Every finding on record at Vineyards at Fowler

Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported immediately (but not later than 2 hours if serious bodily injury is involved, or within 24 hours if no serious bodily injury) to the local ombudsman (neutral, independent public official or office tasked with defending the public's interests and investigating complaints), state survey agency (SA- a state-level government department that inspects health care facilities) and local law enforcement for one of four sampled residents (Resident 1) when Resident 1 reported to Licensed Vocational Nurse (LVN) and Infection Preventionist (IP- professionals who make sure healthcare workers and patients are doing all the things they should to prevent infections) that Certified Nurse Assistant (CNA) 1 showed her a nude video of CNA 2, and the facility did not report the allegation to the required government agencies. This failure had the potential risk for delayed protective interventions and external investigation, allowing ongoing inappropriate conduct and placed Resident 1 at risk for further abuse. During a phone interview on 3/3/26 at 9:46 am with the Ombudsman (OMB), the OMD stated he was not aware of Resident 1's abuse allegation and did not have an SOC 341(a form used by mandated reporter to document and report suspected abuse or neglect of an elder) on file. During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/5/26, the AR indicated Resident 1 admitted to the facility on [DATE] with diagnoses: Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing), Type 2 Diabetes Mellitus (DM2- a condition where your body does not use a hormone that helps move sugar from your blood into your cells for energy properly) with Diabetic Neuropathy (a type of nerve damage that can happen with diabetes), asthma (a chronic lung disease caused by inflammation and muscle tightening around the airways making it hard to breathe), Epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures), Bipolar Disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to lows (depression or depressive episode), Major Depressive Disorder (persistent feeling of sadness and loss of interest), Post-Traumatic Stress Disorder (extreme fear during or after witnessing or experiencing potentially traumatic events, such as war, accidents, natural disasters or sexual violence), and Age-Related Cognitive Decline. During a review of Resident 1's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 12/18/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had no cognitive impairment. During an interview on 3/4/26 at 9:41 am with Resident 1 in the resident's room, Resident 1 stated CNA 1 showed her a nude video of CNA 2 posing naked in the bathroom with a small towel over his privates. Resident 1 stated she told one person and the Administrator (ADM) called her to her office. Resident 1 stated the ADM interviewed her and she identified CNA 1 showed her the nude video of CNA 2. Resident 1 stated she was shocked that an employee would show her a nude video of CNA 2. During an interview on 3/4/26 at 11:23 am with Licensed Vocational Nurse (LVN) in the ADM office, the LVN stated LVNs ensure resident safety and residents are treated with dignity and respect. The LVN stated staff should protect residents from abuse and should report abuse allegations right away. The LVN stated staff showing residents a video of a naked person was not acceptable because residents could take offense and could be considered a form of abuse and could be degrading for the residents to see and affect their dignity. The LVN stated more than a month ago around 6:30 am Resident 1 alleged CNA 1 showed her a naked video of CNA 2. The LVN stated the Infection Preventionist (IP) was notified and they interviewed Resident 1. The LVN stated she reported the alleged incident to the ADM between 8:00am-8:30am. The LVN stated she did not complete the SOC 341. The LVN stated she would report the allegation to the ADM who was the Abuse Coordinator and the ADM would advise whether SOC 341 would need to be completed. The LVN stated the alleged sexual incident should have been reported to the required government agencies. During a concurrent interview and record review on 3/4/26 at 11:43 am with the IP, the facility's policy and procedure titles, Abuse, Neglect and Exploitation, dated 12/16/25 was reviewed. The P&P indicated, VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administer, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes; a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. The IP stated Resident 1 informed her she saw a naked video of CNA 2. The IP stated staff showing a video of a naked person to a resident would be considered a potential abuse situation. The IP stated all facility staff are mandated reporters and must report if they witness or suspect abuse. The IP stated the SOC 341 should have been completed and the allegation of abuse reported within two hours. During an interview on 3/4/26 at 12:10 pm with the Director of Staff Development (DSD), the DSD stated it was not appropriate for staff to show a video