her diagnosis of PTSD. She indicated the resident receives psychological services through Preadmission Screening and Resident Review (PASRR). A telephone interview on 3/24/2024 at 9:29 am with the RN MDS Coordinator revealed she did not do a care plan for PTSD due to the resident having no symptoms of PTSD. An interview on 3/24/2024 at 9:44 am with the Director of Nursing (DON) revealed the resident has not shown any PTSD-type symptoms since admission. An interview on 3/24/2024 at 10:20 am with the Licensed Practical Nurse (LPN) LPN AA revealed the resident has episodes of feeling sad.

Based on observations, staff interviews, record review, and review of the policy titled Falls Management, the facility failed to complete neuro checks for one resident (R) (R22) after a fall and failed to complete fall risk assessments for two residents (R22 and R20) of 22 sampled residents. These failures had the potential for residents to not receive treatment and/or care according to their needs and placed R22 and R20 at risk for adverse consequences. Findings include: A review of the facility's undated Falls Management policy revealed the following sections: Assessment After a fall, a head-to-toe assessment should be comprehensive in order to note any injuries. If an injury is noted, documentation should describe the injury clearly. Any complaint of pain should be noted. If no injuries note. Immediate intervention Nurses may have to choose short term interventions such as alarms, 30 min checks, keeping residents in sight, etc. until review by the Care Plan team. Fall Follow Up Subsequent documentation for the next 72 hours or longer if indicated. Comprehensive Falls Assessment To be completed in coordination with the MDS schedule (i.e. admission, quarterly, significant change, annually, and as clinically indicated). 1. A review of R22's quarterly Minimum Data Set (MDS) dated [DATE] revealed Section GG (Functional Abilities and Goals) documented upper and lower extremity impairment on one side and was mostly independent with mobility. Section I (Active Diagnoses) documented hypertension, diabetes mellitus, cerebrovascular accident, and hemiplegia. Section J (Health Conditions) documented one fall since admission or prior assessment. A review of the Incident/Accident Report documents in the medical record revealed that R22 experienced falls on 10/17/2023, 10/19/2023, and 2/4/2024. The Incident/Accident Report document dated 10/17/2023 documented Resident standing at Nurses Station with cane and fell on the floor and hit the front of head. Call resident by name no response noted, resident unresponsive for about 4 to 5 seconds. The form documented the resident was sent to the emergency room (ER). There was no documentation that neuro checks were performed. The Incident/Accident Report document dated 10/19/2023 documented Resident lost balance in dining room falling backwards hitting head on floor. The documentation stated the physician was notified and stated, assessment done. There was no documentation that neuro checks were performed. The Incident/Accident Report document dated 2/4/2024 documented Resident noted ambulating with no cane. Staff attempted to assist by guiding, resident refused assistance and pulled away leading to a fall. Review of the Fall Risk Assessment Book, revealed the last Fall Risk Assessment Form completed for R22 was dated 12/29/2022 and documented a score of 21. A score of 10 or more indicates a resident is at risk for falls. During an interview with the Director of Nursing (DON) on 3/23/2024 at 4:34 pm it was reported that neuro checks were not completed after R22's fall on 10/17/2023 because R22 was sent to the ER, and they did not order neuro checks upon her return. Interview on 3/24/2024 at 9:10 am interview with DON to review documentation of falls for R22. A review of the policy stating a comprehensive assessment was to be completed and DON reported that this consisted of looking at the resident from head to toe to make sure there were no injuries. She reported that the nurse did so, and she called the physician to see if anything else would be needed since R22 had fallen two days prior. The DON reported that when she spoke with the MDS Coordinator yesterday she reported that she does a fall assessment on admission and for quarterly assessments. Interview on 3/24/2024 at 9:34 am with the DON who reported that she had spoken with the MDS Coordinator again this morning and it was reported that she completed the fall portion of the MDS assessment. The DON confirmed that there were no neuro checks performed after R22's falls that occurred on 10/17/2023 or 10/19/2023 and there was not a Fall Risk Assessment completed for the quarterly MDS assessment dated [DATE]. 2. A review of R20's quarterly MDS dated [DATE] revealed Section GG (Functional Abilities and Goals) documented lower extremity impairment on both sides and was mostly dependent on staff for Activities of Daily Living (ADL). Section I (Active Diagnoses) documented hypertension, diabetes mellitus, and dementia. Section J (Health Conditions) documented no falls since admission or prior assessment. A review of a hospital discharge summary dated 3/15/2023 revealed that R20 was admitted to the hospital on 3/13/2023 and discharged to the facility on [DATE]. The Problem List included: 1. Fall, 2. Fracture of the left hip, 3. Acute pain due to trauma. The Discharge Diagnosis documented a left hip fracture. The Hospital Course documented the resident presented to the hospital after she rolled out of bed and was diagnosed with a left hip fracture. A review of the Fall Risk Assessment Book, revealed the last Fall Risk Assessment Form completed for R20 was dated 5/31/2022 with a score of 14. There was a second undated Fall Risk Assessment Form, also with a score of 14. A score of 10 or more indicates a resident at risk for falls. During an interview on 3/24/2024 at 9:41 am with Registered Nurse (RN) MDS Coordinator she confirmed that she had not completed a recent fall assessment for R20 or R22. RN MDS Coordinator reported that she was unsure if she had spoken with management about not completing the fall assessment for these residents but reported that she does review medications, mobility, and history of falls when assessing for falls, but she just did not do so on the form. It was further reported that the fall assessments are completed on admission and quarterly, but she did not document the fall assessments for R20 and R22.

Based on observations, resident interviews, and staff interviews, the facility failed to ensure one resident (R) (R26) of 22 sampled residents received a meal tray timely to prevent food from being cold. This deficient practice had the potential to cause R26 to have a decreased nutritional intake and the potential for weight loss. Findings include: A review of the Admission Minimum Data Set (MDS) dated [DATE] revealed R26 had a Brief Interview for Mental Status (BIMS) score of 13 (indicating intact cognition) and was dependent on all aspects of Activities of Daily Living (ADL) care, including eating. During an interview on 3/22/2024 at 10:50 am with R26 it was reported that the food was sometimes cold at breakfast, so she would ask for cereal. She said all the meals were cold and that every now and again the food was warm enough to eat. R26 reported that she does not feel that meals are served timely because sometimes lunch is served at 12:30 pm and other times at 1:00 pm. During an interview with R26 on 3/23/2024 at 8:08 am it was reported that her food was cold yesterday. She reported that her food does not tend to be hot enough when delivered to her. In an interview on 3/23/2024 at 8:29 am R26 confirmed that she told a Certified Nursing Assistant (CNA) that she did not want the breakfast served on this date and reported that she attempted to eat it, but it was not good. During an interview with the Dietary Manager on 3/23/2024 at 12:47 pm, she explained that the two carts sitting in front of the steam table were set up for residents who require assistance with their meals. She went on to report that the meals on this cart were not prepared until all the residents in the dining room had been served. It was reported that this was done to ensure the food was warm and not left sitting for long periods of time while staff assisted the residents in the dining room. R26's lunch meal tray was observed to be prepared and placed on the food cart on 3/23/2024 at 12:49 pm. The dietary staff continued to prepare the remainder of the meal trays for the residents in the dining room and once all were prepared, the cart was sent to the dining room at 12:53 pm. R26's lunch tray was observed being taken off the cart in the dining room and delivered to her room at 1:01 pm. R26 sent her lunch tray back to the kitchen at 1:06 pm to be warmed up. The dietary staff stated that R26 always sends her plate back to be warmed up, and the plate was put in the microwave to be warmed up and sent back to R26. An interview on 3/23/2024 at 1:07 pm with R26 revealed that the lunch food was not warm enough and the food seemed to have been sitting out for a while.

Based on observations, staff interviews, record review, and review of the facility policy titled Urinary Catheter Policy, the facility failed to ensure urinary catheter drainage bags were kept off the floor for two of five residents (R) (R19 and R26) with an indwelling urinary catheter. The failure had the potential to expose R19 and R26 to infections due to cross-contamination. Findings include: A review of an undated facility policy titled Urinary Catheter Policy, revealed there was no information about keeping the indwelling urinary catheter bag off the floor. 1. A review of R19's Quarterly Minimum Data (MDS) assessment dated [DATE] revealed Section GG (Functional Abilities and Goals) documented that R19 was dependent on staff for all Activities of Daily Living (ADLs). Section H (Bowel and Bladder) documented that R19 had an indwelling urinary catheter. Observations on 3/22/2024 at 10:36 am and 3/23/2024 at 8:55 am revealed R19's catheter bag lying directly on the floor. In an interview on 3/24/2024 at 11:41 am, Licensed Practical Nurse (LPN) BB revealed urinary catheter bags were supposed to be off the floor. Observation with LPN BB revealed that R19's catheter bag was noted to be in a dignity bag and was touching the floor. She confirmed the resident's bed was in the lowest position and the catheter bag and dignity bag were on the floor. 36200 2. A review of R26's Admission MDS dated [DATE] revealed Section GG (Functional Abilities and Goals) documented that R26 was dependent on staff for all ADLs. Section H (Bowel and Bladder) documented that R26 had an indwelling urinary catheter. Section I (Active Diagnoses) documented diagnoses including, but not limited to, neurogenic bladder, and a urinary tract infection in the last 30 days. During an observation on 3/22/2024 at 12:52 pm R26 was observed sitting in her geriatric chair in her room with her catheter bag on the floor. During an observation on 3/23/2024 at 8:08 am R26's catheter bag was observed lying on the base of the overbed table. During an observation on 3/23/2024 at 4:15 pm R26's catheter bag was observed lying on the floor. In an interview on 3/24/2024 at 11:33 am, Certified Nursing Assistant (CNA) CC, reported that she cares for R26 when on her rotation, and the catheter bag should be kept off the floor.

Based on observation, staff interview, record review, and review of facility policy titled, Lifting Policy, and Policy on Hoyer Lift, the facility failed to ensure safe transfer for one resident (R) (#1) of eight residents requiring transfer using the mechanical list. Actual harm was identified to have occurred on 4/18/23 when R#1 suffered a five-centimeter (cm) laceration to her forehead above her left eye and a skull fracture. Findings include: Review of the undated policy titled, Fall Prevention-Lifting Policy, revealed it is the policy of this facility that all lifting of residents be done with a minimum of two employees. Review of the undated policy titled, Policy on Hoyer Lift, revealed staff should ask a co-worker to help, one staff will guide the lift and the second staff will hold and support the resident as the lift moves. Record Review revealed R#1 was a [AGE] year-old female admitted on [DATE] from a hospital stay for cerebrovascular (CVA) with primary diagnoses that included dementia, sinus tachycardia, altered mental status, seizures, anemia, and Gastrostomy status. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed no Brief Interview of Mental Status (BIMS) score, indicating she was severely cognitively impaired, and rarely/never understood. R#1 required two-person total dependance with transfers. Section J-Health Conditions reported no falls, no pain, no pain medications received. Review of the care plan revealed R#1 at risk for falls related to diagnosis (dx) of dementia, impaired mobility, history (hx) of seizures, and hx of falls. Use the lift with at least two people at all times. Reviewed/revised on 4/18/23 related to fall on 4/18/23. Review of the Incident/Accident Report dated 4/18/23 at 10:50 a.m. documented, R#1 was in room ., Hoyer lift was in use at time of accident. Resident was being transferred via lift x 1 staff, CNA (Certified Nursing Assistant) FF from bed to Geri-chair during transfer resident toppled out of Hoyer lift pad onto floor causing laceration to left head above eye with active bleeding noted, pressure dressing applied. No signs of pain observed. Syncope for seconds but alert prior to exiting facility. The Physician and family were notified, and R#1 was sent out to the emergency room (ER) via emergency medical transport (EMT) ambulance. Review of facility inservice documentation revealed an inservice by the administrator was conducted on 4/18/23 instructing staff using the Hoyer lift that transfer was to be done by two nursing staff members. The lift is never to be used by one member, and make sure the resident is properly placed on the lift pad. Review of the Fall Investigation dated 4/18/23 at 10:50 a.m. revealed location (resident's room), injury from fall-skull fracture, environmental factors-fall from Hoyer lift during transfer. Interventions taken-staff re-educated on proper lift technique and the importance of having two staff present at all times during transfers and while using the Hoyer lift. Injury type-laceration and fracture. First aid treatment was rendered, and the resident was sent to hospital. Review of Physician Orders revealed to send R#1 to emergency room (ER) for evaluation-dated 4/18/23. Review of Hospital Discharge Instructions dated 4/20/23 revealed R#1 had an admitted d 4/18/23, procedures performed included computed tomography (CT scan) and X-rays, diagnosis this visit was laceration of head, dementia, and skull fracture. Review of the Readmission assessment dated [DATE] revealed R#1 returned to facility on 4/20/23 with the diagnoses, fall on 4/18/23 with frontal head skull fracture (fx). Resident noted with no changes neurologically and no changes in level of function. Review of Staffing Schedule for 4/18/23 revealed adequate staffing during the time of the accident. Observation on 4/24/23 at 10:15 a.m., 11:45 a.m., and 2:05 p.m. of R#1 lying in bed revealed a low bed with fall mat on both sides, and head of bed elevated with tube feeding infusing. R#1 observed with a wound with sutures on the left side of forehead from her nose up to above the left eye. Resident alert with no facial expressions of pain observed. Interview on 4/24/23 at 10:48 a.m. with CNA AA revealed she had worked here prn (as needed) for over a year, today she had approximately 12 residents, and confirmed that was manageable. She confirmed she had orientation/education/training when she started and confirmed they covered the Hoyer lift, they were instructed that you are supposed to always use two staff, and explained what each person would do. Both turn the resident side to side and put pad under, lift slowly, one will hold and guide the lift, and one hold the resident. Interview on 4/24/23 at 10:55 a.m. with CNA BB revealed she had worked here since 2017 and received education/training on CNA duties, confirmed they covered mechanical lift transfers, and taught that you should always use two staff for transfer with the lift. Telephone interview on 4/24/23 at 11:10 a.m. with Family of R#1 confirmed that R#1 was dropped from a lift during transfer and the CNA was working alone when the accident happened. She did not know the details, they notified her brother, and he informed her, and confirmed R#1 had a fractured skull because of it. She revealed R#1 was released from hospital and had returned to the facility. No additional information provided. During a telephone interview on 4/24/23 at 12:32 p.m. CNA FF (the CNA involved in the accident) revealed what happened to R#1. CNA FF was getting ready to put R#1 in her Geri-chair and was waiting for the other person to come help, and she went ahead and transferred the resident alone because the other CNA was on the other hall. She had been waiting about 30-40 minutes, and she (R#1) was scooting to the foot of the bed. She confirmed she did CNA training at the facility, she confirmed they trained her on the Hoyer lift, and she knew she was supposed to always have two people. She revealed R#1's head hit the floor and started bleeding right away. R#1 did not yell, cry out or make any noise. CNA FF yelled out for help, but she did not leave R#1. Someone came right away, she thought it was the charge nurse, they began checking her, wrapped her head, called paramedics and it did not take the ambulance very long to get there. Afterwards she was suspended and had not been back. CNA FF stated, I am just so very sorry it happened. CNA FF revealed R#1 was on a low bed, the pad was up under her all the way, and R#1 was scooting. She revealed she always made sure the pad was all the way under residents. She was transferring R#1 to the Geri-chair, it was right beside the bed. Interview on 4/24/23 at 2:00 p.m. with Licensed Practical Nurse (LPN) DD revealed she had worked here four years, confirmed staff had received education/training on using a mechanical lift, and they are supposed to always use two persons when transferring a resident in a lift. Interview on 4/24/23 at 2:15 p.m. with LPN EE revealed she had worked here almost two years, confirmed staff had education/training on using a mechanical lift, and they should always use two staff when transferring a resident in a lift. Interview on 4/24/23 at 4:00 p.m. with the Administrator confirmed R#1 had a fall with major injury related to the CNA transferred the resident alone. The resident was sent out and returned two days later with sutures and no other orders related to the head fracture. She revealed all staff were trained to use two-persons for transfer with the lift, staff had been inserviced before and after the accident. CNA FF is a newly certified nursing assistant. However, she knew she was supposed use two staff for transfer. The Administrator stated her expectation was that staff always use two people to transfer using a mechanical lift. They should follow policy, protocol and safety first when using any equipment.

