Every finding on record at St Jude's Health & Wellness Center

Based on observations, interviews and record reviews, the facility failed to deliver care per professional standards by failing to ensure a resident's medication order was clarified by the physician for 1 (Resident #R7) of 3 sampled residents investigated for pharmacy services. Findings:Review of the February 2026 Louisiana Administrative Code, Title 46, Part XLVII S3915. Standard Number 7: Professional Performance revealed, in part, the Registered Nurse (RN) demonstrates the following professional nursing practice behaviors. The RN clarifies any order or treatment regimen believed to be inaccurate, or contraindicated by consulting with the appropriate licensed practitioner and by notifying the ordering practitioner when the registered nurse makes the decisions not to administer the medication or treatment. Review of the facility's RN job description revealed, in part, the RN was responsible for providing and supervising quality nursing care to residents in accordance with facility policies, state and federal regulations, and accepted nursing standards. Further review revealed RNs should lead and supervise Licensed Practical Nurses (LPN) to ensure high quality care. Review of Resident #R7's admission documentation revealed, in part, Resident #R7 was discharged from a rehabilitation hospital and admitted to the facility on [DATE]. Further review revealed Resident #R7's medications included 50 milligrams (mg) of allopurinol (a medication used to treat high levels of uric acid). Review of Resident #R7's hospital discharge report, dated 05/06/2026, revealed, in part, Resident #R7 was discharged from an acute care hospital and returned back to the facility on [DATE]. Further review revealed Resident #R7's list of medications to continue did not include allopurinol. Review of Resident #R7's June 2026 physician's orders revealed, in part, an order with a start date of 03/06/2026 for Resident #R7 to be administered one oral tablet of allopurinol one time a day. Further review revealed Resident R7's physician order did not include the dosage of the allopurinol. Review of Resident #R7's April 2026 through June 2026 Electronic Medication Administration Record (eMAR) revealed, in part, no dosage for Resident #R7's allopurinol order. Further review revealed nursing staff administered one tablet of allopurinol daily to Resident #R7 from 04/01/2026 through 06/24/2026 while she was at the facility. The facility could not provide any documented evidence Resident #R7's 03/05/2026 physician's order for one tablet of allopurinol with no dosage was clarified to ensure Resident #R7 received the correct dosage of medication. Observation on 06/24/2026 at 9:00AM revealed Resident #R7's medication blister pack of allopurinol indicated the dosage was 100 mg of the medication. Further observation revealed S9LPN administered Resident #R7 100 mg of allopurinol by mouth. In an interview on 06/24/2026 at 9:15AM, S9LPN indicated she administered 100 mg of allopurinol to Resident #R7. S9LPN further indicated she was unable to verify that 100 mg was the correct dosage to administer to Resident #R7 because there was no dosage listed on Resident #R7's allopurinol medication order and should have been. S9LPN further indicated she should have clarified with Resident #R7's physician what the dose of allopurinol should have been. In a telephone interview on 06/24/2026 at 1:02PM, Resident #R7's primary care physician indicated he was unaware Resident #R7's medication order for allopurinol did not include the dosage. Resident #R7's primary care physician indicated he was also unaware of the daily allopurinol dosage Resident #R7 had received since her 03/05/2026 readmission. Resident #R7's primary care physician further indicated he had not been contacted by anyone at the facility to clarify Resident #R7's medication order for allopurinol. In an interview on 06/24/2026 at 1:47PM, S2Director of Nursing (DON) confirmed Resident #R7's 03/05/2026 physician's order for allopurinol should have included a dosage. S2DON further confirmed nursing staff should not have administered Resident #R7's allopurinol medication from 04/01/2026 through 06/24/2026 without first clarifying the incomplete order with Resident #R7's physician.

Based on interviews and record reviews, the facility failed to ensure a resident's responsible party (RP) was invited to, attended, and/or participated in a care plan meeting for 1 (Resident #2) of 3 sampled residents reviewed for care planning requirements. Findings:Review of the facility's Care Plan policy and procedure, with a revision date of 04/22/2009, revealed, in part, the resident's RP should be invited to attend the plan of care conference at least one week in advance of the tentatively scheduled date. Further review revealed the interdisciplinary team would meet with the resident and the resident's RP to develop quantifiable objectives for the highest level of functioning the resident may be expected to attain. Review of Resident #2's medical record revealed, in part, Resident #2 was admitted to the facility on [DATE] with a diagnosis, in part, of vascular dementia. Review of Resident #2's admission packet, dated 04/16/2026, revealed, in part, Resident #2 was incapable of making medical decisions. Further review revealed Resident #2's sister was identified as Resident #2's RP. Review of Resident #2's admission Minimum Data Set with an Assessment Reference Date of 05/04/2026 revealed, in part, Resident #2 had a Brief Interview for Mental Status score of 4, which indicated Resident #2 was severely cognitively impaired. Review of Resident #2's initial care plan, with a start date of 04/22/2026, revealed, in part, Resident #2 had impaired cognitive function and/or impaired thought processes related to dementia, with an approach of communicating with Resident #2's caregivers regarding Resident #2's capabilities and needs. Review of Resident #2's care plan conference notes, dated 04/29/2026, revealed, in part, Resident #2's RP did not attend Resident #2's care plan conference in person or by telephone. Review of the facility's care conference planning form, dated 04/29/2026, revealed, in part, Resident #2's RP was not identified as needing to be present and/or contacted for Resident #2's care plan conference. In an interview on 06/23/2026 at 11:20AM, Resident #2's RP indicated she was unaware Resident #2 had a care plan conference on 04/29/2026. Resident #2's RP further indicated she would have attended the care plan conference if she had been notified to discuss Resident #2's physical therapy concerns. In an interview on 06/23/2026 at 11:30AM, S7Therapy Director (TD) indicated she was unaware Resident #2's RP wanted Resident #2 to start physical therapy until S7TD was notified by the ombudsman. In an interview on 06/24/2026 at 10:02AM, S4Social Services Manager (SSM) indicated she was unaware Resident #2's sister was his RP. S4SSM further indicated Resident #2's RP should have been notified and allowed to attend Resident #2's care plan conference on 04/29/2026. In an interview on 06/24/2026 at 1:47PM, S2Director of Nursing (DON) indicated Resident #2's RP should have been notified and allowed to attend Resident #2's care plan conference on 04/29/2026. In an interview on 06/24/2026 at 2:15PM, S1Administrator confirmed Resident #2's RP should have been identified as needing to attend Resident #2's care plan conference on 04/29/2026.

Based on observations and interviews, the facility failed to post the names, addresses, and telephone numbers of all pertinent state agencies and/or advocacy groups, and/or a statement as to how a resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements and requests for information regarding returning to the community. Findings:Observation of all the facility's resident common areas on 06/22/2026 at 10:30AM, revealed no postings of the names, addresses and telephone numbers of all pertinent state agencies and advocacy groups, and/or no postings regarding the process as to how and/or when a resident may file a complaint with the State Survey Agency. Observation of all the facility's resident common areas on 06/24/2026 at 1:15PM, revealed no postings of the names, addresses and telephone numbers of all pertinent state agencies and/or advocacy groups, and/or no postings regarding the process as to how and/or when a resident may file a complaint with the State Survey Agency. Review of Resident #1's quarterly Minimum Data Set with an Assessment Reference Date of 05/20/2026 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 15, which indicated Resident #1 was cognitively intact. In an interview on 06/23/2026 at 9:15AM, Resident #1 indicated the facility did not have the above mentioned postings in a prominent location for all residents and families to view. In an interview on 06/23/2026 at 11:20AM, Resident #2's responsible party (RP) indicated the facility did not have the above mentioned postings in a location and/or format that made the information accessible. In an interview on 06/23/2026 at 2:30PM, S3Activities Director indicated the facility did not have the above mentioned postings as required. In an interview on 06/24/2026 at 2:00PM, S4Social Services Manager indicated the facility did not have the above mentioned postings as required. In an interview on 06/24/2026 at 2:15PM, S1Administrator confirmed there were no postings of the names, addresses and telephone numbers of all pertinent state agencies and/or advocacy groups, and/or no postings regarding the process as to how and/or when a resident may file a complaint with the State Survey Agency. S1Administrator further indicated she was unaware that information was required to be posted.

Based on observations and interviews, the facility failed ensure a notice that the availability of all reports related to all annual and complaint surveys from the past 3 years and any plans of corrections (POC) in effect were available for review upon request was posted in a prominent and accessible area. Findings:Observation on 06/22/2026 at 10:30AM of the facility's common areas revealed no notices posted that any reports related to all annual and complaint surveys from the past 3 years and any POC in effect were available for review upon request. Review of Resident #1's quarterly Minimum Data Set with an Assessment Reference Date of 05/20/2026 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 15, which indicated Resident #1 was cognitively intact. In an interview on 06/23/2026 at 9:15AM, Resident #1 indicated the facility did not have the above mentioned notice posted in a prominent location for all residents and families to view. In an interview on 06/23/2026 at 11:20AM, Resident #2's responsible party (RP) indicated the facility did not have the above mentioned notice posted in a location that made the information readily accessible to residents and families. In an interview on 06/23/2026 at 2:30PM, S3Activities Director indicated the facility did not have the above mentioned notice posted as required. Observation on 06/24/2026 at 1:15PM of the facility's common areas revealed no notices posted that any reports related to all annual and complaint surveys from the past 3 years and any POC in effect were available for review upon request. In an interview on 06/24/2026 at 2:00PM, S4Social Services Manager indicated the facility did not have the above mentioned notice posted as required. In an interview on 06/24/2026 at 2:15PM, S1Administrator confirmed there was no notices posted that any reports related to all annual and complaint surveys from the past 3 years and any POC in effect were available for review upon request. S1Administrator further indicated she was unaware that information was required to be posted.

Based on observations, interviews, and record reviews, the facility failed to ensure insulin (a medication that lowers blood glucose) multi-dose flex pens were dated when opened and/or removed from refrigerated storage or discarded as required for 1 (Medication Cart a) of 3 sampled medication carts observed for medication storage requirements. Findings:Review of the facility's Insulin policy and procedure, with a revision date of [DATE], revealed, in part, insulin must be refrigerated until needed, and open insulin must be dated the day it is opened. Further review revealed the life span for insulin is only 28 days from the time it is opened. Further review revealed after 28 days, the unused portion must be discarded. Review of the facility's undated Liberalized Medication policy and procedure revealed, in part, when opening a multi dose container, the date opened is recorded on the container. Observation on [DATE] at 7:55AM of Medication Cart a revealed the following:-Resident #3's opened insulin Novolog (a fast-acting insulin medication) multi-dose flex pen had an opened date of [DATE] documented; -Resident #R4's opened insulin Novolog multi-dose flex pen did not have an opened date documented;-Resident #R5's opened insulin Lantus multi-dose flex pen did not have an opened date documented; and,-Resident #R6's opened insulin Lispro (a fast-acting insulin medication) multi-dose flex pen had an opened date of [DATE] documented. In an interview on [DATE] at 7:55AM, S10Licensed Practical Nurse (LPN) indicated Resident #3's and Resident #R6's opened insulin pens should not have been stored at room temperature, expired, and/or available for use. S10LPN further indicated Resident #R4's and Resident #R5's insulin pens were opened and undated, and should not have been available for use. In an interview on [DATE] at 1:47PM, S2Director of Nursing confirmed the above mentioned insulin multi-dose flex pens should have been dated when opened and discarded 28 days after opening as required.

Based on interviews and record reviews, the facility failed to ensure a resident's medication administration and order completion were accurately documented for 1 (Resident #2) of 3 sampled residents investigated for accurate medical record documentation. Findings:Review of the facility's undated Liberalized Medication policy and procedure revealed, in part, the individual administering the medication should document the administration in the electronic Medication Administration Record (eMAR) after giving each medication. Review of the facility's undated Director of Nursing (DON) job description revealed, in part, responsibilities included monitoring clinical documentation for accuracy, completeness, and regulatory compliance. On 06/24/2026 at 11:00AM, S2DON was presented with a request for all 06/19/2026 medication administration records and progress notes for Resident #2. Review of Resident #2's medical record revealed, in part, Resident #2 was admitted to the facility on [DATE] with diagnoses which included, in part, vascular dementia, type 2 diabetes, and Benign Prostatic Hyperplasia (BPH) (a non-cancerous enlargement of the prostate). Review of Resident #2's admission Minimum Data Set with an Assessment Reference Date of 05/04/2026 revealed, in part, Resident #2 had a Brief Interview for Mental Status score of 4, which indicated Resident #2 was severely cognitively impaired. Review of Resident #2's June's 2026 physician's orders revealed, in part, an order for the following:- Atorvastatin (a medication used to treat excess fat in the blood) one 80 milligram (mg) oral tablet by mouth at bedtime;- Donepezil hydrochloride (HCl) (a medication used to treat dementia) one 5 mg oral tablet by mouth at bedtime;- Ezetimibe (a medication used to lower bad cholesterol levels) one 10 mg oral tablet by mouth at bedtime;- Lantus Insulin (a medication used to lower blood glucose levels) 100 units/milliliter (mL) inject 20 units subcutaneously at bedtime;- Tamsulosin HCl (a medication used to treat BPH) one 0.4 mg oral capsule by mouth at bedtime;- Colostomy care and assess stoma site for changes every shift; and,- Blood glucose monitoring at bedtime, call medical doctor if blood sugar is less than 60 or greater than 500. Review of Resident #2's June 2026 eMAR revealed, in part, no documented evidence Resident #2 was administered the following medications on 06/19/2026 at 9:00PM as ordered:- Atorvastatin one 80 mg oral tablet;- Donepezil HCl one 5 mg oral tablet;- Ezetimibe one 10 mg oral tablet;- Lantus Insulin 20 units injected subcutaneously; and,- Tamsulosin HCl one 0.4 mg oral capsule. Further review revealed no documented evidence Resident #9's capillary blood glucose was checked and/or Resident #2's colostomy care was completed on 06/19/2026 at 9:00PM as ordered. Further review revealed S8Registered Nurse (RN) documented other/see progress notes for Resident #2's above mentioned orders on 06/19/2026 at 9:00PM. In an interview on 06/23/2026 at 11:20AM, Resident #2's responsible party (RP) indicated she did not administer Resident #2 any medication during his leave from the facility on 06/19/2026. In an interview on 06/23/2026 at 3:48PM, S8RN indicated upon Resident #2's return to the facility on [DATE], between 8:30PM and 9:00PM, S8RN had administered Resident #2 his above mentioned medication, assessed his blood glucose, and performed colostomy care on Resident #2. S8RN further confirmed she did not document any of the previous mentioned interventions. In an interview on 06/24/2026 at 1:47PM, S2DON confirmed Resident #2's June 2026 eMAR documentation was not completed, and should have been as required. In an interview on 06/24/2026 at 2:15PM, S1Administrator indicated the facility could not provide any documented evidence to dispute the above mentioned deficient practice.

Based on interviews and record reviews, the facility failed to protect the resident's right to be free from physical and verbal abuse by a staff member for 1 (Resident #1) of 3 sampled residents investigated for abuse.The deficient practice resulted in an immediate jeopardy situation for Resident #1 on 02/17/2026 at approximately 4:00PM, when S4Licensed Practical Nurse (LPN) physically and verbally abused Resident #1 by hitting him repeatedly on his face, head, and shoulders with a closed fist, by putting her knee on Resident #1's neck, by grasping Resident #1's shirt and attempting to drag Resident #1 across the floor, and by yelling at Resident #1, b***h, don't hit me and b***h, I'm tired of you. The immediate jeopardy situation continued on 02/17/2026 when S4LPN stated to S5Certified Nursing Assistant (CNA) and S6CNA, in front of Resident #1, leave that b***h on the floor, don't help him up. The above mentioned physical and verbal abuse was witnessed by S5CNA, S6CNA, and Resident #2. The immediate jeopardy situation remained present on 02/17/2025 when S5CNA and S6CNA left Floor b for approximately 8 minutes, leaving Resident #1 and the other 20 residents alone on Floor b with S4LPN. The immediate jeopardy situation was ongoing on 02/17/2026 at approximately 5:00PM, when S4LPN instructed S5CNA, in front of Resident #1, to leave that b***h, in his chair. The immediate jeopardy situation remained unresolved on 02/17/2025 at approximately 5:00PM when S5CNA left S4LPN unmonitored and with access to all 21 residents that resided on Floor b while she went in and out of the rooms on Floor b to complete her rounds. The immediate jeopardy situation remained present until 02/17/2025 at 11:20PM when S4LPN clocked out from the facility.The facility implemented corrective actions which were completed prior to the state agency's investigation, thus it was determined to be a past noncompliance citation.Findings:Review of the facility's undated Abuse Recognition, Reporting, and Investigation policy revealed, in part, the facility would not permit residents to be subjected to abuse by anyone, including staff members. Further review revealed physical abuse was defined as hitting, slapping, pinching, and controlling behavior through corporal punishment. Further review revealed verbal abuse was defined as any use of oral or gestured language that included disparaging and derogatory terms to residents, or within their hearing distance, regardless of their ability to comprehend.Review of the facility's Abuse Prevention policy last revised on 06/17/2002 revealed, in part, any employee who had been identified in a report of alleged abuse would have been immediately suspended from work during the investigation.Review of the facility's Abuse Reporting and Investigation policy, last revised on 04/22/2009 revealed, in part, the facility would not permit residents to be subjected to abuse by anyone, including staff members. Review of the facility's investigative documentation for the above mentioned physical and verbal abuse allegations revealed, in part, the facility reported an incident of physical and verbal abuse of a resident to the state agency on 02/18/2026 at 11:08AM. Further review revealed, on 02/17/2026, S4Licensed Practical Nurse (LPN) physically and verbally abused Resident #1 by hitting him repeatedly on his face, head, and shoulders with a closed fist, by putting her knee on Resident #1's neck, by grasping Resident #1's shirt and attempting to drag Resident #1 across the floor, and by, and yelling at Resident #1, b***h, don't hit me and b***h, I'm tired of you. Further reviewed revealed S4LPN continued to verbally abuse Resident #1 by stating to S5Certified Nursing Assistant (CNA) and S6CNA, in front of Resident #1, leave that b***h on the floor, don't help him up. S4LPN continued to verbally abuse Resident #1 on 02/17/2026 when S4LPN instructed S5CNA, in front of Resident #1, to leave that b***h, in his chair. Further review revealed S1Administrator had investigated the above mentioned allegations of abuse and had substantiated S4LPN physically and verbally abused Resident #1.Review of Resident #2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/24/2025, revealed, in part, Resident #2 had a Brief Interview for Mental Status Score of 15, which indicated Resident #2 was cognitively intact.In an interview on 03/02/2026 at 9:35AM, Resident #2 indicated she witnessed the above mentioned incident between Resident #1 and S4LPN on 02/17/2026. Resident #2 further indicated she had witnessed S4LPN hit Resident #1 on 02/17/2026.In an interview on 03/02/2026 at 9:37AM, S5CNA indicated she witnessed the above mentioned incident of physical and verbal abuse of Resident #1 by S4LPN. S5CNA further indicated when she (S5CNA) and S6CNA got off the elevator on Floor b, she witnessed S4LPN and Resident #1 on the floor. S5CNA also indicated she went up to Resident #1 and S4LPN on the floor and got Resident #1 to let go of S4LPN and give her his hands. S5CNA further indicated after Resident #1 let go of S4LPN, S4LPN got up, as if she would have been walking away, turned around, and put her knee on Resident #1's neck to pin him down. S5CNA indicated S4LPN then began to hit Resident #1 multiple times in his arms, face, and chin area. S5CNA further indicated while S4LPN was hitting Resident #1, S4LPN was yelling b***h, don't hit me and b***h, don't touch me. S5CNA indicated she did not know what to do regarding the above mentioned physical and verbal abuse because she had heard about elder abuse before, but she was in shock and just stood against the wall. S5CNA further indicated she attempted to get Resident #1 up off of the floor, and S4LPN told her, in front of Resident #1, to leave that b***h on the floor. S5CNA also indicated on 02/17/2026, at approximately 5:00PM, she (S5CNA) was going to make rounds and S4LPN instructed her to leave that b***h, in his chair in front of Resident #1. S5CNA further indicated, because she had to complete her 5:00PM rounds to provide care to the other residents that resided on Floor b, she left Resident #1 alone while S4LPN was still working on Floor b. S5CNA further indicated since the incident, she had been re-trained on the facility's abuse reporting procedures and knew where to locate the phone numbers for the facility's administrative staff.Review of Resident #1's quarterly MDS with an ARD of 11/24/2025 revealed, in part, Resident #1 had a BIMS of 12, which indicated Resident #1 was moderately cognitively intact. In an interview on 03/02/2026 at 9:47PM, Resident #1 indicated S4LPN previously hit him.In an interview on 03/02/2025 at 9:55AM, S12CNA indicated if abuse was witnessed, it should have been reported to the facility's Administrator immediately.In an interview on 03/02/3036 at 9:58AM, S9CNA indicated if she witnessed any resident abuse, she would report it to a nurse. S9CNA further indicated if it was a nurse that had committed resident abuse, she would report it to the administrative team. S9CNA further indicated any resident abuse that was witnessed should have been reported as soon as possible.In an interview on 03/02/2026 at 10:01AM, S10Housekeeper indicated she would report abuse to the nurse or the charge nurse immediately. Further, she was knowledgeable of the telephone numbers for S1Administrator and S2Director of Nursing (DON) located at the facility's front desk. In an interview on 03/02/2026 at 10:04AM, S7CNA indicated she had both S2DON and S1Administrator's telephone numbers to report abuse immediately.In an interview on 03/02/2026 at 11:44AM, S1Administrator indicated on 02/18/2026, S5CNA reported the above mentioned physical and verbal abuse of Resident #1 by S4LPN to him. S1Administrator further indicated S5CNA and S6CNA should not have left S4LPN alone with the residents on Floor b after she had committed the above mentioned physical and verbal abuse.In a telephone interview on 03/03/2025 at 8:50AM, S11CNA indicated if he had witnessed abuse, he would tell the nurse immediately. S11CNA further indicated, if it was the nurse that had committed the abuse, he would then tell her supervisor. S11CNA further indicated that he was re-trained on reporting witnessed abuse. In a phone interview on 03/03/2026 at 9:00AM, S13Dietary Staff indicated if she witnessed a staff member committing abuse against a resident, she would report it to the facility's Administrator.In an interview on 03/03/2026 at 9:12AM, S6CNA indicated on 02/17/2026, she saw S4LPN and Resident #1 on the floor. S6CNA further indicated S4LPN was hitting Resident #1 and yelling at Resident #1 b***h I'm tired of you and b***h get off of me. S6CNA further indicated S4LPN then walked off from Resident #1, came back, and tried to drag Resident #1 by his shirt on the floor. S6CNA further indicated S4LPN then got down onto the floor next to Resident #1 and put her knee on Resident #1's neck. S6CNA then indicated, it appeared as if Resident #1 could not breathe with S4LPN kneeling on his neck, so she (S6CNA) and S5CNA pulled S4LPN off of Resident #1. S6CNA further indicated S4LPN then walked off, came back, and again tried to drag Resident #1 by his shirt on the floor. S6CNA indicated S4LPN then told them (S6CNA and S5CNA) to leave that b***h on the floor, don't help him up. S6CNA further indicated both she (S6CNA) and S5CNA left Floor b for approximately 8 minutes to find assistance to get Resident #1 up off of the floor. S6CNA further indicated S4LPN was alone with Resident #1 and the other 20 residents that resided on Floor b during the above 8 minutes they (S6CNA and S5CNA) were not present on Floor b. S6CNA also indicated S4LPN should not have been left alone with the residents on Floor b. S6CNA further indicated, at the time of the incident, she did not know who to report resident abuse to, but after retraining, she now had the telephone numbers of both S2DON and S1Administrator to report abuse immediately.In an interview on 03/03/2026 at 9:56AM, S2DON acknowledged S4LPN should have been separated from Resident #1 and the other residents, in order to keep Resident #1 and the other residents on Floor b safe from S4LPN after the above mentioned incident of physical and verbal abuse occurred.In a telephone interview on 03/04/2026 at 1:02PM, S5CNA indicated on 02/17/2026 from approximately 5:00PM to 6:00PM, she only periodically visualized Resident #1 and S4LPN while completing her rounds on Floor b, and was not constantly monitoring them.In an interview on 03/02/2026 at 1:35PM, S2DON indicated S5CNA and S6CNA should not have left S4LPN alone with the residents on Floor b after they had witnessed the above mentioned physical and verbal abuse. S2DON further indicated the physical and verbal abuse of Resident #1 by S4LPN should not have occurred.In an interview on 03/04/2026 at 8:50AM, S14LPN indicated she would report abuse immediately to S1Administrator.In an interview on 03/05/2026 at 9:41AM, S1Administrator acknowledged Resident #1 should not have been physically and verbally abused by S4LPN on 02/17/2026 at approximately 4:00PM. S1Administrator further acknowledged the continued verbal abuse of Resident #1 by S4LPN that occurred on 02/17/2026 at approximately 5:00PM should have been prevented.Beginning on 02/18/2026, the facility implemented the following actions to correct the deficient practice:1. On 02/18/2026, S1Administrator verbally in-serviced S5CNA and S6CNA on immediately reporting abuse to S1Administrator.2. On 02/18/2026, S1Administrator started an investigation into the allegation of physical and verbal abuse of Resident #1 by S4LPN and requested S5CNA and S6CNA give written statements of the abuse they had witnessed.3. On 02/18/2026, S1Administrator immediately suspended S4LPN from working with residents and requested she give a written statement. S4LPN's last day working with residents was 02/17/2026.4. On 02/18/2026 at 11:00AM, S1Administrator had staff perform an assessment of Resident #1 for any injuries and/or pain. The assessment revealed Resident #1 had no injuries and no pain. Resident #1 refused to be transferred to the local emergency room for evaluation.5. On 02/18/2026 at 11:08AM, S1Administrator entered a report regarding the above mentioned physical and verbal abuse in the State Incident Management System (SIMS).6. On 02/18/2026, Resident #1's medical provider conducted a psychological evaluation on Resident #1.7. On 02/18/2026, S1Administrator had staff do an audit of the 20 other residents that resided on Floor b to determine if they have suffered any abuse. All 20 residents denied experiencing abuse.8. On 02/18/2026, S1Administrator obtained a witness statement from Resident #2. 9. On 02/18/2026, S2DON and S8Director of Education started retraining staff to immediately report any abuse to S1Administrator. S2DON and S8Director of Education had retrained a majority of the staff on abuse reporting procedures on 02/18/2026 and a majority of staff when interviewed, were aware of the when to report abuse.10. On 02/18/2026 at 1:30PM, S1Administrator reported the above mentioned physical and verbal abuse to the local police department.11. On 02/24/2026, S1Administrator reported S4LPN's physical and verbal abuse of Resident #1 to the Louisiana State Board of Practical Nurse Examiners. S4LPN's Practical Nursing License was suspended on 02/25/2026.The facility asserts the likelihood for serious harm no longer existed for the residents residing on floor b on 02/18/2026 at 1:30PM, when the above mentioned physical and verbal abuse was reported to the local police department by S1Administrator.

