Every finding on record at Southwell Health and Rehabilitation

Based on observations, record review, and staff interviews, the facility failed to ensure the Wound Care Coordinator (WCC) followed infection control processes during wound care and supra-pubic catheter care for one of five residents (R) (R6) reviewed and observed for wound care and catheter care. This deficient practice had the potential to place R6 at risk of infection due to cross-contamination.Findings include:Review of R6's electronic medical record (EMR) revealed diagnoses including, but not limited to, quadriplegia, open wound of lower back and pelvis, pressure ulcer sacral region stage 4, and bed confinement status.Review of R6's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Section GG (Functional Abilities and Goals) documented that the resident was dependent for care. Section H (Bladder and Bowel) documented that the resident had an indwelling catheter. Section M (Skin Conditions) documented one unhealed stage 4 pressure ulcer, use of a pressure-reducing device for bed, a turning/repositioning program, nutrition or hydration interventions, pressure ulcer care, and application of nonsurgical dressings.Review of R6's care plan, with an onset date of 2/11/2025, revealed Problem areas of:1. Skin Integrity: Risk for impaired skin integrity due to impaired mobility and sensation, due to quadriplegia, and episodes of incontinence. Approaches included Low air loss mattress in place, start date 6/12/2025. Wound care as ordered, start date 3/3/2025. Apply lotion as needed for moist skin, incontinence care after each episode-2/11/2025. Offer fluids to maintain hydration, as indicated by the provider on 2/11/2025. Skin evaluation scheduled with daily care on 2/11/2025. Care plan last reviewed/revised 1/9/2026.2. Pressure Ulcer: [R6] has a stage IV pressure ulcer to his coccyx, start date 2/11/2025, edited 1/13/2026.3. Urinary Catheter: [R6] requires a suprapubic urinary catheter due to neurogenic bladder, start date 2/11/2025.4. ADLs Functional Status/Rehabilitation Potential Side Rail: [R6] is at risk for difficulty with bed mobility related to physical mobility impairment, as evidenced by the need for assistance with turning and repositioning.Review of R6's Physician Orders revealed an order dated 1/6/2026 of: Wound care: Coccyx wound care - Clean with Anasept spray, pack with Anasept gel moistened 2-inch kling gauze. Cover with sacral Allevyn. Use skin prep to peri wound. Catheter site - Clean with Anasept spray. Apply a drain sponge and secure it with tape. Change daily and PRN (as needed).Observation on 1/14/2026 at 9:57 am by the Wound Care Coordinator (WCC) performing wound care and catheter care for R6 revealed that during the procedures, the WCC removed the outer dressing and the packing from inside the deep wound bed and disposed of them in a trash can. The WCC sanitized her hands, changed gloves, cleaned the sacral wound with Anasept spray wound cleanser, then, using a long, cotton-tip applicator (medical Q-tip swab stick), WCC packed the wound with Anasept gel-moistened gauze that she had placed in Anasept gel beforehand. The WCC then applied skin prep to the surrounding skin and covered it with a dated [Name brand] dressing. Observation revealed the WCC did not change gloves and perform hand hygiene after cleaning the wound and before applying the gel-moistened gauze to the wound and covering it with a dressing. Continued observation of the WCC providing supra-pubic catheter care to R6 revealed the WCC sanitized her hands and put on gloves, cleaned the area around the catheter insertion site with Anasept wound cleanser, and applied a dated split drain sponge/dressing. Observation revealed the WCC did not change gloves and perform hand hygiene after cleaning the site and before placing the dressing.In an interview on 1/14/2026 at 10:13 am, the WCC confirmed she did not sanitize her hands and change gloves after cleaning both wounds, and before applying new dressings. She stated she should have sanitized her hands and changed gloves after cleaning the wounds, when going from dirty to clean, and before applying the new dressing.In an interview on 1/15/2025 at 8:15 am, the DON (Director of Nursing) stated she was made aware by the WCC that she missed a step during wound care and did not sanitize her hands or change gloves after she cleaned the resident's wound, and before packing the wound and covering it with a new dressing. The DON confirmed that the WCC should always sanitize her hands and change gloves after cleaning a wound, and before applying a new dressing. The DON stated her expectation was for the nurse to use hand hygiene and standard infection control precautions to prevent cross-contamination during wound care, including when changing gloves, after removing the dirty/soiled dressing, after cleaning wounds, and during any care when going from dirty or soiled to clean.

Based on staff and resident interviews, record review, and review of the facility's arbitration agreement, the facility failed to ensure three of three Residents (R) (R25, R80, R44) reviewed for arbitration agreements had agreements in place that provided the resident/responsible party a period of 30 days to rescind the agreement after it was signed. The facility's arbitration agreement provided a period of 10 days to rescind the agreement which had the potential to affect all residents of the facility. In addition, R80 and R44 had not been educated regarding the arbitration agreements and were not aware the arbitration agreements had been signed by their family members. Findings include: Review of the facility's Conditions of Service and Consent for Treatment located within the Admission Agreement included a section titled Agreement to Alternative Dispute Resolution, which was the facility's arbitration agreement. The document read, Patient agrees that any claim or dispute arising out of or related to the provision of health care services to Patient by [name of medical provider] . or their employees or agents, except as otherwise provided by herein, shall be resolved by final and binding arbitration . Patient is waiving right to Patient's right to a jury trial . Patient understands that Patient has the right to revoke this agreement no later than ten (10) days following signature . 1.Review of the untitled, undated admission record provided by the facility revealed R25 was admitted to the facility on [DATE]. Review of R25's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/14/2024 in the electronic medical record (EMR) under the MDS tab revealed R25 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Review of R25's Agreement to Alternative Dispute Resolution dated 8/23/2024 revealed it was signed on 8/23/2014 by R25's family member (F)25. The agreement documented a 10-day period after being signed in which the agreement could be revoked. 2. Review of the untitled, undated admission record provided by the facility revealed R80 was admitted to the facility on [DATE]. Review of R80's Admission MDS with an ARD of 8/14/2024 in the EMR under the MDS tab revealed R80 was intact in cognition with a BIMS score of 13 out of 15. Review of R80's Agreement to Alternative Dispute Resolution dated 8/12/2024 revealed the document was signed on this date by R80's family member (F)80. The agreement documented a 10-day period after being signed in which the agreement could be revoked. During an interview on 9/13/2024 at 3:07 pm, R80 was interviewed and stated she did not know anything about an arbitration agreement; however, she trusted F80 to sign documents on her behalf. 3. Review of the untitled, undated admission record provided by the facility revealed R44 was admitted to the facility on [DATE]. Review of R44's Admission MDS with an ARD date of 8/30/2024 in the EMR under the MDS tab revealed R80 was intact in cognition with a BIMS score of 15 out of 15. Review of R44's Agreement to Alternative Dispute Resolution dated 8/12/2024 revealed the R44's document was signed on this date by F44. The agreement documented a 10-day period after being signed in which the agreement could be revoked. Review of R44's Georgia Advance Directives for Health Care dated 8/28/2024 and provided by the facility revealed R44 designated his spouse as health care agent in the event he could not or did not want to make decisions. F44 was back up agent number two. Interview on 9/13/2024 at 3:18 pm, R44 stated his wife and then daughters assisted him with making medical/legal decisions. R44 stated he did not know anything about an arbitration agreement being signed or in place, but it was okay if his family had signed it for him. Interview on 9/13/2024 at 3:20 pm, the Admissions Director verified that F44 was listed as the third decision maker after R44's spouse and daughters. During the interview, the Admissions Director stated the Agreement to Alternative Dispute Resolution was located within the Admission Agreement under the Conditions of Service and Consent for Treatment and she reviewed it with the resident or the family member either before or at the time of admission. The Admissions Director stated if the resident could participate the resident signed it; otherwise, the family did. The Admissions Director verified the facility's arbitration agreement provided a 10-day period for revocation after it had been signed. The Admissions Director stated she implemented the hospital's arbitration agreement (part of the same organization) about two years ago and did not know the requirement was for a 30-day period to rescind the agreement. Interview on 9/13/2024 at 5:29 pm, the Administrator stated the arbitration agreement was hospital based and that was why the period to rescind was 10 days and not 30 days. The Administration stated he had not been aware of the discrepancy between the requirement for 30 days and the facility's policy of 10 days.

Based on staff interview, record review, and review of the facility's arbitration agreement, the facility failed to ensure three of three Residents (R25, R80, R44) reviewed for arbitration had arbitration agreements in place that allowed for a mutually agreed upon arbitrator and venue for arbitration. The facility's arbitration agreement delineated the specific arbitrator that would be used. This deficient practice had the potential to affect all residents in the facility. Findings include: Review of the facility's Conditions of Service and Consent for Treatment located within the Admission Agreement included a section titled Agreement to Alternative Dispute Resolution, which was the facility's arbitration agreement. The document read, The arbitration of any claim or dispute hereunder shall be administered by [name of organization] in Tifton, Georgia . 1.Review of the untitled, undated admission record provided by the facility revealed R25 was admitted to the facility on [DATE]. Review of R25's Agreement to Alternative Dispute Resolution dated 8/23/2024 revealed it was signed on 8/23/2024 by R25's family member (F)25. 2. Review of the untitled, undated admission record provided by the facility revealed R80 was admitted to the facility on [DATE]. Review of R80's Agreement to Alternative Dispute Resolution dated 8/12/2024 revealed the document was signed on this date by F80. The agreement documented the arbitration of any claim or dispute would be administered by [name of organization] in Tifton, Georgia. 3. Review of the untitled, undated admission record provided by the facility revealed R44 was admitted to the facility on [DATE]. Review of R44's Agreement to Alternative Dispute Resolution dated 8/12/2024 revealed the document was signed on this date by F44. The agreement documented the arbitration of any claim or dispute would be administered by [name of organization] in Tifton, Georgia. During an interview on 9/13/2024 at 3:20 pm, the Admissions Director verified the Agreement to Alternative Dispute Resolution identified the arbitrator that would be used, located in Tifton Georgia. The Admissions Director stated she implemented the hospital's arbitration agreement (part of the same organization) about two years ago and did not know the requirement for an arbitrator to be selected who was agreed upon by both parties and the requirement for an agreed upon venue/location. During an interview on 9/13/2024 at 5:29 pm, the Administrator stated the arbitration agreement was hospital based and that was why the arbitrator and venue were specified in the agreement. The Administrator stated he had not been aware of the discrepancy between the requirement for an agreed upon arbitrator and venue.

Based on review of facility policy and interviews, the facility failed to ensure policies were in place to comprehensively address abuse prevention and investigation in the healthcare system's long-term care facility. The healthcare system's policies and procedures utilized to direct the facility's prevention and investigation of abuse did not specifically incorporate elements of the long-term care regulation set related to abuse/neglect. Findings include: The facility's Abuse Prevention Policies were requested on 9/13/2024. The facility provided a system wide policy titled, Compliance Investigations dated 1/1/2020 and addressed the provider system's reporting of potential compliance concerns. The policy did not address expectations related to prevention of abuse and neglect in the long-term care setting, such as the mandatory vetting of staff members prior to hire or the recognition of abuse, nor did it address the specific long-term care requirements related to the investigation of allegations of potential abuse. Interview with the Heath System's Compliance and Accreditation Manager on 9/13/2024 at 10:50 am, she provided the health system's Compliance Investigations Policy and stated the policy was the only policy being utilized related to abuse in the facility. She confirmed the policy only addressed the reporting of potential abuse/timeframes based on the healthcare system's timeframes and did not address the facility's expectations or procedures related to the prevention of abuse, the vetting of staff, staff recognition of abuse, or the elements of an investigation of potential abuse in the long-term care setting. Interview with the Director of Nursing (DON) on 9/13/2024 at 3:29 pm, she stated she thought the facility had old policies and procedures related specifically to the prevention and investigation of abuse in long-term care somewhere, however there had been a push to try to merge the facility's long-term care policies together with the healthcare system's hospital policies related to risk management. The DON stated, We need our own policies and procedures (related to abuse). The DON confirmed the current policies and procedures being utilized by the facility were related to Risk Management rather than to elements required per the long-term care regulation set.

Based on interviews, record review and review of the facility's policy titled, Compliance Investigations, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of two residents (R) (R22) reviewed for abuse. Specifically, R22 alleged she was slapped hard on the hand by Certified Nurse Assistant (CNA) 1 and the allegation was substantiated by the facility, resulting in CNA 1's termination of employment. Findings include: The facility's Abuse Prevention Policies were requested on 9/13/2024. The facility provided a system wide policy titled Compliance Investigations dated 1/1/2020 addressed the provider system's investigations into potential compliance concerns. The policy did not address expectations related to prevention of abuse in neglect in the long-term care setting. Record review of R22's Admission Record. dated 9/12/2024 provided by the facility indicated the resident was admitted to the facility on [DATE] with diagnoses including but not limited to history of stroke. Review of R22's Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/18/2024 indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Review of R22's significant change in status MDS with an ARD of 8/6/2024 and found in the EMR under the MDS tab, indicated a BIMS score of one out of 15, which indicated the resident was severely cognitively impaired. Review of R22's care plan, updated 8/12/2024 indicated R22 had difficulty communicating due to her history of stroke. Interventions included speaking slowly, clearly, and concisely with the resident. The care plan indicated R22 had no behaviors exhibited. Review of the facility's Incident and Accident Log dated 3/1/2024 to 9/13/2024 revealed an incident of potential staff to resident abuse reported by R22 on 9/3/2024. The facility's Incident Report dated 9/3/2024 related to R22's report of potential physical abuse indicated, Resident reported staff was rough during care and would not stop when she was yelling help. She (R22) revealed CNA 1 was loud talking to her and that she slapped her on the hand. Resident stated she stayed awake because she did not know if the CNA would going to [sic] come back and smother me with a pillow. Review of the facility's document titled, Patient Relations dated 9/10/2024 provided by the facility indicated, Narrative description: On the afternoon of 9/3/2024, I visited with (R22) in her room. She told me she was feeling down because of an incident that occurred the night before. She told me that a CNA came into her room and slapped her on the hand when (R22) tried to tell her that she was hurting her. She stated to me She hit me! and She came in the room angry like she was trying to provoke me. R22 also told me that she was scared of this CNA and tried to stay awake all night because she was afraid the CNA will smother me. The document indicated CNA 1 had been suspended on 9/3/2024 pending results of an investigation into the incident and had been terminated related to the investigation on 9/9/2024. Review of the investigation summary related to R22's allegation of potential physical abuse indicated, Conclusion: As a result of the investigation on September 3, 2024, it was determined that the CNA's behavior and actions were not appropriate, and the CNA (CNA 1) was suspended until further notice. After review of the investigation and interview with the Resident and in coordination with Human Resources, CNA 1 will be terminated. Interview on 9/13/2024 at 11:30 am, R22 confirmed she reported the incident during which CNA 1 allegedly slapped her on the hand and stated, She was really rough with me. I was afraid of her. When she hit me, she didn't hit me easily. She hurt me. I was stunned. I was really afraid. Interview on 9/12/2024 at 3:28 pm the Director of Nursing (DON) confirmed R22's reported allegation of abuse and confirmed CNA 1 had been terminated related to the incident. Interview on 9/12/2024 at 3:34 pm with the health care system's Risk Manager, he confirmed he was responsible for investigating incidents system wide and confirmed CNA 1's employment had been terminated at the conclusion of his investigation into the event.

Based on resident and staff interviews, record review, and review of the facility's policy titled, System Policy and Procedures Advance Directives, the facility failed to ensure they had a copy or had followed up to obtain the Advanced Directive for one out of 24 residents reviewed in the initial pool (Resident (R) R80). R80's Family Member (F)80 indicated, at the time of admission, that they had R80's advanced directive documentation; however, did not bring it into the facility at the time of admission. Findings include: Review of the facility policy titled, System Policy and Procedures Advance Directives dated August 2021 revealed, If a patient has an Advance Directive, but does not present the document upon admission, Facility personnel encourage the patient, or his or her representative, to provide a copy as soon as possible .In addition, the Facility personnel member includes a reminder in the patient's medical record which indicates that the patient should be further queried as to whether he/she wishes to provide a copy of the Advance Directive to the Facility .All copies of Advance Directives and any amendments thereto remain in the patient's medical record. Review of the undated Face Sheet provided by the facility revealed R80 admitted to the facility on [DATE]. F80 was designated as R80's emergency contact. Review of R80's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/14/2024 in the electronic medical record (EMR) under the MDS tab revealed R80 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating cognitively intact. Review of the Advance Directive Questionnaire dated 8/12/2024 and signed by F80 provided by the facility revealed, I have executed an advance directive and will provide a copy to (Facility name) personnel as soon as possible. I understand that the staff and physicians of (Facility name) will not be able to follow the terms of my advance directive until I provide them a copy. Review of R80's EMR revealed no advanced directives document in the record. Review of the care plan dated 8/13/2024, and provided by the facility, identified the problem area of Advance Directives. The goal was, Full code will be honored, and intervention, No Advance Directive on file. Review of the Long Term Care Forms Social Service assessment dated [DATE] and provided by the facility revealed, Advance Directive: No, Family or Rep Notify . No. All social service documentation was requested following admission. There was no documentation provided showing the Social Service Coordinator (SSC) had followed up with the family to obtain R80's advance directive. Interview on 9/12/2024 at 3:59 pm, the SSC revealed the Admission Director typically obtained residents' advanced directives documentation on admission, and the Admission Director would give her a copy. The SCC revealed when she completed her admission assessment, she followed up if advanced directives had not been provided. The SCC revealed all residents were designated full code (resuscitate in the event their heart stopped beating/they stopped breathing) until advanced directives were provided or completed. The SCC verified there was no advanced directive provided or completed for R80 and stated she had not followed up with F80 to bring the advanced directive to the facility. Interview on 9/12/2024 at 4:27 pm, the Admission Director revealed when residents were admitted to the facility, the Advance Directive Questionnaire was completed. The Admission Director said she asked the resident or responsible party if there were any advanced directives and to provide them at that time. The Admission Director stated if there was an advanced directive, but it was not provided at admission, she would ask them to bring it to the facility. The Admission Director revealed she did not follow up after that and that the SSC was responsible for following up. Interview on 9/13/2024 at 3:07 pm, R80 revealed that F80 assisted with the completion of paperwork when she was admitted to the facility. R80 stated she was not sure about what advanced directive was in place and indicated she deferred the decision whether to be resuscitated to F80. Interview on 9/13/2024 at 5:40 pm, the Administrator verified the staff should follow up to obtain copies of the advanced directive if they were not provided at admission.

Based on staff interviews, record review, review of the facility's abuse policies, and review of the facility's policy titled, Compliance Investigations, the facility failed to ensure an allegation of abuse by one resident (R) (R22) of two residents reviewed for abuse was thoroughly investigated. R22 alleged she was slapped hard on the hand by a Certified Nurse Aide (CNA) 1 and the investigation into the allegation did not include interviews with additional residents or staff members to ensure no other residents had been exposed to potential abuse by CNA 1. Findings include: The facility's Abuse Prevention Policies were requested on 9/13/2024. The facility provided a system wide policy titled, Compliance Investigations. The policy was dated 1/1/2020 and addressed the provider system's investigations into potential compliance concerns. The policy did not address expectations related to the investigation of allegation of potential abuse. Review of R22's Admission Record. dated 9/12/2024 provided by the facility indicated the resident was admitted to the facility on [DATE] with diagnoses including history of stroke. R22's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/18/2024 and found in the EMR (electronic medical record) under the MDS tab, indicated a Brief Interview for Mental Status (BIMS)score of 14 out of 15, which indicated the resident was cognitively intact. R22's Significant Change in Status MDS with an ARD of 8/6/2024 and found in the EMR under the MDS tab, indicated a BIMS score of one out of 15, which indicated the resident was severely cognitively impaired. Review of the facility's Incident and Accident Log dated 3/1/2024 to 9/14/2024 revealed an incident of potential staff to resident abuse reported by R22 on 9/3/2024. Review of the facility's Incident Report, dated 9/3/2024 and related to R22's report of potential physical abuse indicated, Resident reported staff was rough during care and would not stop when she was yelling help. She (R22) states CNA was loud talking to her and that she slapped her on the hand. Resident stated she stayed awake because she did not know if the CNA would going [sic] to come back and smother me with a pillow. Review of the facility's investigation into R22's allegation of potential physical abuse revealed interviews had been conducted with R22 and CNA 1 related to the reported abuse, however the investigation file did not include any documentation to show interviews had been conducted with other residents in the facility to ensure no additional residents had been abused by CNA 1, nor did it include interviews with staff familiar with CNA 1 to ensure staff had not observed or received any reports of abusive behavior by CNA 1. Interview with the Director of Nursing (DON) on 9/12/2024 at 3:28 pm, revealed the facility did not have a designated abuse coordinator. She stated all potential abuse was reported to the health system's Risk Manager and the Risk Manager conducted all investigations. The DON stated the Risk Manager spoke with R22 as well as CNA 1 during the investigation, but she was not aware of whether he interviewed any additional staff or residents related to R22's allegation of abuse. Interview with the Risk Manager on 9/12/2024 at 3:34 pm, he confirmed he conducted the investigation into R22's allegation of potential abuse by CNA 1. He confirmed he interviewed R22 and CNA 1 during his investigation and stated he also obtained information about R22 from the resident's primary nurse, reviewed the facility's grievances, reviewed R22's medical record, completed a physical assessment of R22, and had R22 demonstrate to him how she had been slapped. The Risk Manager revealed he had not obtained statements from additional residents or staff members related to the allegation to ensure no further abuse had occurred.

Based on staff interviews, record review, and review of the facility's policy titled, System Policy and Procedures Behavioral Health, the facility failed to ensure one of three residents (R) (R36) who was reviewed for Pre-Admission Screening and Resident Review (PASARR) services was referred to the state-designated authority for Level II PASARR after a new mental illness diagnosis of schizoaffective disorder was added during her stay. Findings include: Review of the facility's policy titled, System Policy and Procedures Behavioral Health dated 1/30/2023 and provided by the facility revealed, [Facility name] staff reviews admission orders, history and physical, consultation report, as well as Pre-Admission Screening and Resident Review (PASARR) recommendations for diagnosis of mental disorder or psychosocial adjustment difficulty. When diagnosis is indicated, appropriate services and treatment are provided. Review of the untitled, undated admission record provided by the facility revealed R36 was admitted to the facility on [DATE]. Review of the PASARR Level I assessment dated [DATE] and provided by the facility revealed R36 had no serious mental illness diagnosis at the time of admission. Review of the Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/3/2023 in the electronic medical record (EMR) under the MDS tab revealed R36 had diagnoses including anxiety disorder, schizophrenia, and dementia. Section C reported a Brief Interview for Mental Status Score (BIMS) of two out of 15, which indicated the resident's cognition was severely impaired. Review of the Quarterly MDS with an ARD of 7/31/2024 in the EMR under the MDS tab revealed R36 had a BIMS score of six out of 15, which indicated severely impaired in cognition. Review of a psychiatry Office Clinic Note dated 1/11/2023 and provided by the facility revealed R36 saw a psychiatrist on this date and a diagnosis of schizoaffective disorder was initiated. The note read, She does report long history of mental health issue. Speaks of when she first began seeing psychiatrist in [location]. They told me then, sometimes my mind will be okay and sometimes it won't. Speaks of a time when she had to go get shots to calm me down. Unable to give any specific detail about this .Evidence of paranoia noted . Acting out with staff at times, refusing care, can be difficult to redirect . Interview on 9/12/2024 at 1:59 pm, Registered Nurse (RN) (RN 1) revealed a psychiatrist started seeing R36 on 1/11/2023 and a diagnosis of schizoaffective disorder was added at that time. Interview on 9/12/2024 at 3:51 pm, the Social Services Coordinator (SSC) revealed that when there was a mental illness diagnosis, the facility should request a PASARR Level II. The SCC stated she did not have access electronically to request PASARRs. The SSC stated she could not see the PASARRs; however, if she had been aware of R36's schizoaffective disorder diagnosis added after admission, that would have been a trigger to request a PASARR Level II. The SSC stated other staff such as the Admissions Director had access and could request PASARR Level II. Interview on 9/13/2024 at 10:13 am, the Compliance and Accreditation Manager revealed R36 had not been referred to the state-designated authority for Level II PASARR after the mental illness diagnosis of schizoaffective disorder was added. Interview on 9/13/2024 at 5:42 pm, the Administrator stated R36 should have been referred for a PASARR Level II once the schizoaffective disorder diagnosis was added.

15406 Based on observation, interviews, and record review, the facility failed to implement the comprehensive care plan for three residents (R) (R35, R71 and R25) of 21 sampled residents. Specifically, the failure created the potential for R25 to have inadequate care for an indwelling urinary catheter, and R35 and R71 to have inadequate care for edema in their lower extremities. Findings include: 1. Review of R35's undated Face Sheet provided by the Director of Nurses (DON) revealed R35 was admitted on [DATE] with diagnoses of combined systolic and diastolic heart failure and vascular dementia. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/12/2024 located under the Resident Assessment Instrument (RAI) tab revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 which indicated R35 was severely cognitively impaired. Review of R35's Physician Orders, provided by the DON, revealed an order dated 4/24/2024 for Above the knee Grad Compression Stocking. Review of R35's Care Plan, dated 8/22/2024 provided by the DON, revealed a problem of Fluid volume excess, with a goal to remain free of edema. The interventions included, .compression stockings as ordered; elevate extremities if edema present. Observations of R35 on 9/10/2024 at 11:24 am; 9/10/2024 at 3:46 pm; 9/11/2024 at 8:53 am; 9/11/2024 at 5:00 pm; and 9/13/2024 at 9:04 am revealed the compression stockings had not been put on the resident. Interview on 9/11/2024 at 5:00 pm, Licensed Practical Nurse (LPN2) confirmed R35 did not have TED (thrombo-embolic deterrent) hose (compression stockings that help prevent blood clots in the legs) on and stated, They may be in the laundry. I don't know if he has a second pair. Interview on 9/13/2024 at 9:12 am, LPN 1 confirmed R35 was not wearing TED hose and stated, They had to be put in the laundry, and we have only one pair. 2. Review of R71's undated Face Sheet, provided by the DON, revealed R71 was admitted on [DATE] with diagnosis chronic systolic congestive heart failure. Review of R71's annual MDS with an ARD of 7/23/2024 revealed a BIMS score of 10 out of 15 which indicated R71 had moderate cognitive impairment. Review of R71's Physician Orders, provided by the DON, revealed an order, dated 7/12/2024, for Above the knee grad (graduated) compression stockings, wear in the daytime, may remove at night. Review of R71's Care Plan, dated 6/20/2024, provided by the DON, revealed a problem of Fluid volume excess, with a goal to remain free of edema and have a decrease in fluid overload. The interventions indicated, .graduated compression stockings (TED hose) to be worn daily, may be removed at night. Observations of R71 on 9/10/2024 at 12:12 pm; 9/10/2024 at 2:17 pm; 9/11/2024 at 9:20 am; and 9/11/2024 at 4:45 pm revealed R71 was not wearing his compression (Ted hose) stockings. During an interview on 9/11/2024 at 5:04 pm, R35's physician stated, I do expect both residents to have them (TED hose) on when I order them. Interview on 9/13/2024 at 3:25 pm, the DON stated, We follow the physician's orders. We have extras [NAME] hose, so we don't need to order another pair of [NAME] hose for either resident. 3. Review of the undated Face Sheet provided by the facility revealed R25 was admitted to the facility on [DATE]. Review of R25's admission MDS with an ARD of 8/26/2024 and provided by the facility revealed R25 was moderately impaired in cognition with a BIMS score of 11 out of 15. The MDS assessment also documented R25 utilized an indwelling urinary catheter. Review of All Active Orders dated 8/23/2024 through 9/12/2024 and provided by the facility revealed, Urinary Catheter Care LTC (Long Term Care) (Foley Care LTC) every 12 hr. (hours). The frequency that nurses were to change the indwelling urinary catheter was not documented in the orders. Review of the Care Plan dated 8/28/2024 and provided by the facility revealed a problem of LTC Urinary Incont (incontinence) indwelling cath [catheter]. The goal was, Optimal level of bladder function without complications. Interventions were in pertinent part, .Check urinary bag for proper placement, Change catheter according to MD (Medical Doctor) orders. Observation and interview on 9/10/2024 2:41 pm and on 9/11/2024 at 4:58 pm, R25 was in bed and her catheter bag was wrapped in a sheet and lying directly on the floor near the bed. R25 revealed she did not know how long it had been on the floor. During an observation and interview on 9/11/2024 at 5:00 pm, Registered Nurse (RN) 2 entered R25's room and verified the catheter bag and tubing were lying directly on the floor. RN 2 stated the catheter bag should not be on the floor due to the possibility of infection, and it could be stepped on and pulled out. Interview on 9/13/2024 at 11:44 am, RN 2 verified there were no physician's orders specifying when the indwelling urinary catheter should be changed even though the care plan directed changing it in accordance with physician's orders. Interview on 9/13/2024 at 4:55 pm, the DON revealed staff knew the catheter bag and tubing should be below the bladder but not placed directly on the floor.

Based on observation, staff and resident interviews, and record review, the facility failed to ensure one of one resident (R) (R25) reviewed for indwelling urinary received appropriate care and services to prevent urinary tract infections (UTI). Specifically, there was no physician orders for the size of the indwelling urinary catheter and how often to change it and R25's catheter and/or tubing were observed resting on the floor for three out of four days of the survey. These failures created the potential for R25's catheter to become dislodged and for R25 to get a UTI. The sample size was 31 residents. Findings include: Review of the undated Face Sheet provided by the facility revealed R25 was admitted to the facility on [DATE]. Review of R25's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/26/2024 and provided by the facility revealed R25 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. During an interview on 9/12/2024 at 12:38 pm, the Medical Director, who was also R25's attending physician, revealed he was not sure why R25 had a catheter. The Medical Director stated the rationale for the catheter was likely in the History and Physical (H & P) note. Review of the Physician's History and Physical Consultation Note dated 8/23/2024 and provided by the facility revealed, No dysuria [painful or uncomfortable urination] or frequency. Foley catheter in place for some reason. The rationale/diagnosis was not documented. Review of All Active Orders dated 8/23/2024 through 9/12/2024 and provided by the facility revealed, Urinary Catheter Care LTC [Long Term Care] (Foley Care LTC) every 12 hr. [hours]. Specific information such as the size of the catheter, frequency nurses were to change the catheter, or whether urinary output should be monitored was lacking. The reason for use of the catheter was not documented. Review of the Care Plan dated 8/28/2024, provided by the facility, revealed a problem of LTC Urinary Incont [incontinence] indwelling cath [catheter]. The goal was, Optimal level of bladder function without complications. Interventions indicated, Eval [Evaluate] for symptoms of UTI. Promote hydration, proper cleansing. Check for physician diagnosis of urinary retention or other medical justification for use of continuous foley. Anchor drainage tube of foley to prevent tension. Check urinary bag for proper placement. Change catheter according to MD [Medical Doctor] orders. During an interview on 9/10/2024 at 2:41 pm, R25 stated she did not know why she had the catheter, and she had not used one at home prior to admission. During an observation and interview on 9/10/2024 2:41 pm and on 9/11/2024 at 4:58 pm, R25 was lying in bed and her urinary catheter bag was wrapped in a sheet and the catheter bag and tubing were lying directly on the floor near the bed. R25 stated she did not know how long it had been on the floor. During an observation on 9/11/2024 at 5:00 pm, the Registered Nurse (RN)2 entered R25's room and verified the catheter bag and tubing were lying directly on the floor. RN2 stated there was usually a hook for the catheter bag so it could be hung on the bed frame; however, she stated she did not see a hook as she looked under the bed. RN2 stated R25 would not have been able to put the bag on the floor. RN2 stated that Certified Nursing Assistants (CNAs) were responsible for securing the bag. RN2 stated the catheter bag should not be on the floor due to the possibility of infection, and it could be stepped on and pulled out. During an interview on 9/11/2024 at 5:13 pm, CNA4 stated she was assigned to R25, and the catheter had been hooked on the side of R25's bed earlier. CNA4 stated, It must have fallen off. CNA4 stated the catheter bag, and tubing should not be on the floor. CNA4 verified R25 would not have been able to put the catheter bag on the floor herself. During an observation on 9/13/2024 at 10:05 am, R25 was seated in her wheelchair in her room. The catheter bag was in a privacy bag attached to the chair; however, the tubing was resting on the floor. During an observation and interview on 9/13/2024 at 10:28 am to 10:34 am, the Compliance and Accreditation Manager stated the facility did not have a policy and procedure for catheters. During the observation of R25's catheter tubing on the floor while R25 was in the wheelchair, the Compliance and Accreditation Manager verified the tubing was resting on the floor. During an interview on 9/13/2024 at 11:44 am, RN2 verified there were no physician's orders specifying when the catheter should be changed. RN2 stated the physician's order should document the size of the catheter and when it should be changed. RN2 stated R25 had an appointment on 9/18/2024 to see a urologist and that was why no attempt had been made in the facility to remove the catheter. RN2 stated the catheter had been inserted in the hospital prior to the resident's admission to the facility and an attempt had been made in the hospital to remove it. RN2 stated there was hospital documentation that indicated R25 had urinary retention and obstruction. Review of the hospital Insert Urinary Catheter (Order [number]) dated 8/19/2024 and provided by RN2 revealed, Indicate reason for foley. Urinary retention, obstruction or training. During an interview on 9/13/2024 at 4:55 pm, the Director of Nursing (DON) stated staff knew the catheter bag and tubing should be below the bladder but not directly on the floor. The DON stated the catheter bag should be hung, in a privacy bag, and the catheter bag should have a hook on it. The DON verified there should be an order for the size of the indwelling urinary catheter and how often to change the catheter as well as the reason for the catheter's use.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Bed Rail Policy, the facility failed to ensure one of three Residents (R) (R27) reviewed for accidents had been assessed for the use of bed/side rails, had physicians orders for the bed/side rails, a care plan, and an informed consent from the resident for the use of the bed/side rails. Specifically, R27 had bilateral 1/3 bed/side rails applied to his bed and his bed/side rail assessment, physician orders, and care plan did not accurately reflect the resident's use of the bed/side rails. This failure created the potential for the resident to be injured related to the potentially unnecessary bed/side rails on his bed. The sample size was 31 residents. Findings include: Review of the facility's policy titled, Bed Rail Policy dated 7/31/2023 under the section titled, Policy revealed, An evaluation for bed rail use and an entrapment assessment is completed before bed rails are applied .The risks, alternatives and benefits of bed rails are reviewed with the resident and his/her representative prior to use .Once consent is signed, staff obtain an order from the resident's physician for bed rail use .The resident's care plan is then updated by staff to include the use of bed rails. Review of R27's Admission Record dated 9/13/2024 and provided by the facility indicated the resident was admitted to the facility on [DATE] with diagnosis of quadriplegia. Review of R27's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 7/12/2024 and found in the EMR under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. The MDS indicated the resident was dependent upon staff to move in his bed and was dependent upon staff for transfers in and out of his bed. The assessment indicated R27 was not using bed/side rails on his bed. Review of R27's Physicians Orders, dated 9/13/2024 and found in the EMR under the Orders tab, indicated no orders for the resident's use of bed/side rails on his bed. Review of R27's comprehensive care plan dated 5/30/2024 and found in the EMR under the Care Plan tab did not indicate the resident's use of bed/side rails. Review of R27's EMR under the Assessment tab revealed the most recent Bed Rail Evaluation, was dated 8/9/2020 and indicated bed/side rails were in use for the resident for a sense of security. Review of R27's EMR revealed no documentation that the resident had been provided with information related to the risk and benefits of using bed/side rails and that the resident had given informed consent for the use of bed/side rails on his bed. Observation on 9/11/2024 at 9:45 am, on 9/12/2024 at 9:56 am, 11:22 am, and 5:17 pm, and on 9/13/2024 at 8:51 am revealed R27 was lying in his bed with bilateral 1/3 bed/side rails in the raised position at the head of his bed. Interview on 9/11/2024 at 9:45 am, R27 revealed he was not able to use his bed/side rails at all due to his quadriplegia and contractures to both of his hands/arms. He confirmed he was not able to move at all on his own and was completely dependent upon staff for mobility. Interview with the Compliance and Accreditation Manager on 9/13/2024 at 10:17 am, she confirmed that R27 did not have physician orders for the bed/side rails, the care plan did not indicate the use of the bed/.side rails, a recent bed/side rail assessment, and documentation that the resident had consented for the use of bed/side rails. She stated R27 was not supposed to have bed/side rails on his bed because he was unable to use them.