Based on record review, review of the facility's policy Code Blue 911 Call, and staff interviews, the facility failed to activate Emergency Medical Services (EMS) and continue Cardio-Pulmonary Resuscitation (CPR) until more aggressive life sustaining treatment could be initiated for two residents (R#30 and R#232) of four residents reviewed for code status. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing Services (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 9:22 a.m. The noncompliance related to the IJ was identified to have existed on [DATE]. An Acceptable Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. Findings include: Review of the facility's undated policy Code Blue 911 Call, revealed: Intent: to ensure all Nursing staff is trained to recognize signs and symptoms of a clinical emergency. It is the policy of (the facility) for nursing staff to call a Code Blue immediately for any resident, who's unresponsive, and/or pulseless. Nurses initiate the Code Blue and immediately render aide after checking the code status of the resident until the paramedics arrive. The crash cart is located at the nurse's station and checked nightly by licensed staff for necessary supplies. The phone call to 911 by the person in charge should provide as much details as possible and be initiated by assigned staff while the licensed staff is rendering aide. Once aide has been initiated it cannot be stopped until EMT's are on the scene and take over. The person in charge at the time of the emergency has the authority to initiate a 911 emergency call. Resident and/or their families are encouraged to not call 911 for emergencies occurring in the facility without conferring with nursing staff. The Administrator has the authority to call a Code Blue if there is an identified danger to residents or staff. The Administrator /person in charge will meet and guide law enforcement officers if possible, and appropriate. The Medical Director is informed of all Code Blue calls as soon as possible. An all clear is announced overhead when the danger has been addressed and the scene is safe. 1. Closed record review revealed R#30 was admitted to the facility on [DATE] with diagnoses including but not limited to bipolar disorder, Parkinson disease, and anxiety. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of the care plan dated [DATE] revealed R#30 was a Full Code and that all life sustaining measures were to be done with an intervention for nursing staff to honor request for Full Code. Resident #30 had a Physician's Order dated [DATE] to attempt resuscitation in the event she had no pulse and was not breathing. Review of the Nurse's Progress Note dated [DATE] at 5:20 a.m. revealed R#30 was found not arousable by touch or verbal stimuli, with fixed eyes and no apical pulse, cool to touch with no movement noted. Licensed Practical Nurse (LPN) AA notified the Administrator at 5:25 a.m. Continued review revealed that Registered Nurse (RN) HH pronounced R#30 deceased at 5:55 a.m. There was no documentation that the facility staff provided CPR or contacted EMS, and there was no documentation indicating that the physician was notified. Interview with Certified Nursing Assistant (CNA) LL on [DATE] at 3:26 p.m. revealed she is familiar with R#30 and her care. CNA LL stated R#30 rang the call bell around 4:00 a.m. (on [DATE]) to provide ADL (activities of daily living) care to her. She stated R#30 transferred herself to the toilet and was sitting on the toilet when she arrived at the room. CNA LL stated she cleaned her up and left the room. She stated the nightshift LPN AA called another CNA KK down to R#30's room. She stated that nurses usually round 30 minutes to an hour after CNA rounds. CNA LL went to the room and LPN AA stated she thinks R#30 was gone. CNA LL went to get the crash cart and LPN AA and CNA KK stayed in the room. CNA LL stated LPN AA started doing CPR. CNA LL stated that she took R#30's roommate out of the room so that she would not see what was going on. She stated that when she left the room LPN AA was still in the room. CNA LL stated that LPN AA stopped CPR and went to the nurse's station to make calls to the doctor and to the administrator. CNA LL stated that the administrator owns the place. CNA LL stated she went back to the room about 30 minutes later to clean R#30 up. CNA LL stated that she did not see EMS come into the building. She stated the DON came in around the time that she took R#30's roommate to the dining room. Telephone interview with LPN AA on [DATE] at 11:14 a.m. revealed she noticed that R#30 appeared limp. She stated that she tried to arouse her with a deep sternal rub. LPN AA stated she started CPR and called for CNA LL to bring the crash cart. She stated that she started CPR before the crash cart arrived at the room. She stated when the crash cart arrived at the room, she repositioned R#30 to her back, placed the back board under her back and continued CPR. LPN AA stated that she was doing compressions and gave her a few breaths by using a mouthpiece that she happened to have on her. LPN AA stated that CNA LL called the Administrator, and that she (LPN AA) also called the Administrator. LPN AA stated that the Administrator called RN HH. LPN AA stated that no one called 911. LPN AA stated that she should have called 911 but she didn't. Review of Basic Life Support (BLS) certificate dated [DATE] revealed that LPN AA had successfully completed the cognitive and skills evaluations accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) program. Continued review revealed that the recommended renewal date was [DATE]. Interview with the DON on [DATE] at 10:48 a.m. revealed R#30 was cognitively intact, fed herself, and ambulated with a rollator. She stated that R#30 did not voice any pain. DON also stated there was no change or decline in R#30's condition to her knowledge prior to her death. DON further stated that she was not at the facility at the time of R#30's death. Continued interview with DON revealed for Full Code residents the process is if you enter a resident's room and they have no vital signs, you must check vital signs, breath sounds and if absent start CPR if there are no signs of life. DON read nurses notes dated [DATE] at 5:20 a.m. and stated that CPR should have been started. DON stated that there is no documentation that CPR was started so she could not be sure if CPR was started. Interview with Administrator on [DATE] at 11:33 a.m. revealed the nurse (LPN AA) called her that night from her cell phone from the resident's room and told her that she thought that R#30 was gone because she could not get a pulse. Telephone interview with the Medical Director (MD) on [DATE] at 12:06 p.m. revealed he was coming into the facility to see another patient when RN HH was coming out and informed him that she had pronounced R#30 deceased . He stated that he thought that R#30 was a DNR (Do Not Resuscitate). He stated that he walked into the facility as RN HH was leaving. MD stated that the protocol for a Full Code is to call 911 and start CPR. He stated that he assumed that R#30 was a DNR when RN HH was informing him that she had pronounced the resident. MD stated by nature with a Full Code, CPR should have been started. MD stated on admission R#30 had some skin breakdown that got better. He also stated that there were no substantial events going on or any substantial health risk. MD stated that he would suspect that R#30 had cardiac arrest. Further interview with MD at the facility on [DATE] at 1:06 p.m. revealed there have been problems with EMS not coming to the facility because they only have a limited number of trucks. He stated that the facility should have made another call to EMS to inform them that R#30 had coded, and the nurses had initiated CPR. He stated that he was under the impression that they called EMS and told them that she had arrested. He stated the protocol once CPR is started is that you should not stop until EMS arrives. He stated that he knew they had problems relating to the response time from EMS, but it's not that often but it has happened before. MD stated that nurses should know the residents code status prior to initiating CPR. He stated code status is supposed to be on each resident's chart, and on the Medication Administration Record (MAR). Interview with RN HH on [DATE] at 10:47 a.m. revealed she did not attempt CPR when she came in because of the time lapse. She stated that when she got there, R#30's lips were already blue. RN HH stated LPN AA opened the front door for her when she arrived, and that CPR was not in progress when she entered the room. She stated that she and LPN AA went to R#30's room, and she checked her blood pressure and checked her eyes. RN HH stated she pinched R#30's nipples with no response. She stated that LPN AA had the blood pressure cuff, and she was checking again with her to double check for a blood pressure. RN HH stated she did not know R#30 was a Full Code until after she pronounced her when she went back to the desk and looked at the chart. She stated that she was just coming in to pronounce R#30. RN HH stated the process for an unresponsive resident is to call them and shake them to see if they are breathing and if they are not breathing with no pulse or respirations, start CPR and ask someone to call 911. RN HH stated that you do not stop CPR until the doctor tells you to stop CPR or until EMS arrives. RN HH stated that when she arrived there was no CPR going on. RN HH again stated that when she arrived at the facility LPN AA was not doing CPR. She stated that she did not ask LPN AA why she was not doing CPR because she automatically assumed that R#30 was a DNR. RN HH stated that after she went to the desk and found out that R#30 was a Full Code she had already pronounced her. RN HH stated that as she was leaving the building, the MD was coming into the building. She stated she told the MD that R#30 had died . She stated that she did not tell MD that R#30 was a Full Code because they did not get into an in-depth conversation. RN HH stated she talked to LPN AA after she pronounced R#30 and told her that if residents are a Full Code, you must do CPR and call 911. 2. Review of the medical record revealed R#232 was admitted to the facility on [DATE] with diagnoses including but not limited to hypertension, anemia of chronic disease, encephalopathy, and end stage renal disease. Resident #232 had a care plan last revised [DATE] to honor request for Full Code. Review of the [DATE] Physician Orders revealed R#232 was a Full Code. Record review revealed on [DATE] at 1:40 p.m., R#232 had a change of condition. RN BB started CPR at 1:41 p.m. and continued until 1:58 p.m. when she stopped CPR and pronounced the resident deceased . Interview with CNA LL on [DATE] at 3:26 p.m. revealed she remembered R#232. She stated R#232 was in the dining room between 12:00 p.m. and 1:00 p.m. around lunch time, and she was not responding. CNA LL stated she and LPN assisted R#232 back to bed. She stated if she finds a resident unresponsive, she will try and get them to come around. She stated if they don't come around, she will press the button for the nurse. Interview with LPN CC on [DATE] at 5:00 p.m. revealed around 7:30 a.m. (on [DATE]), R#232 was not looking like herself. She got her vital signs and called the doctor. LPN CC stated the doctor ordered labs, and the DON obtained the labs. She stated around lunchtime R#232 was down the hallway in her Geri-chair. A CNA reported that something was wrong with R#232. Resident #232 became limp, so they assisted her to the bed. She stated the DON assessed her and found no pulse, and the DON initiated CPR. LPN CC stated the DON could not revive her so the DON called MD and reported to him that R#232 was not responding and CPR was initiated, and she could not be revived. LPN CC stated that she helped put R#232 in bed, and the DON did compressions. She stated that she had the Ambu bag, and she put it on R#232 mouth as the DON did compressions. LPN CC stated she is not CPR certified. She stated she was CPR certified, but it expired during COVID. She stated she did not see EMS in the facility, and she did not see EMS in R#232's room. Interview with the Administrator on [DATE] at 9:23 a.m. revealed the EMS came to the facility on [DATE]. Administrator stated she remembers EMS coming into the facility because she opened the door for them. Further interview with the Administrator on [DATE] at 10:32 a.m. revealed she spoke to the police chief who reported that RN BB called 911 and then she called back to cancel 911. Administrator stated that RN BB cancelled 911 because R#232 was dead. Administrator further stated that RN BB pronounced R#232 because she is an RN, and she can pronounce. Telephone interview with RN BB (former DON) on [DATE] at 9:57 a.m. revealed she cannot remember who called EMS. She stated she does not remember calling EMS. She stated from 1:41 p.m. to 1:58 p.m. she was doing CPR. RN BB stated she does not remember who was in the room with her, maybe LPN CC. She stated that EMS did not enter the building. She stated this is a small town with only two trucks. She stated that she is not sure if EMS came or not. RN BB stated that she did not see EMS in the facility. She stated she called the code and started CPR and pronounced R#232 after 17 minutes because there were no signs of life. RN BB stated that she called the doctor at 1:43 p.m. and told him that they were getting ready to send R#232 to the hospital. She stated she was continuing with CPR at the time that she called the doctor. RN BB stated she then called the doctor at 2:03 p.m. to let him know that R#232 had died . She stated she and LPN CC swapped out doing compressions and breath with the Ambu bag. Further interview with RN BB on [DATE] at 1:23 p.m. revealed she really did not remember specifically if she cancelled the call to EMS. She stated that she is the one that is always in the room making sure that everything is getting done. She stated once you start CPR you should continue until EMS arrives. Interview with EMS Director (ED) on [DATE] at 9:22 a.m. revealed that, according to the dispatch report, a call was made from the facility at 1:43 p.m. He stated the remark was room [ROOM NUMBER] elderly female labored breathing, patient needs to go to the emergency room for evaluation. ED stated that per the dispatch report, RN BB called at 1:59 p.m. and cancelled the call. Surveyor informed ED that per RN BB she was in an active code. ED stated that the facility did not inform EMS that they were in an active code. He stated that a truck would have been sent out. Nursing staff failed to continue CPR without interruption until relieved by EMS for R#232 who was Full Code. The facility implemented the following actions to remove the IJ: 1. On [DATE] at 5:20 am Resident #30 was not arousable by touch or verbal stimuli with fixed eyes and no apical pulse, cool to touch. EMT's (Emergency Medical Technicians) were not called. Relief RN pronounced dead. Resident was a full code. 2. Resident #232 on 10//,d+[DATE] had a change in condition. CPR was stopped before EMT's came. 3. On [DATE] the Director of Nursing posted a list of code status to identify full code vs DNR at nursing station for nursing employees only. On [DATE] the Director of Nursing and Education Nurse in-serviced certified nursing assistant of code status list for easy access. Each chart has a label identifying code status. 100% of licensed nurses and certified nursing assistant, which include 3 of 3 RN, 7 of 7 LPN and 11 of 11 Certified Nursing Assistants received the information. 4. On [DATE] at 10:38 am the Director of Nursing updated the Code Blue Policy, New Code Blue Evaluation Form and New AEP Policy completed and approved. Any licensed nurse or certified nursing assistant (including agency staff) not receiving code status education will be in-serviced prior to next shift. New hire nurses and certified nursing assistant will be educated on first orientation. 5. On [DATE] at 10:51 am the Director of Nursing, MDS Nurse, Relief RN and Education Nurse started immediate mandatory in-service for nurses 7am - 3pm nurses and CNA. The in-service included revised Code Blue Policy, New Code Blue Education Form and new AED Policy. The use of AED and scenarios were presented. The focal point being on a full code, immediately start CPR on full code resident do not stop until 'EMT take over.' Chart the name of person calling 911 and notification of physician. 3 of 3 RN, 7 of 7 LPN and 11 of 11 Certified Nursing Assistants received the information. 6. During admission, readmission, significant change, per resident/responsible party request and quarterly care plan meeting, The DON and MDS Nurse will review advanced directive plan of care for any changes to the resident advanced directive care plan. If any changes, the MDS Nurse will update the advanced directive care plan after DNR/POLST forms are validated and received. 7. On [DATE] Mortality Review Audit form for completion following any resident death. This form is used to audit the code status, care plans and easy access list prior to death. 8. On [DATE] the Director of Nursing reviewed the Code Blue Policy, Code Blue Evaluation Tool, AED Policy, and education provided to nurses, CNA's and Administrator. The Administrator will conduct a daily audit for deaths, code status, CPR, and mortality review. A Quality Assurance Improvement meeting will be held on Sunday, [DATE], to review immediate jeopardy 9. All corrective actions will be completed [DATE]. 10. The immediate jeopardy will be removed on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Record review revealed on [DATE] at 5:20 a.m., R#30 required CPR and was a full code status. LPN AA discontinued CPR and did not call EMS. Interviews DON and Administrator confirmed that EMS was not contacted. The resident expired in the facility on [DATE]. 2. Record review revealed on [DATE] at 1:40 p.m., R#232 had a change of condition. RN BB started CPR at 1:41 p.m. and continued until 1:58 p.m. when she stopped CPR and pronounced the resident deceased . Interview with LPN CC on [DATE] at 5:00 p.m. revealed there were no emergency personnel in the room at any time. The resident expired in the facility on [DATE]. 3. Review of the document titled Code Status dated [DATE] revealed the census in the building is 31. [NAME]-one residents were identified on the Code Status form: Four DNR and 27 Full Code. On [DATE] at 8:05 a.m. observation of the nursing station revealed no posting of the Code Status form. However, during an interview on [DATE] at 8:09 a.m., the Administrator stated they decided to put the posting at each medication cart in the MAR instead of at the nursing station. On [DATE] at 8:12 a.m., LPN CC was able to show the surveyor the MAR where the code status was posted. She stated that she received education on where to find the code status. At 8:13 a.m. LPN DD was interviewed, and she stated that she created the code list and placed it on each medication cart. She also created a reference book that she gave to the Administrator and that is placed at the nursing station. Observation on [DATE] at 8:47 a.m. revealed each of the 31 residents' charts have code status sticker on the chart. Review of facility in-service record dated [DATE] revealed 3 RN's, 7 LPN's, and 11 CNA's received education on where to locate the code status for each resident. Also verified the above education via the following staff interviews on [DATE] from 9:00 a.m. through 1:00 p.m. with LPN AA, LPN CC, LPN DD, LPN II, LPN JJ, RN HH, CNA EE, CNA FF, CNA GG, CNA KK, CNA LL, CNA MM, CNA NN, and CNA OO, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 4. Review of the Code Blue Policy, Code Blue Evaluation Form and AED and Policy and Procedure dated [DATE] revealed the policies were updated by the DON and reviewed/signed by the MD. 5. Review of facility in-service record dated [DATE] revealed 3 RN's, 7 LPN's, and 11 CNA's received education on Code Blue Policy, Code Blue Evaluation Form and AED and Policy and Procedure. Also verified the above education via the following staff interviews on [DATE] from 8:00 a.m. through 1:00 p.m. with LPN AA, LPN CC, LPN DD, LPN II, LPN JJ, RN HH, CNA EE, CNA FF, CNA GG, CNA KK, CNA LL, CNA MM, CNA NN, and CNA OO, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. Interviews with nursing staff revealed the procedure when responding to an unresponsive resident is to check the resident first, check the code status, initiate CPR if the resident is a full code, designate someone to call 911 and document, continue CPR until EMS arrives and takes over the code. 6. There were no required assessments for new admissions, readmissions, significant changes, or quarterly care plan meetings for [DATE] and [DATE]. The was confirmed by interview with the MDS/Care Plan Coordinator on [DATE] at 11:19 a.m. 7. Review of the Mortality Review Audit Tool revealed the form was developed and will review each death, code status, CPR, EMS contact and reviewer initials. This was confirmed by interview with the Administrator on [DATE] at 8:09 a.m. 8. Review of the QAPI Meeting Minutes dated [DATE] signed by the Medical Director, Administrator, DON, Office Manager, Education Nurse, Activities Director, MDS Nurse and Social Services revealed specific topics to include review of Administrator and DON job descriptions, code blue policy changes approved by the MD, licensed nursing staff in-services, quick location of code status and the removal of the immediate jeopardy. This was confirmed by interview with the Administrator on [DATE] at 8:20 a.m. Review of the Mortality Review Audit Tool dated [DATE] through [DATE] revealed no deaths. 9. All corrective actions will be completed [DATE]. 10. The immediate jeopardy will be removed on [DATE].