Based on interviews and record reviews, the facility failed to ensure witnessed physical and verbal abuse was reported to the facility's administrator/designee and the state agency within 2 hours for 1 (Resident #1) of 3 sampled residents investigated for abuse.The deficient practice resulted in an immediate jeopardy situation for Resident #1 on 02/17/2026 at approximately 4:00PM, when S4Licensed Practical Nurse (LPN) physically and verbally abused Resident #1 by hitting him repeatedly on his face, head, and shoulders with a closed fist, by putting her knee on Resident #1's neck, by grasping Resident #1's shirt and attempting to drag Resident #1 across the floor, and by yelling at Resident #1, b***h, don't hit me and b***h, I'm tired of you. The immediate jeopardy situation continued on 02/17/2026 when S4LPN stated to S5Certified Nursing Assistant (CNA) and S6CNA, in front of Resident #1, leave that b***h on the floor, don't help him up. The above mentioned physical and verbal abuse was witnessed by S5CNA, S6CNA, and Resident #2. The immediate jeopardy situation remained present on 02/17/2025 when S5CNA and S6CNA left Floor b for approximately 8 minutes, leaving Resident #1 and the other 20 residents alone on Floor b with S4LPN. The immediate jeopardy situation was ongoing on 02/17/2026 at approximately 5:00PM, when S4LPN instructed S5CNA, in front of Resident #1, to leave that b***h, in his chair. The immediate jeopardy situation remained unresolved on 02/17/2025 at approximately 5:00PM when S5CNA left S4LPN unmonitored and with access to all 21 residents that resided on Floor b while she went in and out of the rooms on Floor b to complete her rounds. The immediate jeopardy situation remained ongoing when S5CNA failed to report the above witnessed physical and verbal abuse to S1Administrator and/or his/her designee within 2 hours. The immediate jeopardy situation remained unresolved on 02/17/2025 at 11:20PM when S4LPN clocked out from the facility. The immediate jeopardy situation continued until the above witnessed physical and verbal was reported to S1Administrator on 02/18/2026 at approximately 10:30AM.The facility implemented corrective actions which were completed prior to the state agency's investigation, thus it was determined to be a past noncompliance citation.Cross Reference F600Review of the facility's Abuse Prevention policy last revised on 06/17/2002 revealed, in part, any person who witnessed or suspected abuse would immediately inform the facility's House Supervisor who will in turn notify the facility's Administrator or his/her designee.Review of the facility's undated Abuse Recognition, Reporting, and Investigation policy revealed, in part, the administrator or his/her designee, would report all allegations of suspected or actual abuse through the SIMS reporting portal.Review of the facility's Abuse Reporting and Investigation policy, last revised 04/22/2009 revealed, in part, should an investigation reveal suspected or actual abuse occurred, the administrator must report the allegation to the proper parties as required by current state and federal laws, such as the state licensing agency.In an interview on 03/02/2026 at 9:37AM, S5CNA indicated she did not report the above mentioned physical and verbal abuse of Resident #1 by S4LPN that occurred on 02/17/2026 to any of the facility's administrative staff or nurses until the morning of 02/18/2026. S5CNA further indicated she did not report the above mentioned physical and verbal abuse to any administrative staff because she did not know how to get in touch with them. S5CNA also indicated, before the above mentioned incident of physical and verbal abuse, she was not aware of the process to get in contact with the facility's administrative staff to report abuse, when none of the facility's administrative staff were present in the facility. S5CNA further indicated since the incident, she had been re-trained on the facility's abuse reporting procedures and knew where to locate the phone numbers for the facility's administrative staff.In an interview on 03/02/2025 at 9:55AM, S12CNA indicated if resident abuse was witnessed, it should have been reported to the facility's Administrator immediately.In an interview on 03/02/3036 at 9:58AM, S9CNA indicated if she witnessed any resident abuse, she would report it to a nurse. S9CNA further indicated if it was a nurse that had committed resident abuse, she would report it to the administrative staff. S9CNA further indicated any resident abuse that was witnessed should have been reported as soon as possible.In an interview on 03/02/2026 at 10:01AM, S10Housekeeper indicated she would report abuse to the nurse or the charge nurse immediately. Further, she was knowledgeable of getting contact numbers for S1Administrator and S2DON at the facility's front desk. In an interview on 03/02/2026 at 10:04AM, S7CNA indicated she had assisted with getting Resident #1 off of the floor on 02/17/2026, but had not witnessed the above mentioned physical and verbal abuse of Resident #1 by S4LPN herself. S7CNA further indicated S5CNA reported to her on 02/17/2026, the above mentioned physical and verbal abuse had occurred. S7CNA further indicated she had not reported the above mentioned physical and verbal abuse on 02/17/2026 to any of the facility's administrative staff. S7CNA indicated she had both S2DON and S1Administrator's phone numbers to report abuse immediately.In an interview on 03/02/2026 at 11:44AM, S1Administrator indicated S5CNA did not report the above mentioned physical and verbal abuse of Resident #1 by S4LPN until the morning of 02/18/2026. S1Administrator further indicated S5CNA and S6CNA should have reported the above mentioned physical and verbal abuse to him immediately.In an interview on 03/02/2026 at 1:35PM, S2Director of Nursing (DON) indicated the above mentioned CNAs that had witnessed and/or knew of the above mentioned physical and verbal abuse that occurred on 02/17/2026, should have been reported immediately to the facility's administrative staff.In a telephone interview on 03/03/2025 at 8:50AM, S11CNA indicated if he had witnessed abuse, he would tell the nurse immediately. S11CNA further indicated, if it was the nurse that had committed the abuse, he would then tell the nurse's supervisor. S11CNA further indicated that he was re-trained on reporting witnessed abuse.In a telephone interview on 03/03/2026 at 9:00AM, S13Dietary Staff indicated if she witnessed a staff member committing abuse against a resident, she would report it to the facility's Administrator.In an interview on 03/03/2026 at 9:12AM, S6CNA indicated the above mentioned physical and verbal abuse of Resident #1 by S4LPN should have been reported to the facility's administrative staff immediately, but she did not report it to anyone until the next day (02/18/2026). S6CNA further indicated, at the time of the incident, she did not know who to report resident abuse to, but she now had the telephone numbers of both S2DON and S1Administrator to report abuse immediately.In an interview on 03/03/2026 at 9:56AM, S2DON indicated S5CNA should have contacted her, S1Administrator, and/or S3Registered Nurse Supervisor immediately to report the above mentioned physical and verbal abuseIn an interview on 03/04/2026 at 8:50AM, S14LPN indicated she would report abuse immediately to S1Administrator.In an interview on 03/05/2026 at 12:31PM, S1Administrator acknowledged the above mentioned physical and verbal abuse should have been reported to the state agency within 2 hours.Beginning on 02/18/2026, the facility implemented the following actions to correct the deficient practice:1. On 02/18/2026, S1Administrator verbally in-serviced S5CNA and S6CNA on immediately reporting abuse to S1Administrator.2. On 02/18/2026, S1Administrator started an investigation into the allegation of physical and verbal abuse of Resident #1 by S4LPN and requested S5CNA and S6CNA give written statements of the abuse they had witnessed.3. On 02/18/2026, S1Administrator immediately suspended S4LPN from working with residents and requested she give a written statement. S4LPN's last day working with residents was 02/17/2026.4. On 02/18/2026 at 11:00AM, S1Administrator had staff perform an assessment of Resident #1 for any injuries and/or pain. The assessment revealed Resident #1 had no injuries and no pain. Resident #1 refused to be transferred to the local emergency room for evaluation.5. On 02/18/2026 at 11:08AM, S1Administrator entered a report regarding the above mentioned physical and verbal abuse in the State Incident Management System (SIMS).6. On 02/18/2026, Resident #1's medical provider conducted a psychological evaluation on Resident #1.7. On 02/18/2026, S1Administrator had staff do an audit of the 20 other residents that resided on Floor b to determine if they have suffered any abuse. All 20 residents denied experiencing abuse.8. On 02/18/2026, S1Administrator obtained a witness statement from Resident #2. 9. On 02/18/2026, S2DON and S8Director of Education started retraining staff to immediately report any abuse to S1Administrator. S2DON and S8Director of Education had retrained a majority of the staff on abuse reporting procedures on 02/18/2026 and a majority of staff when interviewed, were aware of the when to report abuse.10. On 02/18/2026 at 1:30PM, S1Administrator reported the above mentioned physical and verbal abuse to the local police department.11. On 02/24/2026, S1Administrator reported S4LPN's physical and verbal abuse of Resident #1 to the Louisiana State Board of Practical Nurse Examiners. S4LPN's Practical Nursing License was suspended on 02/25/2026.The facility asserts the likelihood for serious harm no longer existed for the residents residing on floor b on 02/18/2026 at 1:30PM, when the above mentioned physical and verbal abuse was reported to the local police department by S1Administrator.

Based on interview and record review, the facility failed to ensure a resident's right to smoke for 1 (Resident #6) of 1 sampled resident investigated for smoking. Findings:Review of the facility's Resident Smoking and Tobacco Use Policy, with an effective date of 08/01/2025, revealed, in part, residents had the right to smoke. Further review revealed residents who were cognitively impaired or had mobility limitations may only smoke under staff supervision. Further review revealed the facility's staff were responsible for monitoring compliance with this policy. Review of Resident #6's Quarterly Minimum Data Set with and Assessment Reference Date of 12/26/2025 revealed, in part, Resident #6 had a Brief Interview for Mental Status score of 15, which indicated Resident #6 was cognitively intact. Review of the facility's undated list of smokers revealed, in part, Resident #6 was listed as an unsafe smoker. In an interview on 01/22/2026 at 10:31AM, Resident #6 indicated he was no allowed to go outside to smoke at night because he was not on the list to go out to smoke after 7:00PM. In a telephone interview on 01/22/2026 at 11:06AM, S8Licensed Practical Nurse (LPN) indicated Resident #6 was not on the list of smokers that could smoke past the extended hours of 7:00AM to 8:00PM. In an interview on 01/22/2026 at 12:24PM, S2Director of Nursing (DON) indicated the security guard, the evening receptionist, and/or the night receptionist were to supervise the unsafe smokers who would want to smoke after 7:00PM or before 7:00AM. In a telephone interview on 01/22/2026 at 1:01PM, S12Receptionist indicated that unsafe smokers were not allowed to go outside to smoke at night, and only residents listed on the safe smoker list were allowed to go outside at night. S12Receptionist further indicated she had refused Resident #6 the right to smoke at night in the past because Resident #6 was not listed on the safe smoker list. In a telephone interview on 01/22/2026 at 3:10PM, S13Receptionist indicated residents that were not on the safe smokers list were not allowed to go out between the hours of 7:00PM and 7:00AM. S13Receptionist further indicated Resident #6 could not go outside to smoke after hours because he was not on the safe smokers list. S13Receptionsit further indicated she had previously denied Resident #6 the ability to go outside to smoke between the hours of 7:00PM and 7:00AM because Resident #6 was on the unsafe smokers list. In an interview on 01/22/2026 at 1:26PM, S2DON indicated all residents have the right to smoke when requested, and staff should have allowed Resident #6 to smoke at night with staff supervision.

Based on interviews and record reviews, the facility failed to ensure residents, with a newly evident serious mental disorder, were referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation for 2 (Resident #21, Resident #49) of 4 sampled residents reviewed for PASARR. Findings: On 01/22/2026 at 2:30PM, S15Social Services Director was presented with a request for Resident #21's and Resident #49's Level II PASARR evaluation. On 01/23/2026 at 8:30AM, S15Social Services Director was presented with a request for Resident #21's and Resident #49's Level II PASARR evaluation. Resident #21 Review of Resident #21's face sheet revealed, in part, Resident #21 was admitted to the facility on [DATE]. Further review revealed Resident #21 was diagnosed with major depressive disorder (MDD) on 01/13/2026. Review of Resident #21's record revealed no evidence a PASARR Level II evaluation was completed for Resident #21. In an interview on 01/23/2026 at 10:07AM, S15Social Services Director indicated Resident #21's PASARR Level II evaluation was not completed after was not completed after Resident #21's new diagnosis of major depressive disorder on 01/13/2026, as required. In an interview on 01/23/2026 at 10:17AM, S2Director of Nursing indicated Resident #21's PASARR Level II evaluation was not completed after Resident #21's diagnosis of MDD on 01/13/2026, as required. Resident #49 Review of Resident #49's face sheet revealed, in part, Resident #49 was admitted to the facility on [DATE]. Further review revealed Resident #49 was diagnosed with major depressive disorder (MDD) on 05/03/2021. Review of Resident #49's record revealed no evidence a PASARR Level II evaluation was completed for Resident #49. In an interview on 01/23/2026 at 10:07AM, S15Social Services Director indicated Resident #49's PASARR Level II evaluation was not completed after Resident #49's diagnosis of MDD on 05/03/2021, as required. In an interview on 01/23/2026 at 10:13AM, S2Director of Nursing indicated Resident #49's PASARR Level II evaluation was not completed after Resident #49's diagnosis of MDD on 05/03/2021, as required. In an interview on 01/23/2026 at 1:45PM, S1Administrator confirmed Resident #21's and Resident #49's PASARR Level II were not completed after a new diagnosis of a serious mental illness was received.

Based on interviews and record reviews, the facility failed to review a resident's care plan quarterly for 1 (Resident #6) of 18 sampled resident's care plans reviewed. Findings:Review of the facility's Care Plan policy, last revised on 04/22/2009, revealed, in part, the facility's interdisciplinary team (IDT) will reassess the resident no less than once every 3 months, and as needed, and revise the resident's plan of care together with the resident and/or the residents responsibly party. Review of Resident #6's electronic medical record revealed, in part, Resident #6's last quarterly Minimum Data Set (MDS) was completed on 12/26/2025. Review of Resident #6's progress notes revealed no care plan meeting was held with Resident #6, Resident #6's representative, and/or any of the facility's IDT to review Resident #6's care plan since 07/16/2025. In an interview on 01/23/2026 at 10:02AM, S15Social Services Director (SSD) indicated Resident #6's last care plan meeting was on 07/16/2025. S15SSD further indicated a care plan meeting should have occurred since that date, because care plan meetings were to be completed every quarter. In an interview on 01/23/2026 at 10:12AM, S2Director of Nursing (DON) indicated care plan meetings should occur quarterly. In an interview on 01/23/2026 at 11:02AM, S15SSD confirmed Resident #6's care plan had not been reviewed or revised by the IDT, Resident #6, and/or Resident #6's representative since 07/16/2025.