Based on observations, staff interviews, record review, and review of the facility policy titled, Storage of Medication (SHR), the facility failed to ensure that one resident of 18 residents (R15) was administered insulin that was not expired; failed to ensure that one resident of 18 residents (R16) had prescribed Novolog insulin available for coverage; failed to ensure that two of three medications storage room were free of expired medications. The facility census is 80. Findings include, Review of the facility policy Storage of Medication (SHR) dated October 23, 2023, Proacedure: The following procedure is used to store medications: 1. All medications and any components used in their preparation are labeled with the contents, expiration date and any applicable warnings. Those medications not previously labeled with an expiration date shall be labeled on the vial and not the box. 3. All expired, damaged, mislabeled, and/or contaminated medications are removed from the storage area for medications available for administration and stored separately. 5. When a multi-dose vial has been opened or accessed, the vial is dated and discarded within twenty-eight (28) days unless the manufacturer specifies a different date for that opened vial. If a multi-dose vial has not been opened or accessed, it is discarded according to the manufacturer's expiration date. 1. An observation on 11/27/2023 at 12:15 pm observed with Licensed Practical Nurse (LPN) BB revealed that R15 vial of Humalog (Lispro) insulin vial had an open date of 10/10/2023. The Lispro insulin expired on 11/7/2023. Review of the Medication Administration Record (MAR) dated 11/15 revealed R15 was administered Lispro insulin on 11/15/2023 at 6:58 pm, 11/17/2023 at 9:00 am, 11/17/2023 at 12:00 pm, 11/18/2023 at 9:00 am, 11/18/2023 at 12:00 pm, 11/19/2023 at 12:00 pm, 11/21/2023 at 8:30 am, 11/21/2023 at 5:10 pm, 11/22/2023 at 8:30 am, 11/22/2023 at 1:12 pm, 11/23/2023 at 7:54 am, 11/24/2023 at 11:54 am, 11/24/2023 at 6:33 pm, 11/25/2023 at 1:34 pm, 11/25/2023 at 6:00 pm, and 11/26/2023 at 5:45 pm. Review of the physician order revealed that R15 had an order for the Humalog (Lispro) insulin to administer eight units before meals three times a day. There was no evidence that R15 had an adverse outcome with the expired Lispro insulin. An interview on 11/27/2023 at 12:15 pm, LPN BB revealed that R15 had refused her lunch time insulin. She continued to state that the nurses are responsible for discarding expired medications and that she checks once a week for expired medications. 2. An observation on 11/28/2023 at 11:43 am, observed LPN AA obtained blood glucose (sugar) finger stick on R16 who had a result of 329 mg/dl which required five units of Novolog insulin coverage. There was no evidence of Novolog insulin in the medication cart for R16. LPN AA went into the medication storage room to a pixel and pharmacy stock box, there was no Novolog insulin. Review of the physician order revealed that R16 had an as need order for insulin aspart (Novolog correctional dose Low) with a start date of 11/6/2023. The Novolog insulin has parameter to administer subcutaneous injection for hyperglycemia as needed. An observation on 11/28/2023 at 12:05 pm, LPN AA and Registered Nurse (RN) CC verify that a vial of Novolog insulin that was labeled with another resident (R14) name. LPN AA withdrew five units of the Novolog insulin and administered the Novolog insulin to R16. An interview on 11/28/2023 at 2:12 pm. LPN AA revealed that they had spoken to RN CC about not having any Novolog insulin coverage in the medication cart and wanted permission to use R14 Novolog insulin because of the high result of R16. She continued to state that RN CC had ordered the Novolog insulin for R16 but, it would not get delivered until that night. RN CC told her it was okay to give the Novolog from R14 insulin vial. An interview on 11/28/2023 at 2:34 am RN CC revealed that they went to the Director of Nursing (DON) and informed her that there was no Novolog insulin for R16 coverage. And that it would take a while to get insulin from the pharmacy. The DON gave permission to pull from R14 insulin vial because R16 needed insulin coverage. And was instructed to verify the insulin order. She and LPN AA verify the Novolog insulin order. Normally, there is a lock box in the medication storage room that would have the extra insulin in the lock box, but she did not check behind the LPN. She continued to state that the Novolog insulin had been ordered from the pharmacy. An interview on 11/30/2023 at 9:52 am, the DON revealed that she gave the staff nurses permission to use another resident (R14) Novolog insulin for coverage. And that the multiple vial had not been in the resident's (R14) room. 3. During an observation on 11/27/2023 at 11:33 am, observed with LPN DD on the Live Oak Hall, the Medication Storage room revealed one unopened bottle of Ibuprofen 100 mg with an expiration date of 10/23. An interview on 11/27/2023 at 11:33 am, LPN DD stated that the nurses on the hall are responsible for removing expired medication from the shelf. 4. During an observation on 11/27/2023 at 12:10 pm, observed with RN CC, the Day Lilly Hall medication storage room revealed one unopened bottle of B-2 100 mg with an expiration date of 5/23. An interview on 11/27/2023 at 12:10 pm, RN CC revealed that the charge nurses, or supervisors are responsible for rotating the stock medications and removing any expired medications. And that she will dispose of the expired medication.

Based on family and staff interviews, record review, and review of the facility policy titled, Informing Resident of Health Status, the facility failed to notify the family of a physician's order for one of 14 residents (R) R A. Specifically, the facility failed to notify the family of the results of a bladder scan for RA. Findings include: Review of the facility policy titled Informing Resident of Health Status dated June 17, 2013, indicated the resident and, when appropriate, the family/representative are given clear, concise explanation of: The resident's condition and any changes in the condition. Any proposed treatments(s) or procedure(s). The potential benefit(s), risk(s), and alternative(s) of the proposed treatment(s) or procedure(s) and potential risks or refusal of care. Review of the 10/19/2022 Nurse's Notes for R A documented the overnight sitter reported the resident had not voided all night. The physician was made aware and ordered a bladder scan. Review of the 10/19/2022 bladder scan results showed an impression of large postvoid residual and possibly enlarged prostate. Further review of the clinical record revealed there was no documentation the family was made aware of the physician's order for the bladder scan nor were they notified of the results of the bladder scan. During an interview with the family member on 3/23/2023 at 3:00 p.m., they stated no one from the facility had informed them of the physician's order for a bladder scan. During an interview with the Director of Nursing on 3/23/2023 at 12:45 p.m., she confirmed there was no documentation the family was notified of the physician's order for a bladder scan nor the results of the scan.

Based on record review, staff and family interviews, and review of the facility policy titled, Care Plans, the facility failed to provide a copy of the summary of the baseline care plan to the responsible party for one of 14 residents (R) (RA). Findings include: Review of the policy titled Care Plans dated December 5, 2022, indicated the facility provides the resident and his/her representative, if applicable, with a written summary of the Baselines Care Plan that includes the following: a. Initial goals for the resident. b. A list of current medication and dietary instructions. c. Services and treatments to be administered by the facility and personnel acting on behalf of the facility. The policy further noted Baseline Care Plans are documented in the Electronic Medical Record (EMR). During an interview with the family of R A on 3/23/2023 at 3:00 p.m., she stated that they never received a copy of the baseline care plan for the resident. Review of the EMR, revealed there was no indication a baseline care plan had been done and no evidence a copy of the summary of the baseline care plan had been given to the family. During an interview with the Director of Nursing (DON) on 3/23/2023 at 12:45 p.m., she stated there was no documentation the family had received a copy of the summary of the baseline care plan. During an interview with the Survey Accreditation Manager on 3/22/2023 at 2:45 p.m., she stated they have identified problems with the current system used for electronic charting. They have realized once a resident is discharged from the facility the comprehensive care plan is no longer available.

Based on record review, staff interview, and review of the facility policy titled, Care Plans, the facility failed to implement the care plan interventions to provide wound care as ordered for three of 14 residents (R)(R#4, R#5 and R#6) with pressure ulcers. The deficient practice had the potential to affect the progression of the residents' wounds by not providing wound care as ordered by the physician for R# 4, R#5, and R#6. Findings include: Review of the facility policy titled Care Plans dated December 5, 2022, noted the following under Purpose: The purpose of this Policy is for [NAME] Health and Rehabilitation staff to develop and implement a Baseline Care Plan for each resident that includes instructions needed to provide effective and person-centered care of the resident upon admission. Policy: [NAME] Health and Rehabilitation will develop and implement a Comprehensive Person-centered Care Plan for each resident within 21 days of admission or within seven days of completion of the Comprehensive Assessment. The Comprehensive Care Plan includes interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that are implemented. 1. Resident #4 was admitted to the facility on [DATE] with the following but not limited to diagnoses of: Stage 4 pressure ulcer left buttock, hypertension, coronary atherosclerosis, peripheral vascular disease, cerebrovascular disease, hemiplegia, and mental disability. Review of R#4 care plan updated on 12/12/2022 revealed a pressure ulcer with an intervention to provide wound care as ordered. Review of the Nursing Narrative note dated 12/7/2022 documented the resident had an unstageable decubitus to her left ischium that measured 3.5 centimeter (cm) wide 2.9cm long 0.2 cm deep. The physician was notified on 12/7/2022 and an order was obtained to clean the unstageable decubitus to the left ischium with anasept spray and apply Santyl ointment and medihoney every two days and as needed. However, review of the December 2022 treatment documentation revealed there was no documentation the treatment was done until 12/9/2022 and there was no documentation the dressing was changed every two days as ordered from 12/15/2022 to 12/21/2022. On 12/21/2022 a new physician's order was obtained to clean wound to left ischium with normal saline or anasept, pack wound with anasept moistened gauze and cover with dry dressing daily. Review of the December 2022 treatment documentation revealed there was no documentation the dressing was changed daily as ordered from 12/28/2022 to 12/30/2022. A physician's order was obtained on 1/5/2023 to begin negative pressure wound therapy wound vac continuously at 125mm/hg (millimeter of mercury) pressure, apply white foam in base then apply black foam. Apply anasept spray 10 minutes prior to each dressing change three times weekly and as needed Tuesday/Thursday/Saturday. Review of the 1/2023 treatment documentation revealed there was no documentation the treatment was done as ordered from 1/5/2023 to 1/17/23. A physician's order was obtained on 1/17/2023 to clean sacrum wound with anasept spray and apply anasept spray-soaked gauze everyday as needed and cover with a mepilex dressing if wound vac is off and only until the wound vac is reapplied. Review of the 1/2023 treatment documentation revealed there was no documentation the treatment was done 1/19/2023 to 2/5/2023. A physician's order was obtained on 2/6/2023 to clean left ischium with anasept spray and pack with 1/4-inch packing strip and leave at least two inches outside of the wound and cover with Telfa and Mepilex daily. Review of the 2/2023 and 3/2023 treatment documentation revealed the treatment was documented as done 14 of 28 days in February and 10 of 16 days in March. Refer to F686. 2. Resident #5 was admitted to the facility on [DATE] with the following but not limited to diagnoses of: aortic stenosis, peripheral artery disease, cerebrovascular accident, hypertension, hypothyroidism, atrial fibrillation, chronic pain, and neuropathic pain. Review of R#5 care plan for pressure ulcer with a revision date of 2/21/2023 had an intervention for wound care according to MD orders. Review of the Nursing Narrative note dated 10/8/2022 revealed documentation of a wound to posterior right leg noted to be oozing dark red puss looking drainage. Area was cleaned with anasept spray and anasept gel was applied with Xeroform and ABD pads and netting. MD was notified and stated to continue to clean and monitor. Review of the Physician's orders dated 10/8/2022 noted to clean posterior right leg with anasept spray and apply anasept gel and cover with Xeroform and ABD pads and netting daily and as needed. However, review of the 10/2022 treatment documentation revealed there was no documentation the treatment was done until 10/28/2022. During an interview with the Director of Nursing on 3/15/2023 at 2:30 p.m., she clarified the wound identified on 10/8/2022 as the posterior right leg was actually on the right heel. Review of the physician's orders dated 11/1/2022 noted to clean right heel with normal saline or anasept, apply Santyl ointment and cover with dry dressing daily. Review of the 11/2022 treatment documentation revealed the treatment was documented as done 13 of 30 days. Review of the physician orders dated 12/26/2022 noted to clean right heel with normal saline or anasept, apply Santyl covered by Medihoney, cover with dry dressing every two days. Review of the treatment documentation for 1/2023 through 2/2/2023 revealed there was no documentation treatment had been done as ordered for this timeframe. During this time, the treatment order was changed on 1/12/2023 to clean right heel wound with anasept cleanser and apply Medihoney then a hydrogel sheet covered with 4x4 then cover with Allevyn heel cup then wrap in Kerlix on Thursday and Sunday each week. There was no evidence this was done until 2/5/2023, 2/9/2023, 2/19/2023 and 2/24/2023. Review of the physician order dated 2/24/2023 noted to clean right heel with anasept or normal saline, apply gentamicin and cover with opticell alginate and dry dressing every 2 days. Review of the 2/2023 and 3/2023 treatment documentation revealed the treatments were only documented as done on 2/24/2023, 2/28/2023, 3/2/2023, 3/4/2023 and 3/8/2023. 3. Resident #6 was admitted to the facility on [DATE] with the following but not limited to diagnoses of: catatonic disorder, epilepsy, hypertension, peripheral vascular disease, diabetes, contracture of bilateral upper and lower extremities, morbid obesity and spasticity. Review of R# 6 care plan dated 5/11/2022 revealed a pressure ulcer with an intervention for wound care as ordered. Review of the 1/30/2023 Phone Message to the physician noted the wound to the resident's right outer ankle was reassessed by the Registered Nurse and noted to be a Stage 3 with full thickness tissue loss, but no tendon or bone exposed. The wound measured 6cm x 4cm x 0.1cm. Review of the physician order dated 1/30/2023 noted to clean right outer ankle with anasept spray and apply anasept gel with Mepilex dressing every three days and as needed. Review of the 1/2023 and 2/2023 treatment documentation revealed there was no documentation the treatment was done until 2/4/2023. Review of the 2/4/2023 physician order noted to clean wound to right dorsal foot with anasept or normal saline, apply Medihoney, cover with foam dressing every two days. Review of the 2/2023 and 3/2023 treatment documentation revealed the treatment was only documented as done two of 28 days in February and there was no documentation it had been done between 3/4/2023 and 3/10/2023. During an interview with the DON on 3/15/2023 at 2:30 p.m., she stated that in November 2022 she identified that the previous treatment nurse told Registered Nurse (RN) EE, the current treatment nurse, that they didn't have to chart the treatments being done every day. Refer to F686.

Based on staff interview, record review and review of the facility policy titled Wounds and Pressure Ulcers, the facility failed to thoroughly assess pressure ulcers and failed to consistently document pressure ulcer treatments for three of 14 sampled residents (R) (R#4, R#5, and R#6). Findings include: Review of the policy titled Wounds and Pressure Ulcers dated December 5, 2022, Monitoring and Documentation: [NAME] Health and Rehabilitation personnel should monitor and evaluate the following at each dressing change or at least weekly and should also document in the resident's medical record the determinations of such evaluation: Location and staging Size including width, length, and depth. Exudate, if present: type, color, odor, approximate amount Pain, nature, and frequency of pain Wound bed: color and type of tissue Wound edges and surrounding tissue Type and amount of dressing used. If the wound has packing, the amount removed and the amount replaced. The presence, location and extent of any undermining or tunneling. Description of wound drainage Response to current treatment Compliance or non-compliance to plan of care. Pressure reduction devices Physician and responsible party notification 1. Resident #4 was admitted to the facility on [DATE] with the following but not limited to diagnoses: Stage 4 pressure ulcer left buttock, hypertension, coronary atherosclerosis, peripheral vascular disease, cerebrovascular disease, hemiplegia, seizure disorder and mental disability. Review of the Nursing Narrative note dated 12/7/2022 documented R#4 had an unstageable decubitus to her left ischium that measured 3.5 centimeter (cm) wide 2.9cm long 0.2 cm deep. However, there was descriptive documentation of the wound bed that would have indicated the pressure ulcer was unstageable. The physician was notified on 12/7/2022 and an order was obtained to clean the unstageable decubitus to the left ischium with anasept spray and apply Santyl ointment and medihoney every two days and as needed. However, review of the December 2022 treatment documentation revealed there was no documentation the treatment was done until 12/9/2022 and there was no documentation the dressing was changed every two days as ordered from 12/15/2022 to 12/21/2022. On 12/21/2022 a new physician's order was obtained to clean wound to left ischium with normal saline or anasept, pack wound with anasept moistened gauze and cover with dry dressing daily. Review of the December 2022 treatment documentation revealed there was no documentation the dressing was changed daily as ordered from 12/28/2022 to 12/30/2022. A physician's order was obtained on 1/5/2023 to begin negative pressure wound therapy wound vac continuously at 125mm/hg (millimeter of mercury) pressure, apply white foam in base then apply black foam. Apply anasept spray 10 minutes prior to each dressing change three times weekly and as needed Tuesday/Thursday/Saturday. Review of the 1/2023 treatment documentation revealed there was no documentation the treatment was done as ordered from 1/5/2023 to 1/17/2023. A physician's order was obtained on 1/17/2023 to clean sacrum wound with anasept spray and apply anasept spray-soaked gauze everyday as needed and cover with a mepilex dressing if wound vac is off and only until the wound vac is reapplied. Review of the 1/2023 treatment documentation revealed there was no documentation the treatment was done 1/19/2023 to 2/5/2023. A physician's order was obtained on 2/6/2023 to clean left ischium with anasept spray and pack with 1/4-inch packing strip and leave at least two inches outside of the wound and cover with Telfa and Mepilex daily. Review of the 2/2023 and 3/2023 treatment documentation revealed the treatment was documented as done 14 of 28 days in February and 10 of 16 days in March. 2. Resident #5 was admitted to the facility on [DATE] with the following but not limited to diagnoses: aortic stenosis, peripheral artery disease, dementia, cerebrovascular accident, hypertension, hypothyroidism, atrial fibrillation, chronic pain, and neuropathic pain. Review of the 10/8/2022 Nursing Narrative note revealed documentation of a wound to posterior right leg noted to be oozing dark red puss looking drainage. There was no descriptive documentation of the wound to indicate the type of wound, wound bed appearance or measurements on 10/8/2022. Review of the Physician's orders dated 10/8/2022 noted to clean posterior right leg with anasept spray and apply anasept gel and cover with Xeroform and ABD pads and netting daily and as needed. However, review of the 10/2022 treatment documentation revealed there was no documentation the treatment was done until 10/28/2022. Review of the Weekly Wound Report for 10/16/2022 noted the wound was an unstageable pressure ulcer on the right heel that measured 3.5x3.5x0.1cm with no descriptive documentation of the wound bed. During an interview with the Director of Nursing on 3/15/2023 at 2:30 p.m., she clarified the wound identified on 10/8/2022 as the posterior right leg was actually on the right heel. Review of the physician's orders dated 11/1/2022 noted to clean right heel with normal saline or anasept, apply Santyl ointment and cover with dry dressing daily. Review of the 11/2022 treatment documentation revealed the treatment was documented as done 13 of 30 days. The 12/26/2022 physician orders noted to clean right heel with normal saline or anasept, apply Santyl covered by Medihoney, cover with dry dressing every two days. Review of the treatment documentation for 1/2023 through 2/2/2023 revealed there was no documentation treatment had been done as ordered for this timeframe. During this time, the treatment order was changed on 1/12/2023 to clean right heel wound with anasept cleanser and apply Medihoney then a hydrogel sheet covered with 4x4 then cover with Allevyn heel cup then wrap in Kerlix on Thursday and Sunday each week. There was no evidence this was done until 2/5/2023, 2/9/2023, 2/19/2023 and 2/24/2023. Review of the physician order dated 2/24/2023 noted to clean right heel with anasept or normal saline, apply gentamicin and cover with opticell alginate and dry dressing every 2 days. Review of the 2/2023 and 3/2023 treatment documentation revealed the treatments were only documented as done on 2/24/2023, 2/28/2023, 3/2/2023, 3/4/2023 and 3/8/2023. Per review of the Weekly Wound Report, the facility documented weekly wound measurements since 10/16/22. However, there was no consistent descriptive wound documentation of the wound bed. 3. Resident #6 was admitted to the facility on [DATE] with the following but not limited to diagnoses: catatonic disorder, epilepsy, hypertension, peripheral vascular disease, diabetes, schizophrenia, dementia, asthma, contracture of bilateral upper and lower extremities, morbid obesity, and spasticity. Review of the physician order dated 1/30/2023 noted to clean right outer ankle with anasept spray and apply anasept gel with Mepilex dressing every three days and as needed. Review of the 1/2023 and 2/2023 treatment documentation revealed there was no documentation the treatment was done until 2/4/2023. Review of the 2/4/2023 physician order noted to clean wound to right dorsal foot with anasept or normal saline, apply Medihoney, cover with foam dressing every two days. Review of the 2/2023 and 3/2023 treatment documentation revealed the treatment was only documented as done two of 28 days in February and there was no documentation it had been done between 3/4/2023 and 3/10/2023. Review of the Weekly Wound Report from 2/5/2023 to 3/5/2023 revealed there were weekly measurements documented but the documentation did not include descriptive documentation of the wound bed. During an interview with the DON on 3/15/2023 at 2:30 p.m., she stated that in November 2022 she identified that the previous treatment nurse told Registered Nurse (RN) EE, the current treatment nurse, that they didn't have to chart the treatments being done every day. During an interview with RN EE on 3/21/2023 at 11:30 a.m., he stated that he does a weekly wound report with the measurements, but it did not include descriptions of the wound bed.

Based on record review and staff interview the facility failed to develop a comprehensive care plan for two residents ((R) R#1 and R#35) receiving oxygen therapy, and the facility failed to develop a care plan for [CONDITION(S)] drug use for one resident R#60. This effected three of 38 sampled residents. Findings include: 1.Record review for R#1 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of orders indicated oxygen at 2 liters per minute (L/M) per nasal cannula routinely. On 10/26/22 at 4:02 p.m. Interview with Registered Nurse (RN) BB revealed that the charge nurse would complete the baseline care plan and update it as needed, Social Services, dietary, and Wound care initiate and update their own care plans specific to the resident's needs. During interview it was also disclosed that the Minimum Data Set (MDS) staff is responsible for ensuring that the care plans are correct and are person centered to the residents' needs. Continued interview also confirmed that R # 1 did not have a care plan that addressed the use of oxygen. On 10/26/22 at 4:27 p.m. Interview with Director of Nursing (DON) revealed that there are currently 8 residents in the facility currently receiving oxygen therapy and should have a care plan in place that indicates the use of oxygen along with any interventions as appropriate. During interview it was confirmed that R#1 has been on oxygen therapy since 11/22/20 at 2 L/M and it should have been noted in the care plan as well as on the MDS assessments. Further interview also revealed that they would expect for the Unit Managers and nurse management to ensure that the residents care plans are person centered and addressed all their medical needs. Further interview also confirmed that the facility did not have a care plan policy for reviewing. 2. Record Review (RR) of the clinical record revealed R#35 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RR of R#35 's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RR on 10/25/22 of the current Care Plan for R#35, revealed there was no oxygen therapy or interventions on the care plan. Observation on 10/25/22 at 2:09 p.m., on 10/26/22 at 8:33 a.m., and on 10/26/22 at 2:22 p.m. confirmed R#35 using oxygen at 2 LPM via nasal cannula. Interview at that time revealed she had to wear it almost continuously but removed it occasionally for a few minutes to eat. R#35 complained of having shortness of breath with fluid retention and revealed she had been sent to the hospital ER recently because she couldn't breathe. Interview on 10/27/22 at 2:15 p.m., the MDS Director confirmed the care plan for oxygen therapy was initiated on 10/26/22. She confirmed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the care plan confirmed oxygen was not initiated prior to 10/26/22, she didn't know why it was not initiated at the time the oxygen was started but it should have been. Interview with the Director of Nursing (DON) revealed her expectation was that care plans should reflect the residents' diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Cross refer F641 3. Record Review (RR) revealed R#60 admitted facility on 5/31/18, top three diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview of Mental Status (BIMS) was not conducted because resident was rarely/never understood, indicating severe cognitive decline. RR of current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RR of the current care plan revealed there was no care plan for the medication [MEDICATION(S)]. Further review revealed [MEDICATION(S)] ([MEDICATION(S)]) 1mg IM q6h prn [CONDITION(S)] activity was discontinued from the [CONDITION(S)] medication use care plan, with last updated date of 3/14/22. Interview on 10/27/22 at 3:30 p.m. with the Administrator and the Director of Nursing (DON). DON confirmed a current order for [MEDICATION(S)] 2mg/1ml, administer 0.5ml IM q6h prn [CONDITION(S)] activity, first dose 8/29/18. The Administrator confirmed the care plan had [MEDICATION(S)] discontinued and said that was not correct. R#60 had a current order for [MEDICATION(S)] prn for [CONDITION(S)] activity, it should still be on the care plan, and she did not know why it had been removed. Cross refer 758

Based on interview and record review, the facility failed to ensure [CONDITION(S)] drug use was limited to 14 days unless the physician felt it was appropriate for the as needed (PRN) order to be extended beyond 14 days, documented the rational, and indicated the intended duration for the prn order, for two residents ((R) R#60 and R#81) of five reviewed for unnecessary medications, that had an order for PRN antianxiety medication beyond 14 days. Findings include: 1. Record Review (RR) revealed R#60 admitted facility on 5/31/18, top three diagnoses were Alzheimer's dementia, [CONDITION(S)], Diabetes Mellitus type 2. Additional diagnoses included frailty, generalized anxiety, [CONDITION(S)], bedbound, and cerebral aneurysm-onset 5/16/19. A Brief Interview of Mental Status (BIMS) was not conducted because resident was rarely/never understood, indicating severe cognitive decline. RR of current Physician Orders revealed R #60 had an order for [MEDICATION(S)] 2 milligrams per milliliter (ml) (2mg/ml) injectable solution 0.5 ml intramuscular (IM) every six hours (q6h) as needed (prn) [CONDITION(S)] activity, first dose 8/29/18. Additionally, there was no end date, was not ordered for a specific number of days, and no rational to continue past 14 days. RR of the current care plan revealed there was no care plan for [MEDICATION(S)]. Further review revealed [MEDICATION(S)] ([MEDICATION(S)]) 1mg IM q6h prn [CONDITION(S)] activity was discontinued from the [CONDITION(S)] medication use care plan, with last updated date of 3/14/22. Interview on 10/27/22 at 3:30 p.m. with the Director of Nursing (DON) confirmed a current order for [MEDICATION(S)] 2mg/1ml, administer 0.5ml IM q6h prn [CONDITION(S)] activity, first dose 8/29/18. The administrator confirmed the [MEDICATION(S)] was ordered for R#60 prn for seizures, had no end date, was not ordered for a specific number of days, and had no rational to continue past 14 days. The Administrator's expectation was because the medication was ordered for [CONDITION(S)] activity, the prn order was acceptable as written. 2. R#81 was admitted to the facility on [DATE] with diagnoses of but not limited to Alzheimer's dementia, major depressive disorder and altered mental status. Review of R#81's Admission Minimum Data Set (MDS) revealed Section N-Medications -received an antipsychotic, antianxiety, antidepressant and opioids. Review of R#81's medications revealed but not limited to: [MEDICATION(S)] 0.5 milligrams (MG) one (1) tablet by mouth (PO) two (2) times a day (BID) as needed (PRN) ordered on 9/12/22 for a diagnosis of anxiety. The order did not include a stop date. Review of the Pharmacy Consultant Activity Report dated 9/29/22 revealed: A recommendation to evaluate the current [MEDICATION(S)] order. Review of a scanned document revealed the recommendation was signed by the Physician on 10/4/22 to include a duration of 90 days. Review of the Physicians orders as of 10/27/22 the orders still did not include that duration of 90 days. An interview held on 10/27/22 at 1:47 p.m. with the Director of Nursing (DON) revealed the resident was admitted with the order for the PRN [MEDICATION(S)]. Her order should have had a stop date or parameter added to the order. The nurse should have clarified the order on admission. When she receives a Pharmacy recommendation they are given to the Physician. When recommendations are received from the Physician, the DON or designee will transpose the orders. She does not know why the recommendation was not followed through with. Her expectations would be to write the orders within a 24-hour period after receiving them from the Physician. She verified the recommendation was not followed through with after the Physician signed the recommendation to add a time limit of 90 days to the [MEDICATION(S)] order. She indicated they do not have a policy on PRN antipsychotic medications use.

Based on record review and staff interview the facility failed ensure the Minimum Data Set (MDS) assessments were accurate for two ((R) R#1 and R#35) of eight residents receiving oxygen therapy. Findings Include: 1.Record review for R#1 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review reveald orders for oxygen at 2 liters per minute (LPM) per nasal cannula routinely. Review of the MDS Quarterly assessment dated [DATE] revealed oxygen therapy was not indicated as in use for R#1. On 10/26/22 at 4:02 p.m. Interview with Registered Nurse (RN) BB MDS Director confirmed the MDS quarterly assessments that were completed on 7/01/22 and 9/28/22 should have captured oxygen use on the MDS for both assessments that were completed. 2. Record Review (RR) of the clinical record revealed R#35 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#35 's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed oxygen therapy was not checked under special treatments at Section O-0100C. Review of the quarterly MDS assessment dated [DATE] revealed oxygen therapy was not checked under special treatments at Section O-0100C. Review of the quarterly/5-day reentry MDS assessment dated [DATE] under health conditions at Section J-1100 revealed no shortness of breath or trouble breathing, with exertion, when sitting at rest, or when lying flat; and under special treatments at Section O-0100 oxygen therapy was not checked. Observations on 10/25/22 at 2:09 p.m., on 10/26/22 at 8:33 a.m., and on 10/26/22 at 2:22 p.m. confirmed R#35 using oxygen at 2 LPM via n/c. During an interview on 10/27/22 at 2:15 p.m. with the MDS Director she confirmed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS Director was unsure why the MDS assessment had not been coded to address the oxygen usage.

Based on observations, interviews, record reviews, and review of policy titled Respiratory Therapy, the facility failed to ensure that oxygen therapy was administered as ordered by Physician for one resident ((R) R#1) of eight residents receiving oxygen. Findings include: Review of facility policy titled Respiratory Therapy (dated July 3, 2013), under Procedure: Oxygen Administration revealed - Set oxygen regulator to administer as ordered. Record review for R#1 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the record revealed Minimum Data Set (MDS) Quarterly assessment dated [DATE] with Section O (Treatments/Procedures) not indicating oxygen therapy use for resident. Review of orders revealed oxygen at 2 liters per minute (L/M) per nasal cannula routinely. Observation on 10/25/22 at 9:57 a.m. Resident receiving oxygen therapy current setting is on 1 L/M there was no date noted on oxygen tubing. Observation on 10/26/22 at 8:16 a.m. oxygen therapy current setting is on .5 liters per nasal cannula resident is positioned on her back and has eyes closed. Interview on 10/26/22 at 8:22 a.m. with Licensed Practical Nurse (LPN) AA confirmed that R#1 oxygen was set at .5 liters and should have been on 2 Liters. Further interview also revealed that the residents that have oxygen are checked every two hours to ensure that their oxygen is on the correct setting. LPN AA also confirmed that when rounds were made at 7:00 a.m. they did not notice that R# 1 oxygen was not on the correct setting. Interview on 10/26/22 at 4:27 p.m. with Director of Nursing (DON) revealed that there are currently 8 residents in the facility currently receiving oxygen therapy and should have a care plan in place that indicates the use of oxygen along with any interventions as appropriate. During interview it was confirmed that R#1 has been on oxygen therapy since 11/22/20 at 2 L/M and it should have been noted in their care plan as well as on the MDS assessments. Further interview also revealed that they would expect for the Unit Managers and nurse management to ensure that the residents care plans are person centered and addressed all their medical needs and that the residents are checked daily to ensure that their oxygen settings are as ordered by physician.