Based on record review, staff interviews and review of the Administrator and Director of Nursing Job Description, Administration failed to ensure that staff were following appropriate procedure when providing Cardiopulmonary Resuscitation (CPR) for two residents (R) (R#30 and R#232) of four residents reviewed for code status. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing Services (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 9:22 a.m. The noncompliance related to the IJ was identified to have existed on [DATE]. An Acceptable Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. Findings include: The facility had a Job Description for the job title of Administrator. The description included that the Administrator is responsible for the overall effective operation of the company. Initially the Administrator will be actively involved in the day to day operations. As the organization matures, however, the Administrator will delegate responsibilities to others to provide for continued effective operation. Positions reporting to the Administrator include: a) Director of Nursing. The facility had a Job Description for the job title of Director of Nursing. The description included that the Director of Nursing is responsible to plan, organize and direct the nursing activities of Smith Medical Nursing Care Center. The Director of Nursing will ensure that the quality of service meets the nursing needs of the resident and is in compliance with all applicable state and federal regulatory agencies. The facility failed to provide effective oversight and monitoring of facility procedures related to Full Code residents requiring CPR. The facility provided an undated Code Blue 911 Call policy. The policy intent: to ensure all nursing staff is trained to recognize signs and symptoms of a clinical emergency. It is the policy of (the facility) for nursing staff to call a Code Blue immediately for any resident, who's unresponsive, and/or pulseless. Nurses initiate the Code Blue and immediately render aide after checking the code status of the resident until the paramedics arrive. The crash cart is located at the Nurse's Station and checked nightly by licensed staff for necessary supplies. The phone call to 911 by the person in charge should provide as much details as possible. Be initiated by assigned staff while the Licensed staff is rendering aide. Once aide has been initiated it cannot be stopped until EMT's are on the scene and take over. The person in charge at the time of the emergency has the authority to initiate a 911 emergency call. Resident and/or their families are encouraged to not call 911 for emergencies occurring in the facility without conferring with nursing staff. The Administrator has the authority to call a Code Blue if there is an identified danger to residents or staff. The Administrator /Person in charge will meet and guide law enforcement officers if possible, and appropriate. The Medical Director is informed of all Code Blue calls as soon as possible. An all clear is announced overhead when the danger has been addressed and the scene is safe. 1. Resident #30 had a Physician's Order dated [DATE] to attempt resuscitation in the event she had no pulse and was not breathing. Review of the Nurse's Progress Note dated [DATE] at 5:20 a.m. revealed R#30 was found not arousable by touch or verbal stimuli, with fixed eyes and no apical pulse, cool to touch with no movement noted. Licensed Practical Nurse (LPN) AA notified the Administrator at 5:25 a.m. Continued review revealed that Registered Nurse (RN) HH pronounced R#30 deceased at 5:55 a.m. There was no documentation that the facility staff provided CPR or contacted Emergency Medical Services (EMS), and there was no documentation indicating that the physician was notified. 2. Review of the medical record revealed R#232 was admitted to the facility on [DATE]. Review of the [DATE] Physician Orders revealed R#232 was a Full Code. Record review revealed on [DATE] at 1:40 p.m., R#232 had a change of condition. RN BB started CPR at 1:41 p.m. and continued until 1:58 p.m. when she stopped CPR and pronounced the resident deceased . Post survey interview with the DON on [DATE] at 3:00 p.m. revealed she started working at the facility on [DATE]. She stated she was not made aware of the incident occurring [DATE] until during the survey. She stated there was not a process in place at that time to ensure that she be notified of any such incident as for R#30 when staff failed to continue CPR until EMS arrived. DON revealed her expectation is for staff to initiate CPR, when required, ensure EMS is contacted and arrives to transport to the hospital, and to document. Post survey interview with the Administrator on [DATE] at 3:09 p.m. revealed that she was at the facility for the incident on [DATE] and was contacted by phone for the incident on [DATE] related to resident's requiring CPR. The Administrator stated staff call her for all incidents with the residents. She stated she believed the breakdown was nursing staff becoming too comfortable with pronouncing residents. She believed the nurse felt that there was no sign of life and therefore did not continue to do CPR, but that the nurses did not document to reflect that. Cross refer to F678. The facility implemented the following actions to remove the IJ: 1. All charts, 31 of 31 residents, reviewed by Education Nurse and Director of Nursing for code status on [DATE]. 2. All nursing staff in-serviced by Director of Nursing on new code blue policy [DATE], which included 3 of 3 RN: 7 of 7 LPN and 11 of 11 Certified Nursing Assistants. 3. A mandatory QA meeting called on [DATE] at 1:00 pm, with Medical Director, MDS Nurse, DON, Dietary supervisor, Education Nurse, Activity Director, Social Services, and Office Manager were in attendance. Updated Code Blue Policy implemented after approval by QA Committee on [DATE]. 4. On [DATE] The Director of Nursing reviewed the Code Blue Policy, Code Blue Evaluation Tools, AED Policy, and Education provided to licensed nursing staff. 5. Administrator and Director of Nursing job description were reviewed by the QA Team. 6. On [DATE] a Mortality Review Audit form implemented for completion following any death, code status, care plan updated, and easy access list prior to death. 7. The Administrator will conduct daily audits of deaths, code statues, CPR and mortality review. During admission, readmission, significant change per resident/responsible party request and quarterly care plan meeting. The DON and MDS Nurse will review advance directive plan of care for any changes to the resident advance directive care plan. If any changes, the MDS Nurse will update the advance directive care plan after DNR, POLST form are validated and received. 8. All corrective actions will be completed [DATE]. 9. The immediate jeopardy will be removed on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. All 31 residents code status documentation was reviewed for accuracy: 27 full code and four DNR. Advanced Directive Checklist dated [DATE] reviewed, all charts checked. 2. Review of facility in-service record dated [DATE] revealed 3 RN's, 7 LPN's, and 11 CNA's received education on Code Blue Policy, Code Blue Evaluation Form and AED and Policy and Procedure. Also verified the above education via the following staff interviews on [DATE] from 8:00 a.m. through 1:00 p.m. with LPN AA, LPN CC, LPN DD, LPN II, LPN JJ, RN HH, CNA EE, CNA FF, CNA GG, CNA KK, CNA LL, CNA MM, CNA NN, and CNA OO, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. Interviews with nursing staff revealed the procedure when responding to an unresponsive resident is to check the resident first, check the code status, initiate CPR if the resident is a full code, designate someone to call 911 and document, continue CPR until EMS arrives and takes over the code. 3. Review of the QAPI Meeting Minutes dated [DATE] signed by the Medical Director, Administrator, DON, Office Manager, Education Nurse, Activities Director, and Social Services revealed specific topics to include review of Administrator and DON job descriptions, code blue policy changes approved by the MD, licensed nursing staff in-services, quick location of code status and the removal of the immediate jeopardy. This was confirmed by interview with the Administrator on [DATE] at 8:20 a.m. 4. Review of the Code Blue Policy, Code Blue Evaluation Form and AED and Policy and Procedure dated [DATE] revealed the policies were updated by the DON and reviewed/signed by the MD. Staff were educated as listed above. 5. Administrator and Director of Nursing job description were dated as being reviewed by the QA (Quality Assurance) Team on [DATE]. This was confirmed by interview with the Administrator on [DATE] at 8:15 a.m. 6. Review of the Mortality Review Audit Tool revealed the form was developed and will review each death, code status, CPR, EMS contact and reviewer initials. This was confirmed by interview with the Administrator on [DATE] at 8:09 a.m. 7. Review of the Mortality Review Audit Tool dated [DATE] through [DATE] revealed no deaths. There were no required assessments for new admissions, readmissions, significant changes, or quarterly care plan meetings for [DATE] and [DATE]. Interview with the MDS/ Care Plan Coordinator on [DATE] at 11:19 a.m. revealed she was educated on her responsibility to monitor and update for all changes in the resident's advanced directive plan of care, and when to provide CPR. 8. All corrective actions will be completed [DATE]. 9. The immediate jeopardy will be removed on [DATE].

Based on observation and staff interviews, the facility failed to maintain a clean and sanitary kitchen and failed to ensure all opened items in the reach in cooler and reach in freezer was labeled with an open dated and labeled with a used by date. The deficient practice had the potential to affect 29 of 31 residents receiving an oral diet. Findings include: Initial kitchen observation on 1/27/2023 at 9:00 a.m. revealed upon entry to the kitchen new flooring was in the process of being installed. There were several areas with missing tiles, while other areas had new tiles installed. There was a straight back chair near the hot water heater that was located at entrance of the kitchen. There was a blue tray sitting on the chair with a coffee pot on it. The gas stove was observed with food on the top and inside the stove grates. Pipes between fryer were observed with particles. Reach in freezer observed to have several unlabeled undated food items. DM stated that she did not know what some of the items were and she stated that she could not read the dates on a plastic bag that she identified as meat. The reach in cooler had old plastic wrap stuck to the inside bottom, old broccoli, old bread, and various stains and debris. A bowl with a sticker labeled oatmeal with dates of 1/20/2023-1/21/2023, a bowl labeled pimento with dates of 1/18/2023-1/21/2023, a second bowl labeled pimentos with dates 1/17/2023-1/20/2023, a container labeled applesauce with a date of 1/26/2023, a plastic container with labels dated 1/21/2023-1/24/2023 and 1/9/2023-1/12/2023. In the pantry and dry food storage area, there was a rag mop head on the shelf next to unbagged Styrofoam plates, a rotten onion next to a can of mixed vegetables, a dustpan with trash inside on the floor next to a shelf with canned foods, and containers of condiments, a bag of onions on the floor, a dirty blue chair in front of a shelf with cake mix and potatoes, and an opened unlabeled bag of noodles. Observation of ice machine revealed outside of ice machine noted with dust, however the inside of the ice machine was noted with no dirt or grime build up. DM confirmed all items viewed in the reach in cooler and the reach in freezer. DM stated that she is responsible for making sure that all food items are labeled and dated once they are opened. Observation of the floor surrounding the fryer on 1/27/2023 at 9:10 a.m. revealed a white debris and build-up on the floors, walls, and equipment. Hand washing sink observed with the cold-water handle rusted and corroded. Wall above the hand washing sink noted with chipped paint. Observation confirmed by DM at time of observation. Interview with DM on 1/27/2023 at 9:25 a.m. revealed that she has been working at the facility for five years as the dietary manager and that she received her certification on 10/26/2021. Interview with the Administrator on 1/31/2023 at 3:02 p.m. revealed they have been doing work on the floors in the kitchen and that's where a lot of the dust came from. She stated that her expectation is that dietary staff ensure all opened food items in the reach in cooler and the reach in refrigerator are dated and labeled once open.

Based on staff interviews and review of the facility policy titled, Infection Prevention and Control Program, the facility failed to have a qualified Infection Preventionist who had completed the required specialized training in infection prevention and control. This failure placed all residents at risk for the potential transmission of infections and communicable diseases. The facility census was 31 residents. Findings include: Review of the facility's undated policy, Infection Prevention and Control Program revealed the Infection Prevention and Control Program will include the following elements: A designated individual as the Infection Preventionist (IP) who is responsible for the center's Infection Prevention and Control Program. Designated Infection Preventionist will be a member of the center QAPI (Quality Assurance and Performance Improvement) committee and report on Infection Prevention and Control Program on a regular basis. During an interview on 1/29/2023 at 4:11 p.m. with the Director of Nursing (DON) revealed that the previous DON/IP for the facility quit in October 2022. She stated that she has not received any specialized training for Infection Control. The Administrator informed her that she was responsible for Infection Control practices for the facility. DON revealed there is currently not anyone employed at the facility certified as an IP. During an interview on 1/30/2023 at 1:12 p.m. with the Administrator confirmed there was not a certified IP in the facility since October 2022 when the previous DON resigned. Administrator verified that the current DON serves as the IP and is responsible for infection control in the facility, but she is not certified.

Based on clinical record review, review of the facility's Falls Management policy, and staff interview, it was determined that the facility failed to evaluate the effectiveness of current interventions to prevent falls and failed to revise the FIP (Fall Intervention Plan) to include new interventions to prevent falls for one resident (R) (#1) of three residents reviewed for falls. This failure resulted in actual harm when R#1 sustained facial fractures after a fall on [DATE]. Findings include: Review of the undated facility policy titled Falls Management revealed that the goal of an intervention may not always be to prevent falls (but), to prevent injury .(Staff) should determine the cause of the fall and decide how a similar fall could be prevented for the resident (Staff) should update the FIP (Falls Intervention Plan) immediately and the date the intervention was put into place .At a minimum, the FIP will be reviewed with the MDS schedule and subsequent care plan review .A change in FIP should also trigger a note to explain reason for change (i.e , intervention no longer needed, intervention not working and why, etc.) .All falls should be reviewed daily by reviewing the medical chart to ensure that a new intervention was added to the FIP, evidence that an appropriate intervention was put into place to prevent further falls and the FIP updated. R#1 (a closed record) was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a medical decline and was admitted to Hospice Services on [DATE] for severe dementia. R#1 expired on [DATE]. Review of the Quarterly Minimum Data Set (MDS) for R#1 dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 3 indicating that he had severe cognitive impairment. R#1 had a care plan dated [DATE] for falls related to the use of [MEDICAL CONDITION] medication with the following interventions for nursing staff: Provide safe, clutter free environment; call light within reach with prompt response to all requests; ensure resident wears appropriate well-fitting foot wear to minimize the risk of slipping; safety training and education as needed; and prompt to ask for assistance. R#1 had a fall on [DATE] at 3:30 p.m. Staff encouraged R#1 to call for assistance and wait until he was assisted. The FIP revealed that staff initiated an intervention on [DATE] for staff to ensure that the resident's call light was in reach and consider his cognition. There was no evidence that staff evaluated the appropriateness of the intervention with respect to his impaired cognition. R#1 had a fall on [DATE] at 6:10 p.m. The Incident/Accident Report for this fall dated [DATE] revealed that licensed nursing staff documented that steps taken to prevent further occurrence of falls was to send the resident to the ER. There was no indication that staff evaluated the appropriateness of the intervention (send to the ER) or updated the resident's FIP with an appropriate new intervention to prevent further falls with injuries. R#1 had a fall on [DATE] at 4:00 p.m. The Nurses Notes for [DATE] revealed steps taken to prevent recurrence was to keep the resident's call light in reach and consider his cognition. Nursing staff updated the resident's FIP with an intervention dated [DATE] for staff to educate the resident on how to use the call light and to consider his cognition. There was no indication that nursing staff evaluated the appropriateness of the [DATE] intervention to prevent further falls based on the resident's impaired cognition. R#1 had a fall on [DATE] at 6:10 a.m. The Incident/Accident Report for the fall dated [DATE] revealed that there was no indication that nursing staff updated the FIP with appropriate interventions to prevent further falls with injuries. Review of the Significant Change MDS assessment dated [DATE] revealed that R#1 had a BIMS of 99, indicating severe cognitive impairment. Review of his care plan dated [DATE] and reviewed [DATE], [DATE] and [DATE] revealed the same interventions as his [DATE] care plan with the addition of an intervention for two staff to transfer the resident. R#1 had a fall on [DATE] at 5:50 p.m. The Incident/Accident Report for the fall dated [DATE] revealed that steps taken to prevent further recurrence were to monitor the resident frequently and encourage him to wait for assistance as needed. The FIP was updated on [DATE] with an intervention for staff to keep the call light in reach and consider the resident's cognition. There was no indication that nursing staff evaluated the appropriateness of the interventions or considered the resident's severe cognitive impairment. R#1 had a fall on [DATE] at 9:00 a.m. The Incident/Accident Report dated [DATE] revealed that steps taken to prevent recurrence was to recline the resident's Geri-chair. There was no indication that staff updated the resident's FIP to include the use of the Geri-chair or to keep it reclined. R#1 had a fall on [DATE] at 9:55 a.m. The physician ordered staff to place a tray on the resident's Geri-chair for safety. The FIP was updated to include the intervention of the tray but, there was no date documented as to its initiation. review of the resident's medical record revealed [REDACTED]. However, staff failed to update the FIP to indicate that the tray was discontinued. R#1 had a fall on [DATE] at 3:50 p.m. and sustained acute traumatic fractures of the left maxillary wall and left lateral orbital wall. The Incident/Accident Report for the fall dated [DATE] revealed that the steps taken to prevent recurrence was to monitor the resident closely. However, there was no indication as to the frequency of the monitoring (i.e., every 15 minutes, every 30 minutes, etc.). On [DATE], the physician ordered staff to place a floor mat next to the resident's bed. However, the FIP was not updated to include the fall mat. During an interview on [DATE] at 12:59 p.m., LPN AA stated that the nurse who completes the Incident/Accident Report is responsible for documenting a new intervention on the FIP. Further interview revealed that she notifies the on-coming nurse about the fall and the new intervention. Interview with the Director of Nursing (DON) on [DATE] at 3:46 p.m. revealed that the nurse was responsible for completing the Incident/Accident report after each fall and documenting an appropriate intervention to address the fall. Continued interview revealed that incidences that occurred the previous 24 hours including falls were discussed in the morning meeting. Staff determined the cause of a fall if possible and ensured that interventions were in place as care planned. The DON stated that she reviewed the Incident/Accident Report to ensure that any new interventions were appropriate. On [DATE] at 1:43 p.m., the DON reviewed the falls for R#1. She confirmed at that time that the intervention to keep the call light within reach and encourage the resident to use his call light and wait for staff to assist him was inappropriate based on his cognitive impairment for the falls on [DATE], [DATE] and [DATE]. Continued interview revealed that staff did not attempt to initiate a fall mat as an intervention on [DATE], [DATE] or [DATE] as a means to prevent injuries until after his [DATE] fall with major injury (facial fracture). Further interview revealed that the tray for the Geri-chair was discontinued on [DATE] and staff removed the tray without updating the care plan. Cross Refer to F689.