of a naked person to residents, and could be considered as abuse. The DSD stated all facility staff were mandated reporters which meant if there was suspected abuse, they must report to the abuse coordinator. The DSD stated the abuse coordinator would complete the SOC 341 and report to the local law enforcement and the ombudsman. The DSD stated the SOC 341 should have been completed. During a phone interview conducted on 3/4/26 at 1:09 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated it was not appropriate for staff to show a resident a naked video as it could be considered abuse. CNA 1 stated she did not show Resident 1 a video of CNA 2 naked. CNA 1 stated she was taken off the schedule 2/5/26-2/13/26 by the ADM until the allegation was investigated. CNA 1 returned to work 2/14/26. CNA 1 stated if was aware of an abuse allegation, she would complete the SOC 341 form and notify the ombudsman. She explained that SOC 341 should be filled out and submitted immediately to ensure the facility was informed and could address the issue promptly. CNA 1 stated delayed reporting of alleged abuse could result in continued occurrences. During a concurrent interview and record review on 3/4/26 at 2:42 pm with the DON, the facility's P&P titled, Abuse, Neglect and Exploitation was reviewed. The P&P indicated, .VI. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. The DON stated the facility should report allegations of abuse immediately, no later than 2 hours after the allegation of abuse was made. The DON stated Resident 1's informed her CNA 1 showed her a naked video of CNA 2. The DON stated Resident 1 described the video as CNA 2 was getting out or going into the shower and you could see his nude behind. The DON stated the facility did not report the allegation because Resident 1 did not report distress after seeing the video. The DON stated it was inappropriate for staff to show residents a nude video. The DON stated all facility staff were mandated reporters, meaning if you witnessed or were aware of any form of abuse, they were obliged to report. The DON stated it was important to report abuse allegations to ensure the incident does not recur. The DON stated the facility would be at risk of jeopardizing their license if they did not report allegations of abuse. The DON stated the facility did not maintain mandated reporting for Resident 1's incident because they did not report the allegation. During a review of the facility's P&P titled, Abuse Prevention and Prohibition Program, not dated, the P&P indicated, Purpose-to ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification,, investigation, and reporting of abuse, neglect, mistreatment.and crime in accordance with federal and state requirements.Procedure I. The Administrator may delegate coordination and implementation of components of the abuse prevention program to other staff within the Facility, including A. The Director of Nursing Services, B. The Director of Social Services, C. The Director of Staff Development.III. Training A. All employees.will be trained.on the following topics: i. Who is a covered individual responsible for reporting? .iii. Identification and recognition of signs and symptoms of abuse.vi. Reporting and documentation of abuse.x. Penalties associated with failure to report.IX. Reporting/Response A. Facility Staff are Mandated Reporters i. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and any state specific regulations to report known or suspected instances of abuse of elder or dependent adults. ii. The Facility will not impede or inhibit a Facility's Staff member's reporting duty, nor will Facility Staff reprimanded or disciplined for reporting abuse.iv. Failure to report suspected or known abuse may result in legal action against the individual(s) withholding such information.C. Reporting Requirements i. The Facility will report known or suspected instances of .sexual abuse.to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations.iii. If the reportable event relates to an incident.including emotional or psychological abuse.that occurred at the Facility, a telephone report and a written report will be made to the local Ombudsman or to the local law enforcement agency within 24 hours.vi. Failure to file a report within the required tie frames may be result in disciplinary action, up to and including termination.E. Submission of Report i. If multiple staff members become aware of the same incident, Facility Staff may choose to submit individual reports or submit a joint report containing each staff member's name and information about the suspected abuse from each staff person.XI. Penalties Associated with Failure to Report A. Anyone who fails to report within mandated timeframes will be subject to a civil money penalty of not more than $200,00 and the covered individual who failed to report may be excluded from participation in any Federal health care program.XXVI. Sexual abuse means non-consensual contact of any type, including but not limited to.forced observation of .pornography. During a review of Administrator Job Description (JD) dated 2023, the JD