An abbreviated survey conducted from January 23, 2015 through February 5, 2015 revealed noncompliance at F280 at the Scope/Severity of "K". Additional noncompliance at F280 was not identified during the standard survey of February 2, 2015 through February 5, 2015. Therefore, the noncompliance at F280 identified during the January 23, 2015 through February 5, 2015 abbreviated survey has been brought forward to this standard survey Form CMS-2567, as referenced below: Based on observation, medical record review, Entity Reported Incident Intake review, facility investigative report review, resident Smoking Assessment Questionaire review, facility Smoking Policy and Procedure review, resident interview, facility staff written statement review, and staff interview, the facility failed to review and revise the Plan of Care for one (1) resident ("B") who smoked cigarettes, regarding a facility-imposed restriction on the resident maintaining smoking materials and regarding staff monitoring to ensure the resident's safety; failed to review and revise the Plan of Care to reflect cigarette smoking for one (1) resident ("E"), who did not smoke cigarettes upon admission but later initiated smoking after admission, but for whom the facility failed to implement monitoring to ensure safety while smoking; and failed to review and revise the Plan of Care to reflect routine monitoring related to the unsafe behavior of one (1) resident ("A"), regarding Resident "A"'s behavior of providing cigarettes and a lighter to another resident (Resident #1) who was assessed to require supervision while smoking. The total survey sample was nine (9) residents, all of whom smoked cigarettes. A Smoker's List provided by the facility documented a total of fifteen (15) residents who were identified by the facility to smoke cigarettes. The facility's failure to ensure adequate monitoring and supervision to residents who smoked resulted in a situation in which the facility's 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 immediate jeopardy is outlined as follows: - Resident "B" was assessed as safe to smoke unsupervised and to posses smoking materials upon facility admission. As a result of a 2011 incident involving Resident "B" using a cigarette lighter unsafely, the facility restricted her possession of cigarettes and a lighter. Instead, nursing staff were to keep Resident "B"'s cigarettes and light her cigarettes to allow her to smoke; however, the facility failed to revise the Plan of Care for Resident "B", regarding the facility-imposed restriction to the resident maintaining smoking materials, and did not revise the Plan of Care to reflect any monitoring required by staff to ensure the resident's safety regarding this restriction of unsupervised access to smoking materials. During an observation on 01/23/2015, Resident "B" obtained a cigarette and lighter from another resident and lit the cigarette with the lighter in the absence of staff to supervise. The failure to ensure Plan of Care revision and provide routine monitoring/supervision to Resident "B", allowing her to access a lighter and light a cigarette in the absence of staff supervision, placed Resident "B" at risk for injury. - Resident "E" did not smoke upon admission in June 2014, but a nurse's note of 01/20/2015 documented Resident "E" did smoke cigarettes, and staff interview revealed Resident "E" was found on 01/22/2015 while in possession of packs of cigarettes. However, the facility failed to revise the Plan of Care for Resident "E", per Policy and Procedure, to reflect the resident's post-admission initiation of cigarette smoking, and failed to implement any routine monitoring to ensure the resident's safety while smoking. - Resident "A" was assessed to be safe to smoke without staff supervision and was allowed to maintain his cigarettes and cigarette lighters in his possession. Resident "A"'s Plan of Care identified that Resident "A" smoked cigarettes, and indicated that no staff supervision was needed during smoking. Resident "A" had a known history of providing cigarettes and lighter access to Resident #1 (who was assessed by the facility to be unsafe to smoke without staff supervision and was not to have possession of cigarettes and a lighter). The facility counseled Resident "A" related to this unsafe practice of providing smoking materials to Resident #1 in the absence of staff supervision; however, the facility failed to revise the Plan of Care for Resident "A" to implement any monitoring regarding his unsafe practice of providing smoking materials to Resident #1 and allowing Resident #1 to smoke in the absence of staff supervision. Then, on 01/19/2015, Resident "A" provided two (2) cigarettes to Resident #1, who also gained access to Resident "A"'s lighter and attempted to light a cigarette, at which time she ignited her hair with the lighter. Resident #1 was transferred to the Burn Center, treated for [REDACTED]. Even though Resident "A" was found to again provide Resident #1 with a cigarette on 01/24/2014, the facility still failed to revise the Plan of Care for Resident "A" to put a system of monitoring into place, related to Resident "A"'s ongoing unsafe behavior of providing smoking materials to Resident #1 without the knowledge of facility staff. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on January 30, 2015 at 12:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on January 19, 2015, the date Resident #1, who was assessed by the facility to require staff supervision while smoking, obtained two (2) cigarettes and a cigarette lighter without staff knowledge, attempted to light the cigarette with the lighter, and caught her hair on fire with the lighter. Resident #1 sustained multiple second/third [MEDICAL CONDITION] the left face, forehead, and ear. The immediate jeopardy continued through February 2, 2015, and was removed on February 3, 2015. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 2, 2015. An allegation of jeopardy removal was received on February 2, 2015. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 3, 2015. The facility remained out of compliance at a lower scope and severity of "E" while the process of evaluating modifications of resident assessment systems, care planning systems, and processes involved in the supervision of residents who smoked continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for supervising residents who smoked and who required supervision during smoking. Resident record reviews were conducted to assess facility staffs' conformance with the development of resident Plans of Care regarding smoking supervision. In addition, residents were observed while smoking in the exterior designated smoking area to assess facility staffs' conformance with the supervision of residents while smoking, in accordance with their assessed needs and as specified by their Plans of Care, to therefore ensure resident safety while smoking. Findings include: Review of the facility's Smoking Policy and Procedure revealed the Procedure to specify that residents were to be assessed using the Smoking Assessment Questionaire upon admission, quarterly, and with any change in condition regarding smoking preferences and specific needs. This assessment was to include, but not be limited to, cognitive concerns, the level of assistance needed to smoke (i.e., assistance with lighters, holding of cigarettes), and any safety concerns. Based on the data collected during this assessment process, a specific plan was to be developed to meet the individual needs of the resident. The resident-specific information from the assessment was to be included in the resident's Plan of Care, which was to be reviewed and revised accordingly. 1. Resident "B"'s Annual Minimum Data Set (MDS) assessment of October 2014 documented an original admission in March 2010, and documented in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) Summary Score of 13, indicating she was cognitively intact. Section I - Active [DIAGNOSES REDACTED]. A Smoking Assessment Questionaire dated 10/30/2014 for Resident "B" referenced the resident's history of tobacco use. This Smoking Assessment Questionaire assessed Resident "B"'s current status related to cigarette smoking, and assessed the resident as safe to smoke without supervision. During a 01/23/2015, 12:00 p.m. interview, Resident "B" acknowledged that she smoked without supervision, but stated she could not keep her cigarettes and lighter; rather, staff kept her cigarettes and lighter, and the nurse would light cigarettes for her to smoke. During a 01/29/2015, 2:20 p.m. interview, the DON stated that Resident "B" was allowed to keep her cigarettes and lighter in the past, but was involved in a 2011 incident during which she used a cigarette lighter to light tissue paper on fire. The DON stated that, due to the 2011 incident, Resident "B" no longer kept her smoking materials, but instead, nursing staff kept the resident's cigarettes and lighter. However, review of Resident "B"'s current Plan of Care revealed no reference to the resident's use of cigarettes, and there were no Plan of Care Interventions related to the resident's cigarette use (to include no reference to the requirement that nursing staff were to maintain the resident's cigarettes and lighter secured). This was despite the fact that Resident "B", although assessed to be capable of smoking without supervision (per the 10/30/2014 Smoking Assessment Questionaire referenced above), had been allowed in the past to maintain her smoking materials, but had subsequently been restricted from keeping cigarettes and a lighter on her person due to a 2011 incident involving a cigarette lighter (per the 01/29/2014, 2:20 p.m. DON interview referenced above). This was also despite the facility's Smoking Policy and Procedure referenced above which specified that residents would be assessed with [REDACTED]. The facility had therefore failed to review and revise the Plan of Care for Resident "B" after the 2011 incident resulting in a restriction of her having access to smoking materials, including cigarettes and the cigarette lighter, in the absence of staff supervision. During an interview with the facility's Care Plan (CP) Coordinator conducted on 02/02/2015 at 1:44 p.m., the CP Coordinator acknowledged that for residents requiring supervision while smoking, Plans of Care should include resident cigarette use and interventions for supervision. During a 01/23/2015, 12:45 p.m. observation, Resident "B" was in the smoking area with Resident #3 with no staff in attendance. During this observation, Resident "B" asked Resident #3 for a cigarette. Resident #3 handed a cigarette and lighter to Resident "B", who then lit the cigarette and began smoking. Based on the above, Resident "B" was admitted to the facility in 2010 and was assessed to be safe to smoke without supervision. Due to a 2011 incident involving Resident "B"'s unsafe use of a cigarette lighter, the facility then restricted Resident "B"s access to cigarettes and a lighter. Nursing staff were to maintain the resident's smoking materials and light the resident's cigarettes. However, the facility failed to revise Resident "B"'s Plan of Care, as specified by the Smoking Policy and Procedure, to reflect the plan developed by the facility regarding the resident's use of cigarettes, developed in 2011, to restrict Resident "B"'s access to smoking materials. Cross refer to F323, example 2, for more information regarding Resident "B". 2. Resident "E"'s Admission MDS assessment of July 2014 documented admission in June of 2014. Section I - Active [DIAGNOSES REDACTED]. Section J - Health Conditions documented that Resident "E" did not use tobacco products upon facility admission. A Smoking Assessment Questionaire for Resident "E" dated June of 2014, completed upon the resident's facility admission, documented that the resident was non-smoking. But, a subsequent Smoking Assessment Questionaire of 12/22/2014 then assessed Resident "E" for smoking, indicating that Resident "E" was not safe to smoke without staff supervision. A NPN entry of 01/20/2015 at 10:00 a.m. documented that Resident "E" did smoke cigarettes in the designated smoking area, and Resident "E" acknowledged, during a 01/23/2015, 10:45 a.m. interview, that he did smoke. During a 01/30/2015, 10:45 a.m. interview, Licensed Practical Nurse (LPN) "CC" stated she had observed Resident "E" on 01/22/2015 to have multiple packs of cigarettes. However, even though Resident "E"'s 12/22/2014 Smoking Assessment Questionaire (referenced above) documented that the resident required supervision while smoking, and even though the July 2014 MDS assessment (referenced above) documented Resident "E" did not smoke upon admission, but then the resident began smoking after facility admission (as acknowledged in Resident "E"'s 01/23/2015, 10:45 a.m. interview referenced above), and smoked with the knowledge of facility staff (as documented in the 01/20/2015, 10:00 a.m. NPN, and acknowledged during LPN "CC"'s 01/30/2014, 10:45 a.m. interview, both referenced above), review of Resident "E"'s Plan of Care revealed no reference to the resident smoking cigarettes, and no Plan of Care Interventions related to the resident's cigarette use. This was despite the facility's Smoking Policy and Procedure referenced above which specified that, upon any change, the resident's specific smoking needs (including the need of nursing staff to provide assistance with lighters and holding of cigarettes) would be included in the Plan of Care. The facility had therefore failed to review and revise the Plan of Care for Resident "E" upon the resident's initiation of smoking activities after his June 2014 facility admission. During an interview conducted on 02/02/2015 at 1:44 p.m., the CP Coordinator acknowledged that Plans of Care for residents who smoked should include interventions for supervision during smoking if required. Cross refer to F323, example 3, for more information regarding Resident "E". 3. Resident "A"'s Admission MDS assessment of December 2014 documented the resident's admission that month, and Section C - Cognitive Patterns documented Resident "A" with cognitively intact, having a BIMS Score of 15. Section J - Health Conditions documented that Resident "A" used tobacco products at the time of facility admission. A December 2014 Smoking Assessment Questionaire for Resident "A" assessed the resident to be safe to smoke without supervision. During a 01/29/2014, 9:50 a.m. interview, the Administrator stated that some residents assessed as safe to smoke independently (such as Resident "A", per the Smoking Assessment Questionaire referenced above) were allowed to keep smoking paraphernalia (cigarettes and lighters) in their possession. Review of the Plan of Care for Resident "A" revealed a Problems/Strengths entry of 12/21/2014 which identified that the resident had altered thought process potential. Interventions on this Plan of Care for Resident "A", as related to the resident's altered thought process potential, included a notation that the resident was a smoker, but noted that no supervision was needed for smoking. A Social Progress Notes (SPN) entry for Resident "A" dated 12/29/2014 (approximately one week after the 12/21/14 development of Resident "A"'s Plan of Care Intervention, referenced above, which indicated the resident required no supervision during smoking) documented that Social Services staff had counseled with Resident "A" to inform him not to give cigarettes or light cigarettes for a female resident (Resident #1), because the female resident was on a supervised smoking program with staff supervision only. However, despite the SPN entry of 12/29/2014 referenced above which identified Resident "A"'s having been counseled regarding providing cigarettes to, and lighting cigarettes for, Resident #1 who required supervised smoking, further review of Resident "A"'s Plan of Care revealed no revisions related to any acknowledgement of this behavior of Resident "A"'s unsafe practice of inappropriately providing Resident #1 smoking paraphernalia, nor any Intervention to address this unsafe practice. Entity Reported Incident Intake (ERII) Number GA 603 of 01/21/2015, submitted to the State Agency by the facility regarding Resident #1, then documented that Resident #1 smoked cigarettes and required supervision, but that on 01/19/2015, Resident #1 obtained two cigarettes and a lighter from another resident and caught her hair on fire. A facility investigative report of 01/22/2015 documented that Resident #1 and Resident #9 were in the smoking area and, per Resident #9, Resident #1 produced a hand-rolled cigarette and lighter. Resident #1 attempted to light the cigarette but accidentally lit her hair on fire. Resident #9 informed Resident "C", who smothered the fire on Resident #1's head. Resident #1 was transferred to the hospital and noted with second/third [MEDICAL CONDITION] the left side of the face, third [MEDICAL CONDITION] the left side of the forehead/temple, and second [MEDICAL CONDITION] the left side of the cheek and external ear, and was transferred to the Burn Center. This investigative report documented that Resident "A" admitted he gave Resident #1 two cigarettes and that Resident #1 could have obtained the lighter from his room, and documented a facility conclusion that Resident "A" provided rolled cigarettes to Resident #1. However, despite the ERII and investigative summary referenced above documenting the 01/19/2015 incident during which Resident "A" had again given cigarettes to Resident #1 (with Resident #1 then gaining access to a lighter, ignighting her hair and sustaining multiple burn wounds to her face, forehead, and ear), further review of Resident "A"'s Plan of Care still revealed no notation regarding Resident "A"'s unsafe behavior of providing Resident #1 cigarettes and allowing her access to his cigarette lighters. Then, a NPN entry of 01/24/2015 at 9:22 a.m. for Resident "A" documented that Resident "A" had again given a resident (Resident #1) a hand-made cigarette, and that Resident "A" was again counseled to refrain from giving any resident a cigarette or lighter. In a written statement, RN "EE" documented the 01/24/2014 incident (as documented in the 01/24/2015, 9:22 a.m. NPN entry referenced above) during which Resident "A" had given Resident #1 a hand-made cigarette, and that staff were instructed to monitor Resident #1 and Resident "A" for the exchange of smoking paraphernalia. However, despite Resident "A" again have provided Resident #1 with a cigarette on 01/24/2015 (per the 01/24/2014, 9:22 a.m. NPN referenced above), and even though staff were specifically instructed to monitor Resident "A" (and Resident #1) closely regarding the exchange of smoking materials, further review of Resident "A"'s Plan of Care still revealed no revision to reflect Resident "A"'s continued unsafe behavior of providing Resident #1 with smoking paraphernalia, nor did the Plan of Care reference any Interventions to address this unsafe practice at that time. During a 02/02/2015, 1:44 p.m. interview, the CP Coordinator acknowledged that resident Plans of Care should include interventions for supervision regarding cigarette use. Cross refer to F323, example 1, for more information regarding Resident "A" (in relation to Resident #1). The facility presented a credible allegation of jeopardy removal (CAJR) on February 2, 2015. Based on the CAJR, it was determined that the immediate jeopardy had been removed on February 3, 2015, at which time the facility had implemented the following interventions: A. On 01/26/2015, the Quality Assessment and Assurance (QAA) Committee met. During this meeting, the QAA Committee reviewed the facility's current Smoking Policy and discussed revisions to enhance resident safety. Recommendations were made, and the DON was to make edits and submit the revised Policy for review and approval. The specific recommendation that all resident smoking would be monitored was discussed an initiated immediately. Additionally, the Committee discussed offering smoking cessation services to residents desiring such services. B. On 01/27/2015, the QAA Committee met and the revisions to the Smoking Policy were submitted for review and approval. The QAA Committee meeting focused on the development of a Smoking Monitoring Log, with approval and implementation post meeting. This Smoking Monitoring Log would allow for the staff responsible for monitoring the smoking area (per the newly implemented procedure referenced above specifying that all resident smoking would be monitored) to document attendance and oversight during designated smoking times. The QAA Committee was informed that a smoking cessation instructor would begin services on that date, offering a general orientation to smoking cessation classes. C. On 01/29/2015, the facility implemented the Smoking Policy, the Purpose of which is to provide guidance regarding resident smoking at the facility. This Smoking Policy includes, but is not limited to, the specification that resident smoking is only permitted under staff supervision. Residents will not be allowed to keep any smoking paraphernalia on their person or with their personal belongings. Residents are required to check smoking paraphernalia out from staff members with entrance to the designated smoking area, and check smoking paraphernalia back in with staff at the time of exit from the designated smoking area. No more than two (2) cigarettes may be distributed to a resident, and any cigarettes not smoked will be collected by staff and returned to the storage area upon reentry into the building. Lighters and matches will be distributed to the resident for that smoking session and collected by staff for storage upon reentry into the building. Smoking paraphernalia will be inventoried following every smoking session to ensure all is accounted for. This inventory will be completed by the staff member assigned to supervise at each scheduled smoking time, and will be documented on the Resident Tobacco and Paraphernalia Log. The sharing of cigarettes and/or lighters and matches amongst residents is not permitted. Smoking is not permitted except within the designated area which is the courtyard/patio area located on the facility's South wing. Resident smoking will be conducted during scheduled times via a Smoking Schedule, and the smoking area will be open for resident access based on the posted schedule. Additionally, the Smoking Policy specifies that residents will be assessed upon admission regarding smoking preferences and any special needs. Residents are then reassessed quarterly and with any change in condition. A Smoking Safety Evaluation Form will be utilized to conduct resident smoking assessments. This Smoking Safety Evaluation will be utilized to assess a resident's smoking history, safety concerns, cognitive awareness, and ability to handle a lighter. This assessment includes the evaluation of each smoking resident's capabilities and deficits and determines whether or not supervision during smoking is required. Based on the data collected in the smoking assessment, a specific plan will be developed to meet the individual needs of the resident. The information in the assessment is included in the resident's Plan of Care, which is reviewed and revised accordingly. D. On 01/29/2015, the facility implemented the use of a new Safety Surveillance Log to be utilized in the event of resident non-compliance with the Smoking Policy. This new procedure indicated that, in the event a resident is observed in possession of tobacco and/or paraphernalia (other than at the approved times and in conformance with approved procedures), the facility would implement surveillance to ensure compliance. Said surveillance will be documented in the Safety Surveillance Log. At the time of discovery of an infraction, items will be inventoried for the resident. The Safety Surveillance Log will be completed as supervised by the designated Charge Nurse. The surveillance frequency will be a minimum of twice per day, and include a random search for a seven-day period. With zero findings for the seven-day period, the surveillance would transition to three times per week for 30 days. A reassessment will be conducted post the 30 day mark for the necessity of ongoing surveillance. In addition, an attempt will be made to identify the source of provision of products with subsequent counseling to follow. All findings and recommendations will be submitted to, and monitored by, the QAA Committee. E. On 01/29/2015, a special called Resident Council meeting was held to discuss the changes to the Smoking Policy. All resident smokers were in attendance. F. On 01/29/2015, all residents utilizing tobacco products were assessed by the DON using the new Smoking Safety Evaluation Form. One-hundred percent of all current residents who smoke (a total of fourteen residents on the date of assessment) were assessed with [REDACTED]. G. On 01/29/2015, the facility reviewed/revised the Plans of Care for all residents using tobacco products, and Plans of Care for these residents were developed/updated with the goals of no injury when using tobacco products, safety practices, and encouraging smoking cessation. H. On 01/29/2015, the facility reiterated a procedure requiring that the facility's Interdisciplinary Care Team reassess each resident who smoked on a quarterly basis, or more frequently if needed, to determine if any change in smoking abilities has occurred. All resident Plans of Care will be updated to reflect this assessment. I. On 01/30/2015, a one-on-one sitter was assigned to Resident #1 to provide supervision to the resident. Resident #1 will have a sitter twenty-four hours per day, seven days per week to ensure her safety, and this coverage will continue until a later determination is made. J. On 02/02/2015, the facility implemented the use of fire blankets (which were originally ordered by the facility on 01/30/2015). These fire blankets will be housed in the smoking area and will be used to aid in ensuring resident safety during smoking. K. On 02/02/2015, the facility implemented enforcement of the Policy by which all smoking tobacco products and paraphernalia were removed from resident possession. Going forward, per the new Policy referenced above, smoking tobacco products and paraphernalia will be provided to residents upon request in the designated smoking area. When the resident reenters the facility after smoking activities have concluded, any smoking tobacco product that has not been consumed, as well as any smoking paraphernalia, will be returned to facility staff and inventoried. L. On 02/02/2015, the facility conducted staff in-service training regarding the new Smoking Policy and the new procedures involving the supervision of residents who smoke, the new smoking schedule, the monitoring process for potential resident noncompliance, and resident safety while smoking by the use of fire blankets. This staff in-service training also included staff training related to the smoking assessment process. As of 02/02/2015, the following facility staff had received this in-service training: eighteen (18) of eighteen (18) housekeeping staff; fourteen (14) of fourteen (14) food service staff; three (3) of three (3) activities staff; forty (40) of forty (40) certified nursing assistants; and twenty-two (22) of twenty-three (23) licensed nursing staff. One (1) licensed nursing staff member was unavailable to receive this training due to being on leave status. This one (1) remaining licensed nursing staff member will receive this in-service training upon her return to work. M. On 02/02/2015, the facility implemented the Smoking Policy Compliance Audit to audit the facility's new smoking program to monitor for evidence of ongoing staff compliance. This Audit will serve the purpose of monitoring and assessing staff compliance with the routine completion of the resident Smoking Safety Evaluation assessments, execution and maintenance of resident Plans of Care, the completion of the routine staff inventory of tobacco products and paraphernalia, and completion of the Smoking Surveillance Log (utilized as needed to address identified resident noncompliance with the Smoking Policy). This Smoking Policy Compliance Audit will be conducted by the DON, Assistant Director of Nursing, designated Registered Nurse Supervisor, Administrator, Assistant Administrator, or MDS Coordinator. This Audit will be conducted on every resident who smokes beginning on 02/02/2015, and will be conducted with the following progression: Weekly from 02/02/2015 through 02/28/2015; Biweekly from 03/01/2015 through 04/05/2015; Monthly on 04/06/2015, and ongoing. Any findings and subsequent interventions for ongoing compliance with facility Policy will be discussed with the QAA Committee. The data collected during the Smoking Policy Compliance Audit will be reported monthly to the QAA Committee for the Committee's review and evaluation. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the facility's QAA Committee had convened to review the facility's Smoking Policy, discuss Policy revisions, and instruct the DON to make specified Policy changes. This was in accordance with Step A of the CAJR referenced above. - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the QAA Committee met for review and approval of the revisions to the Smoking Policy. This included the development and implementation of the Smoking Monitoring Log to be used by staff to ensure attendance and oversight during resident designated smoking times. This was in accordance with Step B of the CAJR referenced above. - On 02/03/2015, DON interview and Policy review confirmed that the facility had implemented a new, revised Smoking Policy with specifications which included the restriction of resident smoking to scheduled smoking times and under direct staff supervision only, the restriction of residents' possession of smoking paraphernalia in the absence of staff supervision. This Smoking Policy also specified a procedure involving residents obtaining smoking paraphernalia from staff when entering the smoking area and returning smoking paraphernalia to staff upon exiting the smoking area. This was in accordance with Step C of the CAJR referenced above. - On 02/03/2015, document review, Policy review, and interview with the DON confirmed that the facility had implemented the Safety Surveillance Log to be utilized in the event of resident noncompliance with the Smoking Policy (and to be used on an as-needed basis). This new Safety Surveillance Log and the accompanying procedure would allow staff to implement surveillance, vi

Based on observation, medical record review, Entity Reported Incident Intake review, facility investigative report review, resident Smoking Assessment Questionaire review, facility Smoking Policy and Procedure review, resident interview, facility staff written statement review, and staff interview, the facility failed to review and revise the Plan of Care for one (1) resident (B) who smoked cigarettes, regarding a facility-imposed restriction on the resident maintaining smoking materials and regarding staff monitoring to ensure the resident's safety; failed to review and revise the Plan of Care to reflect cigarette smoking for one (1) resident (E), who did not smoke cigarettes upon admission but later initiated smoking after admission, but for whom the facility failed to implement monitoring to ensure safety while smoking; and failed to review and revise the Plan of Care to reflect routine monitoring related to the unsafe behavior of one (1) resident (A), regarding Resident A's behavior of providing cigarettes and a lighter to another resident (Resident #1) who was assessed to require supervision while smoking. The total survey sample was nine (9) residents, all of whom smoked cigarettes. A Smoker's List provided by the facility documented a total of fifteen (15) residents who were identified by the facility to smoke cigarettes. The facility's failure to ensure adequate monitoring and supervision to residents who smoked resulted in a situation in which the facility's 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 immediate jeopardy is outlined as follows: - Resident B was assessed as safe to smoke unsupervised and to posses smoking materials upon facility admission. As a result of a 2011 incident involving Resident B using a cigarette lighter unsafely, the facility restricted her possession of cigarettes and a lighter. Instead, nursing staff were to keep Resident B's cigarettes and light her cigarettes to allow her to smoke; however, the facility failed to revise the Plan of Care for Resident B, regarding the facility-imposed restriction to the resident maintaining smoking materials, and did not revise the Plan of Care to reflect any monitoring required by staff to ensure the resident's safety regarding this restriction of unsupervised access to smoking materials. During an observation on 01/23/2015, Resident B obtained a cigarette and lighter from another resident and lit the cigarette with the lighter in the absence of staff to supervise. The failure to ensure Plan of Care revision and provide routine monitoring/supervision to Resident B, allowing her to access a lighter and light a cigarette in the absence of staff supervision, placed Resident B at risk for injury. - Resident E did not smoke upon admission in June 2014, but a nurse's note of 01/20/2015 documented Resident E did smoke cigarettes, and staff interview revealed Resident E was found on 01/22/2015 while in possession of packs of cigarettes. However, the facility failed to revise the Plan of Care for Resident E, per Policy and Procedure, to reflect the resident's post-admission initiation of cigarette smoking, and failed to implement any routine monitoring to ensure the resident's safety while smoking. - Resident A was assessed to be safe to smoke without staff supervision and was allowed to maintain his cigarettes and cigarette lighters in his possession. Resident A's Plan of Care identified that Resident A smoked cigarettes, and indicated that no staff supervision was needed during smoking. Resident A had a known history of providing cigarettes and lighter access to Resident #1 (who was assessed by the facility to be unsafe to smoke without staff supervision and was not to have possession of cigarettes and a lighter). The facility counseled Resident A related to this unsafe practice of providing smoking materials to Resident #1 in the absence of staff supervision; however, the facility failed to revise the Plan of Care for Resident A to implement any monitoring regarding his unsafe practice of providing smoking materials to Resident #1 and allowing Resident #1 to smoke in the absence of staff supervision. Then, on 01/19/2015, Resident A provided two (2) cigarettes to Resident #1, who also gained access to Resident A's lighter and attempted to light a cigarette, at which time she ignited her hair with the lighter. Resident #1 was transferred to the Burn Center, treated for [REDACTED]. Even though Resident A was found to again provide Resident #1 with a cigarette on 01/24/2014, the facility still failed to revise the Plan of Care for Resident A to put a system of monitoring into place, related to Resident A's ongoing unsafe behavior of providing smoking materials to Resident #1 without the knowledge of facility staff. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on January 30, 2015 at 12:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on January 19, 2015, the date Resident #1, who was assessed by the facility to require staff supervision while smoking, obtained two (2) cigarettes and a cigarette lighter without staff knowledge, attempted to light the cigarette with the lighter, and caught her hair on fire with the lighter. Resident #1 sustained multiple second/third [MEDICAL CONDITION] the left face, forehead, and ear. The immediate jeopardy continued through February 2, 2015, and was removed on February 3, 2015. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 2, 2015. An allegation of jeopardy removal was received on February 2, 2015. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 3, 2015. The facility remained out of compliance at a lower scope and severity of E while the process of evaluating modifications of resident assessment systems, care planning systems, and processes involved in the supervision of residents who smoked continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for supervising residents who smoked and who required supervision during smoking. Resident record reviews were conducted to assess facility staffs' conformance with the development of resident Plans of Care regarding smoking supervision. In addition, residents were observed while smoking in the exterior designated smoking area to assess facility staffs' conformance with the supervision of residents while smoking, in accordance with their assessed needs and as specified by their Plans of Care, to therefore ensure resident safety while smoking. Findings include: Review of the facility's Smoking Policy and Procedure revealed the Procedure to specify that residents were to be assessed using the Smoking Assessment Questionaire upon admission, quarterly, and with any change in condition regarding smoking preferences and specific needs. This assessment was to include, but not be limited to, cognitive concerns, the level of assistance needed to smoke (i.e., assistance with lighters, holding of cigarettes), and any safety concerns. Based on the data collected during this assessment process, a specific plan was to be developed to meet the individual needs of the resident. The resident-specific information from the assessment was to be included in the resident's Plan of Care, which was to be reviewed and revised accordingly. 1. Resident B's Annual Minimum Data Set (MDS) assessment of October 2014 documented an original admission in March 2010, and documented in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) Summary Score of 13, indicating she was cognitively intact. Section I - Active [DIAGNOSES REDACTED]. A Smoking Assessment Questionaire dated 10/30/2014 for Resident B referenced the resident's history of tobacco use. This Smoking Assessment Questionaire assessed Resident B's current status related to cigarette smoking, and assessed the resident as safe to smoke without supervision. During a 01/23/2015, 12:00 p.m. interview, Resident B acknowledged that she smoked without supervision, but stated she could not keep her cigarettes and lighter; rather, staff kept her cigarettes and lighter, and the nurse would light cigarettes for her to smoke. During a 01/29/2015, 2:20 p.m. interview, the DON stated that Resident B was allowed to keep her cigarettes and lighter in the past, but was involved in a 2011 incident during which she used a cigarette lighter to light tissue paper on fire. The DON stated that, due to the 2011 incident, Resident B no longer kept her smoking materials, but instead, nursing staff kept the resident's cigarettes and lighter. However, review of Resident B's current Plan of Care revealed no reference to the resident's use of cigarettes, and there were no Plan of Care Interventions related to the resident's cigarette use (to include no reference to the requirement that nursing staff were to maintain the resident's cigarettes and lighter secured). This was despite the fact that Resident B, although assessed to be capable of smoking without supervision (per the 10/30/2014 Smoking Assessment Questionaire referenced above), had been allowed in the past to maintain her smoking materials, but had subsequently been restricted from keeping cigarettes and a lighter on her person due to a 2011 incident involving a cigarette lighter (per the 01/29/2014, 2:20 p.m. DON interview referenced above). This was also despite the facility's Smoking Policy and Procedure referenced above which specified that residents would be assessed with [REDACTED]. The facility had therefore failed to review and revise the Plan of Care for Resident B after the 2011 incident resulting in a restriction of her having access to smoking materials, including cigarettes and the cigarette lighter, in the absence of staff supervision. During an interview with the facility's Care Plan (CP) Coordinator conducted on 02/02/2015 at 1:44 p.m., the CP Coordinator acknowledged that for residents requiring supervision while smoking, Plans of Care should include resident cigarette use and interventions for supervision. During a 01/23/2015, 12:45 p.m. observation, Resident B was in the smoking area with Resident #3 with no staff in attendance. During this observation, Resident B asked Resident #3 for a cigarette. Resident #3 handed a cigarette and lighter to Resident B, who then lit the cigarette and began smoking. Based on the above, Resident B was admitted to the facility in 2010 and was assessed to be safe to smoke without supervision. Due to a 2011 incident involving Resident B's unsafe use of a cigarette lighter, the facility then restricted Resident Bs access to cigarettes and a lighter. Nursing staff were to maintain the resident's smoking materials and light the resident's cigarettes. However, the facility failed to revise Resident B's Plan of Care, as specified by the Smoking Policy and Procedure, to reflect the plan developed by the facility regarding the resident's use of cigarettes, developed in 2011, to restrict Resident B's access to smoking materials. Cross refer to F323, example 2, for more information regarding Resident B. 2. Resident E's Admission MDS assessment of July 2014 documented admission in June of 2014. Section I - Active [DIAGNOSES REDACTED]. Section J - Health Conditions documented that Resident E did not use tobacco products upon facility admission. A Smoking Assessment Questionaire for Resident E dated June of 2014, completed upon the resident's facility admission, documented that the resident was non-smoking. But, a subsequent Smoking Assessment Questionaire of 12/22/2014 then assessed Resident E for smoking, indicating that Resident E was not safe to smoke without staff supervision. A NPN entry of 01/20/2015 at 10:00 a.m. documented that Resident E did smoke cigarettes in the designated smoking area, and Resident E acknowledged, during a 01/23/2015, 10:45 a.m. interview, that he did smoke. During a 01/30/2015, 10:45 a.m. interview, Licensed Practical Nurse (LPN) CC stated she had observed Resident E on 01/22/2015 to have multiple packs of cigarettes. However, even though Resident E's 12/22/2014 Smoking Assessment Questionaire (referenced above) documented that the resident required supervision while smoking, and even though the July 2014 MDS assessment (referenced above) documented Resident E did not smoke upon admission, but then the resident began smoking after facility admission (as acknowledged in Resident E's 01/23/2015, 10:45 a.m. interview referenced above), and smoked with the knowledge of facility staff (as documented in the 01/20/2015, 10:00 a.m. NPN, and acknowledged during LPN CC's 01/30/2014, 10:45 a.m. interview, both referenced above), review of Resident E's Plan of Care revealed no reference to the resident smoking cigarettes, and no Plan of Care Interventions related to the resident's cigarette use. This was despite the facility's Smoking Policy and Procedure referenced above which specified that, upon any change, the resident's specific smoking needs (including the need of nursing staff to provide assistance with lighters and holding of cigarettes) would be included in the Plan of Care. The facility had therefore failed to review and revise the Plan of Care for Resident E upon the resident's initiation of smoking activities after his June 2014 facility admission. During an interview conducted on 02/02/2015 at 1:44 p.m., the CP Coordinator acknowledged that Plans of Care for residents who smoked should include interventions for supervision during smoking if required. Cross refer to F323, example 3, for more information regarding Resident E. 3. Resident A's Admission MDS assessment of December 2014 documented the resident's admission that month, and Section C - Cognitive Patterns documented Resident A with cognitively intact, having a BIMS Score of 15. Section J - Health Conditions documented that Resident A used tobacco products at the time of facility admission. A December 2014 Smoking Assessment Questionaire for Resident A assessed the resident to be safe to smoke without supervision. During a 01/29/2014, 9:50 a.m. interview, the Administrator stated that some residents assessed as safe to smoke independently (such as Resident A, per the Smoking Assessment Questionaire referenced above) were allowed to keep smoking paraphernalia (cigarettes and lighters) in their possession. Review of the Plan of Care for Resident A revealed a Problems/Strengths entry of 12/21/2014 which identified that the resident had altered thought process potential. Interventions on this Plan of Care for Resident A, as related to the resident's altered thought process potential, included a notation that the resident was a smoker, but noted that no supervision was needed for smoking. A Social Progress Notes (SPN) entry for Resident A dated 12/29/2014 (approximately one week after the 12/21/14 development of Resident A's Plan of Care Intervention, referenced above, which indicated the resident required no supervision during smoking) documented that Social Services staff had counseled with Resident A to inform him not to give cigarettes or light cigarettes for a female resident (Resident #1), because the female resident was on a supervised smoking program with staff supervision only. However, despite the SPN entry of 12/29/2014 referenced above which identified Resident A's having been counseled regarding providing cigarettes to, and lighting cigarettes for, Resident #1 who required supervised smoking, further review of Resident A's Plan of Care revealed no revisions related to any acknowledgement of this behavior of Resident A's unsafe practice of inappropriately providing Resident #1 smoking paraphernalia, nor any Intervention to address this unsafe practice. Entity Reported Incident Intake (ERII) Number GA 603 of 01/21/2015, submitted to the State Agency by the facility regarding Resident #1, then documented that Resident #1 smoked cigarettes and required supervision, but that on 01/19/2015, Resident #1 obtained two cigarettes and a lighter from another resident and caught her hair on fire. A facility investigative report of 01/22/2015 documented that Resident #1 and Resident #9 were in the smoking area and, per Resident #9, Resident #1 produced a hand-rolled cigarette and lighter. Resident #1 attempted to light the cigarette but accidentally lit her hair on fire. Resident #9 informed Resident C, who smothered the fire on Resident #1's head. Resident #1 was transferred to the hospital and noted with second/third [MEDICAL CONDITION] the left side of the face, third [MEDICAL CONDITION] the left side of the forehead/temple, and second [MEDICAL CONDITION] the left side of the cheek and external ear, and was transferred to the Burn Center. This investigative report documented that Resident A admitted he gave Resident #1 two cigarettes and that Resident #1 could have obtained the lighter from his room, and documented a facility conclusion that Resident A provided rolled cigarettes to Resident #1. However, despite the ERII and investigative summary referenced above documenting the 01/19/2015 incident during which Resident A had again given cigarettes to Resident #1 (with Resident #1 then gaining access to a lighter, ignighting her hair and sustaining multiple burn wounds to her face, forehead, and ear), further review of Resident A's Plan of Care still revealed no notation regarding Resident A's unsafe behavior of providing Resident #1 cigarettes and allowing her access to his cigarette lighters. Then, a NPN entry of 01/24/2015 at 9:22 a.m. for Resident A documented that Resident A had again given a resident (Resident #1) a hand-made cigarette, and that Resident A was again counseled to refrain from giving any resident a cigarette or lighter. In a written statement, RN EE documented the 01/24/2014 incident (as documented in the 01/24/2015, 9:22 a.m. NPN entry referenced above) during which Resident A had given Resident #1 a hand-made cigarette, and that staff were instructed to monitor Resident #1 and Resident A for the exchange of smoking paraphernalia. However, despite Resident A again have provided Resident #1 with a cigarette on 01/24/2015 (per the 01/24/2014, 9:22 a.m. NPN referenced above), and even though staff were specifically instructed to monitor Resident A (and Resident #1) closely regarding the exchange of smoking materials, further review of Resident A's Plan of Care still revealed no revision to reflect Resident A's continued unsafe behavior of providing Resident #1 with smoking paraphernalia, nor did the Plan of Care reference any Interventions to address this unsafe practice at that time. During a 02/02/2015, 1:44 p.m. interview, the CP Coordinator acknowledged that resident Plans of Care should include interventions for supervision regarding cigarette use. Cross refer to F323, example 1, for more information regarding Resident A (in relation to Resident #1). The facility presented a credible allegation of jeopardy removal (CAJR) on February 2, 2015. Based on the CAJR, it was determined that the immediate jeopardy had been removed on February 3, 2015, at which time the facility had implemented the following interventions: 1. On 01/26/2015, the Quality Assessment and Assurance (QAA) Committee met. During this meeting, the QAA Committee reviewed the facility's current Smoking Policy and discussed revisions to enhance resident safety. Recommendations were made, and the DON was to make edits and submit the revised Policy for review and approval. The specific recommendation that all resident smoking would be monitored was discussed an initiated immediately. Additionally, the Committee discussed offering smoking cessation services to residents desiring such services. 2. On 01/27/2015, the QAA Committee met and the revisions to the Smoking Policy were submitted for review and approval. The QAA Committee meeting focused on the development of a Smoking Monitoring Log, with approval and implementation post meeting. This Smoking Monitoring Log would allow for the staff responsible for monitoring the smoking area (per the newly implemented procedure referenced above specifying that all resident smoking would be monitored) to document attendance and oversight during designated smoking times. The QAA Committee was informed that a smoking cessation instructor would begin services on that date, offering a general orientation to smoking cessation classes. 3. On 01/29/2015, the facility implemented the Smoking Policy, the Purpose of which is to provide guidance regarding resident smoking at the facility. This Smoking Policy includes, but is not limited to, the specification that resident smoking is only permitted under staff supervision. Residents will not be allowed to keep any smoking paraphernalia on their person or with their personal belongings. Residents are required to check smoking paraphernalia out from staff members with entrance to the designated smoking area, and check smoking paraphernalia back in with staff at the time of exit from the designated smoking area. No more than two (2) cigarettes may be distributed to a resident, and any cigarettes not smoked will be collected by staff and returned to the storage area upon reentry into the building. Lighters and matches will be distributed to the resident for that smoking session and collected by staff for storage upon reentry into the building. Smoking paraphernalia will be inventoried following every smoking session to ensure all is accounted for. This inventory will be completed by the staff member assigned to supervise at each scheduled smoking time, and will be documented on the Resident Tobacco and Paraphernalia Log. The sharing of cigarettes and/or lighters and matches amongst residents is not permitted. Smoking is not permitted except within the designated area which is the courtyard/patio area located on the facility's South wing. Resident smoking will be conducted during scheduled times via a Smoking Schedule, and the smoking area will be open for resident access based on the posted schedule. Additionally, the Smoking Policy specifies that residents will be assessed upon admission regarding smoking preferences and any special needs. Residents are then reassessed quarterly and with any change in condition. A Smoking Safety Evaluation Form will be utilized to conduct resident smoking assessments. This Smoking Safety Evaluation will be utilized to assess a resident's smoking history, safety concerns, cognitive awareness, and ability to handle a lighter. This assessment includes the evaluation of each smoking resident's capabilities and deficits and determines whether or not supervision during smoking is required. Based on the data collected in the smoking assessment, a specific plan will be developed to meet the individual needs of the resident. The information in the assessment is included in the resident's Plan of Care, which is reviewed and revised accordingly. 4. On 01/29/2015, the facility implemented the use of a new Safety Surveillance Log to be utilized in the event of resident non-compliance with the Smoking Policy. This new procedure indicated that, in the event a resident is observed in possession of tobacco and/or paraphernalia (other than at the approved times and in conformance with approved procedures), the facility would implement surveillance to ensure compliance. Said surveillance will be documented in the Safety Surveillance Log. At the time of discovery of an infraction, items will be inventoried for the resident. The Safety Surveillance Log will be completed as supervised by the designated Charge Nurse. The surveillance frequency will be a minimum of twice per day, and include a random search for a seven-day period. With zero findings for the seven-day period, the surveillance would transition to three times per week for 30 days. A reassessment will be conducted post the 30 day mark for the necessity of ongoing surveillance. In addition, an attempt will be made to identify the source of provision of products with subsequent counseling to follow. All findings and recommendations will be submitted to, and monitored by, the QAA Committee. 5. On 01/29/2015, a special called Resident Council meeting was held to discuss the changes to the Smoking Policy. All resident smokers were in attendance. 6. On 01/29/2015, all residents utilizing tobacco products were assessed by the DON using the new Smoking Safety Evaluation Form. One-hundred percent of all current residents who smoke (a total of fourteen residents on the date of assessment) were assessed with [REDACTED]. 7. On 01/29/2015, the facility reviewed/revised the Plans of Care for all residents using tobacco products, and Plans of Care for these residents were developed/updated with the goals of no injury when using tobacco products, safety practices, and encouraging smoking cessation. 8. On 01/29/2015, the facility reiterated a procedure requiring that the facility's Interdisciplinary Care Team reassess each resident who smoked on a quarterly basis, or more frequently if needed, to determine if any change in smoking abilities has occurred. All resident Plans of Care will be updated to reflect this assessment. 9. On 01/30/2015, a one-on-one sitter was assigned to Resident #1 to provide supervision to the resident. Resident #1 will have a sitter twenty-four hours per day, seven days per week to ensure her safety, and this coverage will continue until a later determination is made. 10. On 02/02/2015, the facility implemented the use of fire blankets (which were originally ordered by the facility on 01/30/2015). These fire blankets will be housed in the smoking area and will be used to aid in ensuring resident safety during smoking. 11. On 02/02/2015, the facility implemented enforcement of the Policy by which all smoking tobacco products and paraphernalia were removed from resident possession. Going forward, per the new Policy referenced above, smoking tobacco products and paraphernalia will be provided to residents upon request in the designated smoking area. When the resident reenters the facility after smoking activities have concluded, any smoking tobacco product that has not been consumed, as well as any smoking paraphernalia, will be returned to facility staff and inventoried. 12. On 02/02/2015, the facility conducted staff in-service training regarding the new Smoking Policy and the new procedures involving the supervision of residents who smoke, the new smoking schedule, the monitoring process for potential resident noncompliance, and resident safety while smoking by the use of fire blankets. This staff in-service training also included staff training related to the smoking assessment process. As of 02/02/2015, the following facility staff had received this in-service training: eighteen (18) of eighteen (18) housekeeping staff; fourteen (14) of fourteen (14) food service staff; three (3) of three (3) activities staff; forty (40) of forty (40) certified nursing assistants; and twenty-two (22) of twenty-three (23) licensed nursing staff. One (1) licensed nursing staff member was unavailable to receive this training due to being on leave status. This one (1) remaining licensed nursing staff member will receive this in-service training upon her return to work. 13. On 02/02/2015, the facility implemented the Smoking Policy Compliance Audit to audit the facility's new smoking program to monitor for evidence of ongoing staff compliance. This Audit will serve the purpose of monitoring and assessing staff compliance with the routine completion of the resident Smoking Safety Evaluation assessments, execution and maintenance of resident Plans of Care, the completion of the routine staff inventory of tobacco products and paraphernalia, and completion of the Smoking Surveillance Log (utilized as needed to address identified resident noncompliance with the Smoking Policy). This Smoking Policy Compliance Audit will be conducted by the DON, Assistant Director of Nursing, designated Registered Nurse Supervisor, Administrator, Assistant Administrator, or MDS Coordinator. This Audit will be conducted on every resident who smokes beginning on 02/02/2015, and will be conducted with the following progression: Weekly from 02/02/2015 through 02/28/2015; Biweekly from 03/01/2015 through 04/05/2015; Monthly on 04/06/2015, and ongoing. Any findings and subsequent interventions for ongoing compliance with facility Policy will be discussed with the QAA Committee. The data collected during the Smoking Policy Compliance Audit will be reported monthly to the QAA Committee for the Committee's review and evaluation. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the facility's QAA Committee had convened to review the facility's Smoking Policy, discuss Policy revisions, and instruct the DON to make specified Policy changes. This was in accordance with Step #1 of the CAJR referenced above. - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the QAA Committee met for review and approval of the revisions to the Smoking Policy. This included the development and implementation of the Smoking Monitoring Log to be used by staff to ensure attendance and oversight during resident designated smoking times. This was in accordance with Step #2 of the CAJR referenced above. - On 02/03/2015, DON interview and Policy review confirmed that the facility had implemented a new, revised Smoking Policy with specifications which included the restriction of resident smoking to scheduled smoking times and under direct staff supervision only, the restriction of residents' possession of smoking paraphernalia in the absence of staff supervision. This Smoking Policy also specified a procedure involving residents obtaining smoking paraphernalia from staff when entering the smoking area and returning smoking paraphernalia to staff upon exiting the smoking area. This was in accordance with Step #3 of the CAJR referenced above. - On 02/03/2015, document review, Policy review, and interview with the DON confirmed that the facility had implemented the Safety Surveillance Log to be utilized in the event of resident noncompliance with the Smoking Policy (and to be used on an as-needed basis). This new Safety Surveillance Log and the accompanying procedure would allow staff to implement surveillance, via inspections at specified intervals for specified timeframes, to ensure resident compliance with the facility's Smoking Policy. This was in accordance with Step #4 of the CAJR referenced above. - On 02