Based on record review, review of the facility's Falls Management policy, and staff interview, the facility failed to determine the root cause of each fall and implement appropriate interventions to prevent further falls with injuries for one of three residents (R) (#1) reviewed for falls. This failure resulted in actual harm for R#1 who had six falls with injuries between [DATE] and [DATE] with a major injury (facial fractures) after a fall on [DATE]. Findings include: Review of the undated facility policy titled Falls Management revealed that the Comprehensive Falls Assessment form is to be completed in coordination with the Minimum Date Set (MDS) schedule (admission, quarterly, significant change, annually and as clinically indicated) The goal of an intervention may not always be to prevent falls (but), to prevent injury .(Staff) should determine the cause of the fall and decide how a similar fall could be prevented for the resident (Staff) should update the FIP (Falls Intervention Plan) immediately and the date the intervention was put into place A change in FIP should also trigger a note to explain reason for change (i.e , intervention no longer needed, intervention not working and why, etc.) .All falls should be reviewed daily by reviewing the medical chart to ensure that the physician and family were notified, that a new intervention was added to the FIP, how the accident occurred, all injuries identified, evidence that an appropriate intervention was put into place to prevent further falls. R#1 (a closed record) was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a medical decline and was admitted to Hospice Services on [DATE] for severe dementia. R#1 expired on [DATE]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that R#1 had a Brief Interview for Mental Status (BIMS) score of 3 indicating that he had severe cognitive impairment. Continued review revealed he was ambulatory; was occasionally incontinent of bladder and bowel; required extensive assistance from staff for toileting; had no falls since the last MDS; and received an antipsychotic and antidepressant medication daily in the last seven days. Review of his care plan reviewed on [DATE] revealed he was at risk for falls related to use of [MEDICAL CONDITION] medication with the following interventions for nursing staff: provide safe, clutter free environment; call light within reach with prompt response to all requests; ensure resident wears appropriate well-fitting foot wear to minimize the risk of slipping; safety training and education as needed; and prompt to ask for assistance. Review of the Nurses Notes dated [DATE] at 3:30 p.m. revealed that certified nursing staff stated that R#1 was lying across the bed looking under the bed and then rolled off the bed. The resident did not sustain any injuries. The physician and responsible party (RP) were notified. Continued review of the Nurses Note revealed that staff encouraged R#1 to call for assistance and wait until he was assisted. Review of the Incident/Accident Report dated [DATE] for this fall revealed that there was no indication that staff attempted to determine the reason why he was looking under his bed. Review of the FIP revealed that staff initiated an intervention on [DATE] for staff to ensure that the resident's call light was in reach and consider his cognition. There was no evidence that staff considered the resident's cognition. Review of the Nurse's Note dated [DATE] at 3:50 a.m. revealed that R#1 was assisted by staff to his room when he began having a [MEDICAL CONDITION] and was lowered to the floor. The physician was notified and R#1 sent to the Emergency Department (ED) for evaluation. R#1 returned to the facility on [DATE] at 8:00 a.m. Review of the Nurse's Note dated [DATE] at 6:10 p.m., revealed that R#1 was found on the floor of his room lying on his back with his feet extended toward the bathroom door. The resident sustained [REDACTED]. The RP and physician were notified, and the physician ordered staff to send R#1 to the ED. Review of the CT of the brain dated [DATE] revealed that R#1 had atrophy but, no acute intracranial processes. He returned to the facility on [DATE] at 2:15 a.m. Review of the Incident/Accident Report for this fall dated [DATE] revealed that licensed nursing staff documented that steps taken to prevent further occurrence of falls was to send the resident to the ER. There was no indication that nursing staff determined the root cause of the resident's fall or his potential need to toilet at that time. Review of the Nurse's Note dated [DATE] at 4:00 p.m. revealed that R#1 was found on the floor on his knees by his bed in his room. The resident did not sustain any injuries. The RP and physician were notified. Review of the Incident/Accident Report for this fall dated [DATE] revealed that the step taken to prevent recurrence was to keep the resident's call light in reach and consider his cognition. Nursing staff updated the resident's FIP with an intervention dated [DATE] for staff to educate the resident on how to use the call light and to consider his cognition. There was no indication that nursing staff determined the root cause of the fall. Review of the Nurse's Note dated [DATE] at 6:10 a.m. revealed that R#1 was found lying on the floor on his right side beside his roommate's bed. R#1 sustained a 0.5-centimeter (cm) skin tear on the right side of his forehead. The RP and physician were notified. Review of the Incident/Accident Report for this fall dated [DATE] revealed that the resident's bed was low. Although R#1 sustained an injury with this fall, nursing staff failed to determine the root cause of his fall. Review of the medical record for R#1 revealed that he was hospitalized on [DATE] and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. The nursing staff had identified a significant change in the resident's cognition and medical condition and documented a Significant Change MDS on [DATE]. Review of the MDS dated [DATE] revealed that R#1 had a BIMS of 99, indicating severe cognitive impairment. Continued review revealed that he was now non-ambulatory and using a Geri-chair; was always incontinent of bladder and bowel; was totally dependent on staff for toileting; and received an antipsychotic and antidepressant daily in the last seven days. Review of his care plan dated [DATE] and reviewed [DATE], [DATE] and [DATE] revealed the same interventions as his [DATE] with the addition of an intervention for two staff to transfer the resident. Review of the medical record for R#1 revealed that he did not have any falls from [DATE] to [DATE]. Review of the Nurse's Notes dated [DATE] at 5:50 p.m. revealed that R#1 was noted with a 3 cm x 0.5 cm x 0.5 cm laceration over his left eyebrow. Continued review revealed that a Certified Nursing Assistant (CNA) stated that R#1 attempted to stand and fell on the floor. The RP and physician were notified, and the physician ordered staff to send R#1 to the ED. The CT of the brain dated [DATE] showed no acute hemorrhage and the CT of the spine was negative for fracture. The resident returned to the facility on [DATE] at 2:55 a.m. with seven sutures to the laceration over his left eyebrow. Review of the Incident/Accident Report for the fall dated [DATE] revealed that the bed was low and that steps taken to prevent further recurrence were to monitor the resident frequently and encourage him to wait for assistance as needed. Review of the FIP revealed that nursing staff updated it on [DATE] with an intervention for staff to keep the call light in reach and consider the resident's cognition. Nursing staff failed to indicate if R#1 was in the bed or in his Geri-chair at the time of the fall. Although R#1 sustained an injury with this fall, nursing staff failed to determine the root cause of the fall. Nursing staff implemented interventions to encourage R#1 to use his call light and to wait for assistance from staff despite the resident's severe cognitive impairment. Review of the Nurse's Note dated [DATE] at 9:00 a.m. revealed that R#1 was noted out of his Geri-chair lying on his right side on the floor at the Nurses Station. The resident sustained [REDACTED]. The RP and physician were notified. The physician did not order R#1 to be sent to the ED. Review of the Nurse's Note and Incident/Accident Report dated [DATE] revealed that steps taken to prevent recurrence was to recline the resident's Geri-chair for his safety. There was no indication that nursing staff determined the root cause of the fall to determine the appropriateness of the intervention. Review of the Nurse's Note dated [DATE] at 9:55 a.m. revealed that R#1 was noted on the floor at the Nurses Station. R#1 sustained a 1 cm x 1 cm laceration on his left eyebrow and a 1 cm x 1 cm laceration on his left elbow. The RP and physician were notified, and the physician ordered staff to place a tray on the resident's Geri-chair for safety. Review of the Incident/Accident Report for the fall dated [DATE] revealed that there was no indication that R#1 was in his Geri-chair at the time of the fall but, nursing staff documented that steps taken to prevent recurrence was to place a tray over the Geri-chair for safety. There was no indication that nursing staff determined the root cause of the fall to evaluate the appropriateness of the intervention. review of the resident's medical record revealed [REDACTED]. Review of the Nurse's Note dated [DATE] at 3:50 p.m. revealed that R#1 was found sitting on the floor beside his bed. R#1 sustained a 3 cm x 1 cm laceration over his left eye brow with small amount bright red blood and a 2 cm x 2 cm skin tear on his right elbow with small amount bright red blood. The RP and physician were notified, and the physician ordered staff to send R#1 to the ED. The CT of the brain dated [DATE] revealed that R#1 had acute traumatic fractures of the left maxillary wall and left lateral orbital wall. He was readmitted [DATE] at 2:40 a.m. with three sutures to his left eye brow. Review of the Incident/Accident Report for the fall dated [DATE] revealed that the steps taken to prevent recurrence was to monitor closely. However, there was no indication as to the frequency of the monitoring (i.e., every 15 minutes). There was no indication that nursing staff determined the root cause of this fall in order to develop appropriate interventions to prevent further falls with injuries. On [DATE], the physician ordered staff to place a floor mat next to the resident's bed. However, staff failed to update the FIP to include the fall mat. Review of the Hospital Records revealed a CT Brain without Contrast dated [DATE] indicating R#1 had acute soft tissue swelling overlying the left forehead and left pre-septal space with acute traumatic fractures left maxillary wall and left lateral orbital wall. Review of the Nurse's Note dated [DATE] revealed that R#1 was assessed by an ophthalmologist who determined that he did not require repair of the fractures of his orbital floor and medial wall because there were no deficiencies of his extraocular (eye) muscles. Interview with Licensed Practical Nurse (LPN) AA on [DATE] at 3:36 p.m. revealed that the nurse was responsible for assessing a resident after a fall for any injuries and notifying the physician, responsible party, Administrator and Director of Nursing (DON). Continued interview revealed that the nurse completed an Incident/Accident Report and placed it in the physician's folder for review. During a clarification interview with LPN AA on [DATE] at 12:59 p.m., she stated that the nurse who completed the Incident/Accident Report documented a new intervention on the FIP. Further interview revealed that she notified the on-coming nurse about the fall and the new intervention and that staff monitored and documented the resident's status for three days in the Nurse's Notes. Interview with the Director of Nursing (DON) on [DATE] at 3:46 p.m. revealed that the Incident/Accident Report was the tool that the facility used to track falls based on location and time of fall. The DON stated at that time that the nurse was responsible for completing the Incident/Accident report after each fall and documenting an appropriate intervention to address the fall. Continued interview revealed that incidences that occurred the previous 24 hours including falls were discussed in the morning meeting that included the DON, the medication nurse, a CNA, and the Social Services Director/Activities Director. Further interview revealed that staff determined the cause of a fall if possible and ensured that interventions were in place as care planned. The DON stated that she reviewed the Incident/Accident Report to ensure that any new interventions were appropriate. Continued interview revealed that those discussions at the daily meetings were not documented. On [DATE] at 1:43 p.m., the DON reviewed the falls for R#1. She confirmed at that time that the intervention to keep the call light within reach and encourage the resident to use his call light and wait for staff to assist him was inappropriate based on his cognitive impairment for the falls on [DATE], [DATE] and [DATE]. She stated that staff did not determine the root cause of the resident's falls because he was confused. Continued interview revealed that staff did not attempt to initiate a fall mat as an intervention on [DATE], [DATE] or [DATE] as a means to prevent injuries until [DATE] after the resident's fall resulting in his facial fractures. Further interview revealed that nursing staff should have been more detailed in their documentation about the falls, i.e., if R#1 was in the bed or in Geri-chair at the time of his fall, if he was wet/soiled, type of footwear. Further interview revealed that the tray for the Geri-chair was discontinued on [DATE] and at that time, staff removed the tray without assessing its potential benefits of ensuring the resident's safety. R#1 had eight falls between [DATE] and [DATE]. Six of those eight falls resulted in injuries with one of the six falls on [DATE] resulting in facial fractures. There was no indication that nursing staff determined the root cause of the resident's falls so that appropriate interventions could be developed and implemented to prevent further falls with injuries. There was no indication that nursing staff evaluated the appropriateness of the interventions to encourage R#1 to call and wait for assistance based on the resident's severe cognitive impairment. Review of the medical records for R#1 revealed no indication that staff had completed Comprehensive Falls Assessments for the resident as per facility policy. Follow-up telephone interview with the Administrator on [DATE] at 2:18 p.m. revealed that staff utilized the MDS as their fall's assessments.

Based on observation, record review, facility policy titled, Smoking Policy, resident and staff interviews, it was determined that the facility failed to revise the care plan for two residents as follows: the facility failed to put new interventions in place to prevent [MEDICAL CONDITION] one resident (V) who sustained a burn while smoking; the facility failed to include new interventions for pain management for resident (R#8) who had multiple wounds and a scrotal abscess. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census was 52 residents. The sample was 28. On 12/5/16, a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Assistant Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on 12/5/16 at 5:35 p.m. The noncompliance related to the immediate jeopardy (IJ) was identified to have existed on 10/11/16, the date Resident V dropped a cigarette and burned his buttock and the facility failed to complete a smoking evaluation/determination, per facility policy, of this resident and failed to put any interventions in place to prevent this resident from any further potential burns. The facility immediately submitted a Credible Allegation of Compliance (AOC) on 12/5/16 related to the immediate jeopardy. The AOC was approved 12/8/16. The immediate jeopardy continued through 12/8/16, and was removed on 12/9/16. The immediate jeopardy is outlined as follows: Review of the medical record revealed an incident that occurred on 10/11/16, that Resident V lit a cigarette, dropped the cigarette, and suffered a burn to his buttock, the facility failed to complete an evaluation/determination, per facility policy for Resident V for safe smoking, on admission and after the resident was burned, and the facility failed to put new interventions in place to protect this resident from any possible future burns, the facility failed to complete smoking evaluations/determinations, per facility policy, on an ongoing basis to determine if the residents who smoked were able to smoke safely for nine residents (R) (residents V, Q, Z, A, B, W, R, Y, S). The facility failed to follow their smoking policy and allowed six residents to keep their own smoking material for residents (R) Q, Z, A, B, W, R). The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.10(c)(2)(i-ii, iv,v)(3), 483.21(b)(2), Right to Participate in Planning Care - Revise care plan, (F280, S/S:K); 42 C.F.R. 483.21(b)(3) (ii), Services By Qualified Persons/Per Care Plan F282, S/S: K); 42 C.F.R. 483.25(d)(1)(2)(n)(1)-(3), Free of Accident Hazards/supervision/devices (F323, S/S:K), and 483.70 Effective Administration/Resident Well-Being (F490, S/S: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25(d)(1)(2)(n)(1)-(3), Free of Accident Hazards/supervision/devices (F323, S/S:K). A Credible Allegation of Compliance (AOC) was received on 12/5/16. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AOC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 12/9/16. The facility remained out of compliance at a lower scope and severity at F280 S/S:E, F282 S/S:E, F323 S/S: E and F490 S/S:E, while the facility continued management level staff oversight of resident smoking assessments and procedures to ensure the safety of residents that smoke. This oversight process also includes analysis of facility staff ' s conformance with the facility ' s Policies and Procedures, and while the facility develops and implements the Plan of Correction (POC); and the facility ' s Quality Assurance (QA) monitors the effectiveness of the systemic changes. In-service materials and records were reviewed. Observation and interviews were conducted with residents and staff to ensure they demonstrated knowledge of facility Policies and Procedures governing residents smoking safely. Resident records were reviewed to ensure that resident assessments were current and accurate. Findings include: Review of the facility's policy titled, Smoking Policy revealed the following: that a determination is performed for all residents/participants upon admission, when there is a significant change of status, quarterly, and annually thereafter to determine if a resident is a smoker; Smokers will have a smoking care plan implemented; determine the amount of assistance needed and level of safety awareness by evaluating the resident and answering the questions on the Resident Data Set; Develop an individualized care plan based on this evaluation; The interdisciplinary team members document their determination of the resident's smoking status on the Resident Data Set and file it in the medical record. The resident's care plan reflects that the resident is a smoker, the supervision that is provided, use of a protective smoking vest/apron, and the Interdisciplinary Progress Notes reflect any warning issued for an infraction of the smoking policy. (Cross refer to F323 for the complete policy) 1. Review of the medical record for Resident V (R V ) revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed that R V documents the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident is cognitively intact. (Cross refer to F323 for details) Review of the smoking care plan dated 3/11/16 for R V revealed that the resident was at risk for serious health issues and injuries related to smoking with interventions for the resident documented as: the resident is to be supervised during smoking; that all smoking materials will be maintained by staff and provided to resident at smoke break; that smoking will occur in designated areas; and that fire extinguishers, smoking blankets and life safety code ashtrays will be provided in smoking area. Review of the Nurses Notes dated 10/11/16 at 10:20 a.m. for R V , revealed that the resident was smoking and dropped a cigarette causing a burn to the buttock. Observation of a smoking break on 12/5/16 beginning at 2:13 p.m., revealed that none of the residents were wearing a smoking apron or any other protective covering, including R V. Interview with R V on 12/5/16 at 3:00 p.m. confirmed the resident was burned on 10/11/16. Review of an Incident/Accident Report dated 10/11/16 at 10:20 a.m. for R V confirmed that R V suffered a burn related to smoking. This same form revealed that staff failed to document any interventions to prevent recurrence of any future burns. There was not any evidence of any documentation indicated in the section of the form titled Additional comments/and or steps taken to prevent recurrence. (Cross refer to F323 for details) Further review of the medical record for R V , revealed that staff had failed to complete a smoking assessment to evaluate the residents ability to smoke safely on admission, and the facility failed to complete a smoking assessment to evaluate the residents ability to smoke safely after the incident on 10/11/16, when the resident was burned while smoking. Furthermore, review of the smoking care plan for R V , revealed that staff failed to revise the resident's care plan after he was burned on 10/11/16 to include new interventions to prevent future burns. Interview with the Director of Nursing (DON) on 12/14/16 at 9:55 a.m. revealed that she was notified by staff that R V was burned while smoking on 10/11/16 and that staff increased monitoring of the resident during the smoke breaks after the incident. She stated that staff did not implement any other interventions at that time and the smoke apron was not used after the incident. After reviewing the resident's care plan, the DON confirmed that staff failed to revise the care plan to include new interventions to prevent future burns. Continued interview with the DON at that time revealed that the resident's care plan should have been revised to include the intervention for increased monitoring after the incident on 10/11/16. She stated that the previous MDS staff should have documented the new intervention on the care plan. Cross Refer to F323. 2. Review of the closed clinical record for Resident #8 (R#8) revealed a Nurse Practitioner (NP) Readmission Note dated 6/28/16, which documented the resident had been hosptalized on [DATE], due to an elevated temperature, and that R#8 returned to the facility on [DATE]. Further review of this note revealed, that the resident was readmitted with Stage II pressure ulcers to the right lower abdomen, sacrum, left lower buttock, and left hip; and a Stage III pressure ulcer to the left lateral buttock, and the resident was documented to have a surgical incision and drainage completed for a scrotal abscess. Review of the care plans for R#8, revealed an Impaired Skin Integrity care plan had been developed on 6/28/16 which included the multiple pressure ulcers and that the scrotum was red and hard to touch. However, review of the approaches revealed that pain management during wound care had not been included. Review of the pain care plan revealed that it was originally developed on 11/2/10, and last reviewed on 8/6/16, documented that R#8 had pain related to contractures and decreased mobility. Further review of the pain care plan revealed that it had not been updated after the readmission on 6/28/16 to include pain management for the multiple wounds. Interview on 12/13/16 at 11:17 a.m., with the Director of Nursing (DON) revealed that the DON verified the number of wounds that the resident was readmitted with and had been treated for [REDACTED]. The facility implemented the following actions to remove the Immediate Jeopardy: 1. In-service initiated on 12/6/16 at 7:00 a.m. until 8:00 a.m. with the DON and the MDS nurse on making sure that all smoking residents are being assessed on admission for safe smoking practices. The smoking assessment will be updated each time there is a significant change in the resident condition, any time the smoking resident has a hospital stay, and quarterly. Residents will also be reassessed after any incident or accident related to smoking. The importance of ensuring that each resident has a current plan of care that is reflective of his or her current condition and is monitored to ensure that each resident is receiving care under the direct supervision of qualified persons. 2. The DON and MDS nurse will be reeducated annually and upon hire by the QA Coordinator to ensure that compliance is maintained by reviewing smoker's chart to ensure that an updated smoking assessment is the chart for each resident that smokes. The CNA and charge nurses will be educated annually to ensure all care is in accordance and updated care plan by the QA Coordinator. 3. All charts of residents who smoke were reviewed on 12/5/16 and all smoker's charts have an updated care plan that address smoking and a smoking assessment that is current. 4. All the charts for all the residents who smoke charts will be monitored weekly by the 11-7 charge nurse to ensure smoking assessments and smoking care plans are updated after any incident or accident related to smoking, after a hospital stay, after a significant change in condition and quarterly effective 12/5/16 and will continue ongoing. 5. All residents that smoke will be assessed daily by the DON, assigned CNA and/or charge nurse on duty. Monitoring will include the location of the resident and if they were in violation of the smoking policy. The DON will make the assignment daily for the monitoring. In her absence the Relief RN will assign the nursing staff. This went into effect 12/5/16 and will be ongoing. 6. All resident charts were checked by the DON and the MDS nurse to check for other residents that could be affected by not being assessed as needing and not having a care plan in place that ensures care is being provided by qualified staff. No problems were found. 7. The MDS nurse will check the charts for all residents who smoke effective 12/5/16 to ensure that all assessments are being completed on all residents on a weekly basis and this check will be ongoing. The MDS nurse will ensure that all residents have a current personalized plan of care that reflects their needs to ensure that care is being provided in a manner in accordance with acceptable standards of care. 8. The QA team will audit the charts for all residents who smoke monthly to check for smoking assessment and smoking care plan that are current beginning 12/6/16 and continuing each month thereafter. The Smoking Policy and Procedures will be evaluated each month by the QA team to ensure continued compliance. In-service education that will include the Smoking Policy and procedures will be required annually relating to the provision of care by qualified persons that meets the care needs of each resident. 9. The DON will also check the charts for all residents who smoke monthly to ensure smoking assessment and smoking care plans are on each smoker's chart. The check by the DON will ensure that all assessments are current and reflects the resident's current status. The State survey agency validated the corrective action taken by the facility as follows: 1. There were no new admissions to the facility during the survey. All 12 current smokers had a Safe Smoking Assessment completed and placed in their clinical records. Review of an in-service sign in sheet dated 12/6/16 noted that MDS LPN EE and the DON were in-serviced by the Assistant Administrator on timely assessment and care planning of residents that smoked. 2. Annual reeducation on smoking assessments and care plans to be completed by the Assistant Administrator. The DON and MDS nurse received an in-service on 12/6/16 on Timely Assessment and Care Planning of Smokers All 12 smoking residents' care plans were reviewed and/or revised 3. All 12 residents that smoked had a Safe Smoking Assessment completed. The care plans for the residents observed keeping smoking material were updated. A new Safe Smoking Assessment Form was developed by the DON, and all 12 residents that smoke were assessed using this form. Resident V' was assessed as needing a smoking apron was Resident V . 4. An 11-7 Nurse Weekly Audit form was provided for documentation revealed completed smoking assessments and care plans. Telephone interview on 12/9/16 at 3:41 p.m., LPN U, a 7:00 p.m. to 7:00 a.m. LPN, revealed that she had been educated that she would be responsible for making sure that all smokers had a care plan for smoking and smoking assessments completed on a weekly basis 5. Interview on 12/9/16 at 2:39 p.m., with the Assistant Administrator revealed that she will check to make sure that the staff are doing the daily smoking monitoring as she made her daily rounds A Quality Assurance (QA) Smoking Audit form was developed to document the monitoring. The following interviews were conducted on 12/9/16, at 2:18 p.m., with CNA II, who works the 7:00 a.m. to 3:00 p.m. shift; at 2:21 p.m., with Activity Director HH; at 2:29 p.m., with LPN TT, who works the 7:00 a.m. to 7:00 p.m. shift; at 2:33 p.m. with LPN FF, who works the 7:00 a.m. to 7:00 p.m. shift; at 3:41 p.m. with LPN UU, who works the 7:00 p.m. to 7:00 a.m. shift, and; at 3:47 p.m. with CNA SS, who works the 3:00 p.m. to 11:00 p.m. shift, they all stated that they had been in-serviced on the smoking policies and procedures that included: that two staff were required to monitor smoke breaks, notify the Administrator for any infraction of the policy, including residents keeping their own smoking material, and that the smokers could not be left unattended during smoking. 6. Safe Smoking Assessments were completed on all 12 residents who smoked, and their Smoking care plan updated as needed. Review of the other residents' charts revealed that there were no other smokers that needed to be assessed. 7. A form was developed titled, MDS Nurse Weekly Audit , to document completion of smoking assessments and care plans. 8. A Quality Assurance (QA) Smoking Audit form was developed to include the following items: Were any smoking materials found in resident possession? Any smoking materials found in smoker's room? Has any smoker been observed smoking in non-designated area? Have any infractions occurred? Are smoke doors locked? Are signs posted to keep locked? Are monitoring sheets being completed? Are smoking assessments up to date? Are care plans current? Are family members taking smoking materials to station? Has any unauthorized staff purchased smoking materials? Are resident smoking materials in locked storage? Are two staff members assigned to smoke break? Do ashtrays have any trash in them? Are smoking blankets and aprons in smoking area? Is smoking room key being kept locked when not in use? Does smoker have cigarettes at the nurse's station? Are employees giving cigarettes to smoking residents? Has any resident purchased smoking materials? Have you observed any resident with [MEDICAL CONDITION] clothing? Are smoking break times being followed? Has any accident occurred with a smoker? 9. An audit tool titled, Director of Nursing Monthly Audit was developed to document that smoking assessments and care plans had been completed.