indicated Major Duties and Responsibilities plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations.Ensures resident incidents and concerns that rise to a reportable event such as alleged abuse.mistreatment.are reported to the correct entity within the stated regulatory requirement.Additional Tasks.Reports noncompliance with policies and procedures, regulations.to appropriate personnel.Reports any allegations of abuse.or mistreatment of residents to appropriate regulatory entities. Protects residents from abuse and cooperates with all investigations. Compliance as a Condition of Employment and Performance Appraisal Agreement to abide by all standards, policies, and procedures of the facility, including the facility's compliance and ethics program, is a condition of employment. Compliance will be a factor in evaluating job performance. Violations, including failure to report violations, will result in disciplinary action, up to and including termination . During a review of Certified Nursing Assistant JD, dated 2023, the JD indicated the Position Purpose-provides certified nursing assistant services to assigned residents in accordance with care plans, facility policies and procedures and at the direction of supervisor(s).Additional Assigned Tasks Treats all residents with dignity and respect. Promotes and protects all residents' rights. Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct, and state/federal regulations and guidelines. Reports noncompliance with policies and procedures, regulations.to appropriate personnel.Protects residents from abuse. Compliance as a Condition of Employment and Performance Appraisal Agreement to abide by all standards, policies and procedures of the facility, including the facility's compliance and ethics program, is a condition of employment.Violations, including failure to report violations, will result in disciplinary action, up t and including termination. During a review of Charge Nurse JD, dated 2023, the JD indicated the Position Purpose-Provides direct nursing care to the residents and supervises the day-to-day nursing activities performed by the certified nursing assistants in accordance with current federal, state, and local regulations and guidelines and established facility policies and procedures.Major Duties and Responsibilities.Ensures that policies and procedures are complied with by nursing personnel assigned.Additional Tasks.Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct, and state/federal regulations and guidelines.Reports noncompliance with policies, procedures, regulations.to appropriate personnel . Reports any allegations of abuse.mistreatment of residents to supervisor and/or administrator. Protects residents from abuse. Compliance as a Condition of Employment and Performance Appraisal Agreement to abide by all standards, policies and procedures of the facility, including the facility's compliance and ethics program, is a condition of employment.Violations, including failure to report violations, will result in disciplinary action, up t and including termination. During a review of Director of Nursing JD, dated 2023, the JD indicated Position Purpose-Planning, organizing, developing and directing the overall operations of the Nursing Service Department in accordance with local, state and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents.Major Duties and Responsibilities.Interprets and communicates policies and procedures to nursing staff, and monitors staff practices and implementation.Oversees resident incidents and concerns daily to identify any unusual occurrences and reports them promptly to the Administrator and/or state agency for appropriate action.Additional Tasks.Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct, and state/federal regulations and guidelines.Reports noncompliance with policies, procedures, regulations.to appropriate personnel .Reports any allegations of abuse.mistreatment of residents to supervisor and/or administrator. Protects residents from abuse. Compliance as a Condition of Employment and Performance Appraisal Agreement to abide by all standards, policies and procedures of the facility, including the facility's compliance and ethics program, is a condition of employment.Violations, including failure to report violations, will result in disciplinary action, up t and including termination. During a review of Infection Preventionist JD, dated 2023, the JD indicated Additional Assigned Tasks. Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct, and state/federal regulations and guidelines.Reports noncompliance with policies, procedures, regulations.to appropriate personnel .Reports any allegations of abuse.mistreatment of residents to supervisor and/or administrator. Protects residents from abuse. Compliance as a Condition of Employment and Performance Appraisal Agreement to abide by all standards, policies and procedures of the facility, including the facility's compliance and ethics program, is a condition of employment.Violations, including failure to report violations, will result in disciplinary action, up t and including termination.