An abbreviated survey conducted January 23, 2015 through February 5, 2015 revealed noncompliance at F281 at the Scope/Severity of "K". Additional noncompliance at F281 was also identified, at a non-immediate jeopardy level, during the standard survey of February 2, 2015 through February 5, 2015. Therefore, the noncompliance at F281 identified during the January 23, 2015 through February 5, 2015 abbreviated survey has been brought forward to this Form CMS-2567, which also represents the noncompliance at F281 identified during the February 2, 2015 through February 5, 2015 standard survey, as referenced below: Based on observation, medical record review, facility investigative report review, resident Smoking Assessment Questionaire review, resident interview, facility staff written statement review, National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules review, and staff interview, the facility failed to ensure routine surveillance and monitoring regarding cigarette smoking, in accordance with professional standards of practice, for one (1) resident (#1) who was assessed by the facility to require supervision while smoking, but for whom the facility failed to ensure routine monitoring regarding the resident's unsafe behavior of obtaining smoking materials without staffs' knowledge; for one (1) resident ("B") who smoked without supervision but who had a restriction on her access to a cigarette lighter; and for one (1) resident ("E"), who did not smoke at the time of facility admission but began smoking cigarettes after admission, but for whom the facility failed to provide routine monitoring to ensure the resident's safety during smoking. The total survey sample for the abbreviated survey was nine (9) residents, all of whom smoked cigarettes. A facility Smoker's List documented fifteen (15) residents who were identified by the facility to smoke. Additionally, the standard survey revealed that facility nursing staff failed to make efforts, in accordance with nursing standards of practice, to address an expressed concern alleging a lack of Activities of Daily Living care related to one (1) resident ("F") from the standard survey sample of twenty-four (24) residents. The facility's failure to ensure adequate monitoring to residents who smoked resulted in a situation in which the facility's 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 immediate jeopardy is outlined as follows: - Resident #1 required staff supervision while smoking, and nursing staff kept her smoking materials locked, but Resident #1 had a history of [REDACTED]. However, despite the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice specifying that the nurse provide monitoring, facility nursing staff failed to ensure routine monitoring, specific to frequency, to address Resident #1's attempts to obtain smoking materials and smoke without supervision. On 01/19/2015, Resident #1 obtained 2 cigarettes from Resident "A", gained access to Resident "A"'s lighter, attempted to light a cigarette in the absence of staff, and ignited her hair. Resident #1 was transferred to the hospital and determined to have second and/or third [MEDICAL CONDITION] the left side of the face, left side of her forehead and temple, and left side of her cheek and external ear, which required skin grafting. Resident #1 returned to the facility on [DATE], but was then found to have another cigarette on 01/24/2014, obtained from Resident "A", initially without the knowledge of staff. - Resident "B" was assessed as safe to smoke unsupervised, but because of a 2011 incident involving Resident "B" using a lighter unsafely, she could not maintain cigarettes and a lighter in her possession. Nursing staff were to keep Resident "B"'s cigarettes and light her cigarettes while smoking. However, there was no evidence of routine monitoring of Resident "B" by nursing staff related to her restricted access to a cigarette lighter, despite the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice specifying that the nurse provide resident monitoring. During a 01/23/2015 observation, in the absence of nursing staff to supervise, Resident "B" obtained a cigarette and lighter from another resident, lit the cigarette, and smoked. - Resident "E" was a non-smoker when admitted in June 2014. A nurse's note of 01/20/15 documented Resident "E" did smoke cigarettes at that time, and staff interview revealed the resident was in possession of packs of cigarettes on 01/22/2015. 12/22/2014 Smoking Assessment Questionaire assessed Resident "E" to require staff supervision while smoking; however, despite the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice specifying that the nurse provide resident monitoring, there was no evidence of routine nursing staff monitoring/supervision of Resident "E" related to smoking. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on January 30, 2015 at 12:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on January 19, 2015, the date that Resident #1, who was assessed by the facility to require staff supervision while smoking cigarettes, obtained two (2) cigarettes and gained access to a cigarette lighter without the knowledge of staff, attempted to light the cigarette with the lighter, and caught her hair on fire with the lighter. Resident #1 sustained multiple second/third [MEDICAL CONDITION] the left face, forehead, and ear. The immediate jeopardy continued through February 2, 2015, and was removed on February 3, 2015. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 2, 2015. During an interview with the DON conducted on 01/23/2015 at 10:00 a.m., when questioned regarding Resident #1 sustaining burn wounds, the DON acknowledged the 01/19/2015 incident during which Resident #1 sustained multiple burn wounds while attempting to light a cigarette using a cigarette lighter. An allegation of jeopardy removal was received on February 2, 2015. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 3, 2015. The facility remained out of compliance at a lower scope and severity of "E" while the process of evaluating modifications of resident assessment systems, care planning systems, and processes involved in the supervision of residents who smoked continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for supervising residents who smoked and who required supervision during smoking. Resident record reviews were conducted to assess facility staffs' conformance with the development of resident Plans of Care regarding smoking supervision. In addition, residents were observed while smoking in the exterior designated smoking area to assess facility staffs' conformance with the supervision of residents while smoking, in accordance with their assessed needs and as specified by their Plans of Care, to therefore ensure resident safety while smoking. Findings include: Review of the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules revealed that the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice, Section 2.3.2(c), specified that the nurse demonstrate attentiveness and provide resident surveillance and monitoring. Additionally, Section 2.3.2(n) specifies that the nurse respects the resident's rights, concerns, decisions, and dignity. 1. Resident #1's 10/30/14 Admission Minimum Data Set (MDS) assessment documented diagnoses, in Section I-Active Diagnoses, including, but not limited to, Dementia and [MEDICAL CONDITION], with Section G - Functional Status documenting mobility via wheelchair and Section J - Health Conditions documenting tobacco use. A Smoking Assessment Questionaire, completed on 10/20/2014 upon Resident #1's admission, assessed the resident as requiring staff supervision while smoking. Charge Nurse "AA" stated, during an interview of 01/29/2014 at 10:45 a.m., that Resident #1 required staff supervision while smoking, and that Resident #1's cigarettes and lighter were to be stored locked in the medication cart. Review of Resident #1's record revealed a Nurse's Progress Notes (NPN) entry of 10/27/2014 at 4:00 p.m. which documented that (despite the need to maintain Resident #1's cigarettes and lighter locked due to her requiring staff supervision, per the 01/29/2014, 10:45 a.m. interview with Charge Nurse "AA" referenced above), other residents reported that Resident #1 would frequently ask them for their cigarettes. A 10/31/2014 NPN entry also documented Resident #1 continued to try to borrow cigarettes from other residents. In a 01/29/2014, 9:50 a.m. interview, the Administrator stated that, based on each resident's assessment, some residents were allowed to keep cigarettes and lighters in their possession and smoke unsupervised. As documented above, Resident #1 was assessed by the 10/20/2014 Smoking Assessment Questionaire to require supervision while smoking, and per the 01/29/2014, 10:45 a.m. interview with Charge Nurse "AA", facility staff were to maintain Resident #1's cigarettes and lighter secured and supervise Resident #1 during smoking. However, even though the 10/27/2014, 4:00 p.m. and 10/31/2014 NPN entries referenced above both documented that nursing staff were aware of Resident #1's behavior of asking other residents for cigarettes (thus posing the risk of her obtaining smoking paraphernalia and smoking without staff supervision), record review revealed no evidence of licensed nursing staff providing routine monitoring, with regular frequency, to ensure that Resident #1 did not obtain cigarettes from other residents and smoke unsupervised. This was despite the standard of nursing practice, per the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice referenced above, specifying that the nurse provide resident surveillance and monitoring. Further review of Resident #1's record revealed a 01/19/2015, 3:15 p.m. NPN entry documenting that a male resident informed the nurse he had extinguished fire from Resident #1's hair, and documented the nurse observed Resident #1's hair singed and the left side of her forehead red. A 01/19/2015, 3:46 p.m. NPN entry documented that when the physician was notified of Resident #1's burns, an order for [REDACTED]. A facility investigative report (IR) dated January 22, 2015 documented the facility's investigation into the January 19, 2015 incident involving Resident #1's burns. In this IR, the facility documented that on January 19, 2015, Resident #1 and Resident #9 were in the smoking area. During facility interview, Resident #9 stated that Resident #1 showed a hand-rolled cigarette and a lighter, leaned over to light the cigarette, and accidentally lit her hair on fire. Resident #9 informed Resident "C" that Resident #1 was on fire, and Resident "C" went to smother the fire with his hands. Nursing staff assessed Resident #1 to have sustained head burns, and Resident #1 was transferred to the local hospital (where she was documented to have produced another hand-rolled cigarette) and observed with second and third [MEDICAL CONDITION] the left side of the face, third [MEDICAL CONDITION] the left side of the forehead and temple, and second [MEDICAL CONDITION] the left side of the cheek and external ear. This IR further documented Resident #1 was transferred to the Burn Center for treatment. The IR documented that it was "apparent" that Resident "A" (who was assessed as an independent smoker and was allowed to maintain smoking paraphernalia in his possession) had been the source of the hand-rolled cigarettes Resident #1 had in her possession. Resident "A" admitted to facility staff that he had given Resident #1 two (2) cigarettes. Further, Resident "A" denied giving Resident #1 a lighter, but stated that he kept 2 lighters on his dresser and that he had discovered one of the lighters missing on 01/19/2015, the incident date. Further review of Resident #1's medical record revealed a NPN entry of 01/23/2014 at 9:25 p.m. which documented she was readmitted to the nursing facility from the Burn Center on that date. This NPN entry documented Resident #1 to have skin grafts to the left ear, left scalp, and left side of the face, and that staff would continue to monitor. However, even though Resident #1 required supervised smoking for safety, as indicated by the 10/20/2014 Smoking Assessment Questionaire referenced above, and even though Resident #1 sustained second and/or third [MEDICAL CONDITION] the left side of the face, forehead/temple, cheek and external ear on 01/19/2015 while smoking unsupervised after being given a cigarette by Resident "A" and obtaining access to a lighter, there was no evidence to indicate that licensed nursing staff provided monitoring, at a routine frequency, to Resident #1 upon her readmission to the facility on [DATE]. This was despite the standard of nursing practice, per the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice referenced above, specifying that the nurse provide resident surveillance and monitoring. During a 02/02/2015, 12:40 p.m. interview, the DON acknowledged that prior to the 01/19/2014 incident referenced above when Resident #1 sustained multiple burn wounds while attempting to light a cigarette in the absence of staff supervision, nursing staff had provided no routine monitoring to Resident #1 regarding her smoking behaviors, other than monitoring during supervised smoking times. A 01/24/2014, 9:30 a.m. NPN entry then documented that nursing staff again found Resident #1 holding a hand-made cigarette which she stated came from another resident. This NPN entry documented that nursing staff again instructed Resident #1 to only obtain cigarettes and a lighter from staff and to smoke while being supervised. In a written statement provided by the facility, Registered Nurse (RN) "EE" documented that on 01/24/2014, the hand-made cigarette taken from Resident #1 had been given to her by Resident "A", and that staff were instructed to closely monitor Resident #1 and Resident "A" for the exchange of smoking paraphernalia. However, even though Resident #1 had again obtained a cigarette without staff knowledge, per the 01/24/2015, 9:30 a.m. NPN referenced above, and even though nursing standards of practice, per the Model Nursing Administrative Rules referenced above, mandated the nurse to provide resident surveillance/monitoring, further record review continued to reveal no evidence of routine licensed nursing staff monitoring, with specific frequency, for Resident #1 related to her continued behavior of obtaining smoking materials other than smoking materials provided by facility nursing staff. Cross refer to F323, example 1, for more information regarding Resident #1. 2. Resident "B"'s January 2015 Quarterly MDS assessment documented admission in March of 2010. Section C - Cognitive Patterns documented a Brief Interview for Mental Status (BIMS) Summary Score of 13, indicating Resident "B" was cognitively intact, and Section I - Active [DIAGNOSES REDACTED]. A Smoking Assessment Questionaire of 10/30/2014 documented that Resident "B" could smoke without supervision. During an interview on 01/23/2015 at 12:00 p.m., Resident "B" stated she could smoke without supervision, but could not keep her cigarettes and cigarette lighter. Resident "B" stated that, due to a past incident, staff kept her cigarettes and lighted her cigarettes. During an interview on 01/29/2015 at 2:20 p.m., the DON stated that Resident "B" was no longer allowed to keep her cigarettes and lighter due to an incident which occurred in 2011 when Resident "B" used her cigarette lighter to light tissue paper. The DON stated that after the 2011 incident involving Resident "B"'s unsafe use of the cigarette lighter, nursing staff were to keep Resident "B"'s smoking materials. Further review of Resident "B"'s medical record revealed, however, that even though the resident was restricted from having cigarettes and a lighter in her possession, except as provided by nursing staff, due to the 2011 incident involving her unsafe use of a lighter (per the 01/29/2015, 2:20 p.m. interview with the DON referenced above), there was no evidence of ongoing monitoring of any specific frequency by licensed nursing staff of Resident "B", related to her restricted access to a cigarette lighter. This was despite the standard of nursing practice, per the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice referenced above, specifying that the nurse provide resident surveillance and monitoring. During an observation of 01/23/2015 at 12:45 p.m., Resident "B" and Resident #3 were in the smoking area. Resident "B" finished smoking a cigarette provided by nursing staff, but then, even though no nursing staff were in attendance, Resident "B" asked Resident #3 for another cigarette. Resident #3 gave Resident "B" a cigarette and lighter, and Resident "B" lit the cigarette and began smoking, with no staff present to supervise. During the 01/29/2015, 2:20 p.m. interview referenced above, the DON acknowledged that Resident "B" did require nursing staff supervision while smoking, and that the resident should not have had a cigarette lighter in her possession to use without nursing staff supervision. However, the DON further acknowledged that even after the 01/23/2015, 12:45 p.m. observation referenced above during which Resident "B" obtained a cigarette and lighter from another resident, with no supervision, there was no system in place to ensure routine nursing staff monitoring related to Resident "B"'s restriction to access regarding smoking materials. Cross refer to F323, example 2, for more information regarding Resident "B". 3. Resident "E"'s Admission MDS assessment of July 2014 documented facility admission in June 2014. Section I - Active [DIAGNOSES REDACTED]. Even though Resident "E"'s Admission MDS assessment referenced above documented the resident did not smoke when admitted in June of 2014, a 01/20/2015, 10:00 a.m. NPN entry documented Resident "E" did smoke cigarettes. During a 01/23/2015, 10:45 a.m. interview, Resident "E" acknowledged that he smoked cigarettes. A Smoking Assessment Questionaire dated 12/22/2014 documented that Resident "E" was assessed to require staff supervision while smoking. However, further record review for Resident "E" revealed no evidence of licensed nursing staff monitoring of Resident "E", specific to frequency, related to the resident's smoking behavior, to ensure his safety while smoking. This was despite Resident "E"'s Smoking Assessment Questionaire assessing to require supervision while smoking, and despite the standard of nursing practice, per the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice referenced above, specifying that the nurse provide resident surveillance and monitoring. Cross refer to F323, example 3, for more information regarding Resident "E". 4. Resident "F"'s December 2014 Quarterly MDS documented a BIMS Score of 15 in Section C-Cognitive Patterns, indicating he was cognitively intact. Section G-Functional Status documented Resident "F" to require extensive assistance with personal hygiene. Review of Resident "F"'s record revealed a physician's 01/07/15 Report of Consultation which documented that Resident "F" alleged he not received regular shaves. However, there was no evidence, either in Resident "F"'s record or in the Grievance File, of any action by facility nursing staff related to this expressed concern of Resident "F". This was despite the National Council of State Boards of Nursing Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice referenced above which specified that the nurse respects the resident's rights and concerns. During a 02/05/2015, 9:28 a.m. interview, the DON acknowledged that Resident "F"'s grievance was not documented in the Grievance Log, and stated, during a later 02/05/2015, 11:25 a.m. interview, that Nurse Supervisors were responsible for reviewing physician consultation reports. Cross refer to F166 for more information regarding Resident "F"'s grievance. The facility presented a credible allegation of jeopardy removal (CAJR) on February 2, 2015. Based on the CAJR, it was determined that the immediate jeopardy had been removed on February 3, 2015, at which time the facility had implemented the following interventions: A. On 01/26/2015, the Quality Assessment and Assurance (QAA) Committee met. During this meeting, the QAA Committee reviewed the facility's current Smoking Policy and discussed revisions to enhance resident safety. Recommendations were made, and the DON was to make edits and submit the revised Policy for review and approval. The specific recommendation that all resident smoking would be monitored was discussed an initiated immediately. Additionally, the Committee discussed offering smoking cessation services to residents desiring such services. B. On 01/27/2015, the QAA Committee met and the revisions to the Smoking Policy were submitted for review and approval. The QAA Committee meeting focused on the development of a Smoking Monitoring Log, with approval and implementation post meeting. This Smoking Monitoring Log would allow for the staff responsible for monitoring the smoking area (per the newly implemented procedure referenced above specifying that all resident smoking would be monitored) to document attendance and oversight during designated smoking times. The QAA Committee was informed that a smoking cessation instructor would begin services on that date, offering a general orientation to smoking cessation classes. C. On 01/29/2015, the facility implemented the Smoking Policy, the Purpose of which is to provide guidance regarding resident smoking at the facility. This Smoking Policy includes, but is not limited to, the specification that resident smoking is only permitted under staff supervision. Residents will not be allowed to keep any smoking paraphernalia on their person or with their personal belongings. Residents are required to check smoking paraphernalia out from staff members with entrance to the designated smoking area, and check smoking paraphernalia back in with staff at the time of exit from the designated smoking area. No more than two (2) cigarettes may be distributed to a resident, and any cigarettes not smoked will be collected by staff and returned to the storage area upon reentry into the building. Lighters and matches will be distributed to the resident for that smoking session and collected by staff for storage upon reentry into the building. Smoking paraphernalia will be inventoried following every smoking session to ensure all is accounted for. This inventory will be completed by the staff member assigned to supervise at each scheduled smoking time, and will be documented on the Resident Tobacco and Paraphernalia Log. The sharing of cigarettes and/or lighters and matches amongst residents is not permitted. Smoking is not permitted except within the designated area which is the courtyard/patio area located on the facility's South wing. Resident smoking will be conducted during scheduled times via a Smoking Schedule, and the smoking area will be open for resident access based on the posted schedule. Additionally, the Smoking Policy specifies that residents will be assessed upon admission regarding smoking preferences and any special needs. Residents are then reassessed quarterly and with any change in condition. A Smoking Safety Evaluation Form will be utilized to conduct resident smoking assessments. This Smoking Safety Evaluation will be utilized to assess a resident's smoking history, safety concerns, cognitive awareness, and ability to handle a lighter. This assessment includes the evaluation of each smoking resident's capabilities and deficits and determines whether or not supervision during smoking is required. Based on the data collected in the smoking assessment, a specific plan will be developed to meet the individual needs of the resident. The information in the assessment is included in the resident's Plan of Care, which is reviewed and revised accordingly. D. On 01/29/2015, the facility implemented the use of a new Safety Surveillance Log to be utilized in the event of resident non-compliance with the Smoking Policy. This new procedure indicated that, in the event a resident is observed in possession of tobacco and/or paraphernalia (other than at the approved times and in conformance with approved procedures), the facility would implement surveillance to ensure compliance. Said surveillance will be documented in the Safety Surveillance Log. At the time of discovery of an infraction, items will be inventoried for the resident. The Safety Surveillance Log will be completed as supervised by the designated Charge Nurse. The surveillance frequency will be a minimum of twice per day, and include a random search for a seven-day period. With zero findings for the seven-day period, the surveillance would transition to three times per week for 30 days. A reassessment will be conducted post the 30 day mark for the necessity of ongoing surveillance. In addition, an attempt will be made to identify the source of provision of products with subsequent counseling to follow. All findings and recommendations will be submitted to, and monitored by, the QAA Committee. E. On 01/29/2015, a special called Resident Council meeting was held to discuss the changes to the Smoking Policy. All resident smokers were in attendance. F. On 01/29/2015, all residents utilizing tobacco products were assessed by the DON using the new Smoking Safety Evaluation Form. One-hundred percent of all current residents who smoke (a total of fourteen residents on the date of assessment) were assessed with [REDACTED]. G. On 01/29/2015, the facility reviewed/revised the Plans of Care for all residents using tobacco products, and Plans of Care for these residents were developed/updated with the goals of no injury when using tobacco products, safety practices, and encouraging smoking cessation. H. On 01/29/2015, the facility reiterated a procedure requiring that the facility's Interdisciplinary Care Team reassess each resident who smoked on a quarterly basis, or more frequently if needed, to determine if any change in smoking abilities has occurred. All resident Plans of Care will be updated to reflect this assessment. I. On 01/30/2015, a one-on-one sitter was assigned to Resident #1 to provide supervision to the resident. Resident #1 will have a sitter twenty-four hours per day, seven days per week to ensure her safety, and this coverage will continue until a later determination is made. J. On 02/02/2015, the facility implemented the use of fire blankets (which were originally ordered by the facility on 01/30/2015). These fire blankets will be housed in the smoking area and will be used to aid in ensuring resident safety during smoking. K. On 02/02/2015, the facility implemented enforcement of the Policy by which all smoking tobacco products and paraphernalia were removed from resident possession. Going forward, per the new Policy referenced above, smoking tobacco products and paraphernalia will be provided to residents upon request in the designated smoking area. When the resident reenters the facility after smoking activities have concluded, any smoking tobacco product that has not been consumed, as well as any smoking paraphernalia, will be returned to facility staff and inventoried. L. On 02/02/2015, the facility conducted staff in-service training regarding the new Smoking Policy and the new procedures involving the supervision of residents who smoke, the new smoking schedule, the monitoring process for potential resident noncompliance, and resident safety while smoking by the use of fire blankets. This staff in-service training also included staff training related to the smoking assessment process. As of 02/02/2015, the following facility staff had received this in-service training: eighteen (18) of eighteen (18) housekeeping staff; fourteen (14) of fourteen (14) food service staff; three (3) of three (3) activities staff; forty (40) of forty (40) certified nursing assistants; and twenty-two (22) of twenty-three (23) licensed nursing staff. One (1) licensed nursing staff member was unavailable to receive this training due to being on leave status. This one (1) remaining licensed nursing staff member will receive this in-service training upon her return to work. M. On 02/02/2015, the facility implemented the Smoking Policy Compliance Audit to audit the facility's new smoking program to monitor for evidence of ongoing staff compliance. This Audit will serve the purpose of monitoring and assessing staff compliance with the routine completion of the resident Smoking Safety Evaluation assessments, execution and maintenance of resident Plans of Care, the completion of the routine staff inventory of tobacco products and paraphernalia, and completion of the Smoking Surveillance Log (utilized as needed to address identified resident noncompliance with the Smoking Policy). This Smoking Policy Compliance Audit will be conducted by the DON, Assistant Director of Nursing, designated Registered Nurse Supervisor, Administrator, Assistant Administrator, or MDS Coordinator. This Audit will be conducted on every resident who smokes beginning on 02/02/2015, and will be conducted with the following progression: Weekly from 02/02/2015 through 02/28/2015; Biweekly from 03/01/2015 through 04/05/2015; Monthly on 04/06/2015, and ongoing. Any findings and subsequent interventions for ongoing compliance with facility Policy will be discussed with the QAA Committee. The data collected during the Smoking Policy Compliance Audit will be reported monthly to the QAA Committee for the Committee's review and evaluation. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the facility's QAA Committee had convened to review the facility's Smoking Policy, discuss Policy revisions, and instruct the DON to make specified Policy changes. This was in accordance with Step A of the CAJR referenced above. - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the QAA Committee met for review and approval of the revisions to the Smoking Policy. This included the development and implementation of the Smoking Monitoring Log to be used by staff to ensure attendance and oversight during resident designated smoking times. This was in accordance with Step B of the CAJR referenced above. - On 02/03/2015, DON interview and Policy review confirmed that the facility had implemented a new, revised Smoking Policy with specifications which included the restriction of resident smoking to scheduled smoking times and under direct staff supervision only, the restriction of residents' possession of smoking paraphernalia in the absence of staff supervision. This Smoking Policy also specified a procedure involving residents obtaining smoking paraphernalia from staff when entering the smoking area and returning smoking paraphernalia to staff upon exiting the smoking area. T