Based on observation, staff and resident interviews, review of the facility's policy titled, Smoking Policy , and clinical record review, it was determined that the facility failed to implement the care plan intervention that all smoking materials would be maintained by staff and provided to residents at smoke break times for six residents (R) (Z, Q, A, B, W, R). As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census was 52 residents. The sample was 28. On 12/5/16, a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Assistant Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on 12/5/16 at 5:35 p.m. The noncompliance related to the immediate jeopardy (IJ) was identified to have existed on 10/11/16, the date Resident V dropped a cigarette and burned his buttock and the facility failed to complete a smoking evaluation/determination, per facility policy, of this resident and failed to put any interventions in place to prevent this resident from any further potential burns. The facility immediately submitted a Credible Allegation of Compliance (AOC) on 12/5/16 related to the immediate jeopardy. The AOC was approved 12/8/16. The immediate jeopardy continued through 12/8/16, and was removed on 12/9/16. The immediate jeopardy is outlined as follows: Review of the medical record revealed an incident that occurred on 10/11/16, that Resident V lit a cigarette, dropped the cigarette, and suffered a burn to his buttock, the facility failed to complete an evaluation/determination, per facility policy for Resident V for safe smoking, on admission and after the resident was burned, and the facility failed to put new interventions in place to protect this resident from any possible future burns, the facility failed to complete smoking evaluations/determinations, per facility policy, on an ongoing basis to determine if the residents who smoked were able to smoke safely for nine residents (R) (residents V, Q, Z, A, B, W, R, Y, S). The facility failed to follow their smoking policy and allowed six residents to keep their own smoking material for six residents (R) Q, Z, A, B, W, R). The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.10(c)(2)(i-ii, iv,v)(3), 483.21(b)(2), Right to Participate in Planning Care - Revise care plan, (F280, S/S:K); 42 C.F.R. 483.21(b)(3) (ii), Services By Qualified Persons/Per Care Plan F282, S/S: K); 42 C.F.R. 483.25(d)(1)(2)(n)(1)-(3), Free of Accident Hazards/supervision/devices (F323, S/S:K), and 483.70 Effective Administration/Resident Well-Being (F490, S/S: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25(d)(1)(2)(n)(1)-(3), Free of Accident Hazards/supervision/devices (F323, S/S:K). A Credible Allegation of Compliance (AOC) was received on 12/5/16. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AOC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 12/9/16. The facility remained out of compliance at a lower scope and severity at F280 S/S:E, F282 S/S:E, F323 S/S: E and F490 S/S:E, while the facility continued management level staff oversight of resident smoking assessments and procedures to ensure the safety of residents that smoke. This oversight process also includes analysis of facility staff ' s conformance with the facility ' s Policies and Procedures, and while the facility develops and implements the Plan of Correction (POC); and the facility ' s Quality Assurance (QA) monitors the effectiveness of the systemic changes. In-service materials and records were reviewed. Observation and interviews were conducted with residents and staff to ensure they demonstrated knowledge of facility Policies and Procedures governing residents smoking safely. Resident records were reviewed to ensure that resident assessments were current and accurate. Findings include: Review of the facility's policy titled, Smoking Policy revealed standards for all smoking residents included, that all smoking materials would be kept in a locked box/cart maintained by staff, and it was an infraction of the smoking policy for a resident to have any smoking materials. 1.) Review of medical records for Resident Z (R Z ) revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] for R Z revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating that he was alert and oriented. Review of the Annual MDS dated [DATE] revealed that he currently used tobacco. Review of the care plan dated 3/11/16 revealed that R Z was at risk for serious health issues and injuries related to smoking with documented interventions that included: all residents who smoke will be supervised; all smoking materials will be maintained by staff and provided to residents at smoke break; that smoking will occur in designated areas; and that fire extinguishers, smoking blankets and life safety code ashtrays will be provided in smoking area. Interview on 12/5/16 at 5:15 p.m., with LPN CC revealed that the nurses were responsible for monitoring the residents to ensure that they did not keep smoking materials. Interview on 12/6/16 at 11:36 a.m., with R Z revealed that he is a smoker and that he has kept his cigarettes and lighter in his room prior to this survey. Interview on 12/8/16 at 12 noon with the Assistant Administrator revealed that R Z frequently signed himself out to walk down to the corner store. She stated that the resident would be able to purchase his own cigarettes and lighter at the store but, that she did not know if he purchased smoking materials for other residents. Continued interview revealed that she expected staff to notify her that a resident was found with lighters but, not necessarily cigarettes. Interview on 12/14/16 at 9:50 a.m., with the DON revealed that she knew the resident walked to the store, but she did not know that he had purchased cigarettes for other residents until after surveyor inquired about this. The facility failed to follow the resident's care plan that the resident would not be allowed to keep his own smoking material. Cross Refer to F323. 2. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for R Q revealed that he had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. Review of his Annual MDS dated [DATE] revealed that he used tobacco. Review of his Smoking care plan developed on 3/11/16 and last reviewed on 9/17/16 revealed approaches that included: that all smoking materials would be maintained by staff and provided to residents at smoke break times. Further review of the smoking care plan approaches included that the first infraction of the smoking policy, would be a warning. The second infraction of the smoking policy, there would be a notice of discharge (see Smoking Policy). Review of the clinical record for R Q revealed that a smoking assessment had not been completed to assess his ability to safely smoke or keep his own smoking materials. Observation on 12/5/16 at 2:00 p.m. of the 2:00 p.m. smoke break revealed that Resident Q (R Q ) was observed to independently ambulate into the smoke porch, and sit down at 2:15 p.m., further observation revealed R Q reached in and pulled a cigarette and a cigarette lighter from his shirt pocket, and lit his own cigarette. Interview with Certified Nursing Assistant (CNA) AA, at this same time, revealed that R Q and that R W kept their own smoking materials. Interview on 12/5/16 at 3:15 p.m., with R Q revealed that he would smoke any time he wanted to, sometimes without staff present. He further stated that he could keep his own cigarettes and lighter, and had never been told he couldn't keep his smoking materials. Observation, during the interview, revealed that he had a pack of cigarettes and a cigarette lighter in his shirt pocket. Interview on 12/5/16 at 3:23 p.m., with the Director of Nursing (DON) revealed that the nurse asked residents, on admission to the facility, if the resident smoked, but this was the only assessment completed for smoking. Review of an Admission Assessment form revealed that there was a section for History of Tobacco Use (Yes or No), and the DON stated that this was the only place a smoking assessment was completed. During further interview, the DON stated that residents were not supposed to keep their own smoking materials, and that if they did, they would be taken away for safety reasons. Interview on 12/5/16 at 5:51 p.m., with the Assistant Administrator and DON revealed that they had found that R Q had cigarettes and a lighter in his possession. Interview on 12/8/16 at 11:55 a.m., with the Assistant Administrator revealed that staff would think nothing about a resident keeping cigarettes, as several residents did, and she verified that their smoking policy stated that residents were not allowed to keep any smoking materials, including cigarettes. 3. Review of the clinical record for Resident A revealed that she had the following Diagnoses: [REDACTED]. Review of the Quarterly MDS dated [DATE] for Resident A (R A ), documented that she had a BIMS score of 15, indicating no cognitive impairment. Review of her clinical record revealed that there had not been a smoking assessment completed assessing her ability to safely keep her own smoking materials. Review of her Smoking care plan revealed an Approach for all smoking materials to be maintained by staff and provided to residents at smoke break times. Interview on 12/5/16 at 2:40 p.m., with the Assistant Administrator revealed that smoking materials were supposed to be kept locked up at the nurse's station, but that residents A and B kept their own cigarettes, but none of the residents were allowed to keep a lighter. Interview on 12/5/16 at 3:00 p.m., with R A revealed that she kept her own lighter and cigarettes. Interview on 12/6/16 at 4:04 p.m., with CNA SS revealed that she had seen R A smoke without staff present on the smoking porch before, but that she did not tell the nurse, but she had told the resident she couldn't do that. 4. Review of the clinical record for Resident B revealed the following Diagnoses: [REDACTED]. Review of the Quarterly MDS dated [DATE] for Resident B (R B ) revealed that she had a BIMS score of 15 indicating that she is cognitively intact. Review of her Smoking care plan revealed an approach that all smoking materials would be maintained by staff and provided to residents at smoke break times. Interview on 12/5/16 at 2:40 p.m., with the Assistant Administrator revealed that R B kept her own cigarettes. Interview on 12/5/16 at 3:06 p.m., with R B revealed that she kept her own cigarettes but no lighter, and a pack of cigarettes was observed under the seat of her walker at this time. Interview on 12/6/16 at 4:04 p.m., with CNA SS revealed that she had seen R B smoke without staff present on the smoking porch before. Cross-refer to F 323. 5. Review of the clinical records revealed that Resident W (R W ) was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed that R W had a BIMS score of 11, indicating that he had moderate cognitive impairment. Review of the care plan dated 3/11/16 revealed that R W was at risk for serious health issues and injuries related to smoking with interventions that all residents who smoke will be supervised; all smoking materials will be maintained by staff and provided to residents at smoke break. Interview on 12/5/16 at 3:12 p.m., with R W revealed that he keeps his own cigarettes and lighter but, can only smoke at certain times with staff present. Interview on 12/14/16 at 9:15 a.m., with the DON revealed that that all staff from the Assistant Administrator to the CNAs were responsible for monitoring the residents for unsafe smoking including ensuring that the residents did not keep their own smoking materials as care planned. Continued interview revealed that prior to the survey, the CNAs on the 3 p.m. to 11 p.m. shift were supposed to clean resident drawers and closets every day. Further interview revealed that if smoking materials were found, the CNAs were supposed to report this to the Charge Nurse. She stated that she was unaware that R W had kept his own smoking materials prior to survey. The facility failed to follow the resident's care plan for staff to secure all smoking materials. Cross Refer to F323. 6. Review of the medical record revealed Resident R (R R) had the following documented Diagnoses: [REDACTED]. Review of the Annual MDS assessment dated [DATE] revealed R R was admitted to the facility on [DATE] and readmitted on [DATE], with a BIMS score of 15 indicating that he was cognitively intact. Review of the care plan dated 9/7/16 revealed R R is at serious health issues and injuries related to smoking. The goal is that R R will be free of injuries related to smoking. Documented interventions include: all residents who smoke will be supervised by staff, all smoking materials will be maintained and provided by staff to residents at smoke break times, fire extinguishers and smoking blankets and ash tray will be provided in smoking area. Interview on 12/05/16 at 3:00 p.m., with R R revealed that he keeps his cigarettes and lighter in his room in a drawer. He also stated that he smokes by himself without supervision by staff. Cross refer to F323. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All 12 residents that smoked had the potential to be affected. Each room for the residents that smoke and residents who signed out to got to the store was searched by the Assistant Administrator, the DON, Office Manager and front hall charge nurse on 12/5/16. 2. All smoking materials were removed from the resident or from their room, and labeled and stored at the nurse's station in a secure area that is not accessible to residents. 3. All residents who smoke were educated on a one to one basis about why the smoking materials were being collected to prevent unsupervised smoking by any resident in the facility to ensure the safety of all residents. 4. Signs were posted on the entrance door on 12/5/16 stating that all smoking materials be taken to nurse at the nurse's station to be labeled and stored. 5. Staff members assigned by Administrator to purchase smoking supplies are the DON, Assistant Administrator, or the Office Manager and all purchases are to be taken directly to the locked storage area. 6. Family members who purchase cigarettes for their smoking residents were informed that no resident will be allowed to keep smoking materials in their possession. The family were also asked to tell any other family members that might purchase smoking materials for a resident to never give the smoking materials to the resident as a part of revised smoking procedures to ensure safety of all residents in the facility. 7. Doors to smoke area were locked by the Assistant Administrator. 8. Signs posted on smoke area doors on 12/5/16 reminding staff to keep doors locked at all times. 9. Key to smoke room door will be kept in locked rawer of front hall nurse med cart effective 12/5/16. 10. Effective 12/5/16 the key to smoke area will only be given to the CNA on the shift assigned to smoke break. 11. Each resident who smokes were checked on 12/5/16 every fifteen minutes for twenty-four hours to ensure that no smoking resident was smoking unsupervised at any time. 12. On 12/6/16 smoking residents were monitored every hour by CNAs assigned by the DON to ensure that the resident was not smoking unsupervised and were not in possession of smoking materials for twenty-four hours. 13. On 12/6/16 smoking residents were given written copies of new smoking procedures. Identification of other residents having potential to be affected: Environmental assessment conducted on 12/6/16 by the Assistant Administrator and the DON checking for safety hazards and environmental issues and lack of supervision that could cause a resident to have an incident or accident. Measures in place to prevent deficient practice: 1. Smokers assessed to need aprons will wear one. The DON will let the assigned staff know who is to wear an apron while smoking and it will be posted on nursing staff board on 12/5/16 and will be updated when a current smoking resident is assessed to need a smoker's apron by the DON. 2. Daily checks by nursing staff to ensure that no resident has smoking materials on each shift effective 12/5/16 and continuing ongoing. Any resident found to be in violation of the Smoking Policy will be reported to the Administrator immediately. 3. Assistant Administrator enlisted the support and cooperation of residents, family members and all staff to make sure the Smoking Policy and procedures are being followed. 4. The Administrator or Assistant Administrator will enforce the policy. 5. Assigned nursing staff will supervise the resident for the entire smoke break. 6. All staff instructed to report any resident observed smoking in non-designated areas and possessing smoking materials beginning 12/5/16 and continuing ongoing to ensure continued compliance. 7. CNAs to sit on each hall to monitor the residents for smoking in non-designated areas and possessing smoking materials beginning 12/5/16 and continuing ongoing to ensure continued compliance. 8. Smoking aprons ordered 12/5/16 arrival date 12/7/16. 9. Lighters will be provided by the Administrator and kept with smoking materials at the nurse's station. 10. Effective 12/5/16 residents who smoke will not be admitted to the facility. We currently have twelve (12) smokers and they will be assisted to safely smoke by nursing staff in a safe manner. Monitoring: 1. A smoking assessment will be completed on each smoker on readmission, quarterly, annually, or when a significant change occurs with the resident. A smoking assessment will be completed when a smoking resident has an incident/accident related to smoking and after a hospital admission. 2. Only staff approved by the Administrator will be allowed to purchase smoking materials for the resident. 3. Residents informed of new smoking procedures on 12/5/16. On 12/6/16 were given copies of revised smoking procedures. On 12/7/16 each resident that smokes was given a written copy of the Smoking Policy that each resident that smokes read, in the Assistant Administrator's presence. Each resident signed an acknowledgement of receipt of the Smoking Policy. The Acknowledgment Sheet was placed on the medical chart for every resident that smokes on 12/8/16. 4. Staff will closely supervise smoking residents while they smoke and never leave them unattended for any reason. 5. Smoking residents will be monitored daily on each shift by the DON, MDS nurse, assigned CNA and/or charge nurse on duty to ensure that the smoking procedures are not being violated. If a violation occurs the Administrator will be notified immediately by the DON or Registered Nurse (RN) on duty. This will be effective 12/5/16 and ongoing. 6. Residents will smoke at 9:00 a.m., 2:00 p.m., 5:00 p.m., and 9:00 p.m. each day on the rear porch of the designated smoking area. 7. Smoking aprons to be used by residents assessed to need apron. 8. Newly hired staff will be educated on smoking policy prior to being allowed to work upon hire and then quarterly thereafter. 9. No resident will be allowed to keep smoking materials effective 12/5/16 on their person or in their room. 10. Smoking materials will be kept locked at nurse's station when not in use. 11. Smoking Policy signed by residents, that smoke, on 12/7/16 after being educated on the Smoking Policy by the Assistant Administrator. 12. All staff required by Administrator to report all accidents/incidents to her effective 12/5/16. 13. Family members will not be allowed to take a smoking resident to smoke without staff present. 14. The Administrator or Assistant Administrator will check daily during the morning, mid-shift and at the end of her shift each day on going to ensure continued compliance with the Smoking Policy effective 12/5/16 and continuing ongoing. 15. Housekeeping staff will check resident rooms/bathrooms and common areas daily effective 12/5/16 for smoking materials and signs of smoking in non-authorized areas. This will be an ongoing check. 16. Doors to smoke area will be locked at all times when not in use during smoke breaks. 17. Assistant Administrator enlisting the cooperation and support of residents, family members and all staff to ensure Smoking Policy and procedures are being followed at all times. 18. Quality Assessment (QA) team will check to ensure that the Smoking Policy and procedures are being followed. Audits of monitoring sheets will be checked each week for one month and then monthly. 19. Administrator will enforce the Smoking Policy and procedures. 20. Verbal warning for first violation of smoking procedures/policy. A resident that smokes will be given a written warning for violations of the smoking procedures and then the Administrator will issue a thirty day discharge notice. All smoking residents have been given a copy of the Smoking Policy and a signed copy was placed on resident chart on 12/8/16. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. Review of a Quality Assurance (QA) Target document dated 12/5/16 noted that each resident that smokes room was searched for smoking materials on 12/5/16, smoking material was removed when found, labeled and stored in a locked area of the nurse's station. Interview on 12/5/16 at 5:51 p.m., with the Assistant Administrator and DON revealed they found that resident Z was in possession of cigarettes. 2. Observation in the locked storage cart on 12/9/16 at 3:30 p.m. with LPN FF revealed that smoking materials were locked inside. 3. An Acknowledgement of Receipt form was given to and signed by all 12 residents that smoke and the Assistant Administrator that documented: I have been informed of the (name of facility) smoking standards and policy. I understand that violation of this policy may result in my discharge from the facility. I have received a copy of the smoking standards and policy and agree to abide by them during my stay at name of facility listed. 4. On 12/9/16 at 3:52 p.m., a sign was observed posted by the locked door entering into the front hall from the main lobby that said: All smoking materials should be taken to the charge nurse at the nurse ' s station for labeling and storing. 5. Interview on 12/9/16 at 2:39 p.m., with the Assistant Administrator revealed that only she, the Office Manager, or the DON were allowed to purchase smoking materials for the residents. 6. Review of a QA Target form dated 12/5/16 documented that the Assistant Administrator notified all family member of the new smoking policy and asked them to bring all smoking materials to the charge nurse at the nurse's station. 