Based on observation, interviews and record reviews, the facility failed to ensure only authorized personnel had access to medications for 1 (Resident #1) of 1 sampled residents observed with medications at the bedside. Findings:Review of the facility's undated Storage of Medications policy revealed, in part, medications were to be stored in locked compartments and in the packaging in which they were received. Further review revealed, only persons authorized to prepare and administer medications should have access to medications. Review of Resident #47's Quarterly Minimum Data Set with an Assessment Reference Date of 10/29/2025 revealed, in part, Resident #47 had a Brief Interview for Mental Status score of 9, which indicated Resident #47 was moderately cognitively impaired. Observation of Resident #47's room on 01/21/2026 at 12:40PM revealed a white pill was on the ground split in two along with a medication cup that had Resident #47's name written on it. Further observation revealed a second medication cup, labeled with Resident #47's name and present on Resident #47's beside table, contained a white pill. In an interview on 01/21/2026 at 12:43PM, S7Licensed Practical Nurse (LPN) confirmed the pills and medication cups were in Resident #47's room. S7LPN further indicated Resident #47's medication should not have been left at Resident #47's bedside, and Resident #47 did not have the mental capacity to administer her own meds. In an interview on 01/21/2026 at 12:58PM, S2Director of Nursing (DON) acknowledged the above mentioned medications should not have been left at Resident #47's bedside in medication cups, unlocked, and unattended by staff.

Based on observation, interview, and record review, the facility failed to ensure a resident was served a diet that met the resident's special dietary needs for 1 (Resident #9) of 1 sampled residents reviewed for nutrition. Findings:Review of the facility's undated Nutrition policy and procedure revealed, in part, all physician ordered diets shall be implemented promptly upon receipt, and the dietary department shall prepare and serve meals which meet the ordered diet and nutritional requirements. Review of Resident #9's record revealed diagnosis of, in part, stage 4 Chronic Kidney Disease (condition in which the resident's kidneys were damaged and were unable to filter out toxins). Review of Resident #9's January 2026 Physician's Orders revealed, in part, Resident #9 was to be provided a renal diet. Review of Resident #9's Meal Ticket dated 01/21/2026 revealed Resident #9 was to receive a renal diet with no potatoes. Observation on 01/21/2026 at 1:05PM revealed Resident #9 was served cubed potatoes. In an interview on 01/21/2026 at 1:06PM, S16Licensed Practical Nurse indicated Resident #9 should not have been served potatoes, per his renal diet. In an interview on 01/22/2026 at 3:30PM, S2Director of Nursing indicated the process to ensure the residents received the correct diet was for the diet recommendations to be placed on the meal ticket, then the dietary aide should follow the meal ticket when preparing the resident's plate. S2Director of Nursing further indicated the staff on the floor then should check the trays as they were distributing the trays to ensure the diet served matched the diet ordered on the resident's meal ticket. S2Director of Nursing further indicated if the staff distributing the trays identified an inconsistency with the meal ticket and the resident's tray, they would notify the nurse and dietary. S2Director of Nursing further indicated Resident #9 should have not been served potatoes.

Based on observations, interviews, and record reviews, the facility failed to ensure staff completed hand hygiene while performing incontinence care for 1 (Resident #63) of 1 sampled residents observed for incontinence care. Findings:Review of the facility's undated Standard Precautions policy and procedure revealed, in part, hand hygiene must be performed immediately after contact with any resident item that may be contaminated. Review of the Centers for Disease Control and Prevention (CDC)'s October 2022 Guidelines for Hand Hygiene in Health-Care Settings revealed, in part, staff should decontaminate their hands if moving from a contaminated body site to a clean body site during patient care. Observation on 01/21/2026 at 11:39AM revealed S17Certified Nursing Assistant (CNA) and S18CNA entered Resident #63's room to perform incontinence care. S17CNA and S18CNA removed Resident #63's soiled diaper and wiped Resident #63's buttocks and perineal area. S17CNA and S18CNA then placed a clean diaper on Resident #63, rolled Resident #63, placed a clean draw sheet under Resident #63, repositioned Resident #63, and covered Resident #63 with clean linen without changing their gloves and performing hand hygiene. S18CNA then opened and closed Resident #63's dresser door and raised the head of Resident #63's bed with her contaminated gloved hands without performing hand hygiene and changing her gloves. In an interview on 01/21/2026 at 11:50AM, S17CNA indicated he did not change his gloves and perform hand hygiene after removing Resident #63's soiled diaper during incontinence care and should have. In an interview on 01/21/2026 at 11:51AM, S18CNA indicated she did not change her gloves and perform hand hygiene care after removing Resident #63's soiled diaper during incontinence care and should have. In an interview on 01/23/2026 at 10:00AM, S2Director of Nursing (DON) confirmed the above mentioned CNAs should have changed their gloves and performed hand hygiene during incontinence care when they moved from a contaminated body area to a clean body area.

Based on interviews and record reviews, the facility failed to ensure the pneumococcal (an infection caused by streptococcus pneumonia bacteria) and influenza (a respiratory infection caused by a virus) vaccines were administered for 1 (Resident #60) of 5 sampled residents investigated for immunizations. Findings:Review of the facility's undated Influenza and Pneumococcal Vaccine policy and procedure revealed, in part, residents should be vaccinated against the pneumococcal disease and influenza virus unless the vaccination was medically contraindicated or the resident and/or legal representative refused the vaccination. Review of Resident #60's Minimum Data Set with an Assessment Reference Date of 01/07/2026 revealed, in part, Resident #60 was admitted to the facility on [DATE]. Further review revealed a Brief Interview for Mental Status score of 10, which indicated Resident #60's cognition was moderately impaired. Review of Resident #60's Pneumonia Vaccine Consent Form revealed, in part, Resident #60's responsible party signed consent for Resident #60 to receive the pneumococcal vaccine on 07/02/2025. Review of Resident #60's Influenza Vaccine Consent Form revealed, in part, Resident #60's responsible party signed consent for Resident #60 to receive the pneumococcal vaccine on 07/02/2025. Review of Resident #60's clinical record on 01/20/2026 at 3:30PM revealed no documented evidence Resident #60 received the influenza and/or pneumococcal vaccines. On 01/20/2026 at 3:40PM, S1Administrator was presented with a request for Resident #60's vaccination records. In an interview on 01/21/2026 at 12:16PM, Resident #60 indicated he wanted the influenza and pneumococcal vaccines, but had not received them. In a telephone interview on 01/21/2026 at 1:37PM, Resident #60's responsible party indicated she consented for Resident #60 to receive the influenza and pneumococcal vaccines from the facility. Resident #60's responsible party further indicated she was unsure if Resident #60 had received the influenza and pneumococcal vaccines. In an interview on 01/21/2026 at 1:35PM, S3Assistant Director of Nursing/Infection Preventionist indicated the facility had no evidence Resident #60 received the influenza and/or pneumococcal vaccinations since admission. In an interview on 01/21/2026 at 3:40PM, S2Director of Nursing indicated Resident #60 had not received the influenza and/or pneumococcal vaccinations prior to 01/21/2026, and should have. In an interview on 01/21/2026 at 3:40PM, S1Administrator indicated Resident #60 had not received the influenza and/or pneumococcal vaccinations prior to 01/21/2026, and should have.

Based on interviews and record reviews, the facility failed to protect a resident's right to be free from resident to resident physical abuse for 1 (Resident #4) of 4 (Resident #1, Resident #2, Resident #3, Resident #4) sampled residents investigated for resident abuse. Findings:Review of the facility's undated Abuse Recognition, Reporting, and Investigation policy revealed, in part, the facility was to protect residents from any physical and mental mistreatment and to not permit residents to be subjected to abuse by anyone, including other residents. Further review revealed physical abuse was defined as hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Review of the facility's Statewide Incident Management System Report investigation entered on 09/17/2025 that occurred on 09/10/2025 at 9:35AM revealed, in part, Resident #2 walked into the day room and hit Resident #4 in the face. Further review revealed the altercation was witnessed by 2 Certified Nursing Assistants (CNAs) (S2CNA and S3CNA), and resident to resident abuse was substantiated. In an interview on 10/01/2025 at 2:26 PM, S2CNA indicated that she witnessed Resident #2 hit Resident #4 in the face on 09/10/2025. In an interview on 10/01/2025 at 3:45PM, Resident #2 confirmed the physical altercation with Resident #4 and indicated that Resident #2 hit Resident #4 in the face. In a phone interview on 10/01/2025 at 4:28PM, S3CNA indicated that she witnessed Resident #2 hit Resident #4 in the face on 09/10/2025. In an interview on 10/01/2025 at 4:34PM, S1Administrator confirmed resident-to-resident abuse on 09/10/2025 from Resident #2 to Resident #4 was substantiated after being investigated by the facility.

Based on observations, interviews and record reviews the facility failed to ensure a resident's Minimum Data Set (MDS) assessment reflected the resident's accurate cognitive status for 1 (Resident #1) of 9 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9) sampled residents investigated for accuracy of assessments. Findings:Review of Resident #1's quarterly MDS with an Assessment Reference Date (ARD) of 08/20/2025 revealed, in part, Resident #1 was comatose. Review of Resident #1's nurse progress note dated 8/20/2025 at 11:23AM revealed, in part, Resident #1 was alert and oriented to person, place and time and was able to make her needs known. Review of Resident #1's nurse progress note dated 8/20/2025 at 9:59PM revealed, in part, Resident #1 was able to express her needs and could self-feed. Further review revealed, Resident #1 was mobile via wheelchair and was able to swallow medications whole. Review of Resident #1's nurse progress note dated 8/20/2025 at 11:42PM revealed, in part, during Resident #1's 7 day lookback Resident #1 was alert and oriented to person, place and time and could make all needs known to staff. Review of Resident #1's nurse progress note dated 8/29/2025 at 12:18AM revealed, in part, Resident #1 was alert and oriented to person, place and time and can make all needs known to staff.Review of Resident #1's nursing progress note dated 9/5/2025 at 1:25AM revealed, in part, Resident #1 was alert and oriented to person, place and time and could make all needs known to staff. In an interview on 09/08/2025 at 1:45PM, Resident #1 was alert and was able to answer screening questions appropriately and was interviewable. Observation on 09/08/2025 at 4:15PM revealed Resident #1 sitting in a wheelchair near the facility front entrance visiting and talking with the staff member working the front desk. In an interview on 09/10/2025 at 9:06AM, S2Director of Nursing (DON) confirmed Resident #1's quarterly MDS dated [DATE] revealed Resident #1 was comatose. S2DON indicated Resident #1 was not comatose and that the MDS did not accurately reflect Resident #1's state of consciousness. In an interview on 09/10/2025 at 9:35AM, S1Administrator indicated Resident #1's quarterly MDS referenced above, was not accurate as Resident #1 was not comatose.

Based on interviews and record reviews, the facility failed to obtain laboratory services in a timely manner per physician's orders for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for pharmaceutical services. This deficient practice resulted in an Immediate Jeopardy situation on 02/04/2025 when Resident #1's valproic acid level (a blood test to measure the amount of valproic acid in the blood) was not drawn after being ordered by Resident #1's nurse practitioner on 01/29/2025. On 02/17/2025, Resident #1 was observed by the facility to be lethargic and was transferred to the hospital. Resident #1 was hospitalized from 02/17/2025 through 02/19/2025 with a diagnosis of valproic acid toxicity (an excessive accumulation of valproic acid in the body which can lead to coma or death). S1Chief Operating Officer (COO) and S2Director of Nursing (DON) were notified of the Immediate Jeopardy on 03/12/2025 at 6:50PM. The Immediate Jeopardy was removed on 03/13/2025 at 4:30PM, after it was verified through observations, interviews, and record reviews, the provider implemented an acceptable Plan of Removal prior to the survey exit. This deficient practice had the likelihood to affect all residents with medications requiring lab orders. Findings: Review of Resident #1's hospital records revealed, in part, Resident #1 was hospitalized from 02/17/2025 through 02/19/2025 with a diagnosis, in part, of valproic acid toxicity. Further review of Resident #1's hospital records revealed on admit, Resident #1's valproic acid level drawn on 02/17/2025 at 12:04PM with a result of 110.7 microgram (ug)/milliliter (ml), which was outside the reference range of 50.0 to 100.0 ug/ml. Review of Resident #1's medical record revealed, in part, Resident #1 was admitted to the facility on [DATE] with diagnoses which included, in part, dementia and anxiety disorder. Review of Resident #1's physician's orders revealed the following: Depakote (medication used for seizures, anxiety, and dementia) Oral Tablet Delayed Release 250 milligrams (mg) tablet. Give 250 mg by mouth two times a day related to dementia with a start date of 12/17/2025 and an end date of 01/03/2025; Depakote Oral Tablet Delayed Release 500 mg tablet. Give 500 mg by mouth two times a day related to anxiety disorder from 01/03/2025 through 02/01/2025; Depakote Oral Tablet Delayed Release 250 mg tablet. Give 1 tablet by mouth two times a day related to anxiety disorder. Give 500 mg tablet with 250 MG tablet by mouth twice daily from 02/01/2025 to 02/20/2025; Depakote Oral Tablet Delayed Release 500 mg tablet. Give 1 tablet twice a day related to anxiety disorder. Give 500 mg tablet with 250 mg tablet twice daily from 02/01/2025 to 02/27/2025; Depakote Oral Tablet Delayed Release 500 mg tablet. Give 1 tablet by mouth at bedtime for dementia with behavioral disturbances beginning on 02/27/2025; and, Depakote Oral Tablet Delayed Release 250 mg tablet. Give 1 tablet by mouth in the morning for dementia with behavioral disturbances beginning on 02/28/2025. Review of Resident #1's medical records revealed Resident #1's nurse practitioner wrote an order dated 01/29/2025, to obtain a valproic acid level. In an interview on 03/11/2025 at 5:02PM, S2DON indicated routine labs were to be drawn on Tuesdays and Thursdays. S2DON further indicated once the orders were written for the labs, S2DON would hand a copy of the orders to the floor nurse to transcribe and submit a lab requisition. S2DON further indicated she would file the orders once she saw the orders were placed and carried out. There was no documented evidence, and the facility was unable to present any documented evidence that Resident #1's laboratory service was carried out as ordered prior to Resident #1's 02/17/2025's hospitalization . Review of Resident #1's Progress Notes revealed a note dated 02/17/2025 at 11:08AM by S3Licensed Practical Nurse (LPN) indicating Resident #1 was slow to respond and Resident #1 gave blank stares when asked questions. Further review revealed S3LPN called Resident #1's doctor and obtained an order to transfer Resident #1 to the emergency room for further evaluation. In an interview on 03/11/2025 at 3:48PM, the facility's consulting pharmacist, S9Consultant Pharmacist, indicated it was important to get valproic acid levels when residents are taking Depakote due to the risk of toxicity. The facility's consulting pharmacist further indicated signs and symptoms of valproic acid toxicity included gastrointestinal distress, neurological distress, drowsiness, and confusion. In an interview on 03/12/2025 at 12:27PM, S2DON confirmed Resident #1 did not have any valproic acid levels drawn prior to her acute care hospitalization . In an interview on 03/12/2025 at 2:09PM, S1Chief Operating Officer (COO) indicated she was currently in charge of quality since administration has been out on leave, and identified problems from grievances, surveys, tracking and trending, and surveys. S1COO indicated she puts Performance Improvement Plans (PIPs) into place after problems are identified. In an interview on 03/12/2025 at 2:20PM, S2DON indicated she was responsible for ensuring laboratory orders are carried out. S2DON indicated she could not offer any explanation as to why a valproic acid level was not drawn on Resident #1. In an interview on 03/12/2025 at 6:25pm, S6Chief Executive Officer (CEO) indicated he did not feel that the above deficient practice was an Immediate Jeopardy situation and would review the above mentioned findings. S6CEO did not provide any additional communication or documentation to dispute the above mentioned findings. A Plan of Removal was accepted on 03/13/2025 at 4:30PM, which included the following actions to correct the deficient practice: A daily audit began starting on March 12th, 2025 and will continue for 1 month. After 30 days, the facility will move to weekly reviews that will happen as part of the high-risk meeting. The audit will include ensuring all lab orders are recorded, drawn timely, and responded to timely. Education will include the physician and their extenders, clinical managers, and facility nurses. A daily review will be completed for a month starting on 03/12/2024 by S2DON or her designee to ensure nothing is missed or not followed-up o timely. Nurses will receive this in-service prior to their next scheduled shift. Education started immediately on 03/12/2025 at 8:00PM. Starting on 03/12/2025 daily monitoring will begin of any lab orders, old or new. Making sure the order has been accurately and successfully carried out and that the results have been communicated to the medical doctor or nurse practitioner office. The Director of Nursing or her designee will review lab orders in point click care (the facility's charting program), lab results in lab portal, and review notification to the medical doctor or nurse practitioner. Starting on 03/12/2025 daily review of labs began and will continue for one month after such time this will be reviewed weekly in the high-risk meeting. Daily audits will continue with daily frequency until expectations are met. Nurses will be re-educated or counseled when and if there is a deviation from the system. Lab orders will be added as one of the agenda items to be discussed during morning stand up meeting. The facility asserted the likelihood for serious harm to any of its residents no longer existed on 03/12/2025 at 8:05PM.

Based on interviews and record reviews, the facility's administrative staff failed to use its resources efficiently and effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents by failing to oversee the effective implementation of physician laboratory orders for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for pharmaceutical services. This lack of administrative oversite resulted in an Immediate Jeopardy situation on 02/04/2025 when Resident #1's valproic acid level (a blood test to measure the amount of valproic acid in the blood) was not drawn after being ordered by Resident #1's nurse practitioner on 01/29/2025. On 02/17/2025, Resident #1 was observed by the facility to be lethargic and was transferred to the hospital. Resident #1 was hospitalized from 02/17/2025 through 02/19/2025 with a diagnosis of valproic acid toxicity (an excessive accumulation of valproic acid in the body which can lead to coma or death). S1Chief Operating Officer (COO) and S2Director of Nursing were notified of the Immediate Jeopardy on 03/12/20205 at 6:50PM. The Immediate Jeopardy was removed on 03/13/2025 at 4:30PM, after it was verified through observations, interviews, and record reviews, the provider implemented an acceptable Plan of Removal prior to the survey exit. This deficient practice had the likelihood to affect all residents with medications requiring lab orders. Findings: Cross reference F770. Review of Resident #1's medical records revealed Resident #1's nurse practitioner wrote an order dated 01/29/2025, to obtain a valproic acid level. There was no documented evidence, and the facility was unable to present any documented evidence Resident #1's laboratory services was carried out as ordered prior to Resident #1's 02/17/2025's hospitalization . In an interview on 03/11/2025 at 5:02PM, S2DON indicated after the physician or nurse practitioner places an order for a lab on the lab form, she gives the orders to the floor nurse to enter into the computer. S2DON further indicated once the orders were noted in a resident's record she would file the form, and routine labs were to be drawn on Tuesdays and Thursdays. In an interview on 03/12/2025 at 2:09PM, S1Chief Operating Officer (COO) indicated she was currently in charge of quality since administration has been out on leave, and identifies problems from grievances, surveys, tracking and trending, and surveys. S1COO indicated she puts Performance Improvement Plans (PIPs) into place after problems are identified. In an interview on 03/12/2025 at 2:20PM, S2DON indicated she was responsible for ensuring laboratory orders are carried out. S2DON indicated she could not offer any explanation as to why a valproic acid level was not drawn for Resident #1. In an interview on 03/12/2025 at 6:25pm, S6Chief Executive Officer (CEO) indicated he did not feel that the above deficient practice was an Immediate Jeopardy situation and would review the above mentioned findings. S6CEO did not provide any additional communication or documentation to dispute the above mentioned findings. A Plan of Removal was accepted on 03/13/2025 at 4:30PM, which included the following actions to correct the deficient practice: The facility planned to improved communication between nursing, pharmacy consult, and medical doctors and put more oversight by leadership of the laboratory process. A daily audit began starting on March 12th, 2025 and will continue for 1 month. After 30 days, the facility will move to weekly reviews that will happen as part of the high-risk meeting. The audit will include ensuring all lab orders are recorded, drawn timely, and responded to timely. S6Chief Executive Officer (CEO) or his designee will do a visual check to ensure the audits have occurred. He will do this once per week for one month. S6CEO or his designee will attend one high risk meeting a month to verify lab orders are being reviewed. Education will include the physician and extenders, clinical managers, and facility nurses. A daily review will be completed for a month starting on 3/12/2025 by S2DON or her designee to ensure nothing is missed or not followed up on timely. S6CEO or his designee will verify education has been completed as stated through a visual review of the sign in sheets once per week for one month. All staff nurses will be in serviced prior to their next shift on the lab order protocol. S6CEO/his designee began providing administrative staff with the same education that is being provided to the nurses on March 13th 2025 around 2PM. All administrative staff at the facility will be in-serviced by close of business on 3/14/2025. Starting on 3/12/2025 daily monitoring began of any lab orders, old or new. Verification that the order has been accurately and successfully been carried out and that the results have been communicated to the medical doctor or nurse practitioner office. These audits are to be done by S2DON or her designee. S2DON or her designee will review lab orders in point click care (the facility's charting program), lab results in lab portal, and review notification to the medical doctor or nurse practitioner. S6CEO or his designee will verify the audits weekly for 4 weeks and will participate in one high risk meeting per month to verify compliance. Starting on 03/12/2025 daily review of labs began and will continue for one month after such time this will be reviewed weekly in the high-risk meeting. Daily audits will continue with daily frequency until expectations are met. Nurses will be re-educated or counseled when and if there is a deviation from the system. Lab orders will be added as an agenda item in the daily, weekday, stand-up meeting. S6CEO or his designee will attend one stand up meeting per week for 60 days to ensure the agenda remains unchanged. The facility asserted the likelihood for serious harm to any of its residents no longer existed on 03/12/2025 at 8:05PM.