Based on observation, medical record review, facility investigative report review, resident Smoking Assessment Questionaire review, resident interview, facility staff written statement review, National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules review, and staff interview, the facility failed to ensure routine surveillance and monitoring regarding cigarette smoking, in accordance with professional standards of practice, for one (1) resident (#1) who was assessed by the facility to require supervision while smoking, but for whom the facility failed to ensure routine monitoring regarding the resident's unsafe behavior of obtaining smoking materials without staffs' knowledge; for one (1) resident (B) who smoked without supervision but who had a restriction on her access to a cigarette lighter; and for one (1) resident (E), who did not smoke at the time of facility admission but began smoking cigarettes after admission, but for whom the facility failed to provide routine monitoring to ensure the resident's safety during smoking. The total survey sample was nine (9) residents, all of whom smoked cigarettes. A Smoker's List provided by the facility documented a total of fifteen (15) residents who were identified by the facility to smoke cigarettes. The facility's failure to ensure adequate monitoring to residents who smoked resulted in a situation in which the facility's 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 immediate jeopardy is outlined as follows: - Resident #1 required staff supervision while smoking, and nursing staff kept her smoking materials locked, but Resident #1 had a history of [REDACTED]. However, despite the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice specifying that the nurse provide monitoring, facility nursing staff failed to ensure routine monitoring, specific to frequency, to address Resident #1's attempts to obtain smoking materials and smoke without supervision. On 01/19/2015, Resident #1 obtained 2 cigarettes from Resident A, gained access to Resident A's lighter, attempted to light a cigarette in the absence of staff, and ignited her hair. Resident #1 was transferred to the hospital and determined to have second and/or third [MEDICAL CONDITION] the left side of the face, left side of her forehead and temple, and left side of her cheek and external ear, which required skin grafting. Resident #1 returned to the facility on [DATE], but was then found to have another cigarette on 01/24/2014, obtained from Resident A, initially without the knowledge of staff. - Resident B was assessed as safe to smoke unsupervised, but because of a 2011 incident involving Resident B using a lighter unsafely, she could not maintain cigarettes and a lighter in her possession. Nursing staff were to keep Resident B's cigarettes and light her cigarettes while smoking. However, there was no evidence of routine monitoring of Resident B by nursing staff related to her restricted access to a cigarette lighter, despite the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice specifying that the nurse provide resident monitoring. During a 01/23/2015 observation, in the absence of nursing staff to supervise, Resident B obtained a cigarette and lighter from another resident, lit the cigarette, and smoked. - Resident E was a non-smoker when admitted in June 2014. A nurse's note of 01/20/15 documented Resident E did smoke cigarettes at that time, and staff interview revealed the resident was in possession of packs of cigarettes on 01/22/2015. 12/22/2014 Smoking Assessment Questionaire assessed Resident E to require staff supervision while smoking; however, despite the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice specifying that the nurse provide resident monitoring, there was no evidence of routine nursing staff monitoring/supervision of Resident E related to smoking. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on January 30, 2015 at 12:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on January 19, 2015, the date that Resident #1, who was assessed by the facility to require staff supervision while smoking cigarettes, obtained two (2) cigarettes and gained access to a cigarette lighter without the knowledge of staff, attempted to light the cigarette with the lighter, and caught her hair on fire with the lighter. Resident #1 sustained multiple second/third [MEDICAL CONDITION] the left face, forehead, and ear. The immediate jeopardy continued through February 2, 2015, and was removed on February 3, 2015. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 2, 2015. During an interview with the DON conducted on 01/23/2015 at 10:00 a.m., when questioned regarding Resident #1 sustaining burn wounds, the DON acknowledged the 01/19/2015 incident during which Resident #1 sustained multiple burn wounds while attempting to light a cigarette using a cigarette lighter. An allegation of jeopardy removal was received on February 2, 2015. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 3, 2015. The facility remained out of compliance at a lower scope and severity of E while the process of evaluating modifications of resident assessment systems, care planning systems, and processes involved in the supervision of residents who smoked continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for supervising residents who smoked and who required supervision during smoking. Resident record reviews were conducted to assess facility staffs' conformance with the development of resident Plans of Care regarding smoking supervision. In addition, residents were observed while smoking in the exterior designated smoking area to assess facility staffs' conformance with the supervision of residents while smoking, in accordance with their assessed needs and as specified by their Plans of Care, to therefore ensure resident safety while smoking. Findings include: Review of the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules revealed that the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice, Section 2.3.2(c), specified that the nurse demonstrate attentiveness and provide resident surveillance and monitoring. 1. Resident #1's 10/30/14 Admission Minimum Data Set (MDS) assessment documented diagnoses, in Section I-Active Diagnoses, including, but not limited to, Dementia and [MEDICAL CONDITION], with Section G - Functional Status documenting mobility via wheelchair and Section J - Health Conditions documenting tobacco use. A Smoking Assessment Questionaire, completed on 10/20/2014 upon Resident #1's admission, assessed the resident as requiring staff supervision while smoking. Charge Nurse AA stated, during an interview of 01/29/2014 at 10:45 a.m., that Resident #1 required staff supervision while smoking, and that Resident #1's cigarettes and lighter were to be stored locked in the medication cart. Review of Resident #1's record revealed a Nurse's Progress Notes (NPN) entry of 10/27/2014 at 4:00 p.m. which documented that (despite the need to maintain Resident #1's cigarettes and lighter locked due to her requiring staff supervision, per the 01/29/2014, 10:45 a.m. interview with Charge Nurse AA referenced above), other residents reported that Resident #1 would frequently ask them for their cigarettes. A 10/31/2014 NPN entry also documented Resident #1 continued to try to borrow cigarettes from other residents. In a 01/29/2014, 9:50 a.m. interview, the Administrator stated that, based on each resident's assessment, some residents were allowed to keep cigarettes and lighters in their possession and smoke unsupervised. As documented above, Resident #1 was assessed by the 10/20/2014 Smoking Assessment Questionaire to require supervision while smoking, and per the 01/29/2014, 10:45 a.m. interview with Charge Nurse AA, facility staff were to maintain Resident #1's cigarettes and lighter secured and supervise Resident #1 during smoking. However, even though the 10/27/2014, 4:00 p.m. and 10/31/2014 NPN entries referenced above both documented that nursing staff were aware of Resident #1's behavior of asking other residents for cigarettes (thus posing the risk of her obtaining smoking paraphernalia and smoking without staff supervision), record review revealed no evidence of licensed nursing staff providing routine monitoring, with regular frequency, to ensure that Resident #1 did not obtain cigarettes from other residents and smoke unsupervised. This was despite the standard of nursing practice, per the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice referenced above, specifying that the nurse provide resident surveillance and monitoring. Further review of Resident #1's record revealed a 01/19/2015, 3:15 p.m. NPN entry documenting that a male resident informed the nurse he had extinguished fire from Resident #1's hair, and documented the nurse observed Resident #1's hair singed and the left side of her forehead red. A 01/19/2015, 3:46 p.m. NPN entry documented that when the physician was notified of Resident #1's burns, an order for [REDACTED]. A facility investigative report (IR) dated January 22, 2015 documented the facility's investigation into the January 19, 2015 incident involving Resident #1's burns. In this IR, the facility documented that on January 19, 2015, Resident #1 and Resident #9 were in the smoking area. During facility interview, Resident #9 stated that Resident #1 showed a hand-rolled cigarette and a lighter, leaned over to light the cigarette, and accidentally lit her hair on fire. Resident #9 informed Resident C that Resident #1 was on fire, and Resident C went to smother the fire with his hands. Nursing staff assessed Resident #1 to have sustained head burns, and Resident #1 was transferred to the local hospital (where she was documented to have produced another hand-rolled cigarette) and observed with second and third [MEDICAL CONDITION] the left side of the face, third [MEDICAL CONDITION] the left side of the forehead and temple, and second [MEDICAL CONDITION] the left side of the cheek and external ear. This IR further documented Resident #1 was transferred to the Burn Center for treatment. The IR documented that it was apparent that Resident A (who was assessed as an independent smoker and was allowed to maintain smoking paraphernalia in his possession) had been the source of the hand-rolled cigarettes Resident #1 had in her possession. Resident A admitted to facility staff that he had given Resident #1 two (2) cigarettes. Further, Resident A denied giving Resident #1 a lighter, but stated that he kept 2 lighters on his dresser and that he had discovered one of the lighters missing on 01/19/2015, the incident date. Further review of Resident #1's medical record revealed a NPN entry of 01/23/2014 at 9:25 p.m. which documented she was readmitted to the nursing facility from the Burn Center on that date. This NPN entry documented Resident #1 to have skin grafts to the left ear, left scalp, and left side of the face, and that staff would continue to monitor. However, even though Resident #1 required supervised smoking for safety, as indicated by the 10/20/2014 Smoking Assessment Questionaire referenced above, and even though Resident #1 sustained second and/or third [MEDICAL CONDITION] the left side of the face, forehead/temple, cheek and external ear on 01/19/2015 while smoking unsupervised after being given a cigarette by Resident A and obtaining access to a lighter, there was no evidence to indicate that licensed nursing staff provided monitoring, at a routine frequency, to Resident #1 upon her readmission to the facility on [DATE]. This was despite the standard of nursing practice, per the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice referenced above, specifying that the nurse provide resident surveillance and monitoring. During a 02/02/2015, 12:40 p.m. interview, the DON acknowledged that prior to the 01/19/2014 incident referenced above when Resident #1 sustained multiple burn wounds while attempting to light a cigarette in the absence of staff supervision, nursing staff had provided no routine monitoring to Resident #1 regarding her smoking behaviors, other than monitoring during supervised smoking times. A 01/24/2014, 9:30 a.m. NPN entry then documented that nursing staff again found Resident #1 holding a hand-made cigarette which she stated came from another resident. This NPN entry documented that nursing staff again instructed Resident #1 to only obtain cigarettes and a lighter from staff and to smoke while being supervised. In a written statement provided by the facility, Registered Nurse (RN) EE documented that on 01/24/2014, the hand-made cigarette taken from Resident #1 had been given to her by Resident A, and that staff were instructed to closely monitor Resident #1 and Resident A for the exchange of smoking paraphernalia. However, even though Resident #1 had again obtained a cigarette without staff knowledge, per the 01/24/2015, 9:30 a.m. NPN referenced above, and even though nursing standards of practice, per the Model Nursing Administrative Rules referenced above, mandated the nurse to provide resident surveillance/monitoring, further record review continued to reveal no evidence of routine licensed nursing staff monitoring, with specific frequency, for Resident #1 related to her continued behavior of obtaining smoking materials other than smoking materials provided by facility nursing staff. Cross refer to F323, example 1, for more information regarding Resident #1. 2. Resident B's January 2015 Quarterly MDS assessment documented admission in March of 2010. Section C - Cognitive Patterns documented a Brief Interview for Mental Status (BIMS) Summary Score of 13, indicating Resident B was cognitively intact, and Section I - Active [DIAGNOSES REDACTED]. A Smoking Assessment Questionaire of 10/30/2014 documented that Resident B could smoke without supervision. During an interview on 01/23/2015 at 12:00 p.m., Resident B stated she could smoke without supervision, but could not keep her cigarettes and cigarette lighter. Resident B stated that, due to a past incident, staff kept her cigarettes and lighted her cigarettes. During an interview on 01/29/2015 at 2:20 p.m., the DON stated that Resident B was no longer allowed to keep her cigarettes and lighter due to an incident which occurred in 2011 when Resident B used her cigarette lighter to light tissue paper. The DON stated that after the 2011 incident involving Resident B's unsafe use of the cigarette lighter, nursing staff were to keep Resident B's smoking materials. Further review of Resident B's medical record revealed, however, that even though the resident was restricted from having cigarettes and a lighter in her possession, except as provided by nursing staff, due to the 2011 incident involving her unsafe use of a lighter (per the 01/29/2015, 2:20 p.m. interview with the DON referenced above), there was no evidence of ongoing monitoring of any specific frequency by licensed nursing staff of Resident B, related to her restricted access to a cigarette lighter. This was despite the standard of nursing practice, per the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice referenced above, specifying that the nurse provide resident surveillance and monitoring. During an observation of 01/23/2015 at 12:45 p.m., Resident B and Resident #3 were in the smoking area. Resident B finished smoking a cigarette provided by nursing staff, but then, even though no nursing staff were in attendance, Resident B asked Resident #3 for another cigarette. Resident #3 gave Resident B a cigarette and lighter, and Resident B lit the cigarette and began smoking, with no staff present to supervise. During the 01/29/2015, 2:20 p.m. interview referenced above, the DON acknowledged that Resident B did require nursing staff supervision while smoking, and that the resident should not have had a cigarette lighter in her possession to use without nursing staff supervision. However, the DON further acknowledged that even after the 01/23/2015, 12:45 p.m. observation referenced above during which Resident B obtained a cigarette and lighter from another resident, with no supervision, there was no system in place to ensure routine nursing staff monitoring related to Resident B's restriction to access regarding smoking materials. Cross refer to F323, example 2, for more information regarding Resident B. 3. Resident E's Admission MDS assessment of July 2014 documented facility admission in June 2014. Section I - Active [DIAGNOSES REDACTED]. Even though Resident E's Admission MDS assessment referenced above documented the resident did not smoke when admitted in June of 2014, a 01/20/2015, 10:00 a.m. NPN entry documented Resident E did smoke cigarettes. During a 01/23/2015, 10:45 a.m. interview, Resident E acknowledged that he smoked cigarettes. A Smoking Assessment Questionaire dated 12/22/2014 documented that Resident E was assessed to require staff supervision while smoking. However, further record review for Resident E revealed no evidence of licensed nursing staff monitoring of Resident E, specific to frequency, related to the resident's smoking behavior, to ensure his safety while smoking. This was despite Resident E's Smoking Assessment Questionaire assessing to require supervision while smoking, and despite the standard of nursing practice, per the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice referenced above, specifying that the nurse provide resident surveillance and monitoring. Cross refer to F323, example 3, for more information regarding Resident E. The facility presented a credible allegation of jeopardy removal (CAJR) on February 2, 2015. Based on the CAJR, it was determined that the immediate jeopardy had been removed on February 3, 2015, at which time the facility had implemented the following interventions: 1. On 01/26/2015, the Quality Assessment and Assurance (QAA) Committee met. During this meeting, the QAA Committee reviewed the facility's current Smoking Policy and discussed revisions to enhance resident safety. Recommendations were made, and the DON was to make edits and submit the revised Policy for review and approval. The specific recommendation that all resident smoking would be monitored was discussed an initiated immediately. Additionally, the Committee discussed offering smoking cessation services to residents desiring such services. 2. On 01/27/2015, the QAA Committee met and the revisions to the Smoking Policy were submitted for review and approval. The QAA Committee meeting focused on the development of a Smoking Monitoring Log, with approval and implementation post meeting. This Smoking Monitoring Log would allow for the staff responsible for monitoring the smoking area (per the newly implemented procedure referenced above specifying that all resident smoking would be monitored) to document attendance and oversight during designated smoking times. The QAA Committee was informed that a smoking cessation instructor would begin services on that date, offering a general orientation to smoking cessation classes. 3. On 01/29/2015, the facility implemented the Smoking Policy, the Purpose of which is to provide guidance regarding resident smoking at the facility. This Smoking Policy includes, but is not limited to, the specification that resident smoking is only permitted under staff supervision. Residents will not be allowed to keep any smoking paraphernalia on their person or with their personal belongings. Residents are required to check smoking paraphernalia out from staff members with entrance to the designated smoking area, and check smoking paraphernalia back in with staff at the time of exit from the designated smoking area. No more than two (2) cigarettes may be distributed to a resident, and any cigarettes not smoked will be collected by staff and returned to the storage area upon reentry into the building. Lighters and matches will be distributed to the resident for that smoking session and collected by staff for storage upon reentry into the building. Smoking paraphernalia will be inventoried following every smoking session to ensure all is accounted for. This inventory will be completed by the staff member assigned to supervise at each scheduled smoking time, and will be documented on the Resident Tobacco and Paraphernalia Log. The sharing of cigarettes and/or lighters and matches amongst residents is not permitted. Smoking is not permitted except within the designated area which is the courtyard/patio area located on the facility's South wing. Resident smoking will be conducted during scheduled times via a Smoking Schedule, and the smoking area will be open for resident access based on the posted schedule. Additionally, the Smoking Policy specifies that residents will be assessed upon admission regarding smoking preferences and any special needs. Residents are then reassessed quarterly and with any change in condition. A Smoking Safety Evaluation Form will be utilized to conduct resident smoking assessments. This Smoking Safety Evaluation will be utilized to assess a resident's smoking history, safety concerns, cognitive awareness, and ability to handle a lighter. This assessment includes the evaluation of each smoking resident's capabilities and deficits and determines whether or not supervision during smoking is required. Based on the data collected in the smoking assessment, a specific plan will be developed to meet the individual needs of the resident. The information in the assessment is included in the resident's Plan of Care, which is reviewed and revised accordingly. 4. On 01/29/2015, the facility implemented the use of a new Safety Surveillance Log to be utilized in the event of resident non-compliance with the Smoking Policy. This new procedure indicated that, in the event a resident is observed in possession of tobacco and/or paraphernalia (other than at the approved times and in conformance with approved procedures), the facility would implement surveillance to ensure compliance. Said surveillance will be documented in the Safety Surveillance Log. At the time of discovery of an infraction, items will be inventoried for the resident. The Safety Surveillance Log will be completed as supervised by the designated Charge Nurse. The surveillance frequency will be a minimum of twice per day, and include a random search for a seven-day period. With zero findings for the seven-day period, the surveillance would transition to three times per week for 30 days. A reassessment will be conducted post the 30 day mark for the necessity of ongoing surveillance. In addition, an attempt will be made to identify the source of provision of products with subsequent counseling to follow. All findings and recommendations will be submitted to, and monitored by, the QAA Committee. 5. On 01/29/2015, a special called Resident Council meeting was held to discuss the changes to the Smoking Policy. All resident smokers were in attendance. 6. On 01/29/2015, all residents utilizing tobacco products were assessed by the DON using the new Smoking Safety Evaluation Form. One-hundred percent of all current residents who smoke (a total of fourteen residents on the date of assessment) were assessed with [REDACTED]. 7. On 01/29/2015, the facility reviewed/revised the Plans of Care for all residents using tobacco products, and Plans of Care for these residents were developed/updated with the goals of no injury when using tobacco products, safety practices, and encouraging smoking cessation. 8. On 01/29/2015, the facility reiterated a procedure requiring that the facility's Interdisciplinary Care Team reassess each resident who smoked on a quarterly basis, or more frequently if needed, to determine if any change in smoking abilities has occurred. All resident Plans of Care will be updated to reflect this assessment. 9. On 01/30/2015, a one-on-one sitter was assigned to Resident #1 to provide supervision to the resident. Resident #1 will have a sitter twenty-four hours per day, seven days per week to ensure her safety, and this coverage will continue until a later determination is made. 10. On 02/02/2015, the facility implemented the use of fire blankets (which were originally ordered by the facility on 01/30/2015). These fire blankets will be housed in the smoking area and will be used to aid in ensuring resident safety during smoking. 11. On 02/02/2015, the facility implemented enforcement of the Policy by which all smoking tobacco products and paraphernalia were removed from resident possession. Going forward, per the new Policy referenced above, smoking tobacco products and paraphernalia will be provided to residents upon request in the designated smoking area. When the resident reenters the facility after smoking activities have concluded, any smoking tobacco product that has not been consumed, as well as any smoking paraphernalia, will be returned to facility staff and inventoried. 12. On 02/02/2015, the facility conducted staff in-service training regarding the new Smoking Policy and the new procedures involving the supervision of residents who smoke, the new smoking schedule, the monitoring process for potential resident noncompliance, and resident safety while smoking by the use of fire blankets. This staff in-service training also included staff training related to the smoking assessment process. As of 02/02/2015, the following facility staff had received this in-service training: eighteen (18) of eighteen (18) housekeeping staff; fourteen (14) of fourteen (14) food service staff; three (3) of three (3) activities staff; forty (40) of forty (40) certified nursing assistants; and twenty-two (22) of twenty-three (23) licensed nursing staff. One (1) licensed nursing staff member was unavailable to receive this training due to being on leave status. This one (1) remaining licensed nursing staff member will receive this in-service training upon her return to work. 13. On 02/02/2015, the facility implemented the Smoking Policy Compliance Audit to audit the facility's new smoking program to monitor for evidence of ongoing staff compliance. This Audit will serve the purpose of monitoring and assessing staff compliance with the routine completion of the resident Smoking Safety Evaluation assessments, execution and maintenance of resident Plans of Care, the completion of the routine staff inventory of tobacco products and paraphernalia, and completion of the Smoking Surveillance Log (utilized as needed to address identified resident noncompliance with the Smoking Policy). This Smoking Policy Compliance Audit will be conducted by the DON, Assistant Director of Nursing, designated Registered Nurse Supervisor, Administrator, Assistant Administrator, or MDS Coordinator. This Audit will be conducted on every resident who smokes beginning on 02/02/2015, and will be conducted with the following progression: Weekly from 02/02/2015 through 02/28/2015; Biweekly from 03/01/2015 through 04/05/2015; Monthly on 04/06/2015, and ongoing. Any findings and subsequent interventions for ongoing compliance with facility Policy will be discussed with the QAA Committee. The data collected during the Smoking Policy Compliance Audit will be reported monthly to the QAA Committee for the Committee's review and evaluation. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the facility's QAA Committee had convened to review the facility's Smoking Policy, discuss Policy revisions, and instruct the DON to make specified Policy changes. This was in accordance with Step #1 of the CAJR referenced above. - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the QAA Committee met for review and approval of the revisions to the Smoking Policy. This included the development and implementation of the Smoking Monitoring Log to be used by staff to ensure attendance and oversight during resident designated smoking times. This was in accordance with Step #2 of the CAJR referenced above. - On 02/03/2015, DON interview and Policy review confirmed that the facility had implemented a new, revised Smoking Policy with specifications which included the restriction of resident smoking to scheduled smoking times and under direct staff supervision only, the restriction of residents' possession of smoking paraphernalia in the absence of staff supervision. This Smoking Policy also specified a procedure involving residents obtaining smoking paraphernalia from staff when entering the smoking area and returning smoking paraphernalia to staff upon exiting the smoking area. This was in accordance with Step #3 of the CAJR referenced above. - On 02/03/2015, document review, Policy review, and interview with the DON confirmed that the facility had implemented the Safety Surveillance Log to be utilized in the event of resident noncompliance with the Smoking Policy (and to be used on an as-needed basis). This new Safety Surveillance Log and the accompanying procedure would allow staff to implement surveillance, via inspections at specified intervals for specified timeframes, to ensure resident compliance with the facility's Smoking Policy. This was in accordance with Step #4 of the CAJR referenced above. - On 02/03/2015, review of meeting minutes confirmed that the facility had met with the Resident Council to discuss the changes to the Smoking Policy, with all smokers in attendance, in accordance with Step #5 of the CAJR referenced above. - On 02/03/2015, and ongoing throughout the abbreviated survey, it was confirmed via record review that all facility residents who used tobacco products were assessed via the new Smoking Safety Evaluation Form. This was in conformance with Step #6 of the CAJR referenced above. - On 02/03/2015, and ongoing throughout the abbreviated survey, it was confirmed via record review that the facility had reviewed the Plans of Care for all residents using tobacco products, with Plan of Care additions and revisions made as needed. This was in accordance with Step #7 of the CAJR referenced above. - On 02/03/2015, Policy review confirmed the facility procedure which specified that the Interdisciplinary Care Team reassess residents who smoke on a quarterly basis, and more frequently if needed, regarding evaluation for changes in smoking abilities. Accompanying Plan of Care updates will be made. This was in accordance with Step #8 of the CAJR referenced above. - On 02/03/2015, review of the One on One Sitter Safety Log confirmed that a one-on-one

An abbreviated survey conducted January 23, 2015 through February 5, 2015 revealed noncompliance at F323 at the Scope/Severity of "K". Additional noncompliance at F323 was not identified during the standard survey of February 2, 2015 through February 5, 2015. Therefore, the noncompliance at F323 identified during the January 23, 2015 through February 5, 2015 abbreviated survey has been brought forward to this standard survey Form CMS-2567, as referenced below: Based on observation, medical record review, Entity Reported Incident Intake review, facility investigative report review, resident Smoking Assessment Questionaire review, facility Smoking Policy and Procedure review, resident interview, facility staff written statement review, and staff interview, the facility failed to ensure routine supervision and monitoring related to cigarette smoking for one (1) resident (#1) who smoked cigarettes and had been assessed by the facility to require staff supervision while smoking; failed to provide supervision and monitoring for one (1) resident ("B") who smoked cigarettes without supervision but for whom the facility restricted access to smoking materials; and failed to ensure routine supervision for one (1) resident ("E"), who began smoking cigarettes after facility admission and was assessed by the facility to require staff supervision while smoking. The total survey sample was nine (9) residents, all of whom smoked cigarettes. A Smoker's List provided by the facility documented a total of fifteen (15) residents who were identified by the facility to smoke cigarettes. The facility's failure to ensure adequate monitoring and supervision to residents who smoked resulted in a situation in which the facility's 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 immediate jeopardy is outlined as follows: - Resident #1 was assessed upon admission to require supervision while smoking for reasons including, but not limited to, an inability to safeguard smoking materials without endangering other residents, and the absence of, or inability to exhibit, cognitive skills for safe smoking. Staff were to maintain Resident #1's smoking materials locked in the medication cart and provide them to the resident during supervised smoking. Resident #1 had a known history of asking other residents for cigarettes, obtaining cigarette butts from other residents, and obtaining cigarettes and lighter access from Resident "A". However, the facility failed to evaluate Resident #1 to develop and implement a system for monitoring, specific to the frequency of monitoring required, to address Resident #1's ongoing attempts to obtain smoking materials and smoke in the absence of staff supervision. Then, on 01/19/2015, Resident #1 obtained two (2) cigarettes from Resident "A", gained access to Resident "A"'s cigarette lighter, attempted to light a cigarette in the absence of staff to supervise, and ignited her hair with the cigarette lighter. Resident #1 was transferred to the hospital, then to the Burn Center, and determined to have second/third degree burns to approximately two (2) percent of her body surface area (second and third degree burns to the left side of the face, third degree burns to the left side of her forehead and temple, and second degree burns to the left side of her cheek and external ear), and required skin grafting. Resident #1 returned to the facility on [DATE], and was again found in possession of a cigarette on 01/24/2014 which she obtained from Resident "A" without the knowledge of staff. However, the facility still failed to evaluate Resident #1 and implement a method for monitoring, to include the frequency of monitoring required, related to the ongoing behavior of obtaining smoking materials without the knowledge of facility staff, thus continuing to place Resident #1 at risk for smoking unsupervised and sustaining additional injury. - Resident "B" was initially assessed as safe to smoke unsupervised and to posses smoking paraphernalia. Due to a 2011 incident involving Resident "B" using a cigarette lighter unsafely, she was still allowed to smoke unsupervised but could not maintain cigarettes and a lighter in her possession. Instead, nursing staff were to keep Resident "B"'s cigarettes and light her cigarettes to allow her to smoke; however, there was no evidence of evaluation of the resident and development of a system to ensure ongoing monitoring for Resident "B" related to her restriction of access to a cigarette lighter. During an observation on 01/23/2015, Resident "B" was observed to obtain a cigarette and lighter from another resident and to light the cigarette with the lighter in the absence of staff to supervise. The failure to provide routine monitoring/supervision to Resident "B", allowing her to access a lighter and light a cigarette in the absence of staff supervision, placed Resident "B" at risk for injury. - Resident "E" did not smoke upon facility admission in June of 2014. A nurse's note of 01/20/2015 then documented Resident "E" did smoke cigarettes in the smoking area, and staff interview revealed Resident "E" was found on 01/22/2015 to be in possession of multiple packs of cigarettes. However, even though a 12/22/2014 Smoking Assessment Questionaire assessed Resident "E" to require supervision while smoking, the facility failed to ensure supervision to Resident "E" to he resident's safety while smoking. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on January 30, 2015 at 12:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on January 19, 2015, the date that Resident #1, who was assessed by the facility to require staff supervision while smoking cigarettes, obtained two (2) cigarettes and gained access to a cigarette lighter without the knowledge of staff, attempted to light the cigarette with the lighter, and caught her hair on fire with the lighter. Resident #1 sustained multiple second/third degree burns of the left face, forehead, and ear. The immediate jeopardy continued through February 2, 2015, and was removed on February 3, 2015. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 2, 2015. During an interview conducted on 01/23/2015 at 10:00 a.m., the DON acknowledged the incident occurring on 01/19/2015 during which Resident #1 sustained multiple burn wounds while using a cigarette lighter. Additionally, during an interview conducted on 01/23/2015 at 2:00 p.m., the DON acknowledged that Resident "B" was not to have smoking supplies in her possession. An allegation of jeopardy removal was received on February 2, 2015. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 3, 2015. The facility remained out of compliance at a lower scope and severity of "E" while the process of evaluating modifications of resident assessment systems, care planning systems, and processes involved in the supervision of residents who smoked continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for supervising residents who smoked and who required supervision during smoking. Resident record reviews were conducted to assess facility staffs' conformance with the development of resident Plans of Care regarding smoking supervision. In addition, residents were observed while smoking in the exterior designated smoking area to assess facility staffs' conformance with the supervision of residents while smoking, in accordance with their assessed needs and as specified by their Plans of Care, to therefore ensure resident safety while smoking. Findings include: 1. Entity Reported Incident Intake (ERII) Number GA 603, having a Received Date of 01/21/2015, documented a report submitted to the State Survey Agency by the facility regarding Resident #1. In ERII Number GA 603, the facility documented that Resident #1 smoked cigarettes and required supervision while smoking via a smoking program, but also documented that Resident #1 was noncompliant with the supervised smoking program. The facility documented that on 01/19/2015, Resident #1 had obtained two (2) cigarettes and a lighter from another resident and gone to the facility's smoking area to light a cigarette, at which time two (2) witnesses stated Resident #1 leaned over and caught her hair on fire. The facility further documented in this ERII that Resident #1 sustained burns to the left side of her head. Review of Resident #1's clinical record revealed an Admission Minimum Data Set (MDS) assessment having an Assessment Reference Date of 10/30/2014 which documented the resident's facility admission date of [DATE]. Section I - Active [DIAGNOSES REDACTED].#1 had [DIAGNOSES REDACTED]. Section G - Functional Status of this MDS documented that Resident #1 was mobile by way of a wheelchair as a mobility device, and Section J - Health Conditions documented the resident's current use of tobacco. A facility Smoking Assessment Questionaire for Resident #1, dated as having been completed on the resident's 10/20/2014 day of facility admission, documented that Resident #1 was assessed to understand the facility's smoking policy regarding safety measures involved in smoking unsupervised. Resident #1's Smoking Assessment Questionaire further documented, however, that due to the resident's not being able to extinguish smoking materials in a safe manner, not having and/or demonstrating cognitive skills related to safe smoking, and not being able to safeguard smoking materials without endangering other residents when smoking, she could not smoke without supervision. A Nursing Progress Notes (NPN) entry of 10/20/2014, timed at 2:15 p.m., documented Resident #1's admission to the facility, and documented [DIAGNOSES REDACTED]. This NPN documented that Resident #1 could self-propel herself (via wheelchair) throughout the facility. This NPN entry also documented that Resident #1 enjoyed frequently going to the patio to smoke and that she required supervised smoking (as assessed by the 10/20/2014 Smoking Assessment Questionaire referenced above). A NPN entry of 10/24/2014, timed at 6:00 p.m., for Resident #1 documented that the resident continued to propel herself throughout the facility via wheelchair, and also documented that Resident #1 was on a smoking schedule. During an interview with Charge Nurse "AA" conducted on 01/29/2014 at 10:45 a.m., Nurse "AA" stated that Resident #1 did require supervision while smoking cigarettes, and that the resident was on a supervised smoking schedule. Nurse "AA" stated that nursing staff maintained Resident #1's cigarettes and lighter locked in the medication cart and would provide the resident's smoking materials to her for use during supervised smoking activities. During an interview with the facility's Administrator conducted on 01/29/2014 at 9:50 a.m., the Administrator was asked about the facility's policy and procedure regarding resident smoking and the storage of smoking paraphernalia (cigarettes and cigarette lighters). The Administrator stated that some residents (such as Resident #1) were assessed to require supervision while smoking and were not allowed to keep smoking paraphernalia in their possession. The Administrator stated that some residents were assessed as being safe to smoke independently and unsupervised, but were not allowed to keep smoking paraphernalia in their possession. However, the Administrator further stated that some residents were assessed as being safe to smoke independently, and were also allowed to keep their smoking paraphernalia in their possession and smoke unsupervised. Continued record review for Resident #1 revealed a NPN entry of 10/27/2014, timed at 4:00 p.m., which referenced the resident's use of cigarettes, but documented that other residents in the facility reported that Resident #1 would frequently ask them for their cigarettes and would ask these other residents to buy cigarettes for her. As documented above, Resident #1's Smoking Assessment Questionaire of 10/20/2014 indicated the resident did not demonstrate cognitive skills related to safe smoking and was not able to safeguard smoking materials. Rather, as indicated in the 01/29/2014, 10:45 a.m. interview with Charge Nurse "AA" referenced above, Resident #1 was to obtain smoking materials (cigarettes and cigarette lighter) from nursing staff who were to keep her smoking materials, including cigarettes, securely locked due to her requirement for supervised smoking. However, even though the NPN entry of 10/27/2014 at 4:00 p.m. referenced above documented nursing staff had been informed that Resident #1 would ask other residents to provide her cigarettes, record review revealed no evidence to indicate that the facility evaluated Resident #1 at that time to develop and implement a system of monitoring, to include the frequency of monitoring required, to therefore ensure routine monitoring of Resident #1 related to her known behavior of attempting to obtain cigarettes (other than cigarettes provided by facility staff per facility protocol). This was despite, as indicated in Charge Nurse "AA"'s 01/29/2014, 10:45 a.m. interview referenced above, Resident #1 was to obtain smoking materials, including cigarettes, only from nursing staff due to her assessed need for supervised smoking, and despite nursing staff subsequently becoming aware, as identified in the 10/27/2014, 4:00 p.m. NPN referenced above, of Resident #1's newly-identified behavior of seeking cigarettes from other residents, in addition to cigarettes provided by facility staff. This was also despite, as indicated in the 01/29/2014, 9:50 a.m. Administrator's interview referenced above, some residents being allowed by facility protocol to keep smoking paraphernalia (including cigarettes and lighters) in their possession, thereby representing the potential hazard of Resident #1 gaining access to both cigarettes, and a cigarette lighter, and smoking unsupervised without the knowledge of facility nursing staff. An un-timed NPN entry of 10/31/2014 for Resident #1 documented that the resident continued to propel herself around the facility to go outside and smoke, and continued to try to borrow cigarettes from other residents. A subsequent NPN entry of 11/29/2014, timed at 10:30 a.m., for Resident #1 documented that the resident had been found that morning on the patio smoking the cigarette butts of other residents. In an interview conducted on 01/29/2015 at 2:00 p.m. with the Director of Nursing (DON), the DON stated that the nurse who wrote the 11/29/2014, 10:30 a.m. NPN entry above (documenting that Resident #1 was discovered smoking the cigarette butts of other residents on that date) was no longer employed by the facility. The DON stated she had contacted this former nurse by telephone, and the nurse had clarified that the report of Resident #1 smoking cigarette butts of other residents on 11/29/2014 came from a member of the housekeeping staff. This former licensed nurse informed the DON during this interview that the housekeeping staff member had reported that Resident #1 had been observed picking up cigarette butts, but not actually smoking. During interview, however, with Resident "C" and Resident "D" conducted on the smoking patio on 01/23/2015 at 12:00 p.m., both Resident "C" and Resident "D" (for whom record reviews revealed Quarterly MDS assessments of November 2014 and January 2014, respectively, to document in Section C - Cognitive Patterns, Brief Interview for Mental Status Summary Scores of 15, indicating both residents were cognitively intact) stated that in the past, they had observed Resident #1 smoking unsupervised "often", with no staff present. Both Resident "C" and Resident "D" stated that Resident "A" would give Resident #1 cigarettes and either give her a cigarette lighter or light cigarettes for her with his lighter when there were no staff present. Both Resident "C" and Resident "D" also stated that they had in the past observed facility staff "catch" Resident #1 smoking unsupervised, and that staff would come out onto the smoking patio, extinguish Resident #1's cigarettes, and remind Resident #1 she was not supposed to smoke unsupervised. During an interview with Certified Nursing Assistant (CNA) "BB" conducted on 01/29/2015 at 11:10 a.m., CNA "BB" acknowledged that Resident #1 required supervision when smoking cigarettes and that nursing staff were to keep the resident's cigarettes and cigarette lighter locked. CNA "BB" stated that she had in the past supervised Resident #1 while smoking and had not found Resident #1 smoking unsupervised; however, CNA "BB" further acknowledged that she had been told by other direct-care staff that they had found Resident #1 smoking unsupervised in the past. However, further record review for Resident #1 revealed that, despite the 10/31/2014 NPN entry referenced above documenting licensed nursing staffs' knowledge of Resident #1's continued attempts to borrow cigarettes from other residents, despite the 11/29/2014, 10:30 a.m. NPN entry referenced above documenting that Resident #1 had actually been found to obtain, while unsupervised by nursing staff, cigarette butts left by other residents, and despite (per the 01/29/2014, 9:50 a.m. Administrator interview referenced above) other residents being allowed by protocol to have cigarettes and cigarette lighters in their possession unsupervised by staff, there was no evidence to indicate that the facility evaluated Resident #1, or identified the need for evaluation, to therefore ensure the development and implementation of a system of monitoring, which included the frequency of monitoring required, to ensure routine monitoring of Resident #1 related to her known and continuing behavior of attempting to obtain cigarettes without the knowledge of staff and smoke unsupervised. Then, a NPN entry of 01/19/2015, timed at 3:15 p.m., for Resident #1 documented that a nurse was approached by a male resident who stated that Resident #1 needed assistance because her hair was on fire. This NPN entry documented the male resident informed the nurse that he had extinguished the fire from Resident #1's hair by "patting it." The nurse documented that upon observation of Resident #1, who was in the smoking area of the patio porch, Resident #1's hair was noted to be singed and the left side of her forehead was red. The nurse documented that Resident #1 was removed from the smoking area and taken to the Charge Nurse, who then immediately notified the physician. A NPN entry of 01/19/2015, timed at 3:46 p.m., for Resident #1 documented that at 3:13 p.m., the resident's physician was called and notified of Resident #1's facial and hair burns, and that an order was received to transport the resident to the hospital emergency room (ER). A subsequent NPN entry of 01/19/2015, timed at 5:03 p.m., for Resident #1 documented that the resident would be sent to the Burn Center for treatment of [REDACTED]. A facility investigative report dated January 22, 2015 was submitted to the State Agency in relation to ERII Number GA 603 referenced above in which the facility reported this incident involving Resident #1. This January 22, 2015 investigative report documented the facility's investigation into the January 19, 2015 incident during which Resident #1 received burns while smoking. In this investigative report, the facility documented the following: Resident #1 had been instructed on the details of her smoking program upon admission to the facility and had received numerous re-education sessions since, with the most recent re-education session documented seven days prior to the incident during which the resident was burned while smoking. On January 19, 2015, slightly past 3:00 p.m., Resident #1 was with another resident (Resident #9) in the designated outside smoking area, where Resident #1 frequently went independently to socialize with other residents. Facility staff interviewed Resident #9, who stated that Resident #1 had produced a hand-rolled cigarette and a lighter. When Resident #1 leaned over to light the cigarette, she accidentally lit her long hair on fire. Resident #9 observed the fire and heard Resident #1 screaming, and went to summon help. Resident #9 informed another resident (Resident "C") that Resident #1 was on fire and to inform the nurse. However, during interview with facility staff, Resident "C" stated there was no time to get the nurse because Resident #1 was on fire, so he went to Resident #1 and extinguished the fire by patting Resident #1's head with his hands, smothering and extinguishing the flames. The nurse was then notified, and both Resident #1 and Resident "C" were assessed for injuries. Resident "C" was assessed to have sustained no injuries during the incident; however, Resident #1 was assessed to have sustained head burns. The physician was notified and ordered to transport Resident #1 to the local hospital ER. Upon Resident #1's transport to the local ER, the ER physician examined the resident and determined second and third degree burns to approximately two (2) percent of her body surface area. The injuries involved second and third degree burns to the left side of Resident #1's face, third degree burns to the left side of her forehead and temple, and second degree burns to the left side of her cheek and external ear (without ear canal involvement). Resident #1 also had singed hair and one eyebrow. This facility investigative report further documented that while Resident #1 was in the hospital ER being assessed, she "reportedly" produced another hand-rolled cigarette. The investigative report documented that Resident #1 was subsequently transferred to the Burn Center for treatment of [REDACTED]. Further review of the January 22, 2015 investigative report referenced above for ERII Number GA 603 regarding Resident #1's January 19, 2015 burn incident revealed the following additional investigative information: Upon the facility's investigation into the incident, the facility concluded that it was "apparent" that the source of the hand-rolled cigarettes Resident #1 had in her possession on January 19, 2015 was Resident "A", the friend of Resident #1. The facility documented this was "apparent" because Resident "A" rolled his own cigarettes. Upon discussion of the incident with Resident "A", he admitted to facility staff that he had given Resident #1 two (2) cigarettes. Resident "A" was documented to have admitted to facility staff that he was not supposed to give Resident #1 cigarettes, but he did it anyway because she had verbally expressed affection for him. Resident "A" denied giving Resident #1 the lighter, but stated that Resident #1 frequently went into his room and was aware that he kept two (2) lighters on his dresser. Resident "A" stated that on the afternoon of the incident (January 19, 2015), he took a nap and when he awoke, one of his lighters was missing. Record review for Resident "A" (from whom Resident #1 obtained the cigarette and cigarette lighter resulting in the 01/19/2015 burn incident, as concluded by the facility in the 01/22/2015 investigative report referenced above) revealed an Admission MDS Assessment having an Assessment Reference Date in December of 2014 which documented, in Section C - Cognitive Patterns, a Brief Interview for Mental Status Summary Score of 15, indicating the resident to be cognitively intact. During an interview with Resident "A" conducted on 01/23/2015 at 12:45 p.m., Resident "A" acknowledged that in the past, he had given cigarettes to Resident #1, and stated that it was his lighter that Resident #1 had taken off the table in his room. Further review of the investigative report referenced above related to ERII Number GA 603 regarding Resident #1's burn incident of January 19, 2015 revealed that the report concluded with the following: The facility referenced Resident #1's need for supervised smoking, per a smoking schedule, and also referenced monitoring to prevent the resident from removing used cigarettes from the ashtray. It was noted that Resident #1 would frequently sit at the door of the designated smoking area and request cigarettes from other residents, staff, and visitors, and that Resident #1 required continuous reinforcement of the scheduled routine for smoking. As part of the supervised smoking program, Resident #1's cigarettes and lighter were to be secured by staff and provided at designated timeframes. Nursing staff were to give Resident #1 cigarettes and light cigarettes for her, but not to give her a cigarette lighter, and were to maintain visual supervision while Resident #1 smoked. This investigative report documented that the facility's investigation revealed no indication that any deviation from the established supervised smoking program had occurred regarding the January 19, 2015 incident when Resident #1 sustained burn wounds. Instruction was reinforced with clinical staff regarding the smoking program and residents requiring supervised smoking. The facility would continue to provide residents with education on the smoking program upon admission and as needed, and residents would be educated not to share cigarettes or lighters with other residents. Further record review for Resident #1 revealed a NPN entry of 01/23/2014, timed at 9:25 p.m., which documented that the resident was readmitted to the nursing facility, having returned to the facility from the Burn Center. This NPN entry documented skin grafting to Resident #1's left ear, left scalp, and left side of the face, with an intact dressing in place. This NPN documented to leave Resident #1's wound dressings in place for one (1) week, until a follow-up appointment of 01/29/2014. This NPN entry further documented that Resident #1 was requesting to go smoke a cigarette in the smoking area, and that staff would continue to monitor the resident. However, even though Resident #1 had been assessed, via the Smoking Assessment Questionaire of 10/20/2014 referenced above, to require staff supervision while smoking for her safety, further record review for Resident #1 revealed no evidence to indicate that the facility evaluated the resident to develop a method of monitoring, to include the frequency of monitoring required, or initiated additional monitoring related to smoking supervision, for Resident #1 upon her readmission to the facility on [DATE]. This was despite the fact that, as documented in the facility's investigative report for ERII Number GA 603 referenced above, on January 19, 2015, Resident #1 obtained a cigarette from Resident "A" and gained possession of a cigarette lighter (provided to Resident #1 from Resident "A") without the knowledge of facility staff, proceeded to the designated smoking area and attempted to light the cigarette in the absence of staff supervision, and caught her hair on fire. Resident #1 subsequently required transfer to the Burn Center and skin grafting for second and third degree burns to the left side of the face, second degree burns to the left side of the cheek and ear, and third degree burns to the left side of the forehead and temple. This was also despite the facility's knowledge, as documented in the investigative report for ERII Number GA 603 referenced above, that Resident #1 frequently requested cigarettes from other residents, staff, and visitors, and had a history of [REDACTED]. This was also despite the facility's protocol, as indicated by the 01/29/2014, 9:50 a.m. Administrator interview referenced above, of allowing other residents to have cigarettes and cigarette lighters in their possession. Per the ERII investigative report, after the January 19, 2015 incident involving Resident #1, staff did receive instruction regarding the established smoking program and residents requiring supervised smoking, and residents would be educated not to share cigarettes or lighters with other residents. However, as indicated above, there was no evidence to indicate that the facility developed any specific method of routine monitoring of Resident #1, to include the frequency of monitoring required, to ensure her safety either before the January 19, 2015 incident during which Resident #1 sustained multiple burn wounds while smoking unsupervised by staff, or upon the resident's 01/23/2014 return to the facility. This was despite Resident #1's exhibited and ongoing behavior, as documented above, of seeking smoking paraphernalia (cigarettes and cigarette lighters) from other residents, actually obtaining cigarettes and a cigarette lighter from Resident "A", and smoking in the absence of staff supervision. During an interview conducted on 02/02/2015 at 12:40 p.m., the Director of Nursing (DON) was questioned regarding the monitoring that had been provided regarding Resident #1's known smoking behavior prior to the 01/19/2014 incident referenced above involving the resident obtaining a cigarette and cigarette lighter and subsequently sustaining multiple facial and head burn wounds while attempting to light the cigarette. The DON stated that, prior to the 01/19/2014 incident resulting in Resident #1 receiving burn wounds, nursing staff had maintained Resident #1's cigarettes and cigarette lighter locked and had provided supervision to Resident #1 during supervised smoking times. However, the DON further acknowledged that no additional monitoring had been provided to Resident #1 related to her smoking behaviors prior to the 01/19/2015 incident resulting in multiple burn wounds, other than the staff monitoring provided during supervised smoking times. Additionally, the DON provided no evidence of evaluation of Resident #1 upon her return to the nursing facility from the Burn Center on 01/23/2015 (as documented in the 01/23/2014, 9:25 p.m. NPN referenced above) to develop a system of monitoring, to include the frequency of monitoring required, to ensure the resident's safety regarding her behavior of obtaining smoking paraphernalia and smoking without the supervision of staff. During the 02/02/2015, 12:40 p.m. interview with the DON referenced above, the DON was also questioned about any interventions which had been developed and implemented for Resident "A", as related to his behavior of providing cigarettes and a lighter to Resident #1. The DON stated she would provide follow-up regarding Resident "A". During a subsequent interview with the DON conducted on 02/02/2015 at 2:50 p.m., the DON provided a written statement dated 02/02/2015 and signed by Registered Nurse (RN) "DD". In this written statement, RN "DD" documented that on 01/21/2015, she had spoken with Resident "A" about the 01/19/2014 incident during which Resident #1 sustained burn wounds. RN "DD" documented that Resident "A" stated to her that he had given Resident #1 two (2) cigarettes, and that she must have also taken one of his cigarette lighters. RN "DD" documented Resident "A" admitted to her that he was aware that Resident #1 was to be supervised while smoking, stating that he knew he was not to give Resident #1 cigarettes, but stated that he did it anyway. RN "DD" documented that as follow-up to Resident "A"'s statements, she provided additional education to Resident "A", instructing him not to share cigarettes with any other resident because this posed a serious safety risk and could potentially lead to injuries for those who needed assistance from staff to smoke. However, a NPN for Resident #1 dated 01/24/2014 and timed at 9:30 a.m. (t