7. Observations were made of the smoking porch doors locked between smoke breaks, including 12/5/16 at 6:30 p.m., and 12/8/16 at 8:19 a.m. Observation on 12/8/16 at 9:10 a.m., of R W revealed the resident was in the solarium. Staff was observed giving the resident a cigarette and staff were observed lighting the cigarette for him. The resident was observed to smoke safely at that time. 8. Observation on 12/9/16 at 2:10 p.m., revealed a sign posted on the outside of the two smoke porch doors that documented: Keep doors locked at all times except during smoke breaks. 9. Observation on 12/9/16 at 3:30 p.m., revealed the key to open the smoke porch doors was observed locked in the front hall med cart. 10. Observation on 12/9/16 at 3:30 p.m., revealed the Daily Assignment Sheet was documented to include the two staff assigned to monitor smoke breaks. See also #9 above. 11. Smokers were checked every fifteen minutes for 24 hours beginning 12/5/16 for their location, and documented on Resident Condition forms. 12. The smokers and smoking area were checked hourly beginning on 12/6/16, and documented on a log that included Door to smoke area locked, Cigarettes or Lighters found on resident, and Cigarettes or lighters found in room. 13. The Acknowledgement of Receipt form signed by all the residents that smoke, and/or the Assistant Administrator, documented that they received a copy of the smoking standards and policy. A revised copy of the Smoking Policy and Procedure was obtained. Identification of other residents having potential to be affected: Review of a QA Target document dated 12/5/16 documented that each resident that smokes room was searched for smoking materials on 12/5/16, the smoking material was removed when found, labeled and stored in a locked area of the nurse's station. Interview on 12/5/16 at 5:51 p.m., with the Assistant Administrator and DON stated that they found that resident A was in possession of cigarettes and lighters. Measures in place to prevent deficient practice: 1. All 12 residents had a Safe Smoking Assessment completed. Part of this assessment included if a resident required a fire resistant smoking apron while smoking. Resident V was assessed to need a smoking apron. Review of a form titled, Smoking Designated Times & Areas posted on the bulletin board by the nurse's station included the smoking times, and that R V required a smoking apron when smoking. 2. Interview on 12/9/16 at 2:39 p.m., with the Assistant Administrator revealed that the smokers would be observed each shift daily, indefinitely, for smoking materials. A written or verbal warning for violating smoking policy was provided if any resident was noted to have smoking materials in their possession. 3. On 12/9/16 at 2:39 p.m., the Assistant Administrator stated that in order to enlist the support and cooperation of the residents and family members, she talked to them 1:1 at the time she discussed the smoking policies and changes, and explained to them how important it was to adhere to the policy for the safety of the residents. This was documented on a Quality Assurance form dated 12/5-12/6/16, and a QA Target form dated 12/5/16. 4. Interview on 12/9/16 at 2:39 p.m., with the Assistant Administrator revealed that she would be responsible for enforcing the smoking policy. 5. and 6. Interviews with the following staff on 12/9/16, revealed that they had been in-serviced on the smoking policies and procedures, which included that two staff were required to monitor smoke breaks, notify the Administrator for any infraction of the policy, which includes residents are not allowed to keep their own smoking material, and that the smokers could not be left unattended during smoking. In-service sign in sheets dated 12/7/16 and 12/8/16 were provided, as well as another in-service conducted related to leaving smoke doors unlocked during the smoke breaks, and location of smoke break assignments. 2:18 p.m. CNA II, 7:00 a.m. to 3:00 p.m. shift. 2:21 p.m. Activity Director HH. 2:29 p.m. LPN TT, 7:00 a.m. to 7:00 p.m. shift. 2:33 p.m. LPN FF, 7:00 a.m. to 7:00 p.m. shift. 3:41 p.m. LPN UU, 7:00 p.m. to 7:00 a.m. shift. 3:47 p.m. CNA SS, 3:00 p.m. to 11:00 p.m. shift. 7. Interview on 12/9/16 at 2:39 p.m., with the Assistant Administrator revealed that between 7:00 p.m. and 7:00 a.m., the CNA's had been instructed to sit in the halls between rounds to ensure that there was no smoking observed or any other smoking-related concerns, and that this would be documented on the same form that the evening shift observations were made. Interview on 12/9/16 at 3:47 p.m., with CNA SS revealed that she had been instructed to sit in one of the chairs in the hall, and that there were chairs on both halls, when she was not providing care for a resident to ensure that there were not any smoking-related concerns. 8. An Order Detail dated 12/5/16 revealed that two Smoker's Aprons had been ordered one-day shipping. Observation on 12/9/16 at 9:14 a.m., revealed that R V , the only resident assessed to need a smoking apron, was observed wearing a smoking apron. 9. Interview on 12/9/16 at 2:33 p.m., with LPN FF revealed that the smoking materials were kept locked in the med room when not in use. 10. No new admissions during the survey. Monitoring: 1. Safe Smoking Assessments were completed on each of the 12 smokers on 12/6/16. 2. Staff members assigned by Administrator to purchase smoking supplies are the DON, Assistant Administrator, or the Office Manager and all purchases are to be taken directly to the locked storage area. 3. Review of a Quality Assurance form dated 12/5-12/6/16 documented that the Assistant Administrator met with the smokers to discuss the new smoking procedures. An Acknowledgment of Receipt was signed by all 12 smokers and/or Assistant Administrator that noted the resident had been informed of the smoking standards and policy and they may be discharged for violating the policy, and that they received a copy of the policy. 4. Interviews with the following staff on 12/9/16, revealed that they had been in-serviced on the smoking policies and procedures, which include smoking assessments, and included that two staff were required to monitor smoke breaks, notify the Administrator for any infraction of the policy, which includes that residents are not allowed to keep their own smoking material, and that the smokers could not be left unattended during smoking. In-service Sign In Sheets dated 12/7/16 and 12/8/16 were provided, as well as another in-service conducted that was related to leaving smoke doors unlocked during the smoke breaks, and location of smoke break assignments. 2:18 p.m. CNA II, 7:00 a.m. to 3:00 p.m. shift. 2:21 p.m. Activity Director HH. 2:29 p.m. LPN TT, 7:00 a.m. to 7:00 p.m. shift. 2:33 p.m. LPN FF, 7:00 a.m. to 7:00 p.m. shift. 3:41 p.m. LPN UU, 7:00 p.m. to 7:00 a.m. shift. 3:47 p.m. CNA SS, 3:00 p.m. to 11:00 p.m. shift. 5. Interview on 12/9/16 at 2:39 p.m., with the Assistant Administrator revealed that the smokers would be observed each shift daily, indefinitely, for keeping their own smoking materials. A Written or Verbal Warning for Violating Smoking Policy was provided if any resident was noted to have smoking materials in their possession. She stated that she would be responsible for enforcing the smoking policy. 6. Review of the revised Smoking Policy revealed that scheduled smoking times are 9:00

Based on observation of a smoking break, staff and resident interviews, review of the facility's policy titled, Smoking Policy, incident report and clinical record review it was determined that the facility failed to put new interventions in place for one resident (R V ), who was burned while smoking, to protect him from any possible future burns, failed to follow the facility's Smoking Policy and allowed six of 10 residents (R) to keep their own smoking materials (Q, Z, A, B, W, R), and failed to complete smoking evaluations/determination, per facility policy, on an ongoing basis to determine if the residents who smoked were able to smoke safely for nine residents (R) (residents V, Q, Z, A, B, W, R, Y, S). There were a total of 12 residents identified by the facility as being smokers, and ten of these residents were reviewed for smoking concerns. In addition to these smoking concerns, the facility failed to ensure that a grab bar in the men's and women's common shower rooms were securely fastened to the wall, and to ensure that one toilet seat and one elevated commode seat was securely fastened to the base of the commode in two resident rooms. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census 52 residents. The sample was 28. On 12/5/16, a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Assistant Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on 12/5/16 at 5:35 p.m. The noncompliance related to the immediate jeopardy (IJ) was identified to have existed on 10/11/16, the date Resident V dropped a cigarette and burned his buttock and the facility failed to complete a smoking evaluation/determination, per facility policy, of this resident and failed to put any interventions in place to prevent this resident from any further potential burns. The facility immediately submitted a Credible Allegation of Compliance (AOC) on 12/5/16 related to the immediate jeopardy. The immediate jeopardy continued through 12/8/16, and was removed on 12/9/16. The immediate jeopardy is outlined as follows: Review of the medical record revealed an incident that occurred on 10/11/16, that Resident V lit a cigarette, dropped the cigarette, and suffered a burn to his buttock, the facility failed to complete an evaluation/determination, per facility policy for Resident V for safe smoking, on admission and after the resident was burned, and the facility failed to put new interventions in place to protect this resident from any possible future burns, the facility failed to complete smoking evaluations/determinations, per facility policy, on an ongoing basis to determine if the residents who smoked were able to smoke safely for nine residents (R) (residents V, Q, Z, A, B, W, R, Y, S). The facility failed to follow their smoking policy and allowed six residents to keep their own smoking material for six residents (R) Q, Z, A, B, W, R). The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.10(c)(2)(i-ii, iv,v)(3), 483.21(b)(2), Right to Participate in Planning Care - Revise care plan, (F280, S/S:K); 42 C.F.R. 483.21(b)(3) (ii), Services By Qualified Persons/Per Care Plan F282, S/S: K); 42 C.F.R. 483.25(d)(1)(2)(n)(1)-(3), Free of Accident Hazards/supervision/devices (F323, S/S:K), and 483.70 Effective Administration/Resident Well-Being (F490, S/S: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25(d)(1)(2)(n)(1)-(3), Free of Accident Hazards/supervision/devices (F323, S/S:K). A Credible Allegation of Compliance (AOC) was received on 12/5/16. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AOC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 12/9/16. The facility remained out of compliance at a lower scope and severity at F280 S/S:E, F282 S/S:E, F323 S/S: E and F490 S/S:E, while the facility continued management level staff oversight of resident smoking evaluations/determinations (assessments) and procedures to ensure the safety of residents that smoke. This oversight process also includes analysis of facility staff ' s conformance with the facility ' s Policies and Procedures, and while the facility develops and implements the Plan of Correction (POC); and the facility ' s Quality Assurance (QA) monitors the effectiveness of the systemic changes. In-service materials and records were reviewed. Observation and interviews were conducted with residents and staff to ensure they demonstrated knowledge of facility Policies and Procedures governing residents smoking safely. Resident records were reviewed to ensure that resident assessments were current and accurate. Findings include: Review of the facility's policy titled, Smoking Policy revealed that the standards were for all smoking residents, and included the following procedures: All smoking materials, e.g., cigarettes, pipes, lighters, lighter fluid, matches, etc., will be kept in a locked box/cart maintained by the staff. All smoking materials need to be brought to the residents' charge nurse upon entering the building. It is an infraction of the smoking policy for a resident to have any smoking materials. Smoking will occur in a designated area at a designated time only. Currently, this area is the back porch and the front area outside area. Times are 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:30 p.m., 3:00 p.m., 5:00 p.m., 7:00 p.m., and 11:00 p.m. All residents deemed unsafe will wear smoking aprons. A first infraction warning for not adhering to the policy will be given to the resident and their family member or representative. A second infraction of the smoking policy may result in a notice of discharge for endangerment to the health and safety of all residents. A determination is performed for all residents/participants upon admission, when there is a significant change of status, quarterly, and annually thereafter to determine if a resident is a smoker. Smokers will have a smoking care plan implemented. Determine the amount of assistance needed and level of safety awareness by evaluating the resident and answering the questions on the Resident Data Set. Develop an individualized care plan based on this evaluation. All residents who smoke will be supervised while smoking. Staff members maintain all smoking materials for residents who smoke, and provide smoking materials to residents at smoking times. Residents are instructed not to share lighted cigarettes with other residents. The interdisciplinary team members document their determination of the resident's smoking status on the Resident Data Set and file in the medical record. The resident's care plan reflects that the resident is a smoker, the supervision that is provided, use of a protective smoking vest/apron. The Interdisciplinary Progress Notes reflect any warning issued for an infraction of the smoking policy. 1. Review of the medical record for Resident V (R V ) revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed that R V documents the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident is cognitively intact. Section G titled Functional Status documents the resident requires full staff performance every time during the 7 days prior for: dressing, personal hygiene, and toilet use and the resident required one person physical assist for each those activities. This same MDS documents the resident requires set up assistance for eating. Review of the Annual MDS dated [DATE] revealed that he currently used tobacco. Review of the Incident/Accident Report dated 10/11/16, at 10:20 a.m. revealed that resident was on a smoke break in the solarium when the cigarette he was smoking fell on to his pants. Small burn area noted to the right buttock. Continued review of the Incident/Accident Report, however, revealed that staff failed to document any interventions to prevent recurrence in the section titled, Additional comments/and or steps taken to prevent recurrence. Review of the Physician monthly notation dated 10/25/16 revealed the Physician assessed the burn as a second degree burn. Observation of a smoking break on 12/5/16 beginning at 2:13 p.m., revealed that there were not any residents wearing a smoking apron or other protective covering, including R V , who was observed reclining in a Geri chair actively smoking and holding his cigarette over his upper torso. Interview on 12/5/16 at 3:00 p.m., with R V confirmed the resident was burned on 10/11/16. Interview on 12/5/16 at 3:55 p.m., with the DON confirmed the incident and confirmed the resident was burned, while smoking, on 10/11/16. Interview on 12/5/16 at 4:55 p.m., with the Assistant Administrator confirmed that smoking aprons were not available for resident use, and she denied knowledge of the burn to R V . (Cross refer to F323 for details) Further review of the medical record for R V , revealed that staff had failed to complete a smoking evaluation/determination to evaluate the residents ' ability to smoke safely after the incident on 10/11/16, when the resident was burned while smoking. Continued interview revealed that the facility did not have smoking aprons for the residents to use and that she had not been notified by staff that R V had been burned while smoking. Furthermore, review of the care plan dated 3/11/16 for R V , revealed that staff failed to revise the resident's care plan after he was burned on 10/11/16 to include new interventions to prevent future burns. Interview with the Director of Nursing (DON) on 12/5/16 at 5:10 p.m. revealed that staff had not completed smoking evaluations/determinations on admission or on an on-going basis for R V . Interview on 12/14/16 at 9:55 a.m., with the Director of Nursing (DON) revealed that she was notified by staff that R V was burned while smoking on 10/11/16, and that staff increased monitoring of the resident during the smoke breaks after the incident. She stated that staff did not implement any other interventions at that time. 2. A.) Review of the clinical records for Resident Q (R Q ) revealed that he was admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. Review of the Quarterly MDS, for R Q , dated 9/17/16 revealed a BIMS score of six, indicating severe cognitive impairment. Review of the clinical record for R Q revealed there was not any evidence of documentation that R Q had an evaluation/determination (assessment) ability to smoke safely, further review revealed there was not any evidence of any assessments conducted to indicate that he was safe to keep his own smoking material. Review of his Smoking care plan dated 3/11/16 revealed that R Q was at risk for serious health issues and injuries related to smoking. Review of the approaches for this care plan included: All residents that smoke will be supervised by staff. All smoking materials will be maintained by staff and provided to residents at smoke break times. Smoking will occur in the designated areas, these areas may be outdoors. Fire extinguishers and smoking blankets and life safety code required ashtrays will be provided in smoking areas. No oxygen use in smoking area Residents are not allowed to share lit cigarettes with other residents. First infraction of smoking policy, warning. Second infraction of smoking policy, a notice of discharge. Family members may only supervise their family member in the smoking area. All smokers have the option for help with smoking cessation. Interview on 12/5/16 at 2:13 p.m., with Certified Nursing Assistant (CNA) AA who was supervising a smoke break during this time, revealed that the nurse kept the smoking supplies, and that she distributed and lit the cigarettes for all of the residents who smoke, and that no residents were allowed to keep their own smoking materials. During continued observation at 2:15 p.m., R Q was observed to independently ambulate into the smoking porch and sit down, pull out a cigarette and lighter out of the pocket of his shirt, and light his cigarette. An additional interview with CNA AA, at this time, revealed that R Q and resident W kept their own cigarettes, but they were supposed to wait for the designated smoke breaks to smoke. Interview on 12/5/16 at 2:40 p.m., with the Assistant Administrator revealed that the only thing she knew was that smoking information was on the residents' care plans, and that the smoking materials were kept locked up in the storage cart at the nurse's station. Interview on 12/5/16 at 3:15 p.m., with R Q revealed that the staff bought him cigarettes with the fifty dollars that he got each month. R Q further stated that he had been a resident at the facility for years, and was never told that he could not keep his own cigarettes. The resident further stated that he had lit other resident's cigarettes before, but had never seen anyone get burned. Observation, at this time, revealed R Q had cigarettes and a lighter in his shirt pocket. Interview on 12/5/16 at 3:23 p.m., with the Director of Nursing (DON) revealed that smoking materials were to be kept locked up in a locked storage cart. Interview on 12/5/16 at 5:15 p.m. with LPN CC revealed that the nurses were responsible for monitoring the residents to ensure that they did not keep smoking materials. Interview on 12/5/16 at 5:51 p.m., with the Assistant Administrator and DON revealed that when they conducted their search for smoking material that they found that R Q had cigarettes and a lighter in his possession. Interview with CNA SS on 12/6/16 at 4:04 p.m., revealed that she had seen R Q keep cigarettes and lighters in the past, and that she had not been told, before today, that the residents were not allowed to keep smoking materials. Interview on 12/08/16 at 9:30 a.m., with the DON revealed that resident S had alerted her that R Q was keeping smoking materials, but that the staff had never notified her of this. She further stated that they could never locate smoking materials in his possession, that they had given him verbal warnings about this in the past, but that these warnings were not documented anywhere. B.) Review of medical records for resident Z revealed he was admitted on [DATE]. Review of the Quarterly MDS dated [DATE] for resident Z revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating that he cognitively intact. Review of the clinical record for resident Z revealed that there was no evidence that an evaluation/determination (assessment) for safe smoking and/or keeping his own smoking material/supplies had been completed. Interview on 12/6/16 at 11:36 a.m., with resident Z revealed that he is a smoker and that he has kept his cigarettes and lighter in his room prior to this survey. Interview on 12/6/16 4:04 p.m., with CNA SS revealed that she knew that resident Z had kept his own cigarettes and lighter in the past. Interview on 12/08/16 at 10:02 a.m., with the DON revealed that her expectation was that if staff witnessed a resident keeping their smoking supplies or smoking without supervision, and that they should immediately tell their charge nurse. Interview on 12/8/16 at 11:55 a.m., with the Assistant Administrator revealed that she was not aware and had never been told that any of the residents had a lighter, and her expectation would be that if staff saw a resident with a lighter they would tell her right away. She further revealed that staff wouldn ' t think anything about a resident keeping cigarettes, as several residents did; however, she verified that the facility's smoking policy documents that residents are not allowed to keep any smoking materials, including cigarettes. Interview on 12/8/16 at 12 p.m., with the Assistant Administrator revealed that resident Z signed himself out to go to the store and would be able to purchase his own cigarettes and lighter at the store but, that she did not know if he purchased smoking materials for other residents. Continued interview revealed that she expected staff to notify her that a resident was found with lighters but, not necessarily cigarettes. Interview on 12/9/16 at 4:30 p.m., with resident Z revealed that, prior to this survey, he would purchase cigarettes for other residents when he went to the store. C. Review of the clinical record for resident A revealed that she had [DIAGNOSES REDACTED]. Review of the Quarterly MDS, for resident A , dated 10/25/16 documents that she had a BIMS score of 15 indicating that she was cognitvely intact. Review of the clinical record for resident A revealed that there was not any evidence that an evaluation/determination (assessment) for safe smoking and/or keeping her own smoking material had been completed. Review of the Smoking care plan for resident A dated 7/20/16 and reviewed on 10/20/16 revealed that the care plan was identical to R Q's Smoking care plan, and included an approach that all smoking materials will be maintained by staff and provided to residents at smoke break times. Review of the Nurses' Notes, for resident A , from April 2016 through December 2016 revealed the following entries related to smoking: 10/24/16 at 6:40 a.m. Resident out of bed at frequent intervals to back porch to smoke. 