Based on observations and interviews, the facility failed to ensure 1.) maintenance services placed an outlet cover over a wall socket in a resident's room (Resident #1); and, 2.) housekeeping services cleaned an unknown brown substance off of a resident's floor (Resident #1). This deficient practice was identified for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for environment. Findings: Observation of Resident #1's room on 03/10/2025 at 6:42AM revealed the outlet cover over a wall socket near the foot of Resident #1's bed did not have a wall covering. Observation further revealed an unknown brown substance about an inch long was seen on the side of Resident #1's bed on the floor. Observation on 03/12/2025 at 9:40AM of Resident #1's room revealed the outlet cover over a wall socket near the foot of Resident #1's bed did not have a wall covering. Observation further revealed an unknown brown substance about an inch long was seen on the side of Resident #1's bed on the floor. In an interview on 03/12/2025 at 11:50AM, S1Chief Operation Officer (COO) confirmed the wall socket in Resident #1's lacked a cover plate and state it should have one. S1COO also confirmed the presence of an unknown brown substance on Resident #1's floor and indicated it should not be there.

Based on record reviews, observations and interviews, the facility failed to ensure staff working as nurse aides met minimum state-approved competency and training requirements for 8 (S4Direct Service Worker [DSW], S5DSW, S6DSW, S7DSW, S8DSW, S11DSW, S12DSW, and S15Front Desk Receptionist [FDR]) of 13 (S3DSW, S4DSW, S5DSW, S6DSW, S7DSW, S8DSW, S9DSW, S10DSW, S11DSW, S12DSW, S13Certified Nursing Assistant [CNA], S14CNA, and S15FDR) personnel files reviewed. On [DATE], at approximately 7:17 a.m., an Immediate Jeopardy occurred when the facility allowed S4DSW, S11DSW, and S12DSW to work independently with residents as nurse aides without having met the minimum state-approved competency and training requirements. Review of the facility's CNA Break and Lunch Schedule Sheets revealed, in part on [DATE] through [DATE], S4DSW, S5DSW, S6DSW, S7DSW, S8DSW, S11DSW, S12DSW, and S15FDR were assigned to work independently as nurse aides to provide direct care to residents without having met the minimum state-approved competency and training requirements. The Immediate Jeopardy continued on [DATE] through [DATE] when the survey team observed, S4DSW, S6DSW, and S15FDR working as nurse aides independently throughout the facility without having met the minimum state-approved competency and training requirements. S1Administrator was notified of the Immediate Jeopardy on [DATE] at 2:08 p.m. The Immediate Jeopardy was removed on [DATE] at 4:12 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. This deficient practice had the likelihood to cause more than minimum harm to all 79 residents in the facility due to uncertified staff providing direct care independently for residents as nurse aides without having met the minimum state-approved competency and training requirements. Findings: Review of the facility's undated policy and procedure titled, Nursing Services, revealed in part, the facility was to assure that there was sufficient qualified nursing staff available at all times to provide nursing and related services to meet the resident's needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. Review of the facility's Certified Nursing Assistant Job Description with a revision date of ,d+[DATE] revealed in part, the job qualification for a CNA included to have successfully completed the stated certification course. Review of the facility's Staff List revealed, in part, S4DSW, S5DSW, S6DSW, S7DSW, S8DSW, and S11DSW were classified as CNAs in training. Review revealed, S12DSW was classified as a CNA supervisor in training. Further review revealed, in part, S15FDR was classified as a front desk receptionist. S4DSW Review of S4DSW's personnel file revealed, in part, a hire date of [DATE]. Review revealed a certified nursing assistant course certificate with a completion date of [DATE]. Further review revealed, there was no documented evidence and the facility did not present any documented evidence that S4DSW had a current CNA certification. Review of the CNA registry database on [DATE] revealed, no data present for S4DSW. Review of S4DSW's time card dated [DATE] through [DATE] revealed, S4DSW worked on [DATE] through [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE], and [DATE]. Further review revealed, S16HumanResources approved S4DSW's above mentioned hours worked. Review of the facility's CNA Break and Lunch Schedule Sheets from the time period of [DATE] through [DATE] revealed, S4DSW was assigned as a CNA on [DATE] through [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE], and [DATE] to work independently on Floor A, Floor B, and Floor C to provide direct care to residents. Observation on [DATE] at 11:16 a.m., S4DSW was present on Floor A working as a nurse aide. Observation on [DATE] at 12:50 p.m., revealed S4DSW passing ice to residents on Floor A. In an interview on [DATE] at 1:32 p.m., S4DSW stated she had been working at the facility for a little over a year. S4DSW confirmed she was hired with the job description of a CNA. S4DSW confirmed she worked as a CNA independently and did not require direct supervision when providing direct care to residents on Floor A, Floor B, and Floor C. S4DSW stated she completed a CNA certification course in [DATE], but had not taken the state approved certification test. S4DSW further confirmed she was performing CNA duties in the facility prior to being enrolled in the CNA course. In an interview on [DATE] at 11:17 a.m., S20Licensed Practical Nurse (LPN) confirmed she was the day shift nurse on Floor A and she did not directly supervise the staff when they provided direct care to the residents. S5DSW Review of S5DSW's personnel file revealed, in part, a hire date of [DATE]. Review revealed a certified nursing assistant course certificate with a completion date of [DATE]. Further review revealed, there was no documented evidence and the facility did not present any documented evidence of S5DSW had a current CNA certification. Review of the CNA registry database revealed on [DATE], no data present for S5DSW. Review of S5DSW's time card and the CNA Break and Lunch Schedule Sheets, dated [DATE] through [DATE] revealed, S5DSW was assigned as a CNA to work independently on Floor C and Floor D to provide direct care to residents on [DATE] through [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE]. Further review revealed, S16HumanResources approved S5DSW's above mentioned hours worked. S6DSW Review of S6DSW's personnel file revealed, in part, a hire date of [DATE]. Review revealed a certified nursing assistant course certificate with a completion date of [DATE]. Review revealed, a signed Certified Nursing Assistant Job Description by S6DSW on [DATE]. Further review revealed, there was no documented evidence, and the facility did not present any documented evidence, of S6DSW had a current CNA certification. Review of the CNA registry database on [DATE] revealed no data present for S6DSW. Review of S6DSW's time card and the CNA Break and Lunch Schedule Sheets, dated [DATE] through [DATE] revealed, S6DSW was assigned as a CNA to work independently on Floor C to provide direct care to residents on [DATE] through [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE] through [DATE], and [DATE] through [DATE]. Further review revealed, S16HumanResources approved S6DSW's above mentioned hours worked. In an interview on [DATE] at 1:26 p.m., S6DSW stated she had been employed since [DATE] and she was hired with the job description of a CNA. S6DSW stated since her hire date she had worked independently as a CNA providing direct care to residents on Floor C and did not have direct supervision. S6DSW stated she completed a CNA certification course in [DATE]. S6DSW confirmed she was not currently scheduled for or in a CNA class and she was not scheduled for a CNA class. S6DSW further confirmed she had not taken the state-approved certification test and successfully passed. In an interview on [DATE] at 10:55 a.m., S19LPN confirmed S6DSW was a full time nurse aide on Floor C. S19LPN further stated she did not directly supervise S6DSW when she provided direct care to residents. S7DSW Review of S7DSW's personnel file revealed a hire date of [DATE]. Further review of S7DSW's personnel file revealed there was no documented evidence, and the facility did not present any documented evidence, of a certificate of completion of a state-approved nursing aide training course. Review of the CNA registry database on [DATE] revealed, S7DSW was certified from [DATE] through [DATE]. Further review revealed S7DSW's current status was not certified. Review of S7DSW's time card and the CNA Break and Lunch Schedule Sheets, dated [DATE] through [DATE] revealed, S7DSW was assigned as a CNA to work independently on Floor A, Floor C, and Floor D to provide direct care to residents on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE]. Further review revealed, S16HumanResources approved S7DSW's above mentioned hours worked. In a telephone interview on [DATE] at 1:44 p.m., S7DSW confirmed she was hired on [DATE] with the job description of a CNA and she currently worked as needed 3 to 4 days a week. S7DSW stated since her hire date, she had worked independently as a CNA providing direct care to residents on Floor A, Floor B, Floor C, and Floor D and did not have direct supervision. S7DSW stated she completed a CNA certification course in 2012. S7DSW confirmed she was not currently scheduled for or in a CNA class and her past certification had expired. S8DSW Review of S8DSW's personnel file revealed, in part, a hire date of [DATE]. Further review of S8DSW's personnel file revealed there was no documented evidence, and the facility did not present any documented evidence, of a certificate of completion from a state-approved nursing aide training course. Review of the CNA registry database on [DATE] revealed no data present for S8DSW. Review of S8DSW's time card dated [DATE] through [DATE] revealed, S8DSW worked on [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE] through [DATE], and [DATE] through [DATE]. Further review revealed, S16HumanResources approved S8DSW's above mentioned hours worked. Review of the facility's CNA Break and Lunch Schedule Sheets [DATE] through [DATE] revealed, S8DSW was assigned on [DATE], [DATE], and [DATE] to work independently on Floor A and Floor B to provide direct care to residents. Observation on [DATE] at 11:55 a.m. revealed S8DSW on the hall way on Floor A working independently as a nurse aide. In an interview on [DATE] at 1:23 p.m., S8DSW stated she had been employed since [DATE] and she was hired with the job description of a CNA. S8DSW stated since her hire date she had worked independently as a CNA providing direct care to residents on Floor C and did not have direct supervision. S8DSW confirmed she had never completed nor was she currently scheduled for or in a CNA certification course. S8DSW further stated she was not scheduled for nor had she ever taken the state-approved certification test and successfully passed. S11DSW Review of S11DSW's personnel file revealed, in part, a hire date of [DATE]. Review revealed a certified nursing assistant course certificate with a completion date of [DATE]. Further review revealed, there was no documented evidence, and the facility did not present any documented evidence, S11DSW had a current CNA certification. Review of the CNA registry database on [DATE] revealed no data present for S11DSW. Review of S11DSW's time card and the CNA Break and Lunch Schedule Sheets, dated [DATE] through [DATE] revealed, S11DSW was assigned as a CNA to work independently on Floor A, Floor B, and Floor D to provide direct care to residents on [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE], and [DATE] through [DATE]. Further review revealed, S16HumanResources approved S11DSW's above mentioned hours worked. S12DSW Review of S12DSW's personnel file revealed, in part, a hire date of [DATE]. Review revealed a certified nursing assistant course certificate with a completion date of [DATE]. Review revealed, a signed Certified Nursing Assistant Job Description by S12DSW on [DATE]. Further review revealed, there was no documented evidence, and the facility did not present any documented evidence, S12DSW had a current CNA certification. Review of the CNA registry database on [DATE] revealed no data present for S12DSW. Review of S12DSW's time card and the CNA Break and Lunch Schedule Sheets, dated [DATE] through [DATE] revealed, S12DSW was assigned as a CNA to work independently on Floor A to provide direct care to residents on [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], and [DATE]. Further review revealed, S16HumanResources approved S12DSW's above mentioned hours worked. S15FDR Review of S15FDR's personnel file revealed, in part, a hire date of [DATE]. Further review of the personnel file revealed there was no documented evidence and the facility did not present any documented evidence of a completion certificate of a state-approved nursing aide training course. Review of the CNA registry database revealed no data present for S15Front Desk Receptionist. Review of S15FDR's time card and the CNA Break and Lunch Schedule Sheets, dated [DATE] through [DATE] revealed, S15FDR was assigned as a CNA to work independently on Floor B, Floor C, and Floor D to provide direct care to residents on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE], and [DATE]. Further review revealed, S16HumanResources approved S15FDR's above mentioned hours worked. Observation on [DATE] at 11:11 a.m. revealed S15FDR working independently on Floor B as a nurse aide. In an interview [DATE] at 11:13 a.m., S21LPN, confirmed she was the full time nurse on the Floor B and she did not directly supervise the nurse aides when they provided direct care to residents. In an interview on [DATE] at 10:43 a.m. S16Human Resources Manager stated she was unaware the facility could not hire DSWs to provide direct care to residents. S16Human Resources confirmed the above mentioned staff were not certified and were working as nurse aides without having met the minimum state-approved competency and training requirements. In an interview on [DATE] at 4:00 p.m., S2Director of Nursing (DON) stated she was unaware the above mentioned staff were not certified nursing assistants because she assumed the facility only hired certified staff. S2DON further stated all staff working on the floor should have a certification or license prior to providing direct care to residents. In an interview on [DATE] at 10:50 a.m., S1Administator stated she was aware the above mentioned staff were working as nurse aides without having met the minimum state-approved competency and training requirements. S1Administrator further confirmed due to the above mentioned actions of the facility, all 79 residents had the likelihood of experiencing serious injury or harm from [DATE] through [DATE] while the above mentioned uncertified staff were providing direct care to residents without supervision without having met the minimum state-approved competency and training requirements.

Based on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to ensure staff working as nurse aides met minimum state-approved competency and training requirements for 8 (S4DSW, S5DSW, S6DSW, S7DSW, S8DSW, S11DSW, S12DSW, and S15FDR) of 13 (S3DSW, S4DSW, S5DSW, S6DSW, S7DSW, S8DSW, S9DSW, S10DSW, S11DSW, S12DSW, S13CNA, S14CNA, and S15FDR) personnel files reviewed. This lack of administrative oversight resulted in an Immediate Jeopardy situation on 02/09/2024, at approximately 7:17 a.m., when the facility's administration allowed S4DSW, S11DSW, and S12DSW to work independently as nurse aides without having met the minimum state-approved competency and training requirements. Review of the facility's CNA Break and Lunch Schedule Sheets revealed, in part for the time period of 02/09/2024 through 03/30/2024 revealed, in part, S4DSW, S5DSW, S6DSW, S7DSW, S8DSW, S11DSW, S12DSW, and S15Front Desk Receptionist were assigned to work independently as nurse aides to provide direct care to residents without having met the minimum state-approved competency and training requirements. The Immediate Jeopardy continued on 04/01/2024 through 04/03/2024 when the survey team observed, S4DSW, S6DSW, and S15Front Desk Receptionist working as nurse aides independently with residents throughout the facility without having met the minimum state-approved competency and training requirements. S1Administrator was notified of the Immediate Jeopardy on 04/03/2024 at 2:08 p.m. The Immediate Jeopardy was removed on 04/04/2024 at 5:46 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. Findings: Cross Reference F728. Review of S5DSW's time card and the CNA Break and Lunch Schedule Sheets, dated 02/04/2024 through 04/03/2024 revealed, S5DSW was assigned as a CNA to work independently on Floor C and Floor D to provide direct care to residents on 02/12/2024 through 02/14/2024, 02/17/2024, 02/19/2024 through 02/22/2024, 02/27/2024, 03/01/2024 through 03/03/2024, 03/05/2024, 03/08/2024, 03/10/2024, 03/11/2024 through 03/13/2024, 03/16/2024 through 03/19/2024, 03/21/2024, 03/22/2024, 03/24/2024 through 03/27/2024, 03/30/2024 through 04/02/2024. Further review revealed, S16HumanResources approved S5DSW's above mentioned hours worked. Review of S6DSW's time card and the CNA Break and Lunch Schedule Sheets, dated 02/04/2024 through 04/03/2024 revealed, S6DSW was assigned as a CNA to work independently on Floor C to provide direct care to residents on 02/09/2024 through 02/14/2024, 02/16/2024, 02/19/2024, 02/20/2024, 02/27/2024, 02/28/2024, 03/04/2024 through 03/06/2024, 03/09/2024 through 03/16/2024, 03/19/2024, 03/23/2024, 03/25/2024 through 03/29/2024, and 03/31/2024 through 04/02/2024. Further review revealed, S16HumanResources approved S6DSW's above mentioned hours worked. Review of S7DSW's time card and the CNA Break and Lunch Schedule Sheets, dated 02/04/2024 through 04/03/2024 revealed, S7DSW was assigned as a CNA to work independently on Floor A, Floor C, and Floor D to provide direct care to residents on 02/24/2024, 02/25/2024, 03/10/2024, 03/12/2024, 03/15/2024, 03/19/2024, 03/20/2024, 03/28/2024 through 03/30/2024. Further review revealed, S16HumanResources approved S7DSW's above mentioned hours worked. Review of S8DSW's time card dated 03/03/2024 through 04/03/2024 revealed, S8DSW worked on 03/07/2024, 03/08/2024, 03/11/2024 through 03/13/2024, 03/16/2024 through 03/18/2024, 03/21/2024, 03/22/2024, 03/25/2024 through 03/27/2024, and 03/30/2024 through 04/03/2024. Further review revealed, S16HumanResources approved S8DSW's above mentioned hours worked. Review of S11DSW's time card and the CNA Break and Lunch Schedule Sheets, dated 02/04/2024 through 04/03/2024 revealed, S11DSW was assigned as a CNA to work independently on Floor A, Floor B, and Floor D to provide direct care to residents on 02/09/2024, 02/10/2024, 02/21/2024 through 02/27/2024, 03/02/2024, 03/05/2024 through 03/11/2024, 03/14/2024, 03/16/2024 through 03/19/2024, 03/22/2024, 03/24/2024, and 03/26/2024 through 03/31/2024. Further review revealed, S16HumanResources approved S11DSW's above mentioned hours worked. Review of S12DSW's time card and the CNA Break and Lunch Schedule Sheets, dated 02/04/2024 through 04/03/2024 revealed, S12DSW was assigned as a CNA to work independently on Floor A to provide direct care to residents on 02/09/2024, 02/10/2024, 02/13/2024 through 02/18/2024, 02/20/2024 through 02/23/2024, 02/26/2024 through 02/29/2024, 03/02/2024, 03/03/2024, 03/05/2024 through 03/10/2024, 03/12/2024 through 03/16/2024, 03/19/2024 through 03/23/2024, 03/26/2024 through 03/30/2024, and 04/02/2024. Further review revealed, S16HumanResources approved S12DSW's above mentioned hours worked. Review of S15FDR's time card and the CNA Break and Lunch Schedule Sheets, dated 02/04/2024 through 04/03/2024 revealed, S15FDR was assigned as a CNA to work independently on Floor B, Floor C, and Floor D to provide direct care to residents on 02/13/2024, 02/15/2024, 02/17/2024, 02/18/2024, 02/20/2024, 02/22/2024, 02/27/2024, 02/29/2024, 03/02/2024 through 03/04/2024, 03/07/2024, 03/08/2024, 03/12/2024, 03/13/2024, 03/16/2024, 03/17/2024, 03/20/2024 through 03/22/2024, 03/25/2024 through 03/27/2024, 04/02/2023, and 04/03/2024. Further review revealed, S16HumanResources approved S15FDR's above mentioned hours worked. In an interview on 04/03/2024 at 10:43 a.m. S16Human Resources Manager stated she was unaware the facility could not hire DSWs to provide direct care to residents. S16Human Resources confirmed the above mentioned staff were not certified and were working as nurse aides without having met the minimum state-approved competency and training requirements. In an interview on 04/03/2024 at 4:00 p.m., S2Director of Nursing (DON) stated she was unaware that all staff were not certified nursing assistants because she assumed the facility only hired certified staff. S2DON further stated all staff working on the floor should have a certification or license prior to providing direct care to residents. In an interview on 04/03/2024 at 10:50 a.m., S1Administator stated she was aware the above mentioned staff were working as nurse aides without having met the minimum state-approved competency and training requirements. S1Administrator further confirmed due actions of the facility, all 79 residents had the likelihood of experiencing serious injury or harm from 02/09/2024 through 04/03/2024 while the uncertified staff were providing direct care to residents without supervision without having met the minimum state-approved competency and training requirements. In an interview on 04/03/2024 at 4:37 p.m., S17CCO stated he was unaware S1Administrator was allowing uncertified staff to work in the facility as nurse aides and provided direct care to residents without having met the minimum state-approved competency and training requirements. S17CCO further stated the staff should not have been allowed to work as nurse aides and provide direct care independently to residents. S17CCO stated S1Administrator, S2DON, and S16Human Resource Manager were educated on the requirements for compliance to ensure no unlicensed assistive personnel were allowed to provide direct care to residents by the S18COO.