Based on observation, medical record review, Entity Reported Incident Intake review, facility investigative report review, resident Smoking Assessment Questionaire review, facility Smoking Policy and Procedure review, resident interview, facility staff written statement review, and staff interview, the facility failed to ensure routine supervision and monitoring related to cigarette smoking for one (1) resident (#1) who smoked cigarettes and had been assessed by the facility to require staff supervision while smoking; failed to provide supervision and monitoring for one (1) resident (B) who smoked cigarettes without supervision but for whom the facility restricted access to smoking materials; and failed to ensure routine supervision for one (1) resident (E), who began smoking cigarettes after facility admission and was assessed by the facility to require staff supervision while smoking. The total survey sample was nine (9) residents, all of whom smoked cigarettes. A Smoker's List provided by the facility documented a total of fifteen (15) residents who were identified by the facility to smoke cigarettes. The facility's failure to ensure adequate monitoring and supervision to residents who smoked resulted in a situation in which the facility's 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 immediate jeopardy is outlined as follows: - Resident #1 was assessed upon admission to require supervision while smoking for reasons including, but not limited to, an inability to safeguard smoking materials without endangering other residents, and the absence of, or inability to exhibit, cognitive skills for safe smoking. Staff were to maintain Resident #1's smoking materials locked in the medication cart and provide them to the resident during supervised smoking. Resident #1 had a known history of asking other residents for cigarettes, obtaining cigarette butts from other residents, and obtaining cigarettes and lighter access from Resident A. However, the facility failed to evaluate Resident #1 to develop and implement a system for monitoring, specific to the frequency of monitoring required, to address Resident #1's ongoing attempts to obtain smoking materials and smoke in the absence of staff supervision. Then, on 01/19/2015, Resident #1 obtained two (2) cigarettes from Resident A, gained access to Resident A's cigarette lighter, attempted to light a cigarette in the absence of staff to supervise, and ignited her hair with the cigarette lighter. Resident #1 was transferred to the hospital, then to the Burn Center, and determined to have second/third degree burns to approximately two (2) percent of her body surface area (second and third degree burns to the left side of the face, third degree burns to the left side of her forehead and temple, and second degree burns to the left side of her cheek and external ear), and required skin grafting. Resident #1 returned to the facility on [DATE], and was again found in possession of a cigarette on 01/24/2014 which she obtained from Resident A without the knowledge of staff. However, the facility still failed to evaluate Resident #1 and implement a method for monitoring, to include the frequency of monitoring required, related to the ongoing behavior of obtaining smoking materials without the knowledge of facility staff, thus continuing to place Resident #1 at risk for smoking unsupervised and sustaining additional injury. - Resident B was initially assessed as safe to smoke unsupervised and to posses smoking paraphernalia. Due to a 2011 incident involving Resident B using a cigarette lighter unsafely, she was still allowed to smoke unsupervised but could not maintain cigarettes and a lighter in her possession. Instead, nursing staff were to keep Resident B's cigarettes and light her cigarettes to allow her to smoke; however, there was no evidence of evaluation of the resident and development of a system to ensure ongoing monitoring for Resident B related to her restriction of access to a cigarette lighter. During an observation on 01/23/2015, Resident B was observed to obtain a cigarette and lighter from another resident and to light the cigarette with the lighter in the absence of staff to supervise. The failure to provide routine monitoring/supervision to Resident B, allowing her to access a lighter and light a cigarette in the absence of staff supervision, placed Resident B at risk for injury. - Resident E did not smoke upon facility admission in June of 2014. A nurse's note of 01/20/2015 then documented Resident E did smoke cigarettes in the smoking area, and staff interview revealed Resident E was found on 01/22/2015 to be in possession of multiple packs of cigarettes. However, even though a 12/22/2014 Smoking Assessment Questionaire assessed Resident E to require supervision while smoking, the facility failed to ensure supervision to Resident E to he resident's safety while smoking. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on January 30, 2015 at 12:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on January 19, 2015, the date that Resident #1, who was assessed by the facility to require staff supervision while smoking cigarettes, obtained two (2) cigarettes and gained access to a cigarette lighter without the knowledge of staff, attempted to light the cigarette with the lighter, and caught her hair on fire with the lighter. Resident #1 sustained multiple second/third degree burns of the left face, forehead, and ear. The immediate jeopardy continued through February 2, 2015, and was removed on February 3, 2015. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 2, 2015. During an interview conducted on 01/23/2015 at 10:00 a.m., the DON acknowledged the incident occurring on 01/19/2015 during which Resident #1 sustained multiple burn wounds while using a cigarette lighter. Additionally, during an interview conducted on 01/23/2015 at 2:00 p.m., the DON acknowledged that Resident B was not to have smoking supplies in her possession. An allegation of jeopardy removal was received on February 2, 2015. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 3, 2015. The facility remained out of compliance at a lower scope and severity of E while the process of evaluating modifications of resident assessment systems, care planning systems, and processes involved in the supervision of residents who smoked continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for supervising residents who smoked and who required supervision during smoking. Resident record reviews were conducted to assess facility staffs' conformance with the development of resident Plans of Care regarding smoking supervision. In addition, residents were observed while smoking in the exterior designated smoking area to assess facility staffs' conformance with the supervision of residents while smoking, in accordance with their assessed needs and as specified by their Plans of Care, to therefore ensure resident safety while smoking. Findings include: 1. Entity Reported Incident Intake (ERII) Number GA 603, having a Received Date of 01/21/2015, documented a report submitted to the State Survey Agency by the facility regarding Resident #1. In ERII Number GA 603, the facility documented that Resident #1 smoked cigarettes and required supervision while smoking via a smoking program, but also documented that Resident #1 was noncompliant with the supervised smoking program. The facility documented that on 01/19/2015, Resident #1 had obtained two (2) cigarettes and a lighter from another resident and gone to the facility's smoking area to light a cigarette, at which time two (2) witnesses stated Resident #1 leaned over and caught her hair on fire. The facility further documented in this ERII that Resident #1 sustained burns to the left side of her head. Review of Resident #1's clinical record revealed an Admission Minimum Data Set (MDS) assessment having an Assessment Reference Date of 10/30/2014 which documented the resident's facility admission date of [DATE]. Section I - Active [DIAGNOSES REDACTED].#1 had [DIAGNOSES REDACTED]. Section G - Functional Status of this MDS documented that Resident #1 was mobile by way of a wheelchair as a mobility device, and Section J - Health Conditions documented the resident's current use of tobacco. A facility Smoking Assessment Questionaire for Resident #1, dated as having been completed on the resident's 10/20/2014 day of facility admission, documented that Resident #1 was assessed to understand the facility's smoking policy regarding safety measures involved in smoking unsupervised. Resident #1's Smoking Assessment Questionaire further documented, however, that due to the resident's not being able to extinguish smoking materials in a safe manner, not having and/or demonstrating cognitive skills related to safe smoking, and not being able to safeguard smoking materials without endangering other residents when smoking, she could not smoke without supervision. A Nursing Progress Notes (NPN) entry of 10/20/2014, timed at 2:15 p.m., documented Resident #1's admission to the facility, and documented [DIAGNOSES REDACTED]. This NPN documented that Resident #1 could self-propel herself (via wheelchair) throughout the facility. This NPN entry also documented that Resident #1 enjoyed frequently going to the patio to smoke and that she required supervised smoking (as assessed by the 10/20/2014 Smoking Assessment Questionaire referenced above). A NPN entry of 10/24/2014, timed at 6:00 p.m., for Resident #1 documented that the resident continued to propel herself throughout the facility via wheelchair, and also documented that Resident #1 was on a smoking schedule. During an interview with Charge Nurse AA conducted on 01/29/2014 at 10:45 a.m., Nurse AA stated that Resident #1 did require supervision while smoking cigarettes, and that the resident was on a supervised smoking schedule. Nurse AA stated that nursing staff maintained Resident #1's cigarettes and lighter locked in the medication cart and would provide the resident's smoking materials to her for use during supervised smoking activities. During an interview with the facility's Administrator conducted on 01/29/2014 at 9:50 a.m., the Administrator was asked about the facility's policy and procedure regarding resident smoking and the storage of smoking paraphernalia (cigarettes and cigarette lighters). The Administrator stated that some residents (such as Resident #1) were assessed to require supervision while smoking and were not allowed to keep smoking paraphernalia in their possession. The Administrator stated that some residents were assessed as being safe to smoke independently and unsupervised, but were not allowed to keep smoking paraphernalia in their possession. However, the Administrator further stated that some residents were assessed as being safe to smoke independently, and were also allowed to keep their smoking paraphernalia in their possession and smoke unsupervised. Continued record review for Resident #1 revealed a NPN entry of 10/27/2014, timed at 4:00 p.m., which referenced the resident's use of cigarettes, but documented that other residents in the facility reported that Resident #1 would frequently ask them for their cigarettes and would ask these other residents to buy cigarettes for her. As documented above, Resident #1's Smoking Assessment Questionaire of 10/20/2014 indicated the resident did not demonstrate cognitive skills related to safe smoking and was not able to safeguard smoking materials. Rather, as indicated in the 01/29/2014, 10:45 a.m. interview with Charge Nurse AA referenced above, Resident #1 was to obtain smoking materials (cigarettes and cigarette lighter) from nursing staff who were to keep her smoking materials, including cigarettes, securely locked due to her requirement for supervised smoking. However, even though the NPN entry of 10/27/2014 at 4:00 p.m. referenced above documented nursing staff had been informed that Resident #1 would ask other residents to provide her cigarettes, record review revealed no evidence to indicate that the facility evaluated Resident #1 at that time to develop and implement a system of monitoring, to include the frequency of monitoring required, to therefore ensure routine monitoring of Resident #1 related to her known behavior of attempting to obtain cigarettes (other than cigarettes provided by facility staff per facility protocol). This was despite, as indicated in Charge Nurse AA's 01/29/2014, 10:45 a.m. interview referenced above, Resident #1 was to obtain smoking materials, including cigarettes, only from nursing staff due to her assessed need for supervised smoking, and despite nursing staff subsequently becoming aware, as identified in the 10/27/2014, 4:00 p.m. NPN referenced above, of Resident #1's newly-identified behavior of seeking cigarettes from other residents, in addition to cigarettes provided by facility staff. This was also despite, as indicated in the 01/29/2014, 9:50 a.m. Administrator's interview referenced above, some residents being allowed by facility protocol to keep smoking paraphernalia (including cigarettes and lighters) in their possession, thereby representing the potential hazard of Resident #1 gaining access to both cigarettes, and a cigarette lighter, and smoking unsupervised without the knowledge of facility nursing staff. An un-timed NPN entry of 10/31/2014 for Resident #1 documented that the resident continued to propel herself around the facility to go outside and smoke, and continued to try to borrow cigarettes from other residents. A subsequent NPN entry of 11/29/2014, timed at 10:30 a.m., for Resident #1 documented that the resident had been found that morning on the patio smoking the cigarette butts of other residents. In an interview conducted on 01/29/2015 at 2:00 p.m. with the Director of Nursing (DON), the DON stated that the nurse who wrote the 11/29/2014, 10:30 a.m. NPN entry above (documenting that Resident #1 was discovered smoking the cigarette butts of other residents on that date) was no longer employed by the facility. The DON stated she had contacted this former nurse by telephone, and the nurse had clarified that the report of Resident #1 smoking cigarette butts of other residents on 11/29/2014 came from a member of the housekeeping staff. This former licensed nurse informed the DON during this interview that the housekeeping staff member had reported that Resident #1 had been observed picking up cigarette butts, but not actually smoking. During interview, however, with Resident C and Resident D conducted on the smoking patio on 01/23/2015 at 12:00 p.m., both Resident C and Resident D (for whom record reviews revealed Quarterly MDS assessments of November 2014 and January 2014, respectively, to document in Section C - Cognitive Patterns, Brief Interview for Mental Status Summary Scores of 15, indicating both residents were cognitively intact) stated that in the past, they had observed Resident #1 smoking unsupervised often, with no staff present. Both Resident C and Resident D stated that Resident A would give Resident #1 cigarettes and either give her a cigarette lighter or light cigarettes for her with his lighter when there were no staff present. Both Resident C and Resident D also stated that they had in the past observed facility staff catch Resident #1 smoking unsupervised, and that staff would come out onto the smoking patio, extinguish Resident #1's cigarettes, and remind Resident #1 she was not supposed to smoke unsupervised. During an interview with Certified Nursing Assistant (CNA) BB conducted on 01/29/2015 at 11:10 a.m., CNA BB acknowledged that Resident #1 required supervision when smoking cigarettes and that nursing staff were to keep the resident's cigarettes and cigarette lighter locked. CNA BB stated that she had in the past supervised Resident #1 while smoking and had not found Resident #1 smoking unsupervised; however, CNA BB further acknowledged that she had been told by other direct-care staff that they had found Resident #1 smoking unsupervised in the past. However, further record review for Resident #1 revealed that, despite the 10/31/2014 NPN entry referenced above documenting licensed nursing staffs' knowledge of Resident #1's continued attempts to borrow cigarettes from other residents, despite the 11/29/2014, 10:30 a.m. NPN entry referenced above documenting that Resident #1 had actually been found to obtain, while unsupervised by nursing staff, cigarette butts left by other residents, and despite (per the 01/29/2014, 9:50 a.m. Administrator interview referenced above) other residents being allowed by protocol to have cigarettes and cigarette lighters in their possession unsupervised by staff, there was no evidence to indicate that the facility evaluated Resident #1, or identified the need for evaluation, to therefore ensure the development and implementation of a system of monitoring, which included the frequency of monitoring required, to ensure routine monitoring of Resident #1 related to her known and continuing behavior of attempting to obtain cigarettes without the knowledge of staff and smoke unsupervised. Then, a NPN entry of 01/19/2015, timed at 3:15 p.m., for Resident #1 documented that a nurse was approached by a male resident who stated that Resident #1 needed assistance because her hair was on fire. This NPN entry documented the male resident informed the nurse that he had extinguished the fire from Resident #1's hair by patting it. The nurse documented that upon observation of Resident #1, who was in the smoking area of the patio porch, Resident #1's hair was noted to be singed and the left side of her forehead was red. The nurse documented that Resident #1 was removed from the smoking area and taken to the Charge Nurse, who then immediately notified the physician. A NPN entry of 01/19/2015, timed at 3:46 p.m., for Resident #1 documented that at 3:13 p.m., the resident's physician was called and notified of Resident #1's facial and hair burns, and that an order was received to transport the resident to the hospital emergency room (ER). A subsequent NPN entry of 01/19/2015, timed at 5:03 p.m., for Resident #1 documented that the resident would be sent to the Burn Center for treatment of [REDACTED]. A facility investigative report dated January 22, 2015 was submitted to the State Agency in relation to ERII Number GA 603 referenced above in which the facility reported this incident involving Resident #1. This January 22, 2015 investigative report documented the facility's investigation into the January 19, 2015 incident during which Resident #1 received burns while smoking. In this investigative report, the facility documented the following: Resident #1 had been instructed on the details of her smoking program upon admission to the facility and had received numerous re-education sessions since, with the most recent re-education session documented seven days prior to the incident during which the resident was burned while smoking. On January 19, 2015, slightly past 3:00 p.m., Resident #1 was with another resident (Resident #9) in the designated outside smoking area, where Resident #1 frequently went independently to socialize with other residents. Facility staff interviewed Resident #9, who stated that Resident #1 had produced a hand-rolled cigarette and a lighter. When Resident #1 leaned over to light the cigarette, she accidentally lit her long hair on fire. Resident #9 observed the fire and heard Resident #1 screaming, and went to summon help. Resident #9 informed another resident (Resident C) that Resident #1 was on fire and to inform the nurse. However, during interview with facility staff, Resident C stated there was no time to get the nurse because Resident #1 was on fire, so he went to Resident #1 and extinguished the fire by patting Resident #1's head with his hands, smothering and extinguishing the flames. The nurse was then notified, and both Resident #1 and Resident C were assessed for injuries. Resident C was assessed to have sustained no injuries during the incident; however, Resident #1 was assessed to have sustained head burns. The physician was notified and ordered to transport Resident #1 to the local hospital ER. Upon Resident #1's transport to the local ER, the ER physician examined the resident and determined second and third degree burns to approximately two (2) percent of her body surface area. The injuries involved second and third degree burns to the left side of Resident #1's face, third degree burns to the left side of her forehead and temple, and second degree burns to the left side of her cheek and external ear (without ear canal involvement). Resident #1 also had singed hair and one eyebrow. This facility investigative report further documented that while Resident #1 was in the hospital ER being assessed, she reportedly produced another hand-rolled cigarette. The investigative report documented that Resident #1 was subsequently transferred to the Burn Center for treatment of [REDACTED]. Further review of the January 22, 2015 investigative report referenced above for ERII Number GA 603 regarding Resident #1's January 19, 2015 burn incident revealed the following additional investigative information: Upon the facility's investigation into the incident, the facility concluded that it was apparent that the source of the hand-rolled cigarettes Resident #1 had in her possession on January 19, 2015 was Resident A, the friend of Resident #1. The facility documented this was apparent because Resident A rolled his own cigarettes. Upon discussion of the incident with Resident A, he admitted to facility staff that he had given Resident #1 two (2) cigarettes. Resident A was documented to have admitted to facility staff that he was not supposed to give Resident #1 cigarettes, but he did it anyway because she had verbally expressed affection for him. Resident A denied giving Resident #1 the lighter, but stated that Resident #1 frequently went into his room and was aware that he kept two (2) lighters on his dresser. Resident A stated that on the afternoon of the incident (January 19, 2015), he took a nap and when he awoke, one of his lighters was missing. Record review for Resident A (from whom Resident #1 obtained the cigarette and cigarette lighter resulting in the 01/19/2015 burn incident, as concluded by the facility in the 01/22/2015 investigative report referenced above) revealed an Admission MDS Assessment having an Assessment Reference Date in December of 2014 which documented, in Section C - Cognitive Patterns, a Brief Interview for Mental Status Summary Score of 15, indicating the resident to be cognitively intact. During an interview with Resident A conducted on 01/23/2015 at 12:45 p.m., Resident A acknowledged that in the past, he had given cigarettes to Resident #1, and stated that it was his lighter that Resident #1 had taken off the table in his room. Further review of the investigative report referenced above related to ERII Number GA 603 regarding Resident #1's burn incident of January 19, 2015 revealed that the report concluded with the following: The facility referenced Resident #1's need for supervised smoking, per a smoking schedule, and also referenced monitoring to prevent the resident from removing used cigarettes from the ashtray. It was noted that Resident #1 would frequently sit at the door of the designated smoking area and request cigarettes from other residents, staff, and visitors, and that Resident #1 required continuous reinforcement of the scheduled routine for smoking. As part of the supervised smoking program, Resident #1's cigarettes and lighter were to be secured by staff and provided at designated timeframes. Nursing staff were to give Resident #1 cigarettes and light cigarettes for her, but not to give her a cigarette lighter, and were to maintain visual supervision while Resident #1 smoked. This investigative report documented that the facility's investigation revealed no indication that any deviation from the established supervised smoking program had occurred regarding the January 19, 2015 incident when Resident #1 sustained burn wounds. Instruction was reinforced with clinical staff regarding the smoking program and residents requiring supervised smoking. The facility would continue to provide residents with education on the smoking program upon admission and as needed, and residents would be educated not to share cigarettes or lighters with other residents. Further record review for Resident #1 revealed a NPN entry of 01/23/2014, timed at 9:25 p.m., which documented that the resident was readmitted to the nursing facility, having returned to the facility from the Burn Center. This NPN entry documented skin grafting to Resident #1's left ear, left scalp, and left side of the face, with an intact dressing in place. This NPN documented to leave Resident #1's wound dressings in place for one (1) week, until a follow-up appointment of 01/29/2014. This NPN entry further documented that Resident #1 was requesting to go smoke a cigarette in the smoking area, and that staff would continue to monitor the resident. However, even though Resident #1 had been assessed, via the Smoking Assessment Questionaire of 10/20/2014 referenced above, to require staff supervision while smoking for her safety, further record review for Resident #1 revealed no evidence to indicate that the facility evaluated the resident to develop a method of monitoring, to include the frequency of monitoring required, or initiated additional monitoring related to smoking supervision, for Resident #1 upon her readmission to the facility on [DATE]. This was despite the fact that, as documented in the facility's investigative report for ERII Number GA 603 referenced above, on January 19, 2015, Resident #1 obtained a cigarette from Resident A and gained possession of a cigarette lighter (provided to Resident #1 from Resident A) without the knowledge of facility staff, proceeded to the designated smoking area and attempted to light the cigarette in the absence of staff supervision, and caught her hair on fire. Resident #1 subsequently required transfer to the Burn Center and skin grafting for second and third degree burns to the left side of the face, second degree burns to the left side of the cheek and ear, and third degree burns to the left side of the forehead and temple. This was also despite the facility's knowledge, as documented in the investigative report for ERII Number GA 603 referenced above, that Resident #1 frequently requested cigarettes from other residents, staff, and visitors, and had a history of [REDACTED]. This was also despite the facility's protocol, as indicated by the 01/29/2014, 9:50 a.m. Administrator interview referenced above, of allowing other residents to have cigarettes and cigarette lighters in their possession. Per the ERII investigative report, after the January 19, 2015 incident involving Resident #1, staff did receive instruction regarding the established smoking program and residents requiring supervised smoking, and residents would be educated not to share cigarettes or lighters with other residents. However, as indicated above, there was no evidence to indicate that the facility developed any specific method of routine monitoring of Resident #1, to include the frequency of monitoring required, to ensure her safety either before the January 19, 2015 incident during which Resident #1 sustained multiple burn wounds while smoking unsupervised by staff, or upon the resident's 01/23/2014 return to the facility. This was despite Resident #1's exhibited and ongoing behavior, as documented above, of seeking smoking paraphernalia (cigarettes and cigarette lighters) from other residents, actually obtaining cigarettes and a cigarette lighter from Resident A, and smoking in the absence of staff supervision. During an interview conducted on 02/02/2015 at 12:40 p.m., the Director of Nursing (DON) was questioned regarding the monitoring that had been provided regarding Resident #1's known smoking behavior prior to the 01/19/2014 incident referenced above involving the resident obtaining a cigarette and cigarette lighter and subsequently sustaining multiple facial and head burn wounds while attempting to light the cigarette. The DON stated that, prior to the 01/19/2014 incident resulting in Resident #1 receiving burn wounds, nursing staff had maintained Resident #1's cigarettes and cigarette lighter locked and had provided supervision to Resident #1 during supervised smoking times. However, the DON further acknowledged that no additional monitoring had been provided to Resident #1 related to her smoking behaviors prior to the 01/19/2015 incident resulting in multiple burn wounds, other than the staff monitoring provided during supervised smoking times. Additionally, the DON provided no evidence of evaluation of Resident #1 upon her return to the nursing facility from the Burn Center on 01/23/2015 (as documented in the 01/23/2014, 9:25 p.m. NPN referenced above) to develop a system of monitoring, to include the frequency of monitoring required, to ensure the resident's safety regarding her behavior of obtaining smoking paraphernalia and smoking without the supervision of staff. During the 02/02/2015, 12:40 p.m. interview with the DON referenced above, the DON was also questioned about any interventions which had been developed and implemented for Resident A, as related to his behavior of providing cigarettes and a lighter to Resident #1. The DON stated she would provide follow-up regarding Resident A. During a subsequent interview with the DON conducted on 02/02/2015 at 2:50 p.m., the DON provided a written statement dated 02/02/2015 and signed by Registered Nurse (RN) DD. In this written statement, RN DD documented that on 01/21/2015, she had spoken with Resident A about the 01/19/2014 incident during which Resident #1 sustained burn wounds. RN DD documented that Resident A stated to her that he had given Resident #1 two (2) cigarettes, and that she must have also taken one of his cigarette lighters. RN DD documented Resident A admitted to her that he was aware that Resident #1 was to be supervised while smoking, stating that he knew he was not to give Resident #1 cigarettes, but stated that he did it anyway. RN DD documented that as follow-up to Resident A's statements, she provided additional education to Resident A, instructing him not to share cigarettes with any other resident because this posed a serious safety risk and could potentially lead to injuries for those who needed assistance from staff to smoke. However, a NPN for Resident #1 dated 01/24/2014 and timed at 9:30 a.m. (the day after Resident #1's 01/23/2014 facility readmission from the Burn Center) documented that nursing staff again found Resident #1 holding a hand-made cigarette in her hand. This NPN entry documented that upon questioning, Resident #1 told the nurse that she had obtained this cigarette from another resident. This NPN entry further documented that Resident #1 was again instructed by st

An abbreviated survey conducted January 23, 2015 through February 5, 2015 revealed noncompliance at F490 at the Scope/Severity of "K". Additional noncompliance at F490 was not identified during the standard survey of February 2, 2015 through February 5, 2015. Therefore, the noncompliance at F490 identified during the January 23, 2015 through February 5, 2015 abbreviated survey has been brought forward to this standard survey Form CMS-2567, as referenced below: Based on observation, record review, facility document review, facility policy review, resident interview, and staff interview, facility administration failed to ensure supervision/monitoring regarding the smoking behaviors of four (4) residents (#1, "A", "B", and "E") who were assessed as unsafe to smoke without staff supervision and/or who exhibited unsafe behaviors of either obtaining smoking paraphernalia from, or providing smoking paraphernalia to, other residents without the knowledge of facility staff. The total survey sample was nine (9) residents, all of whom smoked cigarettes, with a Smoker's List provided by the facility documenting a total of fifteen (15) residents who smoked. For Resident #1, who was assessed to require supervision while smoking, the facility failed to provide routine monitoring to address the resident's unsafe behavior of obtaining smoking paraphernalia from other residents (including Resident "A") and either smoking, or attempting to smoke, unsupervised. For Resident "B", who was restricted from maintaining smoking materials in her possession related to a history of unsafe lighter use, the facility failed to routinely monitor to prevent the resident from unsafely accessing smoking paraphernalia. For Resident "E", who did not smoke upon facility admission, but then began to smoke cigarettes after admission and was assessed to require staff supervision while smoking, the facility failed to provide monitoring to ensure the resident's safety while smoking. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on January 30, 2015 at 12:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on January 19, 2015, the date Resident #1, who was assessed by the facility to require staff supervision while smoking cigarettes, obtained two (2) cigarettes and gained access to a cigarette lighter without the knowledge of staff, attempted to light the cigarette with the lighter, and caught her hair on fire with the lighter. Resident #1 sustained multiple second/third [MEDICAL CONDITION] the left face, forehead, and ear. The immediate jeopardy continued through February 2, 2015, and was removed on February 3, 2015. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 2, 2015. An allegation of jeopardy removal was received on February 2, 2015. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 3, 2015. The facility remained out of compliance at a lower scope and severity of "E" while the process of evaluating modifications of resident assessment systems, care planning systems, and processes involved in the supervision of residents who smoked continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for supervising residents who smoked and who required supervision during smoking. Resident record reviews were conducted to assess facility staffs' conformance with the development of resident Plans of Care regarding smoking supervision. In addition, residents were observed while smoking in the exterior designated smoking area to assess facility staffs' conformance with the supervision of residents while smoking, in accordance with their assessed needs and as specified by their Plans of Care, to therefore ensure resident safety while smoking. Findings include: Cross refer to F323. Based on observation, record review, facility document review, facility policy review, resident interview, and staff interview, the facility failed to ensure supervision/monitoring related to cigarette smoking for Resident #1, who was assessed to require staff supervision while smoking; for Resident "B", who could smoke without supervision but was not allowed to access or maintain smoking materials in her possession without staff supervision; and for Resident "E", who began smoking cigarettes after facility admission and was assessed to require supervision while smoking, but for whom the facility failed to provide routine supervision to ensure the resident's safety. The total survey sample was nine (9) residents, all of whom smoked cigarettes. A Smoker's List provided by the facility documented a total of fifteen (15) residents who were identified by the facility to smoke cigarettes. The facility's failure to ensure adequate monitoring and supervision to residents who smoked resulted in a situation in which the facility's 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. During an interview with the Administrator conducted on 02/02/2015 at 1:59 p.m., the January 19, 2015 incident during which Resident #1 obtained cigarettes and lighter without the knowledge of staff and subsequently sustained multiple burn wounds to the face, forehead, and ear was discussed. The facility's Smoking Policy and Procedure was discussed with the Administrator, and the Administrator was questioned about his involvement in oversight and implementation of the Smoking Policy. During this interview, the Administrator stated that in his position as Administrator, he was directly involved in overseeing the Smoking Policy and Procedure. He stated that he had received information through the DON related to resident smoking issues prior to the January 19, 2015 incident resulting in Resident #1's multiple burn wounds. He stated that after the January 19, 2015 incident resulting in Resident #1's burn wounds from a cigarette lighter, he remained involved in overseeing the Smoking Policy. The Administrator stated that after the January 19, 2015 incident, he implemented a new procedure on January 27, 2015 specifying that all resident smoking would be supervised, and would be documented and tracked via use of the Smoking Monitoring Log. The Administrator further stated that both he and the DON had instructed staff to be more vigilant with watching Resident #1 and Resident "A" after the January 19, 2015 incident, further referencing the January 24, 2015 incident when Resident "A" had again given Resident #1 a cigarette. However, the Administrator presented no evidence of the development and implementation of any specific method by which to track and evaluate direct-care staffs' monitoring and supervision of resident smoking activities (to include oversight of residents requiring supervision while smoking but who were known to exhibit the unsafe behavior of obtaining smoking paraphernalia without the knowledge of staff) prior to the January 19, 2015 incident during which Resident #1 obtained smoking smoking materials from Resident "A" and sustained multiple burns. In addition, no evidence was presented of development and implementation of a method of evaluation of direct-care staff oversight of resident smoking after the January, 19, 2015 incident involving Resident #1 obtaining smoking materials from Resident "A", or after the January 24, 2015 incident when Resident "A" again provided Resident #1 with a cigarette, initially without the knowledge of facility staff. Based on the above, there was no evidence of a facility system, either prior to or after the January 19, 2015 incident resulting in Resident #1 obtaining multiple burn wounds while smoking unsupervised, until January 27, 2015 (after the January 23, 2015 initiation date of this abbreviated survey) which allowed for, and ensured, the ongoing oversight of direct-care staffs' supervision of residents who required supervision due to their assessed inability to smoke safely with supervision and/or who exhibited unsafe smoking behaviors and practices. The facility presented a credible allegation of jeopardy removal (CAJR) on February 2, 2015. Based on the CAJR, it was determined that the immediate jeopardy had been removed on February 3, 2015, at which time the facility had implemented the following interventions: A. On 01/26/2015, the Quality Assessment and Assurance (QAA) Committee met. During this meeting, the QAA Committee reviewed the facility's current Smoking Policy and discussed revisions to enhance resident safety. Recommendations were made, and the DON was to make edits and submit the revised Policy for review and approval. The specific recommendation that all resident smoking would be monitored was discussed an initiated immediately. Additionally, the Committee discussed offering smoking cessation services to residents desiring such services. B. On 01/27/2015, the QAA Committee met and the revisions to the Smoking Policy were submitted for review and approval. The QAA Committee meeting focused on the development of a Smoking Monitoring Log, with approval and implementation post meeting. This Smoking Monitoring Log would allow for the staff responsible for monitoring the smoking area (per the newly implemented procedure referenced above specifying that all resident smoking would be monitored) to document attendance and oversight during designated smoking times. The QAA Committee was informed that a smoking cessation instructor would begin services on that date, offering a general orientation to smoking cessation classes. C. On 01/29/2015, the facility implemented the Smoking Policy, the Purpose of which is to provide guidance regarding resident smoking at the facility. This Smoking Policy includes, but is not limited to, the specification that resident smoking is only permitted under staff supervision. Residents will not be allowed to keep any smoking paraphernalia on their person or with their personal belongings. Residents are required to check smoking paraphernalia out from staff members with entrance to the designated smoking area, and check smoking paraphernalia back in with staff at the time of exit from the designated smoking area. No more than two (2) cigarettes may be distributed to a resident, and any cigarettes not smoked will be collected by staff and returned to the storage area upon reentry into the building. Lighters and matches will be distributed to the resident for that smoking session and collected by staff for storage upon reentry into the building. Smoking paraphernalia will be inventoried following every smoking session to ensure all is accounted for. This inventory will be completed by the staff member assigned to supervise at each scheduled smoking time, and will be documented on the Resident Tobacco and Paraphernalia Log. The sharing of cigarettes and/or lighters and matches amongst residents is not permitted. Smoking is not permitted except within the designated area which is the courtyard/patio area located on the facility's South wing. Resident smoking will be conducted during scheduled times via a Smoking Schedule, and the smoking area will be open for resident access based on the posted schedule. Additionally, the Smoking Policy specifies that residents will be assessed upon admission regarding smoking preferences and any special needs. Residents are then reassessed quarterly and with any change in condition. A Smoking Safety Evaluation Form will be utilized to conduct resident smoking assessments. This Smoking Safety Evaluation will be utilized to assess a resident's smoking history, safety concerns, cognitive awareness, and ability to handle a lighter. This assessment includes the evaluation of each smoking resident's capabilities and deficits and determines whether or not supervision during smoking is required. Based on the data collected in the smoking assessment, a specific plan will be developed to meet the individual needs of the resident. The information in the assessment is included in the resident's Plan of Care, which is reviewed and revised accordingly. D. On 01/29/2015, the facility implemented the use of a new Safety Surveillance Log to be utilized in the event of resident non-compliance with the Smoking Policy. This new procedure indicated that, in the event a resident is observed in possession of tobacco and/or paraphernalia (other than at the approved times and in conformance with approved procedures), the facility would implement surveillance to ensure compliance. Said surveillance will be documented in the Safety Surveillance Log. At the time of discovery of an infraction, items will be inventoried for the resident. The Safety Surveillance Log will be completed as supervised by the designated Charge Nurse. The surveillance frequency will be a minimum of twice per day, and include a random search for a seven-day period. With zero findings for the seven-day period, the surveillance would transition to three times per week for 30 days. A reassessment will be conducted post the 30 day mark for the necessity of ongoing surveillance. In addition, an attempt will be made to identify the source of provision of products with subsequent counseling to follow. All findings and recommendations will be submitted to, and monitored by, the QAA Committee. E. On 01/29/2015, a special called Resident Council meeting was held to discuss the changes to the Smoking Policy. All resident smokers were in attendance. F. On 01/29/2015, all residents utilizing tobacco products were assessed by the DON using the new Smoking Safety Evaluation Form. One-hundred percent of all current residents who smoke (a total of fourteen residents on the date of assessment) were assessed with [REDACTED]. G. On 01/29/2015, the facility reviewed/revised the Plans of Care for all residents using tobacco products, and Plans of Care for these residents were developed/updated with the goals of no injury when using tobacco products, safety practices, and encouraging smoking cessation. H. On 01/29/2015, the facility reiterated a procedure requiring that the facility's Interdisciplinary Care Team reassess each resident who smoked on a quarterly basis, or more frequently if needed, to determine if any change in smoking abilities has occurred. All resident Plans of Care will be updated to reflect this assessment. I. On 01/30/2015, a one-on-one sitter was assigned to Resident #1 to provide supervision to the resident. Resident #1 will have a sitter twenty-four hours per day, seven days per week to ensure her safety, and this coverage will continue until a later determination is made. J. On 02/02/2015, the facility implemented the use of fire blankets (which were originally ordered by the facility on 01/30/2015). These fire blankets will be housed in the smoking area and will be used to aid in ensuring resident safety during smoking. K. On 02/02/2015, the facility implemented enforcement of the Policy by which all smoking tobacco products and paraphernalia were removed from resident possession. Going forward, per the new Policy referenced above, smoking tobacco products and paraphernalia will be provided to residents upon request in the designated smoking area. When the resident reenters the facility after smoking activities have concluded, any smoking tobacco product that has not been consumed, as well as any smoking paraphernalia, will be returned to facility staff and inventoried. L. On 02/02/2015, the facility conducted staff in-service training regarding the new Smoking Policy and the new procedures involving the supervision of residents who smoke, the new smoking schedule, the monitoring process for potential resident noncompliance, and resident safety while smoking by the use of fire blankets. This staff in-service training also included staff training related to the smoking assessment process. As of 02/02/2015, the following facility staff had received this in-service training: eighteen (18) of eighteen (18) housekeeping staff; fourteen (14) of fourteen (14) food service staff; three (3) of three (3) activities staff; forty (40) of forty (40) certified nursing assistants; and twenty-two (22) of twenty-three (23) licensed nursing staff. One (1) licensed nursing staff member was unavailable to receive this training due to being on leave status. This one (1) remaining licensed nursing staff member will receive this in-service training upon her return to work. M. On 02/02/2015, the facility implemented the Smoking Policy Compliance Audit to audit the facility's new smoking program to monitor for evidence of ongoing staff compliance. This Audit will serve the purpose of monitoring and assessing staff compliance with the routine completion of the resident Smoking Safety Evaluation assessments, execution and maintenance of resident Plans of Care, the completion of the routine staff inventory of tobacco products and paraphernalia, and completion of the Smoking Surveillance Log (utilized as needed to address identified resident noncompliance with the Smoking Policy). This Smoking Policy Compliance Audit will be conducted by the DON, Assistant Director of Nursing, designated Registered Nurse Supervisor, Administrator, Assistant Administrator, or MDS Coordinator. This Audit will be conducted on every resident who smokes beginning on 02/02/2015, and will be conducted with the following progression: Weekly from 02/02/2015 through 02/28/2015; Biweekly from 03/01/2015 through 04/05/2015; Monthly on 04/06/2015, and ongoing. Any findings and subsequent interventions for ongoing compliance with facility Policy will be discussed with the QAA Committee. The data collected during the Smoking Policy Compliance Audit will be reported monthly to the QAA Committee for the Committee's review and evaluation. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the facility's QAA Committee had convened to review the facility's Smoking Policy, discuss Policy revisions, and instruct the DON to make specified Policy changes. This was in accordance with Step A of the CAJR referenced above. - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the QAA Committee met for review and approval of the revisions to the Smoking Policy. This included the development and implementation of the Smoking Monitoring Log to be used by staff to ensure attendance and oversight during resident designated smoking times. This was in accordance with Step B of the CAJR referenced above. - On 02/03/2015, DON interview and Policy review confirmed that the facility had implemented a new, revised Smoking Policy with specifications which included the restriction of resident smoking to scheduled smoking times and under direct staff supervision only, the restriction of residents' possession of smoking paraphernalia in the absence of staff supervision. This Smoking Policy also specified a procedure involving residents obtaining smoking paraphernalia from staff when entering the smoking area and returning smoking paraphernalia to staff upon exiting the smoking area. This was in accordance with Step C of the CAJR referenced above. - On 02/03/2015, document review, Policy review, and interview with the DON confirmed that the facility had implemented the Safety Surveillance Log to be utilized in the event of resident noncompliance with the Smoking Policy (and to be used on an as-needed basis). This new Safety Surveillance Log and the accompanying procedure would allow staff to implement surveillance, via inspections at specified intervals for specified timeframes, to ensure resident compliance with the facility's Smoking Policy. This was in accordance with Step D of the CAJR referenced above. - On 02/03/2015, review of meeting minutes confirmed that the facility had met with the Resident Council to discuss the changes to the Smoking Policy, with all smokers in attendance, in accordance with Step E of the CAJR referenced above. - On 02/03/2015, and ongoing throughout the abbreviated survey, it was confirmed via record review that all facility residents who used tobacco products were assessed via the new Smoking Safety Evaluation Form. This was in conformance with Step F of the CAJR referenced above. - On 02/03/2015, and ongoing throughout the abbreviated survey, it was confirmed via record review that the facility had reviewed the Plans of Care for all residents using tobacco products, with Plan of Care additions and revisions made as needed. This was in accordance with Step G of the CAJR referenced above. - On 02/03/2015, Policy review confirmed the facility procedure which specified that the Interdisciplinary Care Team reassess residents who smoke on a quarterly basis, and more frequently if needed, regarding evaluation for changes in smoking abilities. Accompanying Plan of Care updates will be made. This was in accordance with Step H of the CAJR referenced above. - On 02/03/2015, review of the One on One Sitter Safety Log confirmed that a one-on-one sitter had been assigned to Resident #1 to supervise to the resident twenty-four hours per day seven days per week, in conformance with Step I of the facility's CAJR referenced above. - On 02/03/2015, observation and in-service record review confirmed that the facility had implemented the use of fire blankets to help ensure resident safety during smoking, as indicated in Step J of the CAJR referenced above. - On 02/03/2015, resident observations and review of inventory logs confirmed that the facility had removed all smoking tobacco products and paraphernalia from resident possession, and that smoking tobacco products and paraphernalia will be provided to residents by staff upon request in the designated smoking area. This was in accordance with Step K of the CAJR referenced above. - On 02/03/2015, review of facility in-service training records confirmed that staff in-service training had been provided to licensed nursing staff, certified nursing assistants, laundry staff, housekeeping staff, food service staff, and activities services staff regarding the facility's new procedures for the supervision of residents who smoke, the smoking schedule, and the monitoring process for resident noncompliance. This was in accordance with Step L of the CAJR referenced above. - On 02/03/2015, Policy review, monitoring log review, and DON interview confirmed that the facility had implemented, per the specified schedule, the Smoking Policy Compliance Audit to monitor staff compliance with the completion of Smoking Safety Evaluation assessments and Plans of Care, as well as completion of the staff tobacco products and paraphernalia inventory and Smoking Surveillance Log. This was in accordance with Step M of the CAJR referenced above. Based on these corrective actions which had been developed and implemented by the facility on 02/02/2015 as outlined in the facility's CAJR referenced above, and based on the State Survey Agency's review of these CAJR corrective actions to confirm implementation, it was determined that the immediacy of the deficient practice was removed on 02/03/2015. The effectiveness of the corrective action plans, however, could not be fully assessed at the time of survey exit to ensure ongoing application and completion, as outlined below: The facility developed and implemented a new Smoking Policy which, in part, limited resident smoking activities to scheduled times and only under the direct supervision of staff. Residents would no longer be allowed to keep smoking paraphernalia on their person or with their personal belongings. Rather, residents would be required to obtain smoking paraphernalia from staff when entering the outside designated smoking area to smoke, and then return all smoking paraphernalia to staff at the time of reentry into the building from the designated smoking area. Smoking paraphernalia would be inventoried by staff following every smoking session to ensure all was accounted for. On 02/02/2015, the facility implemented enforcement of the Policy by which all smoking tobacco products and paraphernalia were removed from residents' possession, and would instead be obtained directly from staff at the beginning of scheduled smoking times and returned to staff and inventoried at the conclusion of scheduled smoking times. However, the 02/02/2015 implementation date of this new Policy and procedure was on 02/02/2015, the day before the 02/03/2015 exit date of this abbreviated survey. Therefore, the facility's ongoing compliance with this process involving the restriction of resident tobacco product access and scheduled staff inventories to provide accountability of tobacco products and paraphernalia could not be fully assessed at the time of survey exit and will need further evaluation at a future time. Additionally, on 02/02/2015, the facility implemented the Smoking Policy Compliance Audit to be conducted by the DON, Assistant Director of Nursing, designated Registered Nurse Supervisor, Administrator, Assistant Administrator, or MDS Coordinator. This Audit would serve to provide management-level oversight of staff compliance with Smoking Safety Evaluation assessment completion, Plans of Care review and revision, tobacco products/paraphernalia inventory procedures, and completion of the Smoking Surveillance Log (when indicated). This management-level Audit would be conducted for every resident who smokes and would be completed weekly through 02/28/2015, then biweekly from 03/01/2015 through 04/05/2015, then monthly thereafter. However, this Smoking Policy Compliance Audit involving management-level oversight of facility staffs' compliance with the Smoking Policy and procedures was implemented on 02/02/2015, the day prior to the 02/03/2015 exit date of this abbreviated survey. Therefore, ongoing compliance with this management-level Audit procedure could not be fully assessed at the time of survey exit and will need further evaluation at a future time. Based on the above, due to the need for continued evaluation of the facility's corrective action plans to ensure ongoing effectiveness, application, and completion, the noncompliance continues, with the Scope and Severity reduced to the "E" level.