10/26/16 at 6:05 a.m. Out of bed to back porch to smoke. 12/5/16 at 5:00 a.m. Resident up out of bed in smoking area. Interview on 12/05/16 at 3:00 p.m., with resident A revealed that there were scheduled smoking times and a staff member always in attendance during smoke breaks. During further interview with resident A revealed that she kept her own lighter and cigarettes. Interview on 12/5/16 at 5:51 p.m., the Assistant Administrator and DON revealed that during their search, for smoking material, they had found that resident A had cigarettes and a lighter in her possession. D.) Review of the clinical record for resident B revealed that she had [DIAGNOSES REDACTED]. Review of the Quarterly MDS, for resident B dated 9/8/16, revealed that she had a BIMS score of 15 indicating that she was cognitively intact. Review of the Smoking care plan, for resident B dated 7/20/16 and reviewed on 12/8/16 revealed that this Smoking care plan was identical to the Smoking care plans for R Q and resident A , and included approaches that all residents that smoke will be supervised by staff, and all smoking materials will be maintained by staff and provided to residents at smoke break times. Review of the clinical record for resident B revealed that an evaluation/determination (assessment) for safe smoking and/or keeping her own smoking supplies had not been completed. Interview on 12/05/16 at 3:06 p.m., with resident B revealed that she kept her own cigarettes, which were observed, at this same time, under the seat of her walker. Interview on 12/6/16 at 4:04 p.m., with CNA SS revealed that she had seen residents A and B keep cigarettes and lighters in the past, and that she had seen them smoke on the smoking porch without staff supervision before. CNA SS further stated that she didn't tell the nurse when she observed this, but only told the residents that they could not do that. Review of the Nurses ' Notes from October 2016 to December 2016 for resident B revealed the following documentation related to smoking: 11/3/16 at 6:35 a.m. Resident up at frequent intervals during the night. Out to back porch to smoke. Interview on 12/13/16 at 1:40 p.m., with the DON revealed that she verified the above entry in the Nurse's Notes, and that R B should not have been smoking at these times anyway, as the facility's previous smoking policy noted the first smoke break started at 9:00 a.m., and the last one for the day was at 9:00 p.m. E.) Review of medical records revealed that resident W was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed that resident W had a BIMS score of 11, indicating that he had moderate cognitive impairment. Review of the clinical record for resident W revealed that an evaluation/determination (assessment) for safe smoking and/or keeping her own smoking supplies had not been completed Review of the care plan dated 3/11/16 revealed that resident W was at risk for serious health issues and injuries related to smoking with interventions that all residents who smoke will be supervised; all smoking materials will be maintained by staff and provided to residents at smoke break; that smoking will occur in designated areas; and that fire extinguishers, smoking blankets and life safety code ashtrays will be provided in smoking area. Interview on 12/5/16 at 3:12 p.m. with resident W revealed that he keeps his own cigarettes and lighter. Interview on 12/5/16 at 5:10 p.m., with the DON revealed that staff had not completed smoking evaluations/determinations on admission or on-going for R W. F.) Review of the clinical record revealed resident R (R R ) had the following documented Diagnoses: [REDACTED]. Review of the Annual MDS assessment dated [DATE] revealed R R was admitted to the facility on [DATE] and readmitted on [DATE], with a BIMS score of 15 indicating that he was cognitively intact. This same MDS documents that the resident requires limited assistance with activities of daily living (ADLs) and has shortness of breath (SOB). Review of the resident ' s medical record revealed there was no evidence of a safe smoking evaluation/determination for R R until 12/6/16 (during the survey). Interview on 12/05/16 at 3:00 p.m., with R R revealed that he keeps his cigarettes and lighter in his room in a drawer. He also stated that he smokes by himself without supervision by staff. G. Review of the medical record revealed that Resident Y (R Y ) was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status(BIMS) score of 9, indicating that she had some cognitive impairment. Continued review revealed that she currently used tobacco. Review of the care plan, for R Y dated 3/11/16 revealed that the resident was at risk for serious health issues and injuries related to smoking with interventions for the resident to be supervised during smoking; that all smoking materials will be maintained by staff and provided to resident at smoke break; that smoking will occur in designated areas; and that fire extinguishers, smoking blankets and life safety code ashtrays will be provided in smoking area. Interview with R Y on 12/5/16 at 3:07 p.m. revealed that she did not keep her own smoking materials but, that staff kept them at the nurses ' station and gave her a cigarette and lighted it for her during the designated smoke breaks. Further interview revealed that she had not burned herself or her clothing while smoking. Observation at that time revealed no burn holes on her clothing or burns on her hands Review of the medical records, for R Y , revealed that staff had failed to complete a smoking evaluation/determination (assessment) to evaluate the resident ' s ability to smoke safely on admission and on an ongoing basis. Interview with the Director of Nursing (DON) on 12/5/16 at 5:10 p.m. revealed that staff had not completed smoking evaluations/determinations on admission or on-going for R Y. H. Medical Record review revealed that Resident S (R S) was admitted to the facility on [DATE] and was readmitted on [DATE]. Review of the MDS assessment dated [DATE], for Resident S (R S ) revealed that R S had a documented BIMs score of 15 indicating the resident is cognitively intact. This same MDS documents that the resident is independent with transfer, walking in the room, corridor, and eating, needs limited assistance with dressing, and extensive assistance with toilet use and personal hygiene. R S is a current tobacco user. Care Plan dated 3/11/16 revealed R S is at risk for serious health issues and injuries related to smoking. The goal is to keep R S free of injuries related to smoking through supervision by staff, all smoking materials will be maintained by staff and provided to residents at smoke break times, fire extinguishers and smoking blankets and ash trays provided in smoking areas. Chart review revealed a safe smoking evaluation/determination (assessment) had not been completed for R S until 12/6/16 (during the survey). 3. Initial tour of the facility on 12/5/16 beginning at 10:17 a.m., revealed one of three handrails in the men's common bathroom shower stall was observed not to be securely fastened to the wall, and was observed to move freely when pulled on. Continued observations during the initial tour at this time revealed. Observation on 12/5/16 at 10:44 a.m., with the Assistant Administrator verified that the grab handrail was loose when it was pulled on. During the observation with the Assistant Administrator, a screw, that was used to attach the grab bar to the wall, on the lower right side came out. 4. Observation on 12/6/16 at 10:49 a.m., revealed a donut-shaped hard plastic elevated commode seat was observed in the room of R#32, and that it was not secured to the base of the toilet in any manner. Further observation revealed that this commode seat slid easily from the front to the back of the commode base approximately six inches when pushed. This was confirmed during an interview with LPN TT at this same time, who stated that R #32 was able to use the toilet with the assistance of staff. Interview on 12/15/16 at 10:30 a.m. with CNA II revealed that she would verbally tell the maintenance supervisor of any concerns if he were in the facility. Continued interview at that time revealed that if he was not in facility CNA II would write concern on a sheet of paper and give it to the Charge Nurse. Interview on 12/15/16 at 10:35 a.m., with LPN TT revealed that if staff notified her of an environmental issue, she would document on the 24 hour report and verbally tell the maintenance supervisor. If the concern was an emergency and the maintenance supervisor was not in the facility, she would tell the Assistant Administrator who would call an outside source. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All 12 residents that smoked had the potential to be affected. Each room for the residents that smoke and residents who signed out to go to the store was searched by the Assistant Administrator, the DON, Office Manager and front hall charge nurse on 12/5/16. 2. All smoking materials were removed from the resident or from their room, and labeled and stored at the nurse's station in a secure area that is not accessible to residents. 3. All residents who smoke were educated on one to one basis about why the smoking materials were being collected to prevent unsupervised smoking by any resident in the facility to ensure the safety of all residents. 4. Signs were posted on the entrance door on 12/5/16 stating that all smoking materials be taken to nurse at the nurse's station to be labeled and stored. 5. Staff members assigned by Administrator to purchase smoking supplies are the DON, Assistant Administrator, or the Office Manager and all purchases are to be taken directly to the locked storage area. 6. Family members who purchase cigarettes for their smoking residents were informed that no resident will be allowed to keep smoking materials in their possession. The family were also asked to tell any other family members, that might purchase smoking materials for a resident, to never give the smoking materials to the resident as a part of revised smoking procedures to ensure safety of all residents in the facility. 7. Doors to smoke area were locked by the Assistant Administrator. 8. Signs posted on smoke area doors on 12/5/16 reminding staff to keep doors locked at all times. 9. Key to the smoke room door will be kept in locked rawer of front hall nurse storage cart effective 12/5/16. 10. Effective 12/5/16 the key to smoke area will only be given to the CNA on the shift assigned to smoke break. 11. Each resident who smokes were checked on 12/5/16 every fifteen minutes for twenty-four hours to ensure that no smoking resident was smoking unsupervised at any time. 12. On 12/6/16 residents that smoke were monitored every hour by CNAs assigned by the DON to ensure that the resident was not smoking unsupervised and were not in possession of smoking materials for twenty-four hours. 13. On 12/6/16 residents that smoke were given written copies of new smoking procedures. Identification of other residents having potential to be affected: Environmental assessment conducted on 12/6/16 by the Assistant Administrator and the DON checked for safety hazards and environmental issues and lack of supervision that could cause a resident to have an incident or accident. Measures in place to prevent deficient practice: 1. Smokers assessed to need aprons will wear one. The DON will let the assigned staff know who is to wear an apron while smoking and it will be posted on nursing staff board on 12/5/16 and will be updated when a current residents that smoke is assessed to need a smoker's apron by the DON. 2. Daily checks by nursing staff to ensure that no resident has smoking materials on each shift effective 12/5/16 and continuing ongoing. Any resident found to be in violation of the Smoking Policy will be reported to the Administrator immediately. 3. Assistant Administrator enlisting the support and cooperation of residents, family members and all staff to make sure the Smoking Policy and procedures are being followed. 4. The Administrator or Assistant Administrator will enforce the policy. 5. Assigned nursing staff will supervise the residents for the entire smoke break. 6. All staff instructed to report any resident observed smoking in non-designated areas and possessing smoking materials beginning 12/5/16 and continuing ongoing to ensure continued compliance. 7. CNAs to sit on each hall to monitor the residents for smoking in non-designated areas and possessing smoking materials beginning 12/5/16 and continuing ongoing to ensure continued compliance. 8. Smoking aprons ordered 12/5/16 arrival date 12/7/16. 9. Lighters will be provided by the Administrator

Based on observation of a smoke break, review of the facility's Smoking Policy and clinical record review, resident and staff interviews, the facility failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and/or psychosocial well-being of each resident. The facility failed to ensure that their Smoking Policy and smoking care planned interventions were being fully implemented related to all smoking materials being kept in a locked box/cart maintained by the staff, and failed to ensure that smoking assessments were completed to ensure that residents that smoke were able to smoke safely. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on 12/5/16 was 52 residents. The sample was 28. On 12/5/16, a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Assistant Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on 12/5/16 at 5:35 p.m. The noncompliance related to the immediate jeopardy (IJ) was identified to have existed on 10/11/16, the date Resident V dropped a cigarette and burned his buttock and the facility failed to complete a smoking evaluation/determination, per facility policy, of this resident and failed to put any interventions in place to prevent this resident from any further potential burns. The facility immediately submitted a Credible Allegation of Compliance (AOC) on 12/5/16 related to the immediate jeopardy. The AOC was approved 12/8/16. The immediate jeopardy continued through 12/8/16, and was removed on 12/9/16. The immediate jeopardy is outlined as follows: Review of the medical record revealed an incident that occurred on 10/11/16, that Resident V lit a cigarette, dropped the cigarette, and suffered a burn to his buttock, the facility failed to complete an evaluation/determination, per facility policy for Resident V for safe smoking, on admission and after the resident was burned, and the facility failed to put new interventions in place to protect this resident from any possible future burns, the facility failed to complete smoking evaluations/determinations, per facility policy, on an ongoing basis to determine if the residents who smoked were able to smoke safely for nine residents (R) (residents V, Q, Z, A, B, W, R, Y, S). The facility failed to follow their smoking policy and allowed six residents to keep their own smoking material for six residents (R) Q, Z, A, B, W, R). The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.10(c)(2)(i-ii, iv,v)(3), 483.21(b)(2), Right to Participate in Planning Care - Revise care plan, (F280, S/S:K); 42 C.F.R. 483.21(b)(3) (ii), Services By Qualified Persons/Per Care Plan F282, S/S: K); 42 C.F.R. 483.25(d)(1)(2)(n)(1)-(3), Free of Accident Hazards/supervision/devices (F323, S/S:K), and 483.70 Effective Administration/Resident Well-Being (F490, S/S: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25(d)(1)(2)(n)(1)-(3), Free of Accident Hazards/supervision/devices (F323, S/S:K). A Credible Allegation of Compliance (AOC) was received on 12/5/16. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AOC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 12/9/16. The facility remained out of compliance at a lower scope and severity at F280 S/S:E, F282 S/S:E, F323 S/S: E and F490 S/S:E, while the facility continued management level staff oversight of resident smoking assessments and procedures to ensure the safety of residents that smoke. This oversight process also includes analysis of facility staff ' s conformance with the facility ' s Policies and Procedures, and while the facility develops and implements the Plan of Correction (POC); and the facility ' s Quality Assurance (QA) monitors the effectiveness of the systemic changes. In-service materials and records were reviewed. Observation and interviews were conducted with residents and staff to ensure they demonstrated knowledge of facility Policies and Procedures governing residents smoking safely. Resident records were reviewed to ensure that resident assessments were current and accurate. Findings include: Review of the facility's Smoking Policy revealed that the standards were for all residents who smoke and included: that all smoking materials, e.g., cigarettes, pipes, lighters, lighter fluid, matches, etc., will be kept in a locked box/cart maintained by the staff. All smoking materials need to be brought to the residents' charge nurse upon entering the building. It is an infraction of the smoking policy for a resident to have any smoking materials. The policy titled, Smoking Policy further documents a determination is performed for all residents/participants upon admission, when there is a significant change of status, quarterly, and annually thereafter to determine if a resident is a smoker. Residents that smoke will have a smoking care plan implemented. Determine the amount of assistance needed and level of safety awareness by evaluating the resident and answering the questions on the Resident Data Set. Develop an individualized care plan based on this evaluation Observation on 12/5/16 at 2:15 p.m., of a smoke break revealed Resident Q (R Q ) was observed to independently ambulate into the smoking porch, sit down, pull a cigarette and lighter out of the pocket of his shirt, and light his cigarette. Interview with Certified Nursing Assistant (CNA) AA, at this time, revealed that R Q kept his own cigarettes, and revealed that R W keeps his own smoking material as well. Interview on 12/5/16 at 2:40 p.m., with the Assistant Administrator revealed that she thought the Minimum Data Set (MDS) nurse assessed residents for safe smoking, but that the MDS nurse quit about a month-and-a-half ago. The Assistant Administrator revealed that she didn't know how often the smoking assessments were being completed. She further stated that smoking materials were to be kept locked up at the nurse's station, except for residents A and B who were allowed to keep their own cigarettes. The Assistant Administrator added that to her knowledge, no residents were allowed to keep lighters. Interview on 12/5/16 at 3:23 p.m., with the Director of Nursing revealed that no residents were supposed to keep their own smoking materials, and that an assessment for safe smoking and an assessment to determine the residents' ability to safely keep their own smoking materials was not completed for any of the residents that smoke. Interview on 12/5/16 at 3:55 p.m., with the DON and the Assistant Administrator revealed that R V was the only resident that has been burned while smoking, and the Assistant Administrator revealed, at this time, that she was not aware that any residents had ever been burned. Interview on 12/5/16 at 5:51 p.m., with the Assistant Administrator and DON revealed that, with the residents' permission, they checked all the residents that smoke and checked their rooms and found that the following residents had smoking supplies in their possession: R Z: 2 cigarettes found, no lighter. R A: Lighter and cigarettes found. R Q: Cigarettes and lighter. Review of the Quarterly MDS, for R Z , dated 9/6/16 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating that he had no cognitive deficits. Interview on 12/6/16 at 11:36 a.m. with Resident Z (R Z ) revealed that he is a smoker and that he kept his cigarettes and lighter in his room prior to the survey. Continued interview revealed that he would go out to the solarium whenever he wanted to smoke and that he would smoke unsupervised at those times. Interview on 12/8/16 at 12:00 p.m. with the Assistant Administrator revealed that she did not know that resident Z smoked because he was not on the list of residents who smoked that was provided by the DON. Further interview revealed that R Q frequently signed himself out to walk to the corner store and that the resident would be able to purchase his own cigarettes and lighter at the store, but that she did not know if he purchased smoking materials for other residents. Interview on 12/9/16 at 4:30 p.m. with resident Z (R Z ) revealed that, prior to the survey, he would purchase cigarettes for