Based on record review and interview, the facility failed to Protect a resident from physical abuse for 2 Residents (Resident #4 and Resident #5) of 7(Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) sampled residents. This deficient practice resulted in an actual harm on 03/09/2023 for Resident #5 when Resident #3 hit Resident #5 with the arm of his wheelchair several times. Resident #5 was transferred to the hospital for emergency medical evaluation which revealed a laceration to Resident #5's scalp (the skin covering the head excluding the face). Resident #5 subsequently received surgical intervention to repair the laceration to the scalp. Resident #5 required wound care upon his discharged back to the facility on [DATE]. This deficient practice resulted in an actual harm on 05/31/2023 for Resident #4 when Resident #3 threw an object which hit Resident #4 in the face and left arm. Resident #4 received medical attention by the nursing staff and was transferred to the hospital for emergency medical evaluation which revealed a laceration to Resident #4's left cheek, a nasal fracture, a small laceration to the nose, and a contusion to the left upper arm. Resident #4 subsequently received surgical intervention to repair the laceration to the cheek. Resident #4 required wound monitoring upon discharged back to the facility on [DATE]. Based on the facility investigation, physical abuse was substantiated 03/09/2023 and on 05/31/2023. The incident on 03/09/2023 resulted in an actual harm with the potential for more than minimal harm for Resident #5. The incident on 05/31/2023 resulted in actual harm with the potential for more than minimal harm for Resident #4. Findings: Review of the facility's Abuse, Neglect and Exploitation policy revealed, in part; the purpose of the policy was to ensure the protection of residents and for the prevention of abuse and neglect. Definitions Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Resident #5 Review of Resident #5's record revealed, in part, Resident #5 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses, in part, unspecified dementia with behavioral disturbances. Review of Resident #5's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/06/2023 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderated cognitive impairment. Review of facility's incident investigation report revealed, in part, Resident #5 was hit on the head with the arm of a wheelchair by Resident #3 on 03/09/2023. Further review revealed Resident #5 was transferred to the hospital for evaluation and treatment. Review revealed S1Administrator interviewed Resident #3 and he stated Resident #5 was in my bed so I hit him. Review of the facility's Statewide Incident Management System (SIMS) report revealed, in part, Resident #5 had an incident of physical abuse which occurred on 03/09/2023. In an interview on 07/12/2023 at 2:57 p.m., S1Administrator confirmed the incident between Resident #3 and Resident #5 was resident to resident physical abuse. Review of Resident #5's nurse's notes dated 03/09/2023 at 6:48 p.m., revealed, in part, Resident #5 was returned to his unit (Floor 6) by S3Certified Nursing Assistant (S3CNA). S3CNA stated Resident #5 was on another unit (Floor 7) in a similar room (Room b) was located directly above his room on (Floor 6) Room a in the bed. Resident #3 was upset because Resident #5 was in his bed and requested for Resident #5 to get out of his bed. Resident #3 hit Resident #5 on the back of the head with the arm of his wheelchair. Resident #5 had blood noted on the back of the head and neck. Resident #5 had a laceration noted to the back of the head. Resident #5's Physician was notified and he was transferred to the hospital for an evaluation. Review of Resident #3's nurse's note dated 03/09/2023 revealed, in part, Resident #3 became upset when Resident #5 was in his room and yelled. S3CNA went to Resident #3's room to assist Resident #5 out of the bed into his wheelchair. Resident #5 was hit on the back of the head several times with the arm of a wheelchair by Resident #3 as he was escorted out of the room by S3CNA. Resident #3 was redirected and educated on violence. Resident #3 remained upset. Review of Resident #5's hospital record dated 03/09/2023 revealed, in part, he evaluated in the emergency department and diagnosis of laceration to scalp. Review of Resident #5's nurse's note dated 03/10/2023 at 11:00 a.m., revealed, in part, Resident #5 presents with four staples to scalp to back of head related to incident. In an interview on 07/10/2023 at 11:11 a.m., S2Registered Nurse (RN) stated she was the nurse for Resident #3 on 03/09/2023. S2RN stated on 03/09/2023 Resident #3 came to get her because he said a man was in his bed. S2RN stated she accompanied Resident #3 back to his room where she observed Resident #5 was in Resident #3's bed. S2RN stated she instructed Resident #5 to get out of Resident #3's bed and he did not comply. S2RN stated she escorted Resident #3 out of the room with her to get S3CNA to assist Resident #5 out of Resident #3's bed. S2RN stated she left Resident #3 in the hallway while she and S3CNA went back into Resident #3's room to assist Resident #5 out of Resident #3's bed. S2RN stated she left S3CNA in the room to assist Resident #5 into the wheelchair. S2RN stated S3CNA told her that Resident #5 was hit in the back of the head with the wheelchair arm. S2RN stated she assessed Resident #5 after he was hit on the head. S2RN stated Resident #5 had a laceration to his scalp from being hit on the back of the head with the wheelchair arm. S2RN stated Resident #5 was transferred to the emergency room . In an interview on 07/10/2023 at 11:39 a.m., S3CNA stated on 03/09/2023 he heard Resident #3 cursing and upset because Resident #5 was in his room. S3CNA stated Resident #3 hit Resident #5 over eight times with the arm of his wheelchair while he escorted Resident #5 in a wheelchair out of Resident #3's room. Resident #4 Review of Resident #4's record revealed, in part, Resident #4 was admitted to the facility on [DATE] with diagnoses, in part; Bipolar Disorder, Schizoaffective Disorder, difficulty in walking, Epilepsy, and Asthma. Review of Resident #4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/05/2023 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. Review of facility's incident investigation report dated 06/05/2023 revealed, in part, Resident #4 was hit on the head and arm by an object thrown by Resident #3 on 05/31/2023. Further review revealed Resident #4 was transferred to the hospital for evaluation and treatment. Review revealed S1Administrator interviewed Resident #3 and he stated Resident #4 entered his room so he threw something at her. Review of the facility's Statewide Incident Management System (SIMS) report revealed, in part, Resident #4 had an incident of physical abuse that occurred on 05/31/2023. Review of the facility's final report revealed the abuse was substantiated. In an interview on 07/12/2023 at 2:57 p.m., S1Administrator confirmed the incident between Resident #3 and Resident #4 was resident to resident physical abuse. Review of Resident #4's nurse's notes dated 05/31/2023 at 2:30 p.m., revealed, in part, Resident #4 walked into Resident #3's room and was struck in the face with an unknown object which caused a laceration to left side of face and nose , and small laceration to left arm. A pressure dressing to face, and 911 was called. Physician and Resident Representative notified and resident sent to ER by Emergency Medical Services (EMS), S5DON and S1Administrator notified. Review of Resident #3's nurse's note dated 05/31/2023 at 2:39 p.m. revealed, in part, Resident #3 sitting in room when another resident walked in. Resident #3 stated he asked her to leave, but she did not so he struck her with an unknown object. Resident responsible Party notified and MD notified. MD gave orders to send to local ER for psychiatry evaluation and treatment. Sent to ER by EMS, and Don and Administrator notified. Review of Resident #4's hospital record dated 05/31/2023 revealed, in part, was evaluated in the emergency department and diagnosis of laceration to left cheek, nasal fracture, and contusion to left bicep. Resident #4's left cheek sutured. Review of Resident #4's nurse's note dated 05/31/2023 at 8:30 p.m. revealed, in part, Resident #4 returned from evaluation and treatment from hospital. Resident #4 refused to listen to her staff. Arrived back about 7:00p.m. with a bandage above the neck on the left side. Family, doctor, Administrator, and DON notified of her return.

Based on observation, record review, and interview the facility failed to: 1. accurately assess and recognize that the dressings covering a resident's arms, legs, and trunk were combustible and was an accident hazard for 1 of 6 sampled residents (#3) who smoked cigarettes and was around other residents who smoked cigarettes; 2. assess to determine that Resident #3 needed constant supervision when outside smoking or outside in the smoking area with other residents who smoked because of the combustibility of the dressings covering the body; 3. to conduct a periodic comprehensive smoking assessment for 6 of 6 sampled residents (#1, #2, #3, #4, #5, and #6); and failed to ensure that quarterly reviews of residents smoking status was done at least quarterly as indicated per facility policy; 4. to assess residents who displayed aggressive, physical and abusive verbal behavior toward another resident for 2 of 6 sampled residents (#1 and #4); Resident #3's treatment included Curad (Xeroform [MEDICATION NAME] Dressing) and Elastic Bandage with self-closure to wrapped the resident ' s body from head to toe. The wound care nurse stated that the resident was wrapped like a mummy. She also stated that Resident #3 ' s treatment also involved using a soft-form stretch Gauze Bandage, and Silver [MEDICATION NAME] ([MEDICATION NAME] 1% in [MEDICATION NAME]. The Silver [MEDICATION NAME] was used topically all over the entire body and covered with Kling and Ace Wrap. The resident was placed in Immediately Jeopardy on [DATE] when the facility failed to assess the dressings covering the resident's skin as a combustible fire hazard for this resident who smoked cigarettes and was in the smoke area with other residents who smoked including a resident who had a history of [REDACTED]. The resident was smoking without supervision outside in the smoking area when Resident #4 set Resident #3 on fire with a cigarette lighter. Resident #3 sustained 3rd [MEDICAL CONDITION] 90% of his body which eventually caused his death. The Immediate Jeopardy ended for Resident #3 when the resident was transferred to the hospital. The deficient practice continued at a potential for more than minimal harm for any potential resident with combustible dressing treatments admitted to the facility. Based on the facility ' s list there were 31 smokers residing in the facility. Findings: Record review of the facility's policy for smoking, revision date on [DATE], Section for Procedure revealed the following in part: Procedure: 1. Prior to, or upon admission, residents shall be informed in writing, that smoking is permitted in designated areas only, and that smoking articles of any kind are to be stored in the nurses' station (or area designated by the facility ) and not permitted to be stored in resident living or sleeping quarters. 2. All residents will: 2.1 Be evaluated by licensed nursing staff regarding smoking preferences upon admission, quarterly, and with a significant change in resident mental or physical condition. 2.2 Be evaluated for risk factors and responsibility. 2.3 Be orientated to smoking areas and procedures. Resident #3 Review of the facility ' s policy dated [DATE] on smoking Titled Policy #AS-0009 revealed in part the facility is committed to maintaining a safe resident smoking environment in accordance with resident rights and preferences, in accordance with Life Safety Code requirements, and state and local laws governing safe practices for the facility. 8.3 of the facility ' s policy states that the care plan must be reviewed to ascertain if any specific safety devices, like a non-flammable apron must be used during the smoking period. Review of Resident #3 ' s clinical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the blisters were located on the resident ' s arms, legs, and mid body. Review of the resident ' s Evaluation for Unsupervised Smoking dated [DATE] revealed the following: Physical Ability- Question #4. If a history [MEDICAL CONDITION] present, would a smoking apron benefit the resident? Number 4 ' s box was checked no. But the care plan/approaches dated /,[DATE] stated: encourage resident to wear smoking apron when smoking, if needed; There was no documented evidence that the facility ' s staff encouraged Resident #3 to wear a smoke apron to prevent a possible injury. Review of the Physician ' s Wound Care Treatment Protocol for Resident #3 dated [DATE] until his transfer to the hospital on [DATE] revealed he was to get a daily whirlpool, then Silver [MEDICATION NAME] was to be applied all over his body, covering the body with Kling gauze and an ace wrap. Further review of the wound care treatment for [REDACTED]. Review of Resident #3 ' s entire clinical record revealed no documented evidence the facility assessed and evaluated the resident according to the policy regarding a resident with a physician's order [REDACTED]. The facility failed to identify the dressings as an accident hazard for fire for a resident who smoked cigarettes. Review of Resident #3 ' s Incident/Accident Report dated [DATE] at 9:00pm revealed he apparently was smoking unsupervised and his gown along with his Hydro gel gauze was set on fire by Resident #4. Further review revealed Resident #3 was engulfed with flames from neck to feet and had to be transported to a local hospital on [DATE] for treatment. Review of the local emergency room (ER) notes dated [DATE] at 10:21 pm revealed that Resident #3 was responsive upon arriving to the local ER and only verbalized " help me. " The ER notes indicated that the resident sustained [REDACTED]. Review of the hospital documentation dated [DATE] at 11:50pm revealed Resident #3 was transported to a burn unit via a local ambulance services. According to the Burn Unit documentation Resident#3 was admitted to the intensive care burn unit on [DATE] at 2:00 am. where he was intubated and stabilized. According to the burn unit's documentation for Resident #3 indicated that [MEDICAL CONDITION] 80% of his body sparing the face, right forearm and his left foot. Further review of the consultation notes indicated that the neck, chest, abdomen, back, bilateral upper extremities were all burned. The review of the ICU) Intensive Care recommendations for resident#3 revealed that his overall prognosis was poor. Review of the coroner's report for Resident #3 revealed that he expired on [DATE] at 12:57pm in the burn unit. Review of the facility ' s incident report dated [DATE] at 9:27 pm concerning Resident's #3 and #4 revealed in part Resident #3 was [AGE] years old with a [DIAGNOSES REDACTED]. The facility's documented summary revealed that at 9:00 pm a resident was noted coming into the dining room from off of the back porch, engulfed in flames from neck down. The facility ' s documentation continues to indicate that the nurse activated the fire alarm, put the fire out, and Resident #3 was transferred to the local emergency room for treatment. According to the facility ' s documented summary of the incident report indicated that Resident #4 stated on [DATE] that she was possibly responsible for the incident. Resident #4 was diagnosed with [REDACTED]. In interview [DATE] at 1:01 pm with S4, Wound Care Nurse indicated regarding Resident #3 ' s wound care treatment that it was not until after the fire incident that the facility realized the combustion capabilities of the treatment used. According to S#4, Wound Care Nurse the resident ' s treatment included, Curad (Xeroform [MEDICATION NAME] Dressing) and Elastic Bandage with self-closure to wrapped the resident ' s body from head to toe. The wound care nurse stated that the resident was wrapped like a mummy. She also stated that Resident #3 ' s treatment also involves using a soft-form stretch Gauze Bandage, and Silver [MEDICATION NAME] ([MEDICATION NAME] 1% in [MEDICATION NAME]. The Silver [MEDICATION NAME] was used topically all over the entire body and covered with Kling and Ace Wrap. When the surveyor ask about supervision of clients using combustible materials she stated that Resident #3 functioned on his own and did not require supervision. She further indicated the facility did not realize the components and capabilities of the wound care treatment and that it was a combustible material. Resident #1 Review of the facility ' s nursing notes for Resident #1 revealed that on [DATE] at 8:30pm and [DATE] at 6:15 pm the resident purchase cigarettes and walked to the patio to smoke unsupervised. Further review of nursing notes dated [DATE] at 8:00pm and [DATE] at 6:00pm for Resident #1 the nursing staff documented that the resident was caught smoking in bed and refused to give up his cigarettes and lighter. According to the nursing notes the resident gave his cigarettes to the ADON, S#3 after searching the resident personal belongings. The surveyor continued to review the nursing notes, and found on more than 2 occasions the resident refusing to attend his psych visits and was observed on [DATE] punching at another resident. Observation on [DATE] at 2:30pm Resident #1 was observed in his room. The resident was in bed. An attempt was made to interview Resident #1 on [DATE]. The resident indicated in an angry voice and with his eyes closed, " I am sleeping. " Resident #1 ' s roommate indicated Resident #1 is antisocial at times. No cigarettes or cigarette lighters were visible in the resident ' s bedroom. The resident ' s Quarterly MDS dated [DATE] read in part, C1000,Cognitive skills for daily decision-making; The facility enter a code of 1(modified independence), which means that he had some difficulty in new situations. The resident smoking assessment dated [DATE] indicated the resident had question # ' s 3, 4, 5, 6, 7 and 9 checked. According to the evaluation for unsupervised smoking states the following: question #3(Do residents ' fingers or clothing et al indicate a history [MEDICAL CONDITION] by smoking?) Question #4(If a history [MEDICAL CONDITION] present, would a smoking apron benefit the resident?) question #5(Does resident require assistance to enter the smoking area?) #6(Can resident safely demonstrate how to use a match and or a lighter?) question #7. (Can