Based on observation, record review, facility document review, facility policy review, resident interview, and staff interview, facility administration failed to ensure supervision/monitoring regarding the smoking behaviors of four (4) residents (#1, A, B, and E) who were assessed as unsafe to smoke without staff supervision and/or who exhibited unsafe behaviors of either obtaining smoking paraphernalia from, or providing smoking paraphernalia to, other residents without the knowledge of facility staff. The total survey sample was nine (9) residents, all of whom smoked cigarettes, with a Smoker's List provided by the facility documenting a total of fifteen (15) residents who smoked. For Resident #1, who was assessed to require supervision while smoking, the facility failed to provide routine monitoring to address the resident's unsafe behavior of obtaining smoking paraphernalia from other residents (including Resident A) and either smoking, or attempting to smoke, unsupervised. For Resident B, who was restricted from maintaining smoking materials in her possession related to a history of unsafe lighter use, the facility failed to routinely monitor to prevent the resident from unsafely accessing smoking paraphernalia. For Resident E, who did not smoke upon facility admission, but then began to smoke cigarettes after admission and was assessed to require staff supervision while smoking, the facility failed to provide monitoring to ensure the resident's safety while smoking. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on January 30, 2015 at 12:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on January 19, 2015, the date Resident #1, who was assessed by the facility to require staff supervision while smoking cigarettes, obtained two (2) cigarettes and gained access to a cigarette lighter without the knowledge of staff, attempted to light the cigarette with the lighter, and caught her hair on fire with the lighter. Resident #1 sustained multiple second/third [MEDICAL CONDITION] the left face, forehead, and ear. The immediate jeopardy continued through February 2, 2015, and was removed on February 3, 2015. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 2, 2015. An allegation of jeopardy removal was received on February 2, 2015. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 3, 2015. The facility remained out of compliance at a lower scope and severity of E while the process of evaluating modifications of resident assessment systems, care planning systems, and processes involved in the supervision of residents who smoked continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for supervising residents who smoked and who required supervision during smoking. Resident record reviews were conducted to assess facility staffs' conformance with the development of resident Plans of Care regarding smoking supervision. In addition, residents were observed while smoking in the exterior designated smoking area to assess facility staffs' conformance with the supervision of residents while smoking, in accordance with their assessed needs and as specified by their Plans of Care, to therefore ensure resident safety while smoking. Findings include: Cross refer to F323. Based on observation, record review, facility document review, facility policy review, resident interview, and staff interview, the facility failed to ensure supervision/monitoring related to cigarette smoking for Resident #1, who was assessed to require staff supervision while smoking; for Resident B, who could smoke without supervision but was not allowed to access or maintain smoking materials in her possession without staff supervision; and for Resident E, who began smoking cigarettes after facility admission and was assessed to require supervision while smoking, but for whom the facility failed to provide routine supervision to ensure the resident's safety. The total survey sample was nine (9) residents, all of whom smoked cigarettes. A Smoker's List provided by the facility documented a total of fifteen (15) residents who were identified by the facility to smoke cigarettes. The facility's failure to ensure adequate monitoring and supervision to residents who smoked resulted in a situation in which the facility's 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. During an interview with the Administrator conducted on 02/02/2015 at 1:59 p.m., the January 19, 2015 incident during which Resident #1 obtained cigarettes and lighter without the knowledge of staff and subsequently sustained multiple burn wounds to the face, forehead, and ear was discussed. The facility's Smoking Policy and Procedure was discussed with the Administrator, and the Administrator was questioned about his involvement in oversight and implementation of the Smoking Policy. During this interview, the Administrator stated that in his position as Administrator, he was directly involved in overseeing the Smoking Policy and Procedure. He stated that he had received information through the DON related to resident smoking issues prior to the January 19, 2015 incident resulting in Resident #1's multiple burn wounds. He stated that after the January 19, 2015 incident resulting in Resident #1's burn wounds from a cigarette lighter, he remained involved in overseeing the Smoking Policy. The Administrator stated that after the January 19, 2015 incident, he implemented a new procedure on January 27, 2015 specifying that all resident smoking would be supervised, and would be documented and tracked via use of the Smoking Monitoring Log. The Administrator further stated that both he and the DON had instructed staff to be more vigilant with watching Resident #1 and Resident A after the January 19, 2015 incident, further referencing the January 24, 2015 incident when Resident A had again given Resident #1 a cigarette. However, the Administrator presented no evidence of the development and implementation of any specific method by which to track and evaluate direct-care staffs' monitoring and supervision of resident smoking activities (to include oversight of residents requiring supervision while smoking but who were known to exhibit the unsafe behavior of obtaining smoking paraphernalia without the knowledge of staff) prior to the January 19, 2015 incident during which Resident #1 obtained smoking smoking materials from Resident A and sustained multiple burns. In addition, no evidence was presented of development and implementation of a method of evaluation of direct-care staff oversight of resident smoking after the January, 19, 2015 incident involving Resident #1 obtaining smoking materials from Resident A, or after the January 24, 2015 incident when Resident A again provided Resident #1 with a cigarette, initially without the knowledge of facility staff. Based on the above, there was no evidence of a facility system, either prior to or after the January 19, 2015 incident resulting in Resident #1 obtaining multiple burn wounds while smoking unsupervised, until January 27, 2015 (after the January 23, 2015 initiation date of this abbreviated survey) which allowed for, and ensured, the ongoing oversight of direct-care staffs' supervision of residents who required supervision due to their assessed inability to smoke safely with supervision and/or who exhibited unsafe smoking behaviors and practices. The facility presented a credible allegation of jeopardy removal (CAJR) on February 2, 2015. Based on the CAJR, it was determined that the immediate jeopardy had been removed on February 3, 2015, at which time the facility had implemented the following interventions: 1. On 01/26/2015, the Quality Assessment and Assurance (QAA) Committee met. During this meeting, the QAA Committee reviewed the facility's current Smoking Policy and discussed revisions to enhance resident safety. Recommendations were made, and the DON was to make edits and submit the revised Policy for review and approval. The specific recommendation that all resident smoking would be monitored was discussed an initiated immediately. Additionally, the Committee discussed offering smoking cessation services to residents desiring such services. 2. On 01/27/2015, the QAA Committee met and the revisions to the Smoking Policy were submitted for review and approval. The QAA Committee meeting focused on the development of a Smoking Monitoring Log, with approval and implementation post meeting. This Smoking Monitoring Log would allow for the staff responsible for monitoring the smoking area (per the newly implemented procedure referenced above specifying that all resident smoking would be monitored) to document attendance and oversight during designated smoking times. The QAA Committee was informed that a smoking cessation instructor would begin services on that date, offering a general orientation to smoking cessation classes. 3. On 01/29/2015, the facility implemented the Smoking Policy, the Purpose of which is to provide guidance regarding resident smoking at the facility. This Smoking Policy includes, but is not limited to, the specification that resident smoking is only permitted under staff supervision. Residents will not be allowed to keep any smoking paraphernalia on their person or with their personal belongings. Residents are required to check smoking paraphernalia out from staff members with entrance to the designated smoking area, and check smoking paraphernalia back in with staff at the time of exit from the designated smoking area. No more than two (2) cigarettes may be distributed to a resident, and any cigarettes not smoked will be collected by staff and returned to the storage area upon reentry into the building. Lighters and matches will be distributed to the resident for that smoking session and collected by staff for storage upon reentry into the building. Smoking paraphernalia will be inventoried following every smoking session to ensure all is accounted for. This inventory will be completed by the staff member assigned to supervise at each scheduled smoking time, and will be documented on the Resident Tobacco and Paraphernalia Log. The sharing of cigarettes and/or lighters and matches amongst residents is not permitted. Smoking is not permitted except within the designated area which is the courtyard/patio area located on the facility's South wing. Resident smoking will be conducted during scheduled times via a Smoking Schedule, and the smoking area will be open for resident access based on the posted schedule. Additionally, the Smoking Policy specifies that residents will be assessed upon admission regarding smoking preferences and any special needs. Residents are then reassessed quarterly and with any change in condition. A Smoking Safety Evaluation Form will be utilized to conduct resident smoking assessments. This Smoking Safety Evaluation will be utilized to assess a resident's smoking history, safety concerns, cognitive awareness, and ability to handle a lighter. This assessment includes the evaluation of each smoking resident's capabilities and deficits and determines whether or not supervision during smoking is required. Based on the data collected in the smoking assessment, a specific plan will be developed to meet the individual needs of the resident. The information in the assessment is included in the resident's Plan of Care, which is reviewed and revised accordingly. 4. On 01/29/2015, the facility implemented the use of a new Safety Surveillance Log to be utilized in the event of resident non-compliance with the Smoking Policy. This new procedure indicated that, in the event a resident is observed in possession of tobacco and/or paraphernalia (other than at the approved times and in conformance with approved procedures), the facility would implement surveillance to ensure compliance. Said surveillance will be documented in the Safety Surveillance Log. At the time of discovery of an infraction, items will be inventoried for the resident. The Safety Surveillance Log will be completed as supervised by the designated Charge Nurse. The surveillance frequency will be a minimum of twice per day, and include a random search for a seven-day period. With zero findings for the seven-day period, the surveillance would transition to three times per week for 30 days. A reassessment will be conducted post the 30 day mark for the necessity of ongoing surveillance. In addition, an attempt will be made to identify the source of provision of products with subsequent counseling to follow. All findings and recommendations will be submitted to, and monitored by, the QAA Committee. 5. On 01/29/2015, a special called Resident Council meeting was held to discuss the changes to the Smoking Policy. All resident smokers were in attendance. 6. On 01/29/2015, all residents utilizing tobacco products were assessed by the DON using the new Smoking Safety Evaluation Form. One-hundred percent of all current residents who smoke (a total of fourteen residents on the date of assessment) were assessed with [REDACTED]. 7. On 01/29/2015, the facility reviewed/revised the Plans of Care for all residents using tobacco products, and Plans of Care for these residents were developed/updated with the goals of no injury when using tobacco products, safety practices, and encouraging smoking cessation. 8. On 01/29/2015, the facility reiterated a procedure requiring that the facility's Interdisciplinary Care Team reassess each resident who smoked on a quarterly basis, or more frequently if needed, to determine if any change in smoking abilities has occurred. All resident Plans of Care will be updated to reflect this assessment. 9. On 01/30/2015, a one-on-one sitter was assigned to Resident #1 to provide supervision to the resident. Resident #1 will have a sitter twenty-four hours per day, seven days per week to ensure her safety, and this coverage will continue until a later determination is made. 10. On 02/02/2015, the facility implemented the use of fire blankets (which were originally ordered by the facility on 01/30/2015). These fire blankets will be housed in the smoking area and will be used to aid in ensuring resident safety during smoking. 11. On 02/02/2015, the facility implemented enforcement of the Policy by which all smoking tobacco products and paraphernalia were removed from resident possession. Going forward, per the new Policy referenced above, smoking tobacco products and paraphernalia will be provided to residents upon request in the designated smoking area. When the resident reenters the facility after smoking activities have concluded, any smoking tobacco product that has not been consumed, as well as any smoking paraphernalia, will be returned to facility staff and inventoried. 12. On 02/02/2015, the facility conducted staff in-service training regarding the new Smoking Policy and the new procedures involving the supervision of residents who smoke, the new smoking schedule, the monitoring process for potential resident noncompliance, and resident safety while smoking by the use of fire blankets. This staff in-service training also included staff training related to the smoking assessment process. As of 02/02/2015, the following facility staff had received this in-service training: eighteen (18) of eighteen (18) housekeeping staff; fourteen (14) of fourteen (14) food service staff; three (3) of three (3) activities staff; forty (40) of forty (40) certified nursing assistants; and twenty-two (22) of twenty-three (23) licensed nursing staff. One (1) licensed nursing staff member was unavailable to receive this training due to being on leave status. This one (1) remaining licensed nursing staff member will receive this in-service training upon her return to work. 13. On 02/02/2015, the facility implemented the Smoking Policy Compliance Audit to audit the facility's new smoking program to monitor for evidence of ongoing staff compliance. This Audit will serve the purpose of monitoring and assessing staff compliance with the routine completion of the resident Smoking Safety Evaluation assessments, execution and maintenance of resident Plans of Care, the completion of the routine staff inventory of tobacco products and paraphernalia, and completion of the Smoking Surveillance Log (utilized as needed to address identified resident noncompliance with the Smoking Policy). This Smoking Policy Compliance Audit will be conducted by the DON, Assistant Director of Nursing, designated Registered Nurse Supervisor, Administrator, Assistant Administrator, or MDS Coordinator. This Audit will be conducted on every resident who smokes beginning on 02/02/2015, and will be conducted with the following progression: Weekly from 02/02/2015 through 02/28/2015; Biweekly from 03/01/2015 through 04/05/2015; Monthly on 04/06/2015, and ongoing. Any findings and subsequent interventions for ongoing compliance with facility Policy will be discussed with the QAA Committee. The data collected during the Smoking Policy Compliance Audit will be reported monthly to the QAA Committee for the Committee's review and evaluation. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the facility's QAA Committee had convened to review the facility's Smoking Policy, discuss Policy revisions, and instruct the DON to make specified Policy changes. This was in accordance with Step #1 of the CAJR referenced above. - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the QAA Committee met for review and approval of the revisions to the Smoking Policy. This included the development and implementation of the Smoking Monitoring Log to be used by staff to ensure attendance and oversight during resident designated smoking times. This was in accordance with Step #2 of the CAJR referenced above. - On 02/03/2015, DON interview and Policy review confirmed that the facility had implemented a new, revised Smoking Policy with specifications which included the restriction of resident smoking to scheduled smoking times and under direct staff supervision only, the restriction of residents' possession of smoking paraphernalia in the absence of staff supervision. This Smoking Policy also specified a procedure involving residents obtaining smoking paraphernalia from staff when entering the smoking area and returning smoking paraphernalia to staff upon exiting the smoking area. This was in accordance with Step #3 of the CAJR referenced above. - On 02/03/2015, document review, Policy review, and interview with the DON confirmed that the facility had implemented the Safety Surveillance Log to be utilized in the event of resident noncompliance with the Smoking Policy (and to be used on an as-needed basis). This new Safety Surveillance Log and the accompanying procedure would allow staff to implement surveillance, via inspections at specified intervals for specified timeframes, to ensure resident compliance with the facility's Smoking Policy. This was in accordance with Step #4 of the CAJR referenced above. - On 02/03/2015, review of meeting minutes confirmed that the facility had met with the Resident Council to discuss the changes to the Smoking Policy, with all smokers in attendance, in accordance with Step #5 of the CAJR referenced above. - On 02/03/2015, and ongoing throughout the abbreviated survey, it was confirmed via record review that all facility residents who used tobacco products were assessed via the new Smoking Safety Evaluation Form. This was in conformance with Step #6 of the CAJR referenced above. - On 02/03/2015, and ongoing throughout the abbreviated survey, it was confirmed via record review that the facility had reviewed the Plans of Care for all residents using tobacco products, with Plan of Care additions and revisions made as needed. This was in accordance with Step #7 of the CAJR referenced above. - On 02/03/2015, Policy review confirmed the facility procedure which specified that the Interdisciplinary Care Team reassess residents who smoke on a quarterly basis, and more frequently if needed, regarding evaluation for changes in smoking abilities. Accompanying Plan of Care updates will be made. This was in accordance with Step #8 of the CAJR referenced above. - On 02/03/2015, review of the One on One Sitter Safety Log confirmed that a one-on-one sitter had been assigned to Resident #1 to supervise to the resident twenty-four hours per day seven days per week, in conformance with Step #9 of the facility's CAJR referenced above. - On 02/03/2015, observation and in-service record review confirmed that the facility had implemented the use of fire blankets to help ensure resident safety during smoking, as indicated in Step #10 of the CAJR referenced above. - On 02/03/2015, resident observations and review of inventory logs confirmed that the facility had removed all smoking tobacco products and paraphernalia from resident possession, and that smoking tobacco products and paraphernalia will be provided to residents by staff upon request in the designated smoking area. This was in accordance with Step #11 of the CAJR referenced above. - On 02/03/2015, review of facility in-service training records confirmed that staff in-service training had been provided to licensed nursing staff, certified nursing assistants, laundry staff, housekeeping staff, food service staff, and activities services staff regarding the facility's new procedures for the supervision of residents who smoke, the smoking schedule, and the monitoring process for resident noncompliance. This was in accordance with Step #12 of the CAJR referenced above. - On 02/03/2015, Policy review, monitoring log review, and DON interview confirmed that the facility had implemented, per the specified schedule, the Smoking Policy Compliance Audit to monitor staff compliance with the completion of Smoking Safety Evaluation assessments and Plans of Care, as well as completion of the staff tobacco products and paraphernalia inventory and Smoking Surveillance Log. This was in accordance with Step #13 of the CAJR referenced above. Based on these corrective actions which had been developed and implemented by the facility on 02/02/2015 as outlined in the facility's CAJR referenced above, and based on the State Survey Agency's review of these CAJR corrective actions to confirm implementation, it was determined that the immediacy of the deficient practice was removed on 02/03/2015. The effectiveness of the corrective action plans, however, could not be fully assessed at the time of survey exit to ensure ongoing application and completion, as outlined below: The facility developed and implemented a new Smoking Policy which, in part, limited resident smoking activities to scheduled times and only under the direct supervision of staff. Residents would no longer be allowed to keep smoking paraphernalia on their person or with their personal belongings. Rather, residents would be required to obtain smoking paraphernalia from staff when entering the outside designated smoking area to smoke, and then return all smoking paraphernalia to staff at the time of reentry into the building from the designated smoking area. Smoking paraphernalia would be inventoried by staff following every smoking session to ensure all was accounted for. On 02/02/2015, the facility implemented enforcement of the Policy by which all smoking tobacco products and paraphernalia were removed from residents' possession, and would instead be obtained directly from staff at the beginning of scheduled smoking times and returned to staff and inventoried at the conclusion of scheduled smoking times. However, the 02/02/2015 implementation date of this new Policy and procedure was on 02/02/2015, the day before the 02/03/2015 exit date of this abbreviated survey. Therefore, the facility's ongoing compliance with this process involving the restriction of resident tobacco product access and scheduled staff inventories to provide accountability of tobacco products and paraphernalia could not be fully assessed at the time of survey exit and will need further evaluation at a future time. Additionally, on 02/02/2015, the facility implemented the Smoking Policy Compliance Audit to be conducted by the DON, Assistant Director of Nursing, designated Registered Nurse Supervisor, Administrator, Assistant Administrator, or MDS Coordinator. This Audit would serve to provide management-level oversight of staff compliance with Smoking Safety Evaluation assessment completion, Plans of Care review and revision, tobacco products/paraphernalia inventory procedures, and completion of the Smoking Surveillance Log (when indicated). This management-level Audit would be conducted for every resident who smokes and would be completed weekly through 02/28/2015, then biweekly from 03/01/2015 through 04/05/2015, then monthly thereafter. However, this Smoking Policy Compliance Audit involving management-level oversight of facility staffs' compliance with the Smoking Policy and procedures was implemented on 02/02/2015, the day prior to the 02/03/2015 exit date of this abbreviated survey. Therefore, ongoing compliance with this management-level Audit procedure could not be fully assessed at the time of survey exit and will need further evaluation at a future time. Based on the above, due to the need for continued evaluation of the facility's corrective action plans to ensure ongoing effectiveness, application, and completion, the noncompliance continues, with the Scope and Severity reduced to the E level.