other residents when he went to the store. Review of the Quarterly MDS, for R W , dated 9/23/16 revealed that he had a BIMS score of 11, indicating moderate cognitive impairment. Interview on 12/5/16 at 3:12 p.m., with R W revealed that he kept his own cigarettes and lighter. Review of the Quarterly MDS, for R Q , dated 9/17/16 revealed a BIMS score of 6, indicating severe cognitive impairment. Interview on 12/5/16 at 3:15 p.m. with R Q revealed that he would smoke anytime he wanted to, sometimes without staff present, because he was a senior citizen and I'm going to smoke. R Q further stated that he had never been told that he could not keep his own cigarettes, and cigarettes and a lighter were observed in his shirt pocket at this time. The resident further stated that he had lit other resident's cigarettes before. Review of the Quarterly MDS, for Resident A (R A , dated 10/25/16 revealed that she had a BIMS score of 15, indicating no cognitive deficits. Interview on 12/05/16 at 3:00 p.m., with R A revealed that she kept her own lighter and cigarettes. Review of the Annual MDS, for Resident R (R R ) dated 8/8/16 revealed that he had a BIMS score of 15 indicating that he is cognitively intact. Interview on 12/05/16 at 3:00 p.m., with R R revealed that he kept his cigarettes and lighter in his room in a drawer. R R also stated that he smoked by himself without the supervision of staff. Review of R the Quarterly MDS, for Resident B (R B ), dated 9/8/16 revealed that she had a BIMS score of 15, indicating no cognitive deficits. Interview on 12/05/16 at 3:06 p.m., with R B revealed that she kept her own cigarettes, which were observed under the seat of her walker, but no lighter. Clinical record review for Residents: V, Q, Z, A, V, W, R, Y, S that there was not any evidence of any documentation that there were safe smoking assessments had been completed prior to the survey. Interview on 12/8/16 at 11:55 a.m., with the Assistant Administrator revealed that she knew that some of the residents, such as R A kept their own cigarettes, but they were not allowed to keep lighters, and that she had never been told that any of the residents had a lighter. She further revealed that her expectation was that if staff saw a resident with a lighter they would tell her right away, but nobody had. Further interview revealed that staff would think nothing about a resident keeping cigarettes, as several residents do. Continued interview with the Assistant Administrator revealed that their smoking policy documents that residents were not allowed to keep any smoking materials, including cigarettes. Interview on 12/14/16 at 3:45 p.m., with the Assistant Administrator revealed that staff called her about every resident incident, accident, or hospitalization , and that she was shocked to find out last week that R V had been burned while smoking on 10/11/16. She further stated that the DON was supposed to record any resident concern on the Quality Assessment & Assurance Meeting form, and all recorded incidents were discussed at the quarterly QA meeting, but that the DON did not record that R V was burned on 10/11/16, on a QA form. Interview on 12/15/16 at 9:25 a.m., with the DON revealed that other than verbally telling a CNA to sit closer to R V during smoke breaks, no new interventions were added to the care plan after he was burned on 10/11/16. The DON further revealed that she did not recall if she told the Assistant Administrator about R V getting burned. Interview on 12/14/16 at 3:45 p.m., with the Assistant Administrator revealed that she was aware that R A and R B insisted on keeping their cigarettes, but she did not know they were keeping lighters. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All 12 residents that smoked had the potential to be affected. Each room for the residents that smoke and residents who signed out to got to the store was searched by the Assistant Administrator, the DON, Office Manager and front hall charge nurse on 12/5/16. 2. All smoking materials were removed from the resident or from their room, the smoking material was labeled and stored at the nurse's station in a secure area that is not accessible to residents. 3. All residents who smoke were educated on one to one basis about why the smoking materials were being collected to prevent unsupervised smoking by any resident in the facility to ensure the safety of all residents. 4. Signs were posted on the entrance door on 12/5/16 stating that all smoking materials be taken to nurse at the nurse's station to be labeled and stored. 5. Staff members assigned by Administrator to purchase smoking supplies are the DON, Assistant Administrator, or the Office Manager and all purchases are to be taken directly to the locked storage area. 6. Family members who purchase cigarettes for their residents that smoke were informed that no resident will be allowed to keep smoking materials in their possession. The family's were also asked to tell any other family members that might purchase smoking materials for a resident to never give the smoking materials to the resident as a part of revised smoking procedures to ensure safety of all residents in the facility. 7. Doors to the smoking area were locked by the Assistant Administrator. 8. Signs posted on smoke area doors on 12/5/16 reminding staff to keep doors locked at all times. 9. Key to the smoke room door will be kept in locked drawer of front hall storage cart effective 12/5/16. 10. Effective 12/5/16 the key to smoke area will only be given to the CNA on the shift assigned to smoke break. 11. Each resident that smokes were checked on 12/5/16 every fifteen minutes for twenty-four hours to ensure that no smoking resident was smoking unsupervised at any time. 12. On 12/6/16 residents that smoke were monitored every hour by CNAs assigned by the DON to ensure that the resident was not smoking unsupervised and were not in possession of smoking materials for twenty-four hours. 13. On 12/6/16 residents that smoke were given written copies of new smoking procedures. Identification of other residents having potential to be affected: Environmental assessment conducted on 12/6/16 by the Assistant Administrator and the DON checked for safety hazards and environmental issues and lack of supervision that could cause a resident to have an incident or accident. 14. In-service initiated on 12/6/16 at 7:00 a.m. until 8:00 a.m. with the DON and the MDS nurse to ensure that all residents that smoke are being assessed on admission for safe smoking practices. The smoking assessment will be updated each time there is a significant change in the resident condition, any time the smoking resident has a hospital stay, and quarterly. Residents will also be reassessed after any incident or accident related to smoking. The importance of ensuring that each resident has a current plan of care that is reflective of his or her current condition and is monitored to ensure that each resident is receiving care under the direct supervision of qualified persons. 15. The DON and MDS nurse will be reeducated annually and upon hire by the QA Coordinator to ensure that compliance is maintained by reviewing smoker's chart to ensure that an updated smoking assessment is on each smoker's chart. The CNA and charge nurses will be educated annually to ensure all care is in accordance and updated care plan by the QA Coordinator. 16. All charts of the residents that smoke were reviewed on 12/5/16 and all the charts have an updated care plan that address smoking and a smoking assessment that is current. 17. All charts for the residents who smoke will be monitored weekly by the 11-7 charge nurse to ensure smoking assessments and smoking care plans are updated after any incident or accident related to smoking, after a hospital stay, after a significant change in condition and quarterly effective 12/5/16 and will continue ongoing. 18. All residents that smoke will be assessed daily by the DON, assigned CNA and/or charge nurse on duty. Monitoring will include the location of the resident and if they were in violation of the smoking policy. The DON will make the assignment daily for the monitoring. In her absence the Relief RN will assign the nursing staff. This went into effect 12/5/16 and will be ongoing. 19. All resident charts were checked by the DON and MDS nurse to check for any other residents that could have be affected by not being assessed and as needing, and not having a care plan, in place that ensures care is being provided by qualified staff. No problems were found. 20. The MDS nurse will check the charts for all residents that smoke effective 12/5/16 to ensure that all assessments are being completed on all residents on a weekly basis and this check will be ongoing. The MDS nurse will ensure that all residents have a current personalized plan of care that reflects their needs to ensure that care is being provided in a manner in accordance with acceptable standards of care. 21. The QA team will audit the smoker's chart monthly to check for smoking assessments and smoking care plans that are current beginning 12/6/16 and continuing each month thereafter. The Smoking Policy and Procedures will be evaluated each month by the QA team to ensure continued compliance. In-service education that will include the Smoking Policy and procedures will be required annually relating to the provision of care by qualified persons that meets the care needs of each resident. 22. The DON will also check the charts of the residents that smoke monthly to ensure smoking assessment and smoking care plans are on each smoker's chart. The check by the DON will ensure that all assessments are current and reflects the resident's current status. Measures in place to prevent deficient practice: 1. Residents that smoke and are assessed to need aprons will wear a smoking apron. The DON will let the assigned staff know who is to wear a smoking apron while smoking and it will be posted on the nursing staff board on 12/5/16 and will be updated when a resident that smokes is assessed to need a smoker's apron by the DON. 2. Daily checks by nursing staff to ensure that no resident has smoking materials on each shift effective 12/5/16 and continuing ongoing. Any resident found to be in violation of the Smoking Policy will be reported to the Administrator immediately. 3. Assistant Administrator enlisted the support and cooperation of residents, family members and all staff to make sure the Smoking Policy and procedures are being followed. 4. The Administrator or Assistant Administrator will enforce the policy. 5. Assigned nursing staff will supervise the resident for the entire smoke break. 6. All staff instructed to report any resident observed smoking in non-designated areas and possessing smoking materials beginning 12/5/16 and continuing ongoing to ensure continued compliance. 7. CNAs to sit on each hall to monitor the residents for smoking in non-designated areas and possessing smoking materials beginning 12/5/16 and continuing ongoing to ensure continued compliance. 8. Smoking aprons ordered 12/5/16 arrival date 12/7/16. 9. Lighters will be provided by the Administrator and kept with smoking materials at the nurse's station. 10. Effective 12/5/16 residents who smoke will not be admitted to (facility name). We currently have twelve (12) residents that smoke and they will be assisted to safely smoke by nursing staff in a safe manner. Monitoring: 1. A smoking assessment will be completed on each smoker on admission, quarterly, annually, or when a significant change occurs with the resident. A smoking assessment will be completed when a smoking resident has an incident/accident related to smoking and after a hospital admission. 2. Only staff approved by the Administrator will be allowed to purchase smoking materials for the resident. 3. Residents informed of the new smoking procedures on 12/5/16. On 12/6/16 residents that smoke were given copies of revised smoking procedures. On 12/7/16 each resident that smokes was given a written copy of the Smoking Policy that each smoking resident read in the Assistant Administrator's presence. Each resident signed an acknowledgement of receipt of the Smoking Policy. The Acknowledgment Sheet was placed on each smoking resident medical chart on 12/8/16. 4. Staff will closely supervise residents that smoke while they smoke and never leave them unattended for any reason. 5. Residents that smoke will be monitored daily on each shift by the DON, MDS nurse, assigned CNA and/or charge nurse on duty to ensure that the smoking procedures are not being violated. If a violation occurs the Administrator will be notified immediately by the DON or Registered Nurse (RN) on duty. This will be effective 12/5/16 and ongoing. 6. Residents will smoke at 9:00 a.m., 2:00 p.m., 5:00 p.m., and 9:00 p.m. each day on the rear porch of the designated smoking area. 7. Smoking aprons to be used by residents assessed to need apron. 8. Newly hired staff will be educated on smoking policy prior to being allowed to work upon hire and then quarterly thereafter. 9. No resident will be allowed to keep smoking materials effective 12/5/16 on their person or in their room. 10. Smoking materials will be kept locked at nurse's station when not in use. 11. Smoking Policy signed by residents on 12/7/16 after education on the Smoking Policy by the Assistant Administrator. 12. All staff required by Administrator to report all accidents/incidents to her effective 12/5/16. 13. Family members will not be allowed to take a smoking resident to smoke without staff present. 14. The Administrator or Assistant Administrator will check daily during the morning, mid-shift and at the end of her shift each day on going to ensure continued compliance with the Smoking Policy effective 12/5/16 and continuing ongoing. 15. Housekeeping staff will check resident rooms/bathrooms and common areas daily effective 12/5/16 for smoking materials and signs of smoking in non-authorized areas. This will be an ongoing check. 16. Doors to smoke area will be locked at all times when not in use during smoke breaks. 17. Assistant Administrator enlisted the cooperation and support of residents, family members and all staff to ensure Smoking Policy and procedures are being followed at all times. 18. Quality Assessment (QA) team will check to ensure Smoking Policy and procedures are being followed. Audits of monitoring sheets will be checked each week for one month and then monthly. 19. Administrator will enforce the Smoking Policy and procedures. 20. Verbal warning for first violation of smoking procedures/policy. A smoking resident will be given a written warning for violations of the smoking procedures and then the Administrator will issue a thirty day discharge notice. All residents that smoke have been given a copy of the Smoking Policy and a signed copy was placed on resident chart 12/8/16. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. Review of a Quality Assurance (QA) Target document dated 12/5/16 documented that each resident that smokes room was searched for smoking materials on 12/5/16, removed when found, and labeled and stored in a locked area of the nurse's station. On 12/5/16 at 5:51 p.m., the Assistant Administrator and DON stated that they found that residents Z was in possession of cigarettes, and that residents A and Q were in possession of cigarettes and lighters. 2. Observation in the locked storage cart on 12/9/16 at 3:30 p.m. with LPN FF revealed that smoking materials were locked inside. 3. An Acknowledgement of Receipt form was given to and signed by all 12 residents that smoke and the Assistant Administrator that documented: I have been informed of the (name of facility) smoking standards and policy. I understand that violation of this policy may result in my discharge from the facility. I have received a copy of the smoking standards and policy and agree to abide by them during my stay at name of facility listed. 4. Observation on 12/9/16 at 3:52 p.m., revealed a sign was observed posted by the locked door entering into the front hall from the main lobby that said: All smoking materials should be taken to the charge nurse at the nurse ' s station for labeling and storing. 5. Interview on 12/9/16 at 2:39 p.m., with the Assistant Administrator she stated that only the Assistant Administrator, the Office Manager, or DON were allowed to purchase smoking materials for the residents. 6. Review of a QA Target form dated 12/5/16 documented that the Assistant Administrator notified all family members of the new smoking policy and asked them to bring all smoking materials to the charge nurse at the nurse's station. 7. Observations 12/5/16 at 6:30 p.m., and 12/8/16 at 8:19 a.m. revealed the smoking porch doors locked between smoke breaks. Observation on 12/8/16 at 9:10 a.m., of R W revealed the resident was in the solarium. Staff was observed giving the resident a cigarette and observed lighting the cigarette for him. The resident was observed to smoke safely at that time. 8. Observation on 12/9/16 at 2:10 p.m., revealed a sign posted on the outside of the two smoke porch doors that documented: Keep doors locked at all times except during smoke breaks. 9. Observation on 12/9/16 at 3:30 p.m., the key to open the smoke porch doors was observed locked in the front hall storage cart. 10. Observation on 12/9/16 at 3:30 p.m., the Daily Assignment Sheet was documented to include the two staff assigned to monitor smoke breaks. See also #9 above. 11. Residents that smoke were checked every fifteen minutes for 24 hours beginning 12/5/16 for their location, and documented on Resident Condition forms. 12. The residents that smoke and smoking area were checked hourly beginning on 12/6/16, and documented on a log that included Door to smoke area locked, Cigarettes or Lighters found on resident, and Cigarettes or lighters found in room. 13. The Acknowledgement of Receipt form signed by all of the residents that smoke and/or the Assistant Administrator documented that they received a copy of the smoking standards and policy. A revised copy of the Smoking Policy and Procedure was obtained. Identification of other residents having potential to be affected: Review of a QA Target document dated 12/5/16 documented that each room for each resident that smokes was searched for smoking materials on 12/5/16, smoking material was removed when found, and labeled and stored in a locked area of the nurse's station. Interview on 12/5/16 at 5:51 p.m., with the Assistant Administrator and DON revealed that they found that resident A and was in possession of cigarettes and lighters. 14. There were no new admissions to the facility during the survey. All 12 current residents that smoke had a Safe Smoking Assessment completed and placed in their clinical records. Review of an in-service sign in sheet dated 12/6/16 documented that MDS LPN EE and the DON were in-serviced by the Assistant Administrator on timely assessment and care planning of residents that smoked. 15. Annual reeducation on smoking assessments and care plans to be completed by the Assistant Administrator. The DON and MDS nurse received an in-service on 12/6/16 on Timely Assessment and Care Planning of Residents that smoke All 12 care plans for the residents that smoke were reviewed and/or revised 16. All 12 residents that smoked had a Safe Smoking Assessment completed. The care plans for the residents observed keeping smoking material were updated. A new Safe Smoking Assessment Form was developed by the DON, and all 12 residents that smoke were assessed using this form. The only resident assessed for needing a smoking apron was Resident V . 17. An 11-7 Nurse Weekly Audit form was provided for documentation revealed completed smoking assessments and care plans. Telephone interview on 12/9/16 at 3:41 p.m., LPN UU, a 7:00 p.m. to 7:00 a.m. LPN, revealed that she had been educated that she would be responsible for making sure that all residents that smoke had a care plan for smoking and smoking assessments completed on a weekly basis 18. Interview on 12/9/16 at 2:39 p.m., with the Assistant Administrator on 12/9/16 at 2:39 p.m., revealed that she will ensure that the staff are doing the daily smoking monitoring during her daily rounds A Quality Assurance (QA) Smoking Audit form was developed to document the monitoring. The following interviews were conducted on 12/9/16, at 2:18 p.m., with CNA II, who works the 7:00 a.m. to 3:00 p.m. shift; at 2:21 p.m., with Activity Director HH; at 2:29 p.m., with LPN TT, who works the 7:00 a.m. to 7:00 p.m. shift; at 2:33 p.m. with LPN FF, who works the 7:00 a.m. to 7:00 p.m. shift; at 3:41 p.m. with LPN UU, who works the 7:00 p.m. to 7:00 a.m. shift, and; at 3:47 p.m. with CNA SS, who works the 3:00 p.m. to 11:00 p.m. shift, they all stated that they had been in-serviced on the smoking policies and procedures that included: that two staff were required to monitor smoke breaks, notify the Administrator for any infraction of the policy including residents keeping their own smoking material, and that the residents that smoke could not be left unattended during smoking. 19. Safe Smoking Assessments were completed on all 12 residents who smoked, and their Smoking care plan updated as needed. Review of the other residents' charts revealed that there were no other residents that smoke that needed to be assessed. 20. A form was developed titled, MDS Nurse Weekly Audit, to document completion of smoking assessments and care plans. 21. A Quality Assurance (QA) Smoking Audit form was developed to include the following items: Were any smoking materials found in resident possession? Any smoking materials found in smoker's room? Has any smoker been observed smoking in non-designated area? Have any infractions occurred? Are smoke doors locked? Are signs posted to keep locked? Are monitoring sheets being completed? Are smoking assessments up to date? Are care plans current? Are family members taking smoking materials to station? Has any unauthorized staff purchased smoking materials? Are resident smoking materials in locked storage? Are two staff members assigned to smoke break? Do ashtrays have any trash in them? Are smoking blankets and aprons in smoking area? Is smoking room key being kept locked when not in use? Does smoker have cigarettes at the nurse's station? Are employees giving cigarettes to smoking residents? Has any resident purchased smoking materials? Have you observed any resident with [MEDICAL CONDITION]