a resident safely demonstrate how to hold a cigarette/pipe?) question #9. (Does the resident exhibit any signs of tremors?). According to the Evaluation for Unsupervised Smoking, if the facility has a yes checked for Question # ' s 2,3,5,9 or 10 the resident required supervision while smoking. However the facility did not adhere to their assessment/evaluation check sheet for Resident #1 as it relates to supervision when smoking on the back patio and or away from the nursing unit. Resident #2 Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident ' s Quarterly MDS dated [DATE] read in part, C1000,Cognitive skills for daily decision-making; The facility enter a blank code with no response to decision-making. The resident ' s smoking assessment dated [DATE] indicated the resident had no smoking problems and did not require supervision. However, review of the facility ' s nurse ' s notes dated [DATE] at 11:40am, [DATE] at 3:15pm, and [DATE] at 3:50 and on the same date at 4:15pm and on [DATE] at 7:30pm resident was caught smoking in bed instead in a supervised location. However, review of the Behavior Intervention record for the months of ,[DATE] through [DATE] the facility documented zero ' s indicating that Resident#2 had no behavioral problems. Further review of the clinical record for Resident #2, revealed Resident #2 attended a community behavioral service outside the facility. However, at times would refuse to go to the community behavioral center. The facility had no documented evidence the plan care addressed this or any documented evidence of ongoing assessments regarding these problems. Resident #4 Resident #4 was not able to be observed in the Nursing Home. S1, Administrator, stated that she left the nursing home with the police on [DATE] after she confessed that she set fire to Resident #3 on [DATE]. Observation on [DATE] at 8:45am was made of Resident #4 ' s room. This room was occupied by two other residents. Resident #4 ' s bed was located by the window. Review of Resident #4 ' s 90L dated on [DATE] and [DATE] and PASRR Screen and Determination, revealed that Resident #4 was hospitalized at the local psychiatric hospital from [DATE] through [DATE] and [DATE] through [DATE] for a [DIAGNOSES REDACTED]. Record review of the Nurse ' s Note dated on [DATE] at 5:15, did not document AM or PM, revealed upon making rounds resident was in a wheel chair in her room, not responding appropriately, talking to her knees and the wall, very confused and disoriented, vital sign could not be obtained; Resident stated that the blood pressure cuff was a snake. The doctor notified and ordered was send Resident to a local hospital emergency room . Record review of the resident ' s Nurse ' s Notes dated [DATE], could not read time, revealed that Resident #4 was found outside building, sitting in a wheel chair in front of a grocery store. Resident stated that she wanted someone to buy her a pack of cigarettes. Nurse asked Resident to return to the facility. Resident became very combative stating " I am not leaving. " Record review of the Nurse ' s Note dated on [DATE] at 10:45am revealed that a fell ow resident reported that the resident told roommate to stop staring at me before I poke your eyes. Resident then lifted herself up from her wheel chair and walked toward roommate placing her two fingers on roommate ' s face. Record review of the Psychiatric Evaluation from the local Psychiatric Hospital, date of admission on [DATE] and date of dictation on [DATE] (Resident discharged from psychiatric hospital on [DATE]) revealed the following in part: Resident #4 was admitted to the Local Psychiatric Hospital referred by the nursing home due to assaultive behavior and paranoid [MEDICAL CONDITION]. CHIEF COMPLAINT: " A lady over there was staring at me and I told her not to stare and that should not be the reason for coming to the hospital. " HISTORY OF PRESENTING ILLNESS: According to the intake note, the patient was paranoid and accusing roommate of staring at her. She hit her roommate with a walker and poked her in her eyes. The patient states that her roommate was talking about her. She has been panhandling on the street corner. She has increased sexual behavior and frequently wakes during the night. The patient was being aggressive with other residents also. The patient is obsessed about her cigarettes and was upset when getting cigarettes late. She is angry, irritable, easily agitated and has poor insight into this situation. PAST PSYCHIATRIC HISTORY: The patient states that she was hospitalized for [REDACTED]. The patient did not want to talk about that but she states that is over with flashbacks, dreams, and anger problems. Review of the Local Psychiatric Hospital Physicians Order Form dated on [DATE] revealed a referral to the Hospital Intensive Outpatient Care. Record review of the Hospital Discharge Instructions & Aftercare Plan dated on [DATE], section for Psychiatric & Medical aftercare Plan revealed the following: Psychiatric Follow-up with: Private Psychiatrist Dr. S12 at nursing home. Other programs/ Meeting/ Support groups specify: D/C instructions & Packet faxed to this Intensive Outpatient Care. The facility had no documented evidence of that Resident #4 was assessed by S12, Psychiatrist, and attended Intensive Outpatient Care (IOP) or other programs as requested by the psychiatrist. Record review of the Resident #4 ' s admission Minimum Data Set (MDS), dated on [DATE], revealed following in part; Section A1800 revealed that Resident #4 was admitted to the nursing home from a psychiatric hospital, Section C0500 Cognitive Score 15 (,[DATE]), D0100 Resident Mood interview (PH-9)- Question C. Trouble falling asleep, or sleeping too much-Symptom presence (0) and Symptom Frequency (0)- Total Severity Score-0, Section E0100. [MEDICAL CONDITION]-None, E0200. Behavior Symptom-none, E 0600. Impact on others- did not coded. Record review of the Nurse ' s Note dated on [DATE] at 2:00am revealed Resident up in wheel chair rolling around facility going out to patio often to smoke. Record review of the Nurse ' s Note dated on [DATE] at 2:00am revealed the resident was out of bed sitting in wheel chair at bedside. At 4:00am Resident remained in a wheel chair stated that " I don ' t ' want to get in bed. " At 6:00am Resident going out to the patio for smoking. Record review of the Nurse ' s Note dated on [DATE] at 2:30pm, Resident was in front of the store begging for money, and she state that she went in the store to get her some cigarettes and she slammed her finger. Record review of the Facility ' s Behavior Intervention Monthly Flow Record for the month of ,[DATE] revealed the following: Behavior Problem: Socially inappropriate as evidenced by Nurse ' s Note dated [DATE], wherein Resident #4 was in front of the store begging for money. Goal: Resident will have fewer episodes of (Specify behavior): begging Pedestrians for money, as evidenced by behavior occurring: less than 3 times per week by next review. Interventions/ Approaches: Monitor behavior episodes & attempt to determine under-lying cause. Consider location, time of day, person involved etc -Discipline by Social services. In an interview on [DATE] at 9:17am S17, LPN, indicated that she was working with the Resident #4, when she alleged that she set another resident on fire. She further indicated that in reference to the aftercare follow-up orders and aftercare is checked within 24 hours. S17, LPN, indicated the resident had several psychiatric admits to the hospital within the last 3 months. S 17, LPN, also indicated that the aftercare appointments are set up by the ward clerk. The S17, LPN, stated after reviewing Resident#4 ' s medical record " I do not see documentation of the appointments " . During an interview on [DATE] at 12:08pm with S#3, ADON and S#5, Director of Clinical Evaluation, they indicated that when resident goes out of the facility or comes back to the facility for any appointment, the facility has no system for documents because that activity is normal and staff knows. If any medication changes then the nurse documents the change after the resident comes back from the appointment. When surveyor questioned how many times Resident #4 went to the Intensive Outpatient Care, they both could not give an answer. [DATE] at 11:15am Dr. S11 (Medical Director & primary physician) revealed during interview that he was Resident #4 ' s primary physician. He was not aware of the aftercare orders which were presented to S11, MD. The After Care/Discharge Summary revealed that the resident needed to be seen by S#12, the psychiatrist, and be referred to Intensive out Patient Program for group sessions etc. S#11, MD, indicated that he had concerns in the past with residents being discharged from the behavior units with very little documentation as to what aftercare services are needed at the facility. S#11, MD, stated " That has been a concern of mind for a while. " S#11, MD, indicated that the Nurse Practitioner also make visits when appointments are made. S#11, MD, was unsure of the last psychiatric visit made to Resident #4 after being discharged from the behavior incident on [DATE]. S#11, MD, was questioned concerning Resident #4 ' s [MEDICATION NAME] which was discontinued on [DATE] because Resident #4 refused to take according to Physician ' s Telephone Orders. S#11, MD, responded by saying that the state regulations are causing the doctors to have no choice but to discontinue medications when the resident is on multiple [MEDICAL CONDITION] medications. An interview was conducted on [DATE] at 9:00am with S3, DON, regarding the psychiatric follow-up/aftercare. He indicated that Resident #4 was admitted to the hospital for behavioral concerns in May and in [DATE]. After he reviewed the documents (Aftercare/ Discharge notes and Progress notes dated on [DATE]) he indicated that Resident #4 needed to be seen by the psychiatrist and referred to the center for support groups. The DON indicated he was not sure who made the appointments for aftercare. Normally the nurse will contact S12, Psychiatrist, and schedule the aftercare appointments. The DON was unsuccessful in locating documentation indicating a follow-up for aftercare was scheduled and followed as indicated per discharge physician. During the survey on [DATE] and [DATE], policies on assessments supervision, monitoring and aftercare follow-ups for a psychiatric patient were requested. The DON could not locate a policy addressing what system and/or protocol was in place in order to ensure the facility was following the physicians ' orders and follow-up recommendations once psychiatric patients are discharged from the hospital back to the nursing facility. An interview was conducted on [DATE] at 11:33am with S12, Psychiatrist. He indicated that he was familiar with Resident #4. He further indicated that she was a very difficult patient and had a history of [REDACTED]. S12, Psychiatrist, also indicated that once he discharged the patient from the psychiatric hospital he documented his recommendations and the aftercare plan is written by staff at the hospital. In addition S12, Psychiatrist, indicated an aftercare form is sent back to the nursing facility with the patient once the patient is discharged from the hospital. The Aftercare Form includes follow-up recommendations. S12, Psychiatrist, indicated that Resident #4 was seen at the outpatient program at the hospital. He indicated that the copies of the notes can be obtained from the hospital. In addition, the Psychiatrist reported that the " Nursing Home is overwhelmed and that they cannot document everything. I was told that Resident #4 has a chart at Psychiatric Hospital. " S12, Psychiatrist, indicated that the resident was refusing to take the [MEDICATION NAME] therefore, S11, Primary Dr., discontinued the medications. He further indicated that the resident is on another medication, [MEDICATION NAME] 5mg at bed time. S12, Psychiatrist, stated that she was a difficult patient and that he saw her twice. The first time he saw her was in [DATE]. He also indicated that the resident had [MEDICAL CONDITION] and required oxygen. He stated that she wanted to remove the oxygen in order to smoke. During an interview on [DATE], S6, MDS Coordinator, indicated that MDS Section B- Hearing, Speech, and Vision, Section C- Cognitive patterns, Section D-Mood, Section E-Behavior, and Section Q- participation in Assessment were done by the Social Worker. During an interview on [DATE] at 9:30am, S2, DON, he indicated that Resident ' s behavior assessment should have been done according problems. During an interview on [DATE] at 1:11pm, S19, Director of Social Services, indicated that the Resident ' s inappropriate behavior happened outside of the facility and that the resident has a history of panhandling. She further indicated that MDS assessment requires a 7 day look back. She also indicated that the MDS assessment does not require that the incident happen outside of the facility. Record review of the Social Services progress Notes dated [DATE] revealed the following in part: Resident #4 had no problems, fully participating in assessment for look back for [DATE]- [DATE]. No sign/symptom of mood, [MEDICAL CONDITION] or behaviors at present. Resident can be good talking to peers and staff or outside smoking. Resident #4 is a safe smoker. Record review of Resident #4 ' s the Evaluation for Unsupervised Smoking revealed the evaluation was dated [DATE]. The evaluation revealed the resident did not require supervision with smoking, next smoking assess was done [DATE] revealed question #2 was answered " yes " as to indicate if resident requires O2, is he/she unable to recognize need to remove before smoking? The assessment form indicated if question #2 is " yes " the resident needed supervision when smoking. Record review of Resident #4 ' s Plan of Care Goal Dated [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] revealed the following in part: Evaluation for unsupervised smoking (CWP802) to be completed on admission, quarterly, and PRN as long as the resident continues to smoke. Supervise smoking activity. During an interview on [DATE] at 1:47pm, S2, DON, confirmed that the last smoking assessment done for Resident #4 was [DATE]. He further indicated that the smoking assessment for Resident #4 was not done quarterly. Resident #5: Review of Resident #5 ' s clinical record revealed that he was admitted to the facility on [DATE], and he had a [DIAGNOSES REDACTED]. Review of the Physician ' s Progress Notes dated [DATE] revealed under Social History Resident that Resident #5 was a smoker but no longer smokes. Record review revealed that the resident needed maximal assistance with activities of daily living. Peg tube utilized for medications and feedings. Right side and left side weakness per History and Physical dated [DATE]. Resident wheelchair bound. Nurses Notes dated [DATE] at 1:00pm revealed Resident #5 ' s speech slurred, smokes cigarettes frequently with supervision. Record review revealed the Evaluation for Unsupervised Smoking revealed the evaluation was dated [DATE]. The evaluation revealed the resident needed supervision with smoking. Review of the Evaluation for unsupervised smoking dated [DATE] revealed question #5 was answered " yes " as to indicate the resident needed assistance to enter the smoking room. The assessment form indicated if question #5 is " yes " the resident needed supervision when smoking. Review of The Evaluation for Unsupervised Smoking dated [DATE] revealed questions #5, #9 & #10 were answered " yes. " The Smoking Evaluation Form revealed the Interdisciplinary Care Team (IDT) determines the safety of unsupervised resident smoking. If the IDT determine that this resident cannot safely smoke independently, supervised smoking is recommended. Personal smoking apparatus is to be stored according to the facility protocol. Review of unsupervised smoking status will be reviewed quarterly and with significant change in the resident ' s condition. In an interview on [DATE] at 12:31pm, S2, DON, indicated that the monitoring system put in place to monitor residents who are smoking is hard to do. The DON indicated that the residents have a right to go to the stores and make purchases. " This is their home. " The residents who are wheelchair bound will get cognitive residents to purchase cigarettes from the store. The DON indicated the residents cognitively impaired should be screened and monitored. Care Plan review dated [DATE] (first notation by IDT) revealed Resident wishes to smoke. Evaluate, observe, and store cigarettes and lighter in safe place, provide smoking apron, smoke in designated area, supervise smoking activity. Record review revealed the facility assessment per physician revealed the resident was no longer smoking. However the nurse ' s notes and smoking assessments revealed the resident was still smoking. The facility failed to ensure that quarterly reviews of residents smoking status was done at least quarterly as indicated per policy. The smoking policy evaluation for Resident # 5 was done on [DATE] and not again until [DATE] (day of incident with complaint). Resident #6: Review of Resident #6 ' s clinical record revealed that he was admitted to the facility on [DATE] and that he had a [DIAGNOSES REDACTED]. Record review of the Evaluation for Unsupervised Smoking revealed the evaluation was dated [DATE]. The evaluation revealed that the resident did not require supervision with smoking. Record review revealed the Evaluation for Unsupervised Smoking evaluation was done on [DATE] and not again until [DATE](after the incident on [DATE]). Care Plan review dated [DATE] revealed Resident wishes to smoke. Smoking assessment to be completed on admission and quarterly, as long as resident continues to smoke. Resident to smoke in designated areas only. An interview was conducted on [DATE] at 12:40pm, with S2, DON. He indicated that the smoking evaluations were done by S19, Director of Social Services; however, he acknowledged that the smoking assessments were not done as indicated per policy. An interview was conducted on [DATE] at 1:11pm, with S 19, Director of Social Services. She indicated that she and S5, Director of Clinical Evaluation, did smoking assessments for entire residents in the facility, and smoker ' s assessment records are in the chart. A stack of assessment records are still in S5 ' s office those are residents who are not smokers. She further indicated that she was hired around [DATE]. In interview on [DATE] at 1:40 pm S9, Corporate Nurse, indicated that staff needed to communicate with each other and the facility needs a system in place for accurate smoking assessment. .