An abbreviated survey conducted January 23, 2015 through February 5, 2015 revealed noncompliance at F282 at the Scope/Severity of "J". Additional noncompliance at F282, not related to immediate jeopardy, was also identified during the standard survey of February 2, 2015 through February 5, 2015. The noncompliance at F282 identified during the January 23, 2015 through February 5, 2015 abbreviated survey (cited at the Scope/Severity of "J") has been brought forward to this standard survey Form CMS-2567, which also reflects the noncompliance at F282 identified during the standard survey of February 2, 2015 through February 5, 2015, as referenced below: Based on medical record review, Entity Reported Incident Intake review, facility investigative report review, resident interview, and staff interview, the facility failed to ensure monitoring, in accordance with the Plan of Care, for one (1) resident (#1) who smoked cigarettes and whose Plan of Care specified monitoring for the behavior of obtaining cigarettes from other residents, from the total abbreviated survey sample of nine (9) residents, all of whom smoked cigarettes. A Smoker's List provided by the facility documented a total of fifteen (15) residents who were identified to smoke cigarettes. In addition, the facility failed to provide care in accordance with the Plans of care for two (2) residents ("F" and #82), related to personal hygiene/shaving, and for one (1) resident ("Q"), related to vision care, from the standard survey sample of twenty-four (24) residents. The facility's failure to ensure adequate monitoring of Resident #1 related to cigarette smoking resulted in 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 immediate jeopardy is outlined as follows: - Resident #1 required supervision while smoking, and staff were to keep smoking her materials in the medication cart. Resident #1 had a history of [REDACTED]. Resident #1's Plan of Care specified that staff monitor her related to her behavior of obtaining cigarettes from other residents. However, the facility failed to ensure monitoring, as specified by the Plan of Care, to address Resident #1's attempts to obtain smoking materials. On 01/19/2015, Resident #1 obtained 2 cigarettes from Resident "A" and gained access to Resident "A"'s lighter, attempted to light a cigarette and ignited her hair. Resident #1 was transferred to the Burn Center with second and/or third [MEDICAL CONDITION] the left side of the face, forehead, temple, cheek and external ear, requiring skin grafts. Resident #1 returned to the facility on [DATE], but on 01/24/15, was again found with a cigarette provided by Resident "A" without staff knowledge. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on January 30, 2015 at 12:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on January 19, 2015, the date that Resident #1, who was assessed by the facility to require staff supervision while smoking cigarettes, obtained two (2) cigarettes and gained access to a cigarette lighter without the knowledge of staff, attempted to light the cigarette with the lighter, and caught her hair on fire with the lighter. Resident #1 sustained multiple second/third [MEDICAL CONDITION] the left face, forehead, and ear. The immediate jeopardy continued through February 2, 2015, and was removed on February 3, 2015. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 2, 2015. During a 01/23/2015, 10:00 a.m. interview, the DON acknowledged the 01/19/2015 incident resulting in Resident #1 sustaining burn wounds. An allegation of jeopardy removal was received on February 2, 2015. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 3, 2015. The facility remained out of compliance at a lower scope and severity of "D" while the process of evaluating modifications of resident assessment systems, care planning systems, and processes involved in the supervision of residents who smoked continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for supervising residents who smoked and who required supervision during smoking. Resident record reviews were conducted to assess facility staffs' conformance with the development of resident Plans of Care regarding smoking supervision. In addition, residents were observed while smoking in the exterior designated smoking area to assess facility staffs' conformance with the supervision of residents while smoking, in accordance with their assessed needs and as specified by their Plans of Care, to therefore ensure resident safety while smoking. Findings include: 1. Resident #1's Admission Minimum Data Set (MDS) assessment of 10/30/14 documented her 10/20/14 admission, and Section I-Active Diagnoses, documented [DIAGNOSES REDACTED]. Section N - Medications documented that Resident #1 received antipsychotic/antidepressant medications. Section M - Skin Conditions documented no current pressure ulcers, but documented a risk of pressure-ulcer development, and Section J - Health Conditions documented Resident #1's tobacco use. Review of Resident #1's Plan Of Care revealed a Problem/Strength dated 11/02/2014 which identified the resident's risk for skin integrity impairment, and identified Interventions which included that the resident required supervised smoking. Resident #1's Plan Of Care also identified as a Problem/Strength dated 11/06/2014 that she had the potential for altered thought processes related to [MEDICAL CONDITION] medication use and her disease process, and identified Interventions which included monitoring for the behavior of obtaining the cigarettes of other residents from the ashtray. Resident #1's Plan of Care did not specify the frequency by which staff were to monitor the resident in relation to her known behavior, as indicated on the Plan of Care, of obtaining the cigarettes of other residents, even though the Plan of Care also documented the resident's requirement for supervised smoking. During a 01/29/2014, 10:45 a.m. interview, Charge Nurse "AA" acknowledged that Resident #1 was supervised while smoking and stated that the resident's cigarettes and lighter were locked by staff in the medication cart. During a 01/29/2014, 9:50 a.m. interview, the Administrator stated that some residents who required supervision while smoking were not allowed to keep cigarettes and lighters, but that some residents could smoke independently and were allowed to keep cigarettes and lighters. During a 01/23/2015, 12:00 p.m. interview, Residents "C" and "D" (whose respective November 2014 and January 2015 MDS assessments documented Brief Interview for Mental Status Scores of 15, indicating both were cognitively intact) stated they had observed Resident #1 smoking unsupervised frequently in the past when Resident "A" had given Resident #1 cigarettes and a lighter when no staff were present. Residents "C" and "D" also stated they had seen staff find Resident #1 while smoking unsupervised. A 10/31/2014 NPN entry documented that Resident #1 was known to try to borrow cigarettes from other residents (as also indicated in the 01/23/2015, 12:00 p.m. interview with Residents "C" and "D" referenced above), and an 11/29/2014, 10:30 a.m. NPN entry documented that Resident #1 had been found in possession of cigarette butts. As referenced above, Resident #1's Plan Of Care specified Interventions requiring supervised smoking and that, due to her altered thought process, she would be monitored for her behavior of obtaining cigarettes of other residents. However, despite Resident #1's Plan Of Care specifying supervised smoking and monitoring regarding smoking behaviors, and despite Resident #1's known behavior of obtaining cigarettes from other residents and sometimes smoking unsupervised (per the 01/23/2015, 12:00 p.m. interview with Residents "C" and "D" and the 10/31/2014 NPN entry referenced above), review of Resident #1's medical record revealed no evidence of routine monitoring of Resident #1 regarding her behavior of obtaining cigarettes from other residents. A 01/19/2015, 3:15 p.m. NPN entry then documented the nurse was informed of a fire involving Resident #1's hair, and a 01/19/2015, 3:46 p.m. NPN entry documented that Resident #1's physician ordered hospital transfer after being notified of facial/hair burns. A 01/22/2015 investigative report related to this 01/19/2015 incident involving Resident #1 documented that Resident #1 and Resident #9 were in the smoking area when Resident #1 revealed a hand-rolled cigarette and lighter. Resident #1 leaned over to light the cigarette and lit her hair on fire. Resident #9 informed Resident "C", and Resident "C" extinguished the fire by patting Resident #1's head. Resident #1 was transported to the hospital having second/third [MEDICAL CONDITION] the left side of the face, third [MEDICAL CONDITION] the left side of the forehead/temple, and second [MEDICAL CONDITION] the left side of the cheek and external ear. In this report, the facility concluded that Resident "A" gave the hand-rolled cigarette to Resident #1. Resident "A" admitted had gave Resident #1 two cigarettes, and stated that Resident #1 knew that he kept lighters on his dresser and that on January 19, 2015, he had noted one of his lighters missing. A 01/23/2014, 9:25 p.m. NPN entry then documented Resident #1's readmission to the facility from the Burn Center, having received left ear, left scalp, and left facial skin grafts. Resident #1's Plan Of Care referenced above specified supervised smoking and monitoring related to the resident's behavior of obtaining cigarettes from other residents, and the facility's January 22, 2015 investigative report referenced above documented that on 01/19/2015, Resident #1 obtained a cigarette and lighter without the knowledge of staff and caught her hair on fire while attempting to light the cigarette. However, record review for Resident #1 revealed no evidence to indicate the facility provided routine monitoring (as specified by the Plan of Care), after Resident #1's 01/23/2014 facility readmission, to ensure supervision regarding Resident #1 smoking unsupervised. A 01/24/2014, 9:30 a.m. NPN entry then documented that staff had again found Resident #1 holding a hand-made cigarette, and that Resident #1 told the nurse she obtained this cigarette from another resident. This NPN entry documented that Resident #1 was instructed by staff to obtain cigarettes and a lighter from a staff member only. However, despite Resident #1 again obtaining a cigarette from another resident (per the 01/24/2015, 9:30 a.m. NPN referenced above), further record review revealed no evidence of routine monitoring for Resident #1 related to her behavior of obtaining cigarettes from other residents, even though the resident's Plan of Care specified monitoring for this behavior of obtaining cigarettes without staff knowledge. The facility's failure to provide monitoring to Resident #1, as specified by the Plan of Care, related to her attempts to obtain smoking materials and smoke without staff knowledge placed Resident #1 at risk for smoking unsupervised and sustaining additional injury. Cross refer to F323, example 1, for more information regarding Resident #1. 2. Resident "F"'s December 2014 Quarterly MDS assessment documented a Brief Interview of Mental Status Score of 15 in Section C - Cognitive Patterns, indicating he was cognitively intact. Section I - Active [DIAGNOSES REDACTED]. Section G - Functional Status documented Resident "F"'s impairment in upper extremity Range of Motion on one side, and indicated the resident required extensive assistance with personal hygiene. Review of the Plan of Care for Resident "F" revealed a Problem/Strength, originally dating from 08/04/2014, which identified the resident to have a self-care deficit related to impaired mobility and a contracture of the left wrist. Interventions on Resident "F"'s Plan of Care to address this self-care deficit included, but were not limited to, for staff to monitor the resident's appearance and take action as indicated, and also to shave the resident as needed. However, during observations of Resident "F" conducted on 02/03/2015 at 9:30 a.m. and 5:05 p.m., and on 02/04/2015 at 7:53 a.m., Resident "F" was observed to have several days growth of facial hair. During a 02/03/2015, 9:30 a.m. interview, Resident "F" stated he had not been shaven since the prior week. During a 02/05/2015, 11:35 a.m. interview, RN "FF" stated that Resident "F" was shaven earlier that morning, and acknowledged there being an issue with care. Cross refer to F312, example 1, for more information regarding Resident "F". 3. Resident #82's Quarterly MDS assessment of 01/07/2015 documented diagnoses, in Section I - Active Diagnoses, including, but not limited to, Hypertension, [MEDICAL CONDITION], and Dementia. Section G - Functional Status documented Functional Limitation in Resident #82's Range of Motion, and that Resident #82 was totally dependent for dressing and personal hygiene, and required physical help with bathing. Review of Resident #82's Plan of Care revealed a Problem/Strength which identified the resident to have a self-care deficit related to the effects of weakness and poor tolerance. Plan of Care Interventions to address this self-care deficit for Resident #82 included, but were not limited to, for staff to monitor the resident's appearance and take action as indicated, and also for staff to assist with daily dressing/grooming, as tolerated. However, observation on 02/02/2015 at 3:50 p.m. revealed Resident #82's eyes matted with thick orange yellow matter and her hair uncombed. Observations on 02/03/2015 at 8:05 a.m. and 11:50 a.m. revealed Resident #82 to be wearing a stained gown, and she had uncombed hair and crusty matter in her eyelashes. Observations on 02/04/2015 at 8:00 a.m., 10:00 a.m., and 12:00 noon revealed Resident #82 still wearing a stained gown, her hair was uncombed, and she had yellow crusty matter on her eyes. During a 02/04/2015, 6:00 p.m. observation, Resident #82 continued to have eye drainage, matted hair, and a soiled gown. During a 02/04/2015, 6:00 p.m. interview with RN "GG" who was in attendance at the time of this observation, RN "GG" acknowledged Resident #82's lack of grooming care. Cross refer to F312, example 2, for more information regarding Resident #82. 4. Resident "Q"'s November 2014 Annual MDS assessment documented a BIMS Score of 13 in Section C - Cognitive Patterns, indicating the resident was cognitively intact. Section I - Active [DIAGNOSES REDACTED]. Section B - Hearing, Speech, and Vision documented Resident "Q" to have impaired vision. Review of the Plan of Care for Resident "Q" revealed a Problem/Strength identifying a self-care deficit related to reasons including, but not limited to, the resident's impaired vision. Care Plan Interventions for Resident "Q"'s self care deficit, as related to impaired vision, included for staff to assist in maintenance of the resident's eye glasses and to encourage the resident to wear eye glasses. However, during a 02/04/2015, 10:00 a.m. observation of Resident "Q", the resident was not wearing eye glasses. During interview conducted at the time of this observation, Resident "Q" stated he had previously made a request to staff that he obtain eye glasses. During an interview conducted on 02/04/2015 at 2:07 p.m., RN "GG" stated that if a resident requested an eye examination, a local optometrist was to be contacted and an appointment made, but further acknowledged that Resident "Q" had not had an eye examination while a resident of this facility. Cross refer to F313 for more information regarding Resident "Q". The facility presented a credible allegation of jeopardy removal (CAJR) on February 2, 2015. Based on the CAJR, it was determined that the immediate jeopardy had been removed on February 3, 2015, at which time the facility had implemented the following interventions: A. On 01/26/2015, the Quality Assessment and Assurance (QAA) Committee met. During this meeting, the QAA Committee reviewed the facility's current Smoking Policy and discussed revisions to enhance resident safety. Recommendations were made, and the DON was to make edits and submit the revised Policy for review and approval. The specific recommendation that all resident smoking would be monitored was discussed an initiated immediately. Additionally, the Committee discussed offering smoking cessation services to residents desiring such services. B. On 01/27/2015, the QAA Committee met and the revisions to the Smoking Policy were submitted for review and approval. The QAA Committee meeting focused on the development of a Smoking Monitoring Log, with approval and implementation post meeting. This Smoking Monitoring Log would allow for the staff responsible for monitoring the smoking area (per the newly implemented procedure referenced above specifying that all resident smoking would be monitored) to document attendance and oversight during designated smoking times. The QAA Committee was informed that a smoking cessation instructor would begin services on that date, offering a general orientation to smoking cessation classes. C. On 01/29/2015, the facility implemented the Smoking Policy, the Purpose of which is to provide guidance regarding resident smoking at the facility. This Smoking Policy includes, but is not limited to, the specification that resident smoking is only permitted under staff supervision. Residents will not be allowed to keep any smoking paraphernalia on their person or with their personal belongings. Residents are required to check smoking paraphernalia out from staff members with entrance to the designated smoking area, and check smoking paraphernalia back in with staff at the time of exit from the designated smoking area. No more than two (2) cigarettes may be distributed to a resident, and any cigarettes not smoked will be collected by staff and returned to the storage area upon reentry into the building. Lighters and matches will be distributed to the resident for that smoking session and collected by staff for storage upon reentry into the building. Smoking paraphernalia will be inventoried following every smoking session to ensure all is accounted for. This inventory will be completed by the staff member assigned to supervise at each scheduled smoking time, and will be documented on the Resident Tobacco and Paraphernalia Log. The sharing of cigarettes and/or lighters and matches amongst residents is not permitted. Smoking is not permitted except within the designated area which is the courtyard/patio area located on the facility's South wing. Resident smoking will be conducted during scheduled times via a Smoking Schedule, and the smoking area will be open for resident access based on the posted schedule. Additionally, the Smoking Policy specifies that residents will be assessed upon admission regarding smoking preferences and any special needs. Residents are then reassessed quarterly and with any change in condition. A Smoking Safety Evaluation Form will be utilized to conduct resident smoking assessments. This Smoking Safety Evaluation will be utilized to assess a resident's smoking history, safety concerns, cognitive awareness, and ability to handle a lighter. This assessment includes the evaluation of each smoking resident's capabilities and deficits and determines whether or not supervision during smoking is required. Based on the data collected in the smoking assessment, a specific plan will be developed to meet the individual needs of the resident. The information in the assessment is included in the resident's Plan of Care, which is reviewed and revised accordingly. D. On 01/29/2015, the facility implemented the use of a new Safety Surveillance Log to be utilized in the event of resident non-compliance with the Smoking Policy. This new procedure indicated that, in the event a resident is observed in possession of tobacco and/or paraphernalia (other than at the approved times and in conformance with approved procedures), the facility would implement surveillance to ensure compliance. Said surveillance will be documented in the Safety Surveillance Log. At the time of discovery of an infraction, items will be inventoried for the resident. The Safety Surveillance Log will be completed as supervised by the designated Charge Nurse. The surveillance frequency will be a minimum of twice per day, and include a random search for a seven-day period. With zero findings for the seven-day period, the surveillance would transition to three times per week for 30 days. A reassessment will be conducted post the 30 day mark for the necessity of ongoing surveillance. In addition, an attempt will be made to identify the source of provision of products with subsequent counseling to follow. All findings and recommendations will be submitted to, and monitored by, the QAA Committee. E. On 01/29/2015, a special called Resident Council meeting was held to discuss the changes to the Smoking Policy. All resident smokers were in attendance. F. On 01/29/2015, all residents utilizing tobacco products were assessed by the DON using the new Smoking Safety Evaluation Form. One-hundred percent of all current residents who smoke (a total of fourteen residents on the date of assessment) were assessed with [REDACTED]. G. On 01/29/2015, the facility reviewed/revised the Plans of Care for all residents using tobacco products, and Plans of Care for these residents were developed/updated with the goals of no injury when using tobacco products, safety practices, and encouraging smoking cessation. H. On 01/29/2015, the facility reiterated a procedure requiring that the facility's Interdisciplinary Care Team reassess each resident who smoked on a quarterly basis, or more frequently if needed, to determine if any change in smoking abilities has occurred. All resident Plans of Care will be updated to reflect this assessment. I. On 01/30/2015, a one-on-one sitter was assigned to Resident #1 to provide supervision to the resident. Resident #1 will have a sitter twenty-four hours per day, seven days per week to ensure her safety, and this coverage will continue until a later determination is made. J. On 02/02/2015, the facility implemented the use of fire blankets (which were originally ordered by the facility on 01/30/2015). These fire blankets will be housed in the smoking area and will be used to aid in ensuring resident safety during smoking. K. On 02/02/2015, the facility implemented enforcement of the Policy by which all smoking tobacco products and paraphernalia were removed from resident possession. Going forward, per the new Policy referenced above, smoking tobacco products and paraphernalia will be provided to residents upon request in the designated smoking area. When the resident reenters the facility after smoking activities have concluded, any smoking tobacco product that has not been consumed, as well as any smoking paraphernalia, will be returned to facility staff and inventoried. L. On 02/02/2015, the facility conducted staff in-service training regarding the new Smoking Policy and the new procedures involving the supervision of residents who smoke, the new smoking schedule, the monitoring process for potential resident noncompliance, and resident safety while smoking by the use of fire blankets. This staff in-service training also included staff training related to the smoking assessment process. As of 02/02/2015, the following facility staff had received this in-service training: eighteen (18) of eighteen (18) housekeeping staff; fourteen (14) of fourteen (14) food service staff; three (3) of three (3) activities staff; forty (40) of forty (40) certified nursing assistants; and twenty-two (22) of twenty-three (23) licensed nursing staff. One (1) licensed nursing staff member was unavailable to receive this training due to being on leave status. This one (1) remaining licensed nursing staff member will receive this in-service training upon her return to work. M. On 02/02/2015, the facility implemented the Smoking Policy Compliance Audit to audit the facility's new smoking program to monitor for evidence of ongoing staff compliance. This Audit will serve the purpose of monitoring and assessing staff compliance with the routine completion of the resident Smoking Safety Evaluation assessments, execution and maintenance of resident Plans of Care, the completion of the routine staff inventory of tobacco products and paraphernalia, and completion of the Smoking Surveillance Log (utilized as needed to address identified resident noncompliance with the Smoking Policy). This Smoking Policy Compliance Audit will be conducted by the DON, Assistant Director of Nursing, designated Registered Nurse Supervisor, Administrator, Assistant Administrator, or MDS Coordinator. This Audit will be conducted on every resident who smokes beginning on 02/02/2015, and will be conducted with the following progression: Weekly from 02/02/2015 through 02/28/2015; Biweekly from 03/01/2015 through 04/05/2015; Monthly on 04/06/2015, and ongoing. Any findings and subsequent interventions for ongoing compliance with facility Policy will be discussed with the QAA Committee. The data collected during the Smoking Policy Compliance Audit will be reported monthly to the QAA Committee for the Committee's review and evaluation. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the facility's QAA Committee had convened to review the facility's Smoking Policy, discuss Policy revisions, and instruct the DON to make specified Policy changes. This was in accordance with Step A of the CAJR referenced above. - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the QAA Committee met for review and approval of the revisions to the Smoking Policy. This included the development and implementation of the Smoking Monitoring Log to be used by staff to ensure attendance and oversight during resident designated smoking times. This was in accordance with Step B of the CAJR referenced above. - On 02/03/2015, DON interview and Policy review confirmed that the facility had implemented a new, revised Smoking Policy with specifications which included the restriction of resident smoking to scheduled smoking times and under direct staff supervision only, the restriction of residents' possession of smoking paraphernalia in the absence of staff supervision. This Smoking Policy also specified a procedure involving residents obtaining smoking paraphernalia from staff when entering the smoking area and returning smoking paraphernalia to staff upon exiting the smoking area. This was in accordance with Step C of the CAJR referenced above. - On 02/03/2015, document review, Policy review, and interview with the DON confirmed that the facility had implemented the Safety Surveillance Log to be utilized in the event of resident noncompliance with the Smoking Policy (and to be used on an as-needed basis). This new Safety Surveillance Log and the accompanying procedure would allow staff to implement surveillance, via inspections at specified intervals for specified timeframes, to ensure resident compliance with the facility's Smoking Policy. This was in accordance with Step D of the CAJR referenced above. - On 02/03/2015, review of meeting minutes confirmed that the facility had met with the Resident Council to discuss the changes to the Smoking Policy, with all smokers in attendance, in accordance with Step E of the CAJR referenced above. - On 02/03/2015, and ongoing throughout the abbreviated survey, it was confirmed via record review that all facility residents who used tobacco products were assessed via the new Smoking Safety Evaluation Form. This was in conformance with Step F of the CAJR referenced above. - On 02/03/2015, and ongoing throughout the abbreviated survey, it was confirmed via record review that the facility had reviewed the Plans of Care for all residents using tobacco products, with Plan of Care additions and revisions made as needed. This was in accordance with Step G of the CAJR referenced above. - On 02/03/2015, Policy review confirmed the facility procedure which specified that the Interdisciplinary Care Team reassess residents who smoke on a quarterly basis, and more frequently if needed, regarding evaluation for changes in smoking abilities. Accompanying Plan of Care updates will be made. This was in accordance with Step H of the CAJR referenced above. - On 02/03/2015, review of the One on One Sitter Safety Log confirmed that a one-on-one sitter had been assigned to Resident #1 to supervise to the resident twenty-four hours per day seven days per week, in conformance with Step I of the facility's CAJR referenced above. - On 02/03/2015, observation and in-service record review confirmed that the facility had implemented the use of fire blankets to help ensure resident safety during smoking, as indicated in Step J of the CAJR referenced above. - On 02/03/2015, resident observations and review of inventory logs confirmed that the facility had removed all smoking tobacco products and paraphernalia from resident possession, and that smoking tobacco products and paraphernalia will be provided to residents by staff upon request in the designated smoking area. This was in accordance with Step K of the CAJR referenced above. - On 02/03/2015, review of facility in-service training records confirmed that staff in-service training had been provided to licensed nursing staff, certified nursing assistants, laundry staff, housekeeping staff, food service staff, and activities services staff regarding the facility's new procedures for the supervision of residents who smoke, the smoking schedule, and the monitoring process for resident noncompliance. This was in accordance with Step L of the CAJR referenced above. - On 02/03/2015, Policy review, monitoring log review, and DON interview confirmed that the facility had implemented, per the specified schedule, the Smoking Policy Compliance Audit to monitor staff compliance with the completion of Smoking Safety Evaluation assessments and Plans of Care, as well as completion of the staff tobacco products and paraphernalia inventory and Smoking Surveillance Log. This was in accordance with Step M of the CAJR referenced above. Based on these corrective actions which had been developed and implemented by the facility on 02/02/2015 as outlined in the facility's CAJR referenced above, and based on the State Survey Agency's review of these CAJR corrective actions to confirm implementation, it was determined that the immediacy of the deficient practice was removed on 02/03/2015. The effectiveness of the corrective action plans, however, could not be fully assessed at the time of survey exit to ensure ongoing application and completion, as outlined below: The facility developed and implemented a new Smoking Policy which, in part, limited resident smoking activities to scheduled times and only under the direct supervision of staff. Residents would no longer be allowed to keep smoking paraphernalia on their p

Based on medical record review, Entity Reported Incident Intake review, facility investigative report review, resident interview, and staff interview, the facility failed to ensure monitoring, in accordance with the Plan of Care, one (1) resident (#1) who smoked cigarettes and whose Plan of Care specified monitoring for the behavior of obtaining cigarettes from other residents, from the total survey sample of nine (9) residents, all of whom smoked cigarettes. A Smoker's List provided by the facility documented a total of fifteen (15) residents who were identified to smoke cigarettes. The facility's failure to ensure adequate monitoring of Resident #1 related to cigarette smoking resulted in 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 immediate jeopardy is outlined as follows: - Resident #1 required supervision while smoking, and staff were to keep smoking her materials in the medication cart. Resident #1 had a history of [REDACTED]. Resident #1's Plan of Care specified that staff monitor her related to her behavior of obtaining cigarettes from other residents. However, the facility failed to ensure monitoring, as specified by the Plan of Care, to address Resident #1's attempts to obtain smoking materials. On 01/19/2015, Resident #1 obtained 2 cigarettes from Resident A and gained access to Resident A's lighter, attempted to light a cigarette and ignited her hair. Resident #1 was transferred to the Burn Center with second and/or third [MEDICAL CONDITION] the left side of the face, forehead, temple, cheek and external ear, requiring skin grafts. Resident #1 returned to the facility on [DATE], but on 01/24/15, was again found with a cigarette provided by Resident A without staff knowledge. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on January 30, 2015 at 12:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on January 19, 2015, the date that Resident #1, who was assessed by the facility to require staff supervision while smoking cigarettes, obtained two (2) cigarettes and gained access to a cigarette lighter without the knowledge of staff, attempted to light the cigarette with the lighter, and caught her hair on fire with the lighter. Resident #1 sustained multiple second/third [MEDICAL CONDITION] the left face, forehead, and ear. The immediate jeopardy continued through February 2, 2015, and was removed on February 3, 2015. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 2, 2015. During a 01/23/2015, 10:00 a.m. interview, the DON acknowledged the 01/19/2015 incident resulting in Resident #1 sustaining burn wounds. An allegation of jeopardy removal was received on February 2, 2015. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 3, 2015. The facility remained out of compliance at a lower scope and severity of D while the process of evaluating modifications of resident assessment systems, care planning systems, and processes involved in the supervision of residents who smoked continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for supervising residents who smoked and who required supervision during smoking. Resident record reviews were conducted to assess facility staffs' conformance with the development of resident Plans of Care regarding smoking supervision. In addition, residents were observed while smoking in the exterior designated smoking area to assess facility staffs' conformance with the supervision of residents while smoking, in accordance with their assessed needs and as specified by their Plans of Care, to therefore ensure resident safety while smoking. Findings include: Resident #1's Admission Minimum Data Set (MDS) assessment of 10/30/14 documented her 10/20/14 admission, and Section I-Active Diagnoses, documented [DIAGNOSES REDACTED]. Section N - Medications documented that Resident #1 received antipsychotic/antidepressant medications. Section M - Skin Conditions documented no current pressure ulcers, but documented a risk of pressure-ulcer development, and Section J - Health Conditions documented Resident #1's tobacco use. Review of Resident #1's Plan Of Care revealed a Problem/Strength dated 11/02/2014 which identified the resident's risk for skin integrity impairment, and identified Interventions which included that the resident required supervised smoking. Resident #1's Plan Of Care also identified as a Problem/Strength dated 11/06/2014 that she had the potential for altered thought processes related to [MEDICAL CONDITION] medication use and her disease process, and identified Interventions which included monitoring for the behavior of obtaining the cigarettes of other residents from the ashtray. Resident #1's Plan of Care did not specify the frequency by which staff were to monitor the resident in relation to her known behavior, as indicated on the Plan of Care, of obtaining the cigarettes of other residents, even though the Plan of Care also documented the resident's requirement for supervised smoking. During a 01/29/2014, 10:45 a.m. interview, Charge Nurse AA acknowledged that Resident #1 was supervised while smoking and stated that the resident's cigarettes and lighter were locked by staff in the medication cart. During a 01/29/2014, 9:50 a.m. interview, the Administrator stated that some residents who required supervision while smoking were not allowed to keep cigarettes and lighters, but that some residents could smoke independently and were allowed to keep cigarettes and lighters. During a 01/23/2015, 12:00 p.m. interview, Residents C and D (whose respective November 2014 and January 2015 MDS assessments documented Brief Interview for Mental Status Scores of 15, indicating both were cognitively intact) stated they had observed Resident #1 smoking unsupervised frequently in the past when Resident A had given Resident #1 cigarettes and a lighter when no staff were present. Residents C and D also stated they had seen staff find Resident #1 while smoking unsupervised. A 10/31/2014 NPN entry documented that Resident #1 was known to try to borrow cigarettes from other residents (as also indicated in the 01/23/2015, 12:00 p.m. interview with Residents C and D referenced above), and an 11/29/2014, 10:30 a.m. NPN entry documented that Resident #1 had been found in possession of cigarette butts. As referenced above, Resident #1's Plan Of Care specified Interventions requiring supervised smoking and that, due to her altered thought process, she would be monitored for her behavior of obtaining cigarettes of other residents. However, despite Resident #1's Plan Of Care specifying supervised smoking and monitoring regarding smoking behaviors, and despite Resident #1's known behavior of obtaining cigarettes from other residents and sometimes smoking unsupervised (per the 01/23/2015, 12:00 p.m. interview with Residents C and D and the 10/31/2014 NPN entry referenced above), review of Resident #1's medical record revealed no evidence of routine monitoring of Resident #1 regarding her behavior of obtaining cigarettes from other residents. A 01/19/2015, 3:15 p.m. NPN entry then documented the nurse was informed of a fire involving Resident #1's hair, and a 01/19/2015, 3:46 p.m. NPN entry documented that Resident #1's physician ordered hospital transfer after being notified of facial/hair burns. A 01/22/2015 investigative report related to this 01/19/2015 incident involving Resident #1 documented that Resident #1 and Resident #9 were in the smoking area when Resident #1 revealed a hand-rolled cigarette and lighter. Resident #1 leaned over to light the cigarette and lit her hair on fire. Resident #9 informed Resident C, and Resident C extinguished the fire by patting Resident #1's head. Resident #1 was transported to the hospital having second/third [MEDICAL CONDITION] the left side of the face, third [MEDICAL CONDITION] the left side of the forehead/temple, and second [MEDICAL CONDITION] the left side of the cheek and external ear. In this report, the facility concluded that Resident A gave the hand-rolled cigarette to Resident #1. Resident A admitted had gave Resident #1 two cigarettes, and stated that Resident #1 knew that he kept lighters on his dresser and that on January 19, 2015, he had noted one of his lighters missing. A 01/23/2014, 9:25 p.m. NPN entry then documented Resident #1's readmission to the facility from the Burn Center, having received left ear, left scalp, and left facial skin grafts. Resident #1's Plan Of Care referenced above specified supervised smoking and monitoring related to the resident's behavior of obtaining cigarettes from other residents, and the facility's January 22, 2015 investigative report referenced above documented that on 01/19/2015, Resident #1 obtained a cigarette and lighter without the knowledge of staff and caught her hair on fire while attempting to light the cigarette. However, record review for Resident #1 revealed no evidence to indicate the facility provided routine monitoring (as specified by the Plan of Care), after Resident #1's 01/23/2014 facility readmission, to ensure supervision regarding Resident #1 smoking unsupervised. A 01/24/2014, 9:30 a.m. NPN entry then documented that staff had again found Resident #1 holding a hand-made cigarette, and that Resident #1 told the nurse she obtained this cigarette from another resident. This NPN entry documented that Resident #1 was instructed by staff to obtain cigarettes and a lighter from a staff member only. However, despite Resident #1 again obtaining a cigarette from another resident (per the 01/24/2015, 9:30 a.m. NPN referenced above), further record review revealed no evidence of routine monitoring for Resident #1 related to her behavior of obtaining cigarettes from other residents, even though the resident's Plan of Care specified monitoring for this behavior of obtaining cigarettes without staff knowledge. The facility's failure to provide monitoring to Resident #1, as specified by the Plan of Care, related to her attempts to obtain smoking materials and smoke without staff knowledge placed Resident #1 at risk for smoking unsupervised and sustaining additional injury. Cross refer to F323, example 1, for more information regarding Resident #1. The facility presented a credible allegation of jeopardy removal (CAJR) on February 2, 2015. Based on the CAJR, it was determined that the immediate jeopardy had been removed on February 3, 2015, at which time the facility had implemented the following interventions: 1. On 01/26/2015, the Quality Assessment and Assurance (QAA) Committee met. During this meeting, the QAA Committee reviewed the facility's current Smoking Policy and discussed revisions to enhance resident safety. Recommendations were made, and the DON was to make edits and submit the revised Policy for review and approval. The specific recommendation that all resident smoking would be monitored was discussed an initiated immediately. Additionally, the Committee discussed offering smoking cessation services to residents desiring such services. 2. On 01/27/2015, the QAA Committee met and the revisions to the Smoking Policy were submitted for review and approval. The QAA Committee meeting focused on the development of a Smoking Monitoring Log, with approval and implementation post meeting. This Smoking Monitoring Log would allow for the staff responsible for monitoring the smoking area (per the newly implemented procedure referenced above specifying that all resident smoking would be monitored) to document attendance and oversight during designated smoking times. The QAA Committee was informed that a smoking cessation instructor would begin services on that date, offering a general orientation to smoking cessation classes. 3. On 01/29/2015, the facility implemented the Smoking Policy, the Purpose of which is to provide guidance regarding resident smoking at the facility. This Smoking Policy includes, but is not limited to, the specification that resident smoking is only permitted under staff supervision. Residents will not be allowed to keep any smoking paraphernalia on their person or with their personal belongings. Residents are required to check smoking paraphernalia out from staff members with entrance to the designated smoking area, and check smoking paraphernalia back in with staff at the time of exit from the designated smoking area. No more than two (2) cigarettes may be distributed to a resident, and any cigarettes not smoked will be collected by staff and returned to the storage area upon reentry into the building. Lighters and matches will be distributed to the resident for that smoking session and collected by staff for storage upon reentry into the building. Smoking paraphernalia will be inventoried following every smoking session to ensure all is accounted for. This inventory will be completed by the staff member assigned to supervise at each scheduled smoking time, and will be documented on the Resident Tobacco and Paraphernalia Log. The sharing of cigarettes and/or lighters and matches amongst residents is not permitted. Smoking is not permitted except within the designated area which is the courtyard/patio area located on the facility's South wing. Resident smoking will be conducted during scheduled times via a Smoking Schedule, and the smoking area will be open for resident access based on the posted schedule. Additionally, the Smoking Policy specifies that residents will be assessed upon admission regarding smoking preferences and any special needs. Residents are then reassessed quarterly and with any change in condition. A Smoking Safety Evaluation Form will be utilized to conduct resident smoking assessments. This Smoking Safety Evaluation will be utilized to assess a resident's smoking history, safety concerns, cognitive awareness, and ability to handle a lighter. This assessment includes the evaluation of each smoking resident's capabilities and deficits and determines whether or not supervision during smoking is required. Based on the data collected in the smoking assessment, a specific plan will be developed to meet the individual needs of the resident. The information in the assessment is included in the resident's Plan of Care, which is reviewed and revised accordingly. 4. On 01/29/2015, the facility implemented the use of a new Safety Surveillance Log to be utilized in the event of resident non-compliance with the Smoking Policy. This new procedure indicated that, in the event a resident is observed in possession of tobacco and/or paraphernalia (other than at the approved times and in conformance with approved procedures), the facility would implement surveillance to ensure compliance. Said surveillance will be documented in the Safety Surveillance Log. At the time of discovery of an infraction, items will be inventoried for the resident. The Safety Surveillance Log will be completed as supervised by the designated Charge Nurse. The surveillance frequency will be a minimum of twice per day, and include a random search for a seven-day period. With zero findings for the seven-day period, the surveillance would transition to three times per week for 30 days. A reassessment will be conducted post the 30 day mark for the necessity of ongoing surveillance. In addition, an attempt will be made to identify the source of provision of products with subsequent counseling to follow. All findings and recommendations will be submitted to, and monitored by, the QAA Committee. 5. On 01/29/2015, a special called Resident Council meeting was held to discuss the changes to the Smoking Policy. All resident smokers were in attendance. 6. On 01/29/2015, all residents utilizing tobacco products were assessed by the DON using the new Smoking Safety Evaluation Form. One-hundred percent of all current residents who smoke (a total of fourteen residents on the date of assessment) were assessed with [REDACTED]. 7. On 01/29/2015, the facility reviewed/revised the Plans of Care for all residents using tobacco products, and Plans of Care for these residents were developed/updated with the goals of no injury when using tobacco products, safety practices, and encouraging smoking cessation. 8. On 01/29/2015, the facility reiterated a procedure requiring that the facility's Interdisciplinary Care Team reassess each resident who smoked on a quarterly basis, or more frequently if needed, to determine if any change in smoking abilities has occurred. All resident Plans of Care will be updated to reflect this assessment. 9. On 01/30/2015, a one-on-one sitter was assigned to Resident #1 to provide supervision to the resident. Resident #1 will have a sitter twenty-four hours per day, seven days per week to ensure her safety, and this coverage will continue until a later determination is made. 10. On 02/02/2015, the facility implemented the use of fire blankets (which were originally ordered by the facility on 01/30/2015). These fire blankets will be housed in the smoking area and will be used to aid in ensuring resident safety during smoking. 11. On 02/02/2015, the facility implemented enforcement of the Policy by which all smoking tobacco products and paraphernalia were removed from resident possession. Going forward, per the new Policy referenced above, smoking tobacco products and paraphernalia will be provided to residents upon request in the designated smoking area. When the resident reenters the facility after smoking activities have concluded, any smoking tobacco product that has not been consumed, as well as any smoking paraphernalia, will be returned to facility staff and inventoried. 12. On 02/02/2015, the facility conducted staff in-service training regarding the new Smoking Policy and the new procedures involving the supervision of residents who smoke, the new smoking schedule, the monitoring process for potential resident noncompliance, and resident safety while smoking by the use of fire blankets. This staff in-service training also included staff training related to the smoking assessment process. As of 02/02/2015, the following facility staff had received this in-service training: eighteen (18) of eighteen (18) housekeeping staff; fourteen (14) of fourteen (14) food service staff; three (3) of three (3) activities staff; forty (40) of forty (40) certified nursing assistants; and twenty-two (22) of twenty-three (23) licensed nursing staff. One (1) licensed nursing staff member was unavailable to receive this training due to being on leave status. This one (1) remaining licensed nursing staff member will receive this in-service training upon her return to work. 13. On 02/02/2015, the facility implemented the Smoking Policy Compliance Audit to audit the facility's new smoking program to monitor for evidence of ongoing staff compliance. This Audit will serve the purpose of monitoring and assessing staff compliance with the routine completion of the resident Smoking Safety Evaluation assessments, execution and maintenance of resident Plans of Care, the completion of the routine staff inventory of tobacco products and paraphernalia, and completion of the Smoking Surveillance Log (utilized as needed to address identified resident noncompliance with the Smoking Policy). This Smoking Policy Compliance Audit will be conducted by the DON, Assistant Director of Nursing, designated Registered Nurse Supervisor, Administrator, Assistant Administrator, or MDS Coordinator. This Audit will be conducted on every resident who smokes beginning on 02/02/2015, and will be conducted with the following progression: Weekly from 02/02/2015 through 02/28/2015; Biweekly from 03/01/2015 through 04/05/2015; Monthly on 04/06/2015, and ongoing. Any findings and subsequent interventions for ongoing compliance with facility Policy will be discussed with the QAA Committee. The data collected during the Smoking Policy Compliance Audit will be reported monthly to the QAA Committee for the Committee's review and evaluation. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the facility's QAA Committee had convened to review the facility's Smoking Policy, discuss Policy revisions, and instruct the DON to make specified Policy changes. This was in accordance with Step #1 of the CAJR referenced above. - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the QAA Committee met for review and approval of the revisions to the Smoking Policy. This included the development and implementation of the Smoking Monitoring Log to be used by staff to ensure attendance and oversight during resident designated smoking times. This was in accordance with Step #2 of the CAJR referenced above. - On 02/03/2015, DON interview and Policy review confirmed that the facility had implemented a new, revised Smoking Policy with specifications which included the restriction of resident smoking to scheduled smoking times and under direct staff supervision only, the restriction of residents' possession of smoking paraphernalia in the absence of staff supervision. This Smoking Policy also specified a procedure involving residents obtaining smoking paraphernalia from staff when entering the smoking area and returning smoking paraphernalia to staff upon exiting the smoking area. This was in accordance with Step #3 of the CAJR referenced above. - On 02/03/2015, document review, Policy review, and interview with the DON confirmed that the facility had implemented the Safety Surveillance Log to be utilized in the event of resident noncompliance with the Smoking Policy (and to be used on an as-needed basis). This new Safety Surveillance Log and the accompanying procedure would allow staff to implement surveillance, via inspections at specified intervals for specified timeframes, to ensure resident compliance with the facility's Smoking Policy. This was in accordance with Step #4 of the CAJR referenced above. - On 02/03/2015, review of meeting minutes confirmed that the facility had met with the Resident Council to discuss the changes to the Smoking Policy, with all smokers in attendance, in accordance with Step #5 of the CAJR referenced above. - On 02/03/2015, and ongoing throughout the abbreviated survey, it was confirmed via record review that all facility residents who used tobacco products were assessed via the new Smoking Safety Evaluation Form. This was in conformance with Step #6 of the CAJR referenced above. - On 02/03/2015, and ongoing throughout the abbreviated survey, it was confirmed via record review that the facility had reviewed the Plans of Care for all residents using tobacco products, with Plan of Care additions and revisions made as needed. This was in accordance with Step #7 of the CAJR referenced above. - On 02/03/2015, Policy review confirmed the facility procedure which specified that the Interdisciplinary Care Team reassess residents who smoke on a quarterly basis, and more frequently if needed, regarding evaluation for changes in smoking abilities. Accompanying Plan of Care updates will be made. This was in accordance with Step #8 of the CAJR referenced above. - On 02/03/2015, review of the One on One Sitter Safety Log confirmed that a one-on-one sitter had been assigned to Resident #1 to supervise to the resident twenty-four hours per day seven days per week, in conformance with Step #9 of the facility's CAJR referenced above. - On 02/03/2015, observation and in-service record review confirmed that the facility had implemented the use of fire blankets to help ensure resident safety during smoking, as indicated in Step #10 of the CAJR referenced above. - On 02/03/2015, resident observations and review of inventory logs confirmed that the facility had removed all smoking tobacco products and paraphernalia from resident possession, and that smoking tobacco products and paraphernalia will be provided to residents by staff upon request in the designated smoking area. This was in accordance with Step #11 of the CAJR referenced above. - On 02/03/2015, review of facility in-service training records confirmed that staff in-service training had been provided to licensed nursing staff, certified nursing assistants, laundry staff, housekeeping staff, food service staff, and activities services staff regarding the facility's new procedures for the supervision of residents who smoke, the smoking schedule, and the monitoring process for resident noncompliance. This was in accordance with Step #12 of the CAJR referenced above. - On 02/03/2015, Policy review, monitoring log review, and DON interview confirmed that the facility had implemented, per the specified schedule, the Smoking Policy Compliance Audit to monitor staff compliance with the completion of Smoking Safety Evaluation assessments and Plans of Care, as well as completion of the staff tobacco products and paraphernalia inventory and Smoking Surveillance Log. This was in accordance with Step #13 of the CAJR referenced above. Based on these corrective actions which had been developed and implemented by the facility on 02/02/2015 as outlined in the facility's CAJR referenced above, and based on the State Survey Agency's review of these CAJR corrective actions to confirm implementation, it was determined that the immediacy of the deficient practice was removed on 02/03/2015. The effectiveness of the corrective action plans, however, could not be fully assessed at the time of survey exit to ensure ongoing application and completion, as outlined below: The facility developed and implemented a new Smoking Policy which, in part, limited resident smoking activities to scheduled times and only under the direct supervision of staff. Residents would no longer be allowed to keep smoking paraphernalia on their person or with their personal belongings. Rather, residents would be required to obtain smoking paraphernalia from staff when entering the outside designated smoking area to smoke, and then return all smoking paraphernalia to staff at the time of reentry into the building from the designated smoking area. Smoking paraphernalia would be inventoried by staff following every smoking session to ensure all was accounted for. On 02/02/2015, the facility implemented enforcement of the Policy by which all smoking tobacco products and paraphernalia were removed from residents' possession, and would instead be obtained directly from staff at the beginning of scheduled smoking times and returned to staff and inventoried at the conclusion of scheduled smoking times. However, the 02/02/2015 implementation date of this new Policy and procedure was on 02/02/2015, the day before the 02/03/2015 exit date of this abbreviated survey. Therefore, the facility's ongoing compliance with this process involving the restriction of resident tobacco product access and scheduled staff inventories to provide accountability of tobacco products and paraphernalia could not be fully assessed at the time of survey exit and will need further evaluation at a future time. Additionally, on 02/02/2015, the facility implemented the Smoking Policy Compliance Audit to be conducted by the DON, Assistant Director of Nursing, designated Registered Nurse Supervisor, Administrator, Assistant Administrator, or MDS Coordinator. This Audit would serve to provide management-level oversight of staff compliance with Smoking Safety Evaluation assessment completion, Plans of Care review and revision, tobacco products/paraphernalia inventory procedures, and completion of the Smoking Surveillance Log (when indicated). This management-level Audit would be conducted for every resident who smokes and would be completed weekly through 02/28/2015, then biweekly from 03/01/2015 through 04/05/2015, then monthly thereafter. However, this Smoking Policy Compliance Audit involving management-level oversight of facility staffs' compliance with the Smoking Policy and procedures was implemented on 02/02/2015, the day prior to the 02/03/2015 exit date of this abbreviated survey. Therefore, ongoing compliance with this management-level Audit procedure could not be fully assessed at the time of survey exit and will need further evaluation at a future time. Based on the above, due to the need for continued evaluation of the facility's corrective action plans to ensure ongoing effectiveness, application, and completion, the noncompliance continues, with the Scope and Severity reduced to the D level.