Based on observation, record review, and interview the facility failed to: a) identify a total body gauze dressings as a potential accident fire hazard on a resident who smoked (#3); b) supervise a resident with total body guaze dressings while he was outside in the smoking area smoking or with other residents who smoke (#3); c) supervise a resident who had a history of [REDACTED]. d) assure members of the staff provided all smokers with adequate supervision to prevent accidents by not supervising 5 of 6 sampled residents (#1,#2,#3,#4 and #6) identified by the facility as smokers in need of supervision when smoking. Resident #3 was placed in an Immediate Jeopardy situation on [DATE] while smoking outside with no supervision when another smoker, Resident #4, set Resident #3's bandages on fire causing the resident to sustain 3rd degree burns over 90% of his body eventually resulting in Resident #3's death on [DATE] at 1:00pm. The Immediate Jeopardy was removed for Resident #3 when he was transferred to a local hospital on [DATE]. The Immediate Jeopardy situation continued for 31 of 31 residents identified by the facility as smokers residing at the facility as documented on the facility's list of unsupervised smokers (#1, #2, and #4 through #31). On [DATE] at 4:00pm S1, Administrator and S5, Director of Clinical Evaluation presented a list of all the smokers in the facility. S1, Administrator indicated no resident would be allowed to smoke without being supervised. S1, Administrator further indicated a nursing assistant would be assigned to monitor all residents when they are outside smoking. S#5, Director of Clinical Evaluation indicated all residents were assessed and re-evaluated for unsupervised smoking as of [DATE]. S1, Administrator further indicated the assigned nursing assistant will have a binder with all smokers and their cigarettes and lighters would be locked up in a black lock box located on the back patio. S2, Director of Nurses (DON) indicated after the incident of the resident being burned by another resident, all cigarettes and lighters were removed from the resident's rooms. A smoking supervisory evaluation was done on every resident. Resident #4 was arrested and removed from the facility by the police on [DATE] at 2:30pm. The Immediate Jeopardy was removed for the smokers on [DATE] at 2:30pm when the facility implemented an acceptable plan of removal. This deficient practice continues at Level III Actual Harm for Resident #3 and potential for more than minimal harm for the residents who smoke cigarettes as the facility had not fully implemented a system with quality assurance to ensure the deficient practice does not occur again. The total facility census was 100 residents as documented on the facility's Census and Conditions of Residents form. A total of 31 smokers were identified as being in need of supervision when smoking. Findings: Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE] with the diagnoses of Bullous (Pemphigoid) Perphysia, Schizophrenia, Dehydration, Cellulitis, Anemia, blisters, Stage IV to the buttocks and Malnutrition. Review of the nurse's notes for Resident #3 dated [DATE] revealed Resident #3 was admitted with multiple blisters that had erupted with drainage all over the body. Further review revealed Resident #3 was also admitted with Stage IV pressure ulcers to the left and right buttocks. According to the documentation in the nursing notes, Resident #3 was able to ambulate as desired, but his gait remains unsteady. Review of the nurse's notes dated on [DATE] at 9:15 pm and 9:30 pm revealed S7, LPN and S16, LPN documented Resident #3 was observed engulfed in flames from neck down, yelling " help me. " Record review of the nurse ' s notes dated [DATE] at 9:15 pm revealed S16, LPN documented that she ran and obtain the fire extinguisher, called a code, and began spraying the resident with the fire extinguisher until the room became overwhelmed with smoke. During an interview on [DATE] at 3:15 PM S16, LPN indicated she had to back out of the dining room because of the thick smoke, but continue to spray the resident until the fire extinguisher was empty. In interview on [DATE] at 3:30 pm S7 and S16, LPNs indicated as the smoke thinned out Resident #3 was observed on his knees on the dining room floor, pleading for help. S16, LPN further indicated the resident was coughing and choking from the smoke inhalation and she instructed the resident to lie down on the floor until the ambulance arrived. Review of Resident #3's local emergency room (ER) record dated [DATE] at 10:21 pm revealed Resident #3 was responsive upon arriving to the local ER and only verbalized " help me. " The ER notes dated [DATE] revealed the Resident had sustained 3rd degree burns from his neck to his feet which was listed as 90% of his body. Review of the local hospital's documentation dated [DATE] at 11:50pm revealed Resident #3 was transported to a burn unit via a local ambulance services. Further review revealed Resident #3 was admitted to the intensive care burn unit on [DATE] at 2:00 am. where he was intubated and stabilized. Review of the intensive care burn unit documentation for Resident #3 revealed his burns covered 90% of his body sparing the face, right forearm, and his left foot. Review of the consultation notes dated [DATE] revealed the neck, chest, abdomen, back, bilateral upper extremities were all burned. Review of the ICU recommendations for Resident #3 dated [DATE] revealed his overall prognosis was poor. Review of the Coroner's Report for Resident #3 revealed that he expired on [DATE] at 12:57pm in the burn unit. In interview on [DATE] at 3:45pm S2, DON indicated on [DATE] at 9pm he heard the fire alarm go off and attempted to go down stairs to see what happened. He further indicated when he arrived on first floor the fire had been put out. He indicated he observed Resident#3 on his knees moving his head back and forth but the resident did not say anything. He also indicated on the next day, [DATE] Resident #4 admitted to setting Resident #3 on fire because he was not taking her cigarettes from her anymore. In interview on [DATE] at 3:59pm S8, Certified Nursing Assistant indicated on [DATE] at 9pm the fire alarm went off and a female resident was heard yelling " man was on fire. " She further indicated she and the nurse had a fire extinguisher to put out the fire. She also indicated the whole dining room was filling with smoke. In interview on [DATE] at 3pm S7, LPN indicated she has been employed at the facility since [DATE]. She further indicated she was working on 2nd floor seated at nursing station when she heard the fire alarm go off and the system indicated the fire was on the first floor in the dining room area. She stated another nurse was observed backing up with fire extinguisher, yelling "he is on fire." She also stated the dining room was full of smoke and she could not get to the resident because of the thick smoke. In interview on [DATE] at 1:40am Resident #11 indicated she was sitting in the dining room by the window when she saw a man on fire. She indicated she could not get to the phone. She also indicated no staff was outside. She also stated staff could not get to the man right away because he was next to the extinguisher on the wall. She further indicated Resident #4, the perpetrator, got along with some of the residents but not everybody. She said Resident #4 smoked a lot but she had never seen the resident hit anybody. She did indicate she had witnessed Resident #4 getting upset in the past. In interview on [DATE] at 9:28 am S15, LPN indicated she works on the ,[DATE] shift. She described Resident #4 as being difficult at times. She stated many times the resident would refuse her medication, especially the Depakote. S15, LPN stated that the doctor would instruct the staff to put all concerns in a problem book to remind him, upon his visit, to discontinue the Depakote. She further stated Resident #4 was on Abilifly. She said Resident #4 was not well liked by some of the residents. S15, LPN stated that a smoking assessment had been done upon admission and Resident #4 was allowed to keep her own lighter and cigarettes. She further indicated the resident was care planned as competent to smoke. She stated on the night of the incident the resident was not acting any different from usual. She stated that she did not document anything after the incident. The nurse stated she did not know where Resident #4 was at time of the fire. She stated that she called 911 and instructed staff to close all doors. Resident #4 approached the nurse and stated that she burned Resident #3 with her lighter. S15, LPN stated she did not document on [DATE] and was written up for not documenting the incident, as well as not documenting that she heard Resident #4 confessing to burning Resident #3. S15, LPN stated that Resident #4 confessed in front of the Medical Examiner and ADON, but the ADON denies hearing that Resident #4 confessed to burning Resident #3. Resident #4's speech was very clear when she confessed to burning Resident #3. She further indicated at about 8pm on [DATE] Resident #4 stated she burned him (Resident #3) because he would not give her a cigarette. S15, LPN stated that she tried to get Resident #3 to come inside, but refused to come in. She stated he asked her for a cigarette and he was told that she does not give residents cigarettes. He then pulled out his own cigarette. S15, LPN stated that Resident #3 showed her that he had cigarettes and did not need her to give him a cigarette. S15, LPN stated that she did not repeat it to her supervisor on the night of the incident. She stated that about 10:30pm the medical examiner called for an interview. She stated she left the facility at 1:00am and prior leaving, Resident #4 was instructed to go the bed. She stated that she checked on Resident #4 before leaving and found her to be asleep. She further indicated on Saturday [DATE] at 2:30pm the police investigators were waiting to question her. She stated that she did not remember documenting that Resident #4 was not a safe smoker. She admitted to not reviewing Resident #4's record. She did indicate the residents all kept their own lighter and cigarettes. Resident #3's MDS (Minimum Data Set) Admission assessment dated on [DATE] revealed Resident ' s cognitive score as 15 out of 15. Review of Resident #3's care plan dated [DATE] revealed safe smoking was identified as a problem. Further review revealed the following: Goal: will be safe from injury related to smoking. Approaches: Encourage resident to store cigarettes and lighters in a secure location; encourage resident to wear smoking apron when smoking, if needed; Supervise smoking activity. Review of the Resident#3's clinical record dated [DATE] revealed no documented evidence the facility had implemented goals and approaches that might have protected him (Resident #3) from the injury which lead to his death. Review of Resident #3's Evaluation for Unsupervised Smoking form dated [DATE] revealed the following: #4: if a history of burns is present, would a smoking apron benefit the resident? Number 4, box was checked no. But the care plan/approaches dated [DATE] stated: encourage resident to wear smoking apron when smoking, if needed; There was no documented evidence in the resident's clinical record to support that the facility ' s staff had encouraged Resident #3 to wear a smoke apron to prevent possible injuries. In interview on [DATE] at 10:28 am when asked why Resident #3 did not have a smoking apron on when smoking as stated in the resident's care plan under the approaches. S4, Wound Care Nurse and S3, ADON indicated the resident was encouraged to use a smoking apron, but he refused to wear the smoking apron. Review of Resident #3's clinical record revealed no documented evidence the resident refused to wear the apron and no documentation stating that he was encouraged to wear a smoking apron when smoking on the patio. S3, ADON and S4, Wound Care Nurse further indicated that the apron would have only covered the front of the resident, not the whole body. S4 acknowledged there was no documentation in the clinical record to support that the resident was encouraged to wear a smoking apron as per plan of care. Review of Resident #3's Physician's Wound Care Treatment Protocol dated [DATE] until his death revealed he was to get the following treatments to treat the blisters all over his body: he was to get a daily whirlpool, then Silver Sulfadiazine was to be applied all over his body, and the body was to be covered with Kling gauze and an ace wrap. Further review of the wound care treatment for [REDACTED]. Review of the facility's Smoker's Policy #AS-0009 revealed in part the facility is committed to maintaining a safe resident smoking environment in accordance with resident rights and preferences, in accordance with Life safety Code requirements, and state and local laws governing safe practices for the facility. Review of the facility's current Incident ID: dated [DATE] at 9:27pm concerning Residents #3 and #4 revealed in part that Resident #3, age [AGE] years old with a [DIAGNOSES REDACTED]. The facility's documented summary revealed on [DATE] at 9:00pm a resident was noted coming into the dining room from off of the back porch, engulfed in flames from neck down. The facility's documentation continues to indicate that the nurse activated the fire alarm, put the fire out, and Resident #3 was transferred to the local emergency room for treatment. According to the facility's documented summary of the incident report, Resident #4 stated on [DATE] at 8:00 am that she was possibly responsible for the incident. Resident #4 was diagnosed with [REDACTED]. According to the facility ' s incident/ investigational report, resident#3 was set fire because he would not give her a cigarette. This was no accident. The resident, #4/perpetrator stated that she set fire to resident #3 ' s clothing. There no documentation stating that she was cognitive at the time of the incident. According to the MDS dated [DATE] the facility documented a 15 which means she was cognitively intact. However resident #4 admitting record revealed that the Resident was diagnosed with [REDACTED]. According to nurses notes the resident frequently refused her psychiatric medication. The resident never had a Mental Health Evaluation which would have indicated that she was not mentally stable to admit into the nursing home Review of the clinical records of the other sampled residents, #1, #2, #4, and #6 revealed they were identified as Independent Smokers and had been reviewed on [DATE]. The review revealed the following: Resident #1 Resident #1 was admitted on [DATE] with diagnoses of in part, Diabetes Mellitus, Bipolar Disorder, Throat Cancer, Gastro Esophageal Reflux Disease, Insomnia, Psychiatric Illness Mood Disorder, Drug Abuse, Neuropathy, Aggressive Behavior, and COPD. The resident's Quarterly MDS dated [DATE] read in part, C1000,Cognitive skills for daily decision-making; The facility enter a code of 1( modified independence), which means that he had some difficulty in new situations. The resident's smoking assessment dated [DATE] indicated the resident had # ' s 3, 4, 5, 6, 7 and 9 checked. Review of the facility's Evaluation for Unsupervised Smoking revealed the following: #3. (yes) (Do resident's fingers or clothing et al indicate a history of burns caused by smoking? #4. (yes) If a history of burns is present, would a smoking apron benefit the resident? #5. (yes) Does resident require assistance to enter the smoking area? (yes) #6. Can resident safely demonstrate how to use a match and or a lighter? (yes)#7. Can a resident safely demonstrate how to hold a cigarette/pipe? (yes) #9. Does the resident exhibit any signs of tremors? According to the Evaluation for Unsupervised Smoking, if the facility has a yes checked for # ' s 2,3,5,9 or 10 the resident required supervision while smoking. However, the facility did not adhere to their assessment/evaluation check sheet for Resident #1 as residents were being allowed to smoke unsupervised. According to the facility's evaluation resident 1 needed supervision when smoking. Resident #2 Resident #2 was admitted on [DATE] with diagnoses of Paranoid Unspecified, Major Depression, Mood Disorder, Alcohol Abuse, Cerebrovascular Accident, Left-sided Hemi paresis, History of Pancreatitis Hypertension, Osteoarthritis, and Use of Tobacco. The resident ' s Quarterly MDS dated [DATE] read in part, C1000, Cognitive skills for daily decision-making; The facility entered a blank code with no response to decision-making. The resident smoking assessment dated [DATE] revealed the resident had no smoking problems and did not require supervision. However, review of the resident's nurse's notes dated [DATE] at 11:40am, [DATE] at 3:35pm, and [DATE] at 3:50pm and 4:45pm revealed the resident had been smoking in bed unsupervised. Resident #2 was reported on several occasions smoking in bed unsupervised, but his evaluation for unsupervised smoking dated [DATE] indicated that Resident #2 had no problems and did not need supervision while or when smoking. Review of the facility's nursing notes dated [DATE] at 7:30am for Resident #2 revealed that the nursing assistant smelled smoke upon entering the resident's room. According to the nurse's notes the resident denied smoking and refuses to give the staff the cigarettes and lighter. According to the facility's nurse's notes the administrator was called out to retrieved the cigarettes and lighter from Resident #2. Resident #4 Resident #4 was not able to be observed in the Nursing Home. S1, Administrator, stated that she left the nursing home with the police on [DATE] after she confessed that she set fire to Resident #3 on [DATE]. Observation on [DATE] at 8:45am was made of Resident #4's room. This room was occupied by two other residents. Resident #4's bed was located by the window. Review of Resident #4's 90L dated on [DATE] and [DATE] and PASRR Screen and Determination revealed Resident #4 was hospitalized at the local psychiatric hospital from [DATE] through [DATE] and [DATE] through [DATE] for a [DIAGNOSES REDACTED]. Resident #4's admission Minimum Data Set (MDS), dated on [DATE], Section A1800 revealed that Resident #4 was admitted to the nursing home from a Psychiatric hospital. Record review of the Nurse's Notes dated on [DATE] at 11:40pm, revealed Resident #4 was sitting in TV room area shouting to a black resident " Jesus is a white man, all you black people are going to get what ' s coming to you. " Nurses approached to the resident calm situation and removed other residents from area. Resident #4 began speaking with different voice and different facial expression and aggressive voice " you all are going to get it whites go to the mental house, blacks go to the crazy house. " Resident continues to ramble to imaginary person, with questions or approaches. Resident continues to ramble without acknowledging staff or others in presence. Record review of the Return to Clinic/Follow up, signed by S12, Psychiatrist, on [DATE] revealed Resident ' s [DIAGNOSES REDACTED]. Record review of the Psychiatric Evaluation from the local Psychiatric Hospital dated on [DATE] revealed: Identification Data: This is a [AGE] year old divorced white female who is a resident of Nursing Home, seen first at the nursing home for aggressive behavior. Chief Complaint: " I speak for my rights and people do not like that. " History of presenting Illness: According to the staff, the patient has been aggressive for the last three days. She refuses all of her medicines. The patient is talking to herself and speaks in changing voices. She threw oxygen off and was confused, agitated and up most of the night. She is hyperactive, irritable, angry and paranoid. As per the psychiatric evaluation, the patient states that she wanted to have a white eye doctor, not the black one. She was depressed a couple of weeks ago. She is hyperactive, impulsive, and intrusive for the last few days. Past Psychiatric History: The patient states that she was in psychiatric hospitals in the past. She has not been in psychiatric facilities for at least a couple of years. She does not want to talk about suicide because according to her, it was her past. Mental Status Examination: She is very paranoid and talks in different tones. She is intrusive and focused on her legal rights. Insight and Judgment are impaired. Psychiatric Diagnoses: [REDACTED]. AXIS II: No diagnosis. AXIS III: Hypertension, diabetes mellitus, CVA, DVT, arthritis, COPD AXIS IV: Medical problems, missing friend who is on home visit, declining memory, noncompliance with medication, poor support system, chronic mental illness. Record review of the Nurse ' s Note dated on [DATE] at 5:15, no documentation to indicate AM or PM, revealed upon making rounds Resident in a wheel chair in her room, not responding appropriately, talking to her knees and the wall. Very confused and disoriented, vital sign could not be obtained; Resident stated that the blood pressure cuff was a snake. The doctor notified and ordered was send Resident to a local hospital emergency room . Record review of the Nurse ' s Notes dated on [DATE], could not read time, revealed that Resident #4 was found outside building, sitting in a wheel chair in front of a grocery store. Resident stated that she wanted someone to buy her a pack of cigarettes. Nurse asked Resident to return to the facility. Resident became very combative stating " I am not leaving. " Record review of the Nurse ' s Note dated on [DATE] at 10:45 am revealed that a fell ow resident reported that the Resident told roommate to stop staring at me before I poke your eyes. Resident then lifted herself up from her wheel chair and walked toward roommate placing her two fingers on roommate ' s face. Record review of the Nurse ' s Note dated on [DATE] at 2:00am revealed Resident up in wheel chair rolling around facility going out to patio often to smoke. Record review of the Nurse ' s Note dated on [DATE] at 2:00am revealed Resident out of bed sitting in wheel chair at bedside. At 4:00am Resident remained in a wheel chair stated that " I don ' t ' want to get in bed. " At 6:00 is Resident going out to the patio for smoking. Record review of the Nurse ' s Note dated on [DATE] at 2:30pm, Resident was in front of the store begging for money, and she state that she went in the store to get her some cigarettes and she slammed her finger. Record review of the Psychiatric Evaluation from the local Psychiatric Hospital, Date of admission on [DATE] and Date of dictation on [DATE] (Resident discharged from psychiatric hospital on [DATE]) revealed the following in part: IDENTIFICATION DATA: This is a [AGE] year old female who is a resident of a nursing home referred by the nursing home due to assaultive behavior and paranoid delusions. CHIEF COMPLAINT: " A lady over there was staring at me and I told her not to stare and that should not be the reason for coming to the hospital. " HISTORY OF PRESENTING ILLNESS: According to the intake note, the patient was paranoid and accusing roommate of staring at her. She hit her roommate with a walker and poked her in her eyes. The patient states that her roommate was talking about her. She has been panhandling on the street corner. She has increased sexual behavior and frequently wakes during the night. The patient was being aggressive with other residents also. The patient is obsessed about her cigarettes and was upset when getting cigarettes late. She is angry, irritable, easily agitated and has poor insight into this situation. PAST PSYCHIATRIC HISTORY: The patient states that she was hospitalized for [REDACTED]. The patient did not want to talk about that but she states that is over with flashbacks, dreams, and anger problems. Review of the Hospital physician's order [REDACTED]. Record review of the Hospital Discharge Instructions & Aftercare Plan dated on [DATE], section for Psychiatric & Medical aftercare Plan revealed the following: Psychiatric Follow-up with: Private Psychiatrist Dr. S12 at assessing Nursing home. Other programs/ Meeting/ Support groups specify: D/C instructions & Packet faxed to this Intensive Outpatient Care (IOP). During an interview on [DATE] at 9:17am, S17, LPN indicated that the aftercare appointments are set up by the ward clerk, also transportation is arranged by the ward clerk. The LPN stated after reviewing Resident #4 ' s medical record " I do not see documentation of the appointments. " During an interview on [DATE] at 12:08pm with S#3, ADON and S#5, Director of Clinical Evaluation, they indicated when the resident goes out of the facility or comes back to the facility for any appointment, the facility has no system for documents because that activity is normal and staff knows. If any medication changes, then the nurse documents the change after the resident comes back from the appointment. When surveyor questioned how many times Resident #4 went to the Intensive Outpatient Care, they both could not give an answer. On [DATE] at 11:15am Dr. S11 (Medical Director & primary physician) revealed during interview that he was Resident #4 ' s primary physician. He was not aware of the aftercare orders which were presented to S11, MD. The After Care/Discharge Summary revealed that the resident needed to be seen by S#12, the psychiatrist, and be referred to Intensive out Patient Program for group sessions etc. S#11, MD, indicated that he had concerns in the past with residents being discharged from the behavior units with very little documentation as to what aftercare services are needed at the facility (NH). S#11, MD, stated " That has been a concern of mind for a while. " S#11, MD, indicated that the Nurse Practitioner also make visits when appointments are made. S#11, MD, was unsure of the last psychiatric visit made to Resident #4 after being discharged from the behavior incident on [DATE]. S#11, MD, was questioned concerning Resident #4 ' s Depakote which was discontinued on [DATE] because Resident #4 refused to take according to Physician ' s Telephone Orders. S#11, MD, responded by saying that the state regulations are causing the doctors to have no choice but to discontinue medications when the resident is on multiple ant psychotropic medications. An interview was conducted on [DATE] at 9:00am with S3, DON, regarding the psychiatric follow-up/Aftercare. He indicated that Resident #4 was admitted to the hospital for behavioral concerns in May and in [DATE]. After he reviewed the documents (Aftercare/ Discharge notes and Progress notes dated on [DATE]) he indicated that Resident #4 needed to be seen by the psychiatrist and referred to the center for Support groups. The DON indicated he was not sure who made the appointments for aftercare. Normally the nurse will contact S12, Psychiatrist, and schedule the aftercare appointments. The DON was unsuccessful in locating documentation indicating a follow-up. Aftercare was scheduled and followed as indicated per discharge physician. During the survey on [DATE] and [DATE], policies on Assessments supervision, monitoring and aftercare follow-ups for a psychiatric patient were requested. The DON could not locate a policy addressing what system and/or protocol was in place in order to ensure the facility was following the physicians ' orders and follow-up recommendations once psychiatric patients are discharged from the hospital back to the nursing facility. An interview was conducted on [DATE] at 11:33am with S12, Psychiatrist. He indicated that he was familiar with Resident #4. He further indicated that she was a very difficult patient and had a history of [REDACTED]. S12, Psychiatrist, also indicated that once he discharged the patient from the psychiatric hospital he documented his recommendations and the aftercare plan is written by staff at the hospital. In addition S12, Psychiatrist, indicated an aftercare Form is sent back to the nursing facility with the patient once the patient is discharged from the hospital. The Aftercare Form includes follow-up recommendations. The S12, Psychiatrist, indicated that Resident #4 was seen at the Outpatient program. He indicated that the copies of the notes can be obtained from the hospital. In addition the Psychiatrist reported that the " Nursing Home is overwhelmed and that they cannot document everything. I was told that Resident #4 has a chart at the Psychiatric Hospital. S12, Psychiatrist, indicated that the resident was refusing to take the Depakote therefore, S11, Primary Dr., discontinued the medications. He further indicated that the Resident is on another medication, Abilify 5mg at bed time. S12, Psychiatrist, stated that she was a difficult patient and that he saw her twice. The first time he saw her was in [DATE]. He also indicated that the Resident had COPD and required oxygen. He stated that she wanted to remove the oxygen in order to smoke. An interview was conducted with S1, Administrator, on [DATE] at 4:00pm. He indicated that when the incident happened on [DATE] Resident #3 was on fire around 9:00pm. He died at the hospital on [DATE]. He indicated that no staff was outside with residents, Resident #3 and Resident #4, while they were smoking outside. Resident #4 was admitted to the facility on [DATE], with admitting [DIAGNOSES REDACTED]. Record review of the Local Hospital ' s consultation report dated on [DATE] revealed that Resident #4 ' s reason for consultation was Hypoxia. Resident #4 has a history of Chronic Obstructive lung disease. Resident #4 was a safe smoker, and she did not needed supervision for smoking/smoking articles (Cigarette and lighter). Interviews were conducted throughout the survey with both sampled residents and staff. They indicated that they had no smoking restrictions and that residents keep their smoking articles. They also indicated that no one was supervising the residents while they were smoking before the incident on [DATE]. Record review of the facility ' s policy for smoking, Revision dated on [DATE], Section for Procedure revealed the following in part: 5. Smoking restrictions: 5.5 Any resident who has been classified as non-responsible shall not be permitted to smoke without the direct supervision of a responsible staff member, visitor, or volunteer worker; and direct supervision must be provided through the entire smoking period. 6. Smoking Articles: 6.1 All residents who smoke, regardless of their classification, will not be permitted to keep any smoking articles/ paraphernalia in their room. 6.3 Through the Ambassador Program, staff will visit rooms daily and be alert for any smoking materials improperly stored. 6.5 Residents classified as responsible shall not be permitted to give non-responsible residents smoking articles 7. Purchasing and/or storage of smoking articles: 7.2 A

Based on record review and interviews the facility's Administrator and the Director of Nursing failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well- being of each resident for 5 of 6 sampled residents ( #1, #2, #3, #4, and #6). The facility's Administrator and Director of Nursing failed to: 1. implement their smoking policy; 2. ensure the smoking policy included recognizing fire accident hazards including gauze dressings covering a resident's body for a resident who smoked cigarettes (#3); 3. ensure smoking assessments were accurate and/or done timely per policy, implement a quality assurance system to ensure smoking assessments were accurate and/or timely including smoking assessments were being conducted regarding resident's ability to smoke unsupervised for 5 of 6 residents identified as independent unsupervised smokers (#1, #2, #3, #4, #6). 4. put a system in place to monitor that smokers were being supervised when needed supervision to prevent accidents/incidents, failed to implement a system of clinical supervision to ensure smokers who were care planned for smoking were monitored for 5 of 6 sampled residents (#1, #2, #3, #4, and #6); 5. implement quality assurance to ensure residents who needed constant supervision while smoking or while in the smoking area with other residents who were smoking were recognized and were supervised for 5 of 6 sampled residents (#1, #2, #3, #4, and #6); Resident #3, whose skin was covered with gauze dressings was placed in an Immediate Jeopardy on [DATE] while smoking outside with no supervision when another smoker, Resident #4, set Resident #3's bandages on fire causing the resident to sustain 3rd [MEDICAL CONDITION] 90% of his body eventually resulting in Resident #3's death on [DATE] at 1:00pm. The Immediate Jeopardy was removed for Resident #3 when he was transferred to a local hospital on [DATE]. The Immediate Jeopardy situation continued for 31 of 31 residents identified by the facility as independent smokers residing at the facility as documented on the facility's list of independent smokers (#1, #2, and #4-#31). On [DATE] at 4:00pm S1, Administrator and S5, Director of Clinical Evaluation presented a list of all the smokers in the facility. S1, Administrator indicated no resident will be allowed to smoke without being supervised. S1, Administrator further indicated a nursing assistant will be assigned to monitor all residents when they are outside smoking. S#5, Director of Clinical Evaluation indicated all residents were assessed and re-evaluated for unsupervised smoking as of [DATE]. S1, Administrator further indicated the assigned nursing assistant will have a binder with all smokers and their cigarettes and lighters will be locked up in a black lock box located on the back patio. S2, Director of Nurses (DON) indicated after the incident of the resident being burned by another resident, all cigarettes and lighters were removed from the resident's rooms. A smoking supervisory evaluation was done on every resident. Resident #4 was arrested and removed from the facility by the police on [DATE] at 2:30pm. The Immediate Jeopardy was removed for the independent smokers on [DATE] at 2:30pm when the facility implemented an acceptable plan of removal. This deficient practice continues at Level III Actual Harm and scoped at "G" and a potential for more than minimal harm for residents who need supervision while smoking. The total facility census was 100 residents documented on the facility's Census and Conditions of Resident ' s form. A total of 31 smokers were identified as being in need of supervision when smoking. Findings: Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE] with the diagnoses of Bullous (Pemphigoid) Perphysia, [MEDICAL CONDITION], Dehydration, [MEDICAL CONDITIONS], blisters, Stage IV to the buttocks and [MEDICAL CONDITION]. Review of the nurse's notes for Resident #3 dated [DATE] revealed Resident #3 was admitted with multiple blisters that had erupted with drainage all over the body. Further review revealed Resident #3 was also admitted with Stage IV pressure ulcers to the left and right buttocks. According to the documentation in the nursing notes, Resident #3 was able to ambulate as desired, but his gait remains unsteady. Review of the nurse ' s notes dated on [DATE] at 9:15 pm and 9:30 pm revealed S7, LPN and S16, LPN documented Resident #3 was observed engulfed in flames from neck down, yelling " help me. " Record review of the nurses ' notes dated [DATE] at 9:15 pm revealed S16, LPN documented that she ran and obtain the fire extinguisher, called a code, and began spraying the resident with the fire extinguisher until the room became overwhelmed with smoke. During an interview on [DATE] at 3:15 PM S16, LPN indicated she had to back out of the dining room because of the thick smoke, but continue to spray the resident until the fire extinguisher was empty. In interview on [DATE] at 3:30 pm S7 and S16, LPNs indicated as the smoke thinned out Resident #3 was observed on his knees on the dining room floor, pleading for help. S16, LPN further indicated the resident was coughing and choking from the smoke inhalation and she instructed the resident to lie down on the floor until the ambulance arrived. Review of Resident #3 ' s local emergency room (ER) record dated [DATE] at 10:21 pm revealed Resident #3 was responsive upon arriving to the local ER and only verbalized " help me. " The ER notes dated [DATE] revealed the Resident had sustained 3rd [MEDICAL CONDITION] his neck to his feet which was listed as 90% of his body. Review of the local hospital ' s documentation dated [DATE] at 11:50pm revealed Resident #3 was transported to a burn unit via a local ambulance services. Further review revealed Resident #3 was admitted to the intensive care burn unit on [DATE] at 2:00 am. Review of the Intensive Care Unit (ICU) history for Resident #3 dated [DATE] revealed the resident was brought to a local hospital where he was intubated and stabilized and then transferred to the Burn Unit. Review of the intensive care burn unit ' s documentation for Resident #3 revealed [MEDICAL CONDITION] 90% of his body sparing the face, right forearm, and his left foot. Further review of the consultation notes dated [DATE] revealed the neck, chest, abdomen, back, bilateral upper extremities were all burned. The review of the ICU recommendations for Resident #3 dated [DATE] revealed his overall prognosis was poor. Review of the Coroner ' s Report for Resident #3 revealed that he expired on [DATE] at 12:57pm in the burn unit. During an interview on [DATE] at 3:15 PM S16, LPN indicated she had to back out of the dining room because of the thick smoke, but continue to spray the resident until the fire extinguisher was empty. In interview on [DATE] at 3:30 pm S7 and S16, LPNs indicated as the smoke thinned out Resident #3 was observed on his knees on the dining room floor, pleading for help. S16, LPN further indicated the resident was coughing and choking from the smoke inhalation and she instructed the resident to lie down on the floor until the ambulance arrived. In interview on [DATE] at 3:45pm S#2, DON indicated on [DATE] at 9pm he heard the fire alarm go off and attempted to go down stairs to see what happened. He further indicated when he arrived on first floor the fire had been put out. He indicated he observed Resident#3 on his knees moving his head back and forth but the resident did not say anything. He also indicated on the next day, [DATE] Resident #4 admitted to setting Resident#3 on fire because he was not taking her cigarettes from her anymore. In interview on [DATE] at 3:59pm S#8, Certified Nursing Assistant indicated on [DATE] at 9pm the fire alarm went off and a female resident was heard yelling " man was on fire. " She further indicated she and the nurse had a fire extinguisher to put out the fire. She also indicated the whole dining room was filling with smoke. In interview on [DATE] at 3pm S#7, LPN indicated she has been employed at the facility since [DATE]. She further indicated she was working on 2nd. Floor seated at nursing station when she heard the fire alarm go off and it the system indicated the fire was on the first floor in the dining room area. She stated another nurse was observed backing up with fire extinguisher, yelling he is on fire. She also stated the dining room was full of smoke and she could not get to the resident because of the thick smoke. In interview on [DATE] at 1:40am Resident #11 indicated she was sitting in the dining room by the window when she saw a man on fire. She indicated she could not get to the phone. She also indicated no staff was outside. She also stated staff could not get to the man right away because he was next to the extinguisher on the wall. She further indicated Resident #4, the perpetrator, gets along with some of the residents but not everybody. She said Resident #4 smoked a lot and she had never seen the perpetrator hit anybody. She did indicate she had witnessed Resident #4 getting upset in the past. In interview on [DATE] at 9:28 am S#15, LPN indicated she works on the ,[DATE] shift. She described Resident #4 as being difficult at times. She stated many times the resident would refuse her medication, especially the [MEDICATION NAME]. S#15, LPN stated that the doctor would instruct the staff to put all concerns in a problem book to remind him, upon his visit, to discontinue the [MEDICATION NAME]. She further stated Resident #4 was on Abilifly. She said Resident #4 was not well liked by some of the residents. S#15, LPN stated that a smoking assessment had been done upon admission and Resident #4 was allowed to keep her own lighter and cigarettes. She further indicated the resident was care planned as competent to smoke. She stated on the night of the incident the resident was not acting any different from usual. She stated that she did not document anything after the incident. The nurse stated she did not know where Resident #4 was at time of the fire. She stated that she called 911 and instructed staff to close all doors. Between 9:30 pm and 10pm, the ER investigational Team was in the house. Resident #4 approached the nurse and stated that she burned Resident #3 with her lighter. S#15, LPN stated she did not document on [DATE] and was written up for not documenting the incident, as well as not documenting that she heard Resident #4 confessing to burning the Resident #3. S#15, LPN stated that Resident #4 confessed in front of the Medical Examiner and ADON, but the ADON denies hearing that Resident#4 confessed to burning Resident#3. Resident #4 ' s speech was very clear when she confessed to burning Resident #3. She further indicated at about 8pm on [DATE] Resident #4 stated she burned him (resident #3) because he would not give her a cigarette. S15, LPN stated that she tried to get Resident #3 to come inside, but refused to come in. She stated he asked her for a cigarette and he was told that she does not give residents cigarettes. He then pulled out his own cigarette. S15, LPN stated that Resident #3 showed her that he had cigarettes and did not need her to give him a cigarette. S15, LPN stated that she did not repeat it to her supervisor on the night of the incident. She stated that about 10:30pm the medical examiner called for an interview. She stated she left the facility at 1:00am and prior leaving, Resident #4 was instructed to go the bed. She stated that she checked on Resident #4 before leaving and found her to be asleep. She further indicated on Saturday [DATE] at 2:30pm the police investigators were waiting to question her. She stated that she did not remember documenting that Resident #4 was not a safe smoker. She admitted to not reviewing Resident#4's record. She did indicate the residents all kept their own lighter and cigarettes. Resident #3 ' s MDS (Minimum Data Set) Admission assessment dated on [DATE] revealed Resident ' s cognitive score as 15 out of 15. Review of Resident #3 ' s care plan dated [DATE] revealed safe smoking was identified as a problem. Further review revealed the following: Goal: will be safe from injury related to smoking. Approaches: Encourage resident to store cigarettes and lighters in a secure location; encourage resident to wear smoking apron when smoking, if needed; Supervise smoking activity. Review of the Resident#3 ' s clinical record dated [DATE] revealed no documented evidence the facility had implemented goals and approaches that might have protected him (Resident #3) from the injury which lead to his death. Review of Resident #3 ' s Evaluation for Unsupervised Smoking form dated [DATE] revealed the following: #4: if a history [MEDICAL CONDITION] present, would a smoking apron benefit the resident? Number 4 " box was checked no. But the care plan/approaches dated [DATE] stated: encourage resident to wear smoking apron when smoking, if needed; There was no documented evidence in the resident ' s clinical record to support that the facility ' s staff had encouraged Resident #3 to wear a smoke apron to prevent possible injuries. In interview on [DATE] at 10:28 am when asked why Resident #3 did not have a smoking apron on when smoking as stated in the resident ' s care plan under the approaches. S#, 4 Wound Care Nurse and S#3, ADON indicated the resident was encouraged to use a smoking apron, but he refused to wear the smoking apron. Review of Resident #3 ' s clinical record revealed no documented evidence the resident refused to wear the apron and no documentation stating that he was encouraged to wear a smoking apron when smoking on the patio. S3, ADON and S4, Wound Care Nurse further indicated that the apron would have only covered the front of the resident, not the whole body. S#4 acknowledged there was no documentation in the clinical record to support that the resident was encouraged to wear a smoking apron as per plan of care. Review of Resident #3 ' s Physician ' s Wound Care Treatment Protocol dated [DATE] until his death revealed he was to get the following treatments to treat the blisters all over his body: he was to get a daily whirlpool, then Silver [MEDICATION NAME] was to be applied all over his body, and the body was to be covered with Kling gauze and an ace wrap. Further review of the wound care treatment for [REDACTED]. Review of the facility ' s Smoker ' s Policy #AS-0009 revealed in part the facility is committed to maintaining a safe resident smoking environment in accordance with resident rights and preferences, in accordance with Life safety Code requirements, and state and local laws governing safe practices for the facility. Review of the facility ' s current Incident ID: dated [DATE] at 9:27pm concerning Residents #3 and #4 revealed in part that Resident #3, age [AGE] years old with a [DIAGNOSES REDACTED]. The facility ' s documented summary revealed on [DATE] at 9:00pm a resident was noted coming into the dining room from off of the back porch, engulfed in flames from neck down. The facility ' s documentation continues to indicate that the nurse activated the fire alarm, put the fire out, and Resident #3 was transferred to the local emergency room for treatment. According to the facility ' s documented summary of the incident report, Resident #4 stated on [DATE] at 8:00 am that she was possibly responsible for the incident. Resident #4 was diagnosed with [REDACTED]. Review of the clinical records of the other sampled residents, #1, #2, #4, #5, and #6 revealed they were identified as Independent Smokers and had been reviewed on [DATE]. The review revealed the following: Resident #1 was admitted on [DATE] with diagnoses of in part, Diabetes Mellitus, [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION], Gastro [MEDICAL CONDITION] Reflux Disease, [MEDICAL CONDITION], Psychiatric Illness Mood Disorder, Drug Abuse, [MEDICAL CONDITION], Aggressive Behavior, and [MEDICAL CONDITION]. The resident ' s Quarterly MDS dated [DATE] read in part, C1000,Cognitive skills for daily decision-making; The facility enter a code of 1( modified independence), which means that he had some difficulty in new situations. The resident ' s smoking assessment dated [DATE] indicated the resident had # ' s 3, 4, 5, 6, 7 and 9 checked. Review of the facility ' s Evaluation for Unsupervised Smoking revealed the following: #3. (yes) (Do residents ' fingers or clothing et al indicate a history [MEDICAL CONDITION] by smoking? #4. (yes) If a history [MEDICAL CONDITION] present, would a smoking apron benefit the resident? #5. (yes) Does resident require assistance to enter the smoking area? (yes) #6. Can resident safely demonstrate how to use a match and or a lighter? (yes)#7. Can a resident safely demonstrate how to hold a cigarette/pipe? (yes) #9. Does the resident exhibit any signs of tremors? According to the Evaluation for Unsupervised Smoking, if the facility has a yes checked for # ' s 2,3,5,9 or 10 the resident required supervision while smoking. However, the facility did not adhere to their assessment/evaluation check sheet for Resident #1 as residents were being allowed to smoke unsupervised. According to the facility ' s evaluation resident 1 needed supervision when smoking. Resident #2 was admitted on [DATE] with diagnoses of Paranoid Unspecified, [MEDICAL CONDITION], Mood Disorder, [MEDICAL CONDITIONS], Left-sided Hemi paresis, History of Pancreatitis Hypertension, [MEDICAL CONDITION], and Use of Tobacco. The resident ' s Quarterly MDS dated [DATE] read in part, C1000, Cognitive skills for daily decision-making; The facility entered a blank code with no response to decision-making. The resident smoking assessment dated [DATE] revealed the resident had no smoking problems and did not require supervision. However, review of the resident ' s nurse ' s notes dated [DATE] at 11:40am, [DATE] at 3:35pm, and [DATE] at 3:50pm and 4:45pm revealed the resident had been smoking in bed unsupervised. Resident #2 was reported on several occasions smoking in bed unsupervised, but his evaluation for unsupervised smoking dated [DATE] indicated that Resident #2 had no problems and did not need supervision while or when smoking. Review of the facility ' s nursing notes dated [DATE] at 7:30am for Resident #2 revealed that the nursing assistant smell smoke upon entering the resident ' s room. According to the nurse ' s notes the resident denied smoking and refuses to give the staff the cigarettes and lighter. According to the facility ' s nurses ' notes the administrator was called out to retrieved the cigarettes and lighter from Resident #2. Resident #4 was not able to be observed in the Nursing Home. S1, Administrator, stated that she left the nursing home with the police on [DATE] after she confessed that she set fire to Resident #3 on [DATE]. Observation on [DATE] at 8:45am was made of Resident #4 ' s room. This room was occupied by two other residents. Resident #4 ' s bed was located by the window. Review of Resident #4 ' s 90L dated on [DATE] and [DATE] and PASRR Screen and Determination revealed Resident #4 was hospitalized at the local psychiatric hospital from [DATE] through [DATE] and [DATE] through [DATE] for a [DIAGNOSES REDACTED]. Resident #4 ' s admission Minimum Data Set (MDS), dated on [DATE], Section A1800 revealed that Resident #4 was admitted to the nursing home from a Psychiatric hospital. Record review of the Nurse ' s Notes dated on [DATE] at 11:40pm, revealed Resident #4 was sitting in TV room area shouting to a black resident " Jesus is a white man, all you black people are going to get what ' s coming to you. " Nurses approached to the resident calm situation and removed other residents from area. Resident #4 began speaking with different voice and different facial expression and aggressive voice " you all are going to get it whites go to the mental house, blacks go to the crazy house. " Resident continues to ramble to imaginary person, with questions or approaches. Resident continues to ramble without acknowledging staff or others in presence. Record review of the Return to Clinic/Follow up, signed by S12, Psychiatrist, on [DATE] revealed Resident ' s [DIAGNOSES REDACTED]. Record review of the Psychiatric Evaluation from the local Psychiatric Hospital dated on [DATE] revealed: Identification Data: This is a [AGE] year old divorced white female who is a resident of Nursing Home, seen first at the nursing home for aggressive behavior. Chief Complaint: " I speak for my rights and people do not like that. " History of presenting Illness: According to the staff, the patient has been aggressive for the last three days. She refuses all of her medicines. The patient is talking to herself and speaks in changing voices. She threw oxygen off and was confused, agitated and up most of the night. She is hyperactive, irritable, angry and paranoid. As per the psychiatric evaluation, the patient states that she wanted to have a white eye doctor, not the black one. She was depressed a couple of weeks ago. She is hyperactive, impulsive, and intrusive for the last few days. Past Psychiatric History: The patient states that she was in psychiatric hospitals n the past. She has not been in psychiatric facilities for at least a couple of years. She does not want to talk about suicide because according to her, it was her past. Mental Status Examination: She is very paranoid and talks in different tones. She is intrusive and focused on her legal rights. Insight and Judgment are impaired. Psychiatric Diagnoses: [REDACTED]. AXIS II: No diagnosis. AXIS III: Hypertension, diabetes mellitus, [MEDICAL CONDITIONS], arthritis, [MEDICAL CONDITION] AXIS IV: Medical problems, missing friend who is on home visit, declining memory, noncompliance with medication, poor support system, chronic mental illness. Record review of the Nurse ' s Note dated on [DATE] at 5:15, no documentation to indicate AM or PM, revealed upon making rounds Resident in a wheel chair in her room, not responding appropriately, talking to her knees and the wall. Very confused and disoriented, vital sign could not be obtained; Resident stated that the blood pressure cuff was a snake. The doctor notified and ordered was send Resident to a local hospital emergency room . Record review of the Nurse ' s Notes dated on [DATE], could not read time, revealed that Resident #4 was found outside building, sitting in a wheel chair in front of a grocery store. Resident stated that she wanted someone to buy her a pack of cigarettes. Nurse asked Resident to return to the facility. Resident became very combative stating " I am not leaving. " Record review of the Nurse ' s Note dated on [DATE] at 10:45 am revealed that a fell ow resident reported that the Resident told roommate to stop staring at me before I poke your eyes. Resident then lifted herself up from her wheel chair and walked toward roommate placing her two fingers on roommate ' s face. Record review of the Nurse ' s Note dated on [DATE] at 2:00am revealed Resident up in wheel chair rolling around facility going out to patio often to smoke. Record review of the Nurse ' s Note dated on [DATE] at 2:00am revealed Resident out of bed sitting in wheel chair at bedside. At 4:00am Resident remained in a wheel chair stated that " I don ' t ' want to get in bed. " At 6:00 am Resident going out to the patio for smoking. Record review of the Nurse ' s Note dated on [DATE] at 2:30pm, Resident was in front of the store begging for money, and she state that she went in the store to get her some cigarettes and she slammed her finger. Record review of the Psychiatric Evaluation from the local Psychiatric Hospital, Date of admission on [DATE] and Date of dictation on [DATE] (Resident discharged from psychiatric hospital on [DATE]) revealed the following in part: IDENTIFICATION DATA: This is a [AGE] year old female who is a resident of a nursing home referred by the nursing home due to assaultive behavior and paranoid [MEDICAL CONDITION]. CHIEF COMPLAINT: " A lady over there was staring at me and I told her not to stare and that should not be the reason for coming to the hospital. " HISTORY OF PRESENTING ILLNESS: According to the intake note, the patient was paranoid and accusing roommate of staring at her. She hit her roommate with a walker and poked her in her eyes. The patient states that her roommate was talking about her. She has been panhandling on the street corner. She has increased sexual behavior and frequently wakes during the night. The patient was being aggressive with other residents also. The patient is obsessed about her cigarettes and was upset when getting cigarettes late. She is angry, irritable, easily agitated and has poor insight into this situation. PAST PSYCHIATRIC HISTORY: The patient states that she was hospitalized for [REDACTED]. The patient did not want to talk about that but she states that is over with flashbacks, dreams, and anger problems. Review of the Hospital physician's order [REDACTED]. Record review of the Hospital Discharge Instructions & Aftercare Plan dated on [DATE], section for Psychiatric & Medical aftercare Plan revealed the following: Psychiatric Follow-up with: Private Psychiatrist Dr. S12 at assessing Nursing home. Other programs/ Meeting/ Support groups specify: D/C instructions & Packet faxed to this Intensive Outpatient Care (IOP). During an interview on [DATE] at 9:17am, S17, LPN indicated that the aftercare appointments are set up by the ward clerk, also transportation is arranged by the ward clerk. The LPN stated after reviewing Resident #4 ' s medical record " I do not see documentation of the appointments. " During an interview on [DATE] at 12:08pm with S#3, ADON and S#5, Director of Clinical Evaluation, they indicated when the resident goes out of the facility or comes back to the facility for any appointment, the facility has no system for documents because that activity is normal and staff knows. If any medication changes, then the nurse documents the change after the resident comes back from the appointment. When surveyor questioned how many times Resident #4 went to the Intensive Outpatient Care, they both could not give an answer. On [DATE] at 11:15am Dr. S11 (Medical Director & primary physician) revealed during interview that he was Resident #4 ' s primary physician. He was not aware of the aftercare orders which were presented to S11, MD. The After Care/Discharge Summary revealed that the resident needed to be seen by S#12, the psychiatrist, and be referred to Intensive out Patient Program for group sessions etc. S#11, MD, indicated that he had concerns in the past with residents being discharged from the behavior units with very little documentation as to what aftercare services are needed at the facility (NH). S#11, MD, stated " That has been a concern of mind for a while. " S#11, MD, indicated that the Nurse Practitioner also make visits when appointments are made. S#11, MD, was unsure of the last psychiatric visit made to Resident #4 after being discharged from the behavior incident on [DATE]. S#11, MD, was questioned concerning Resident #4 ' s [MEDICATION NAME] which was discontinued on [DATE] because Resident #4 refused to take according to Physician ' s Telephone Orders. S#11, MD, responded by saying that the state regulations are causing the doctors to have no choice but to discontinue medications when the resident is on multiple [MEDICAL CONDITION] medications. An interview was conducted on [DATE] at 9:00am with S3, DON, regarding the psychiatric follow-up/Aftercare. He indicated that Resident #4 was admitted to the hospital for behavioral concerns in May and in [DATE]. After he reviewed the documents (Aftercare/ Discharge notes and Progress notes dated on [DATE]) he indicated that Resident #4 needed to be seen by the psychiatrist and referred to the center for Support groups. The DON indicated he was not sure who made the appointments for aftercare. Normally the nurse will contact S12, Psychiatrist, and schedule the aftercare appointments. The DON was unsuccessful in locating documentation indicating a follow-up. Aftercare was scheduled and followed as indicated per discharge physician. During the survey on [DATE] and [DATE], policies on Assessments supervision, monitoring and aftercare follow-ups for a psychiatric patient were requested. The DON could not locate a policy addressing what system and/or protocol was in place in order to ensure the facility was following the physicians ' orders and follow-up recommendations once psychiatric patients are discharged from the hospital back to the nursing facility. An interview was conducted on [DATE] at 11:33am with S12, Psychiatrist. He indicated that he was familiar with Resident #4. He further indicated that she was a very difficult patient and had a history of [REDACTED]. S12, Psychiatrist, also indicated that once he discharged the patient from the psychiatric hospital he documented his recommendations and the aftercare plan is written by staff at the hospital. In addition S12, Psychiatrist, indicated an aftercare Form is sent back to the nursing facility with the patient once the patient is discharged from the hospital. The Aftercare Form includes follow-up recommendations. The S12, Psychiatrist, indicated that Resident #4 was seen at the Outpatient program. He indicated that the copies of the notes can be obtained from the hospital. In addition the Psychiatrist reported that the " Nursing Home is overwhelmed and that they cannot document everything. I was told that Resident #4 has a chart at the Psychiatric Hospital. S12, Psychiatrist, indicated that the resident was refusing to take the [MEDICATION NAME] therefore, S11, Primary Dr., discontinued the medications. He further indicated that the Resident is on another medication, [MEDICATION NAME] 5mg at bed time. S12, Psychiatrist, stated that she was a difficult patient and that he saw her twice. The first time he saw her was in [DATE]. He also indicated that the Resident had [MEDICAL CONDITION] and required oxygen. He stated that she wanted to remove the oxygen in order to smoke. An interview was conducted with S1, Administrator, on [DATE] at 4:00pm. He indicated that when the incident happened on [DATE] Resident #3 was on fire around 9:00pm. He died at the hospital on [DATE]. He indicated that no staff was outside with residents, Resident #3 and Resident #4, while they were smoking outside. Resident #4 was admitted to the facility on [DATE], with admitting [DIAGNOSES REDACTED]. Record review of the Local Hospital ' s consultation report dated on [DATE] revealed that Resident #4 ' s reason for consultation was [MEDICAL CONDITION]. Resident #4 has a history of [MEDICAL CONDITION]. Resident #4 was a safe smoker, and she did not needed supervision for smoking/smoking articles (Cigarette and lighter). Interviews were conducted throughout the survey with both sampled residents and staff. They indicated that they had no smoking restrictions and that residents keep their smoking articles. They also indicated that no one was supervising the residents while they were smoking before the incident on [DATE]. Record review of the facility ' s policy for smoking,