Based on observation, interview and record review, the facility failed to ensure the Dietary Manager was qualified to perform the duties of a dietary supervisor when the facility was unable to provide documentation the Dietary Supervisor (DS) completed a state-approved program in dietetic service supervision. Regulatory requires individuals in this role to meet one of seven recognized qualification pathways. The DS Food Handler Card, high school transcripts, and Regional Occupational Program (ROP-hands on training and career preparation in various fields including culinary arts, health care, automotive and technology) course documentation were insufficient to meet the regulatory requirements under HCS (Health and Safety Code- state laws and regulations governing public health, healthcare facilities, and safety standards, including requirements related to dietary services and staff qualifications)1265.4.This failure had the potential to result in 40 of 41 residents at risk of receiving nutritionally inappropriate meals or inadequate dietary services due to insufficient oversight of food preparation, menu compliance and staff performance.During an interview on 1/6/26 at 12:51p.m. with Kitchen Staff (KS) 1, KS 1 stated she reported to the Dietary Supervisor (DS), who was responsible for training all kitchen staff. KS 1 stated the Registered Dietitian (RD) came onsite to observe the tray line and communicated any identified issues to the DS and not directly to staff. During an interview on 1/7/26 at 10:25 a.m. with the RD, the RD stated his role included assessing residents, attending weight meetings, conducting sanitation audits and ensuring a well-functioning kitchen. The RD stated he was onsite 1-2 days per week due to the small size of the facility, typically rounding on Thursdays and spending the whole day onsite on Fridays. The RD stated he also worked from home and was available to staff for consultation or to come onsite on other days with advanced notice, averaging approximately 12 hours onsite per week. The RD stated he reported to the Administrator (ADM) and if the DS had issues requiring attention, he provided support, but the matters were addressed with the ADM. The RD stated he communicated regularly with the DS and received feedback from her regarding kitchen issues. The RD stated the DS served as the day-to-day manager of the kitchen, was responsible for staff evaluations and performance, managed daily operations and ordering and stated the DS was a Certified Dietary Manager (CDM). During an interview on 1/7/26 at 10:46 a.m. with the DS, the DS stated she began working at the facility in 2015. The DS stated she was not initially hired as the DS; however, shortly after she started, the CDM went out on medical leave. The DS stated she temporarily assumed the role due to her experience with ordering and subsequently continued in the position. During an interview on 1/7/26 at 3:08p.m. with the DS, the DS stated her duties included reviewing temperature logs, attending meetings and completing room rounds with residents. The DS stated she obtained food preferences for new admissions and completed grocery ordering. The DS stated the RD completed resident evaluations, while she entered nutritional data. The DS stated if she had concerns regarding a resident, she addressed them with the RD and stated she and the RD communicated regularly and held weekly meetings. The DS stated kitchen staff reported to her and she was responsible for completing their training, evaluations and performance reviews. The DS stated she was trained in-house by a dietary manager and previously worked in a nursing home in Kentucky. The DS stated she attended the Valley Regional ROP program and completed the program while in high school, which she described as a college-level course. The DS stated her qualification documents had been misplaced. The DS stated she contacted the ROP program but was unable to obtain a copy of her certificate, because the program was now managed by a different company. The DS stated she had submitted her high school transcripts to verify her qualifications. The DS stated her ROP course was listed on her high-school transcripts under Restaurant Careers and she received 30 units for the class. During an interview on 1/8/26 at 1:30p.m. with the ADM, the ADM stated the DS was responsible for ordering, ensuring the menu was current and followed by staff, coordinating with the RD and attending clinical and weight meetings. The ADM stated the DS and the RD facilitated wound and weight meetings together. The ADM stated the facility had reviewed the DS's qualifications and believed her education met regulatory requirements. The ADM stated the facility did not have a copy of the DS certificate and the certificate could not be located or verified online. The ADM stated a copy of the certificate would need to be requested from the DS. During a concurrent interview and document review of HSC 1265.4 with the DS and the RD on 1/8/26 at 3:15p.m. the DS stated she believed she met qualification requirements under pathway number six, which required graduation from a state-approved program providing 90 or more hours of classroom instruction in dietetic service supervision, or 90 or more hours of combined classroom instruction and instructor-led interactive web-based instruction in dietetic service supervision. The DS stated she had completed more than 90 hours of instruction. The RD stated the documentation provided, including the DS's high school diploma and transcripts, did not demonstrate graduation from a state-approved program in dietetic service supervision and did not support compliance with pathway number six. During an interview on 1/8/26 at 3:25p.m. with the ADM, the ADM stated she had spoken with the DS regarding HSC 1265.4 requirements. The ADM stated she was unable to confirm the DS's education met any of one of the seven recognized qualification pathways. The ADM the facility could not provide documentation demonstrating the DS graduated from a state-approved program in dietetic service supervision, including a certificate supporting qualification under pathway number six. During an interview on 1/9/26 at 9:28a.m. with the ADM, the ADM stated employees were expected to meet the requirements of their assigned positions. During a review of California Food Handler Card, dated 10/1/25, the California Food Handler Card was issued to DS on 10/1/25 and set to expire on 9/30/28.During a review of HSC 113948 dated 1/1/2024, the HSC indicated the Food Handler Card (A) (i) The course provides basic, introductory instruction on the elements of knowledge described in subdivisions (a), (b), (c), (d), (e), and (g) of Section 113947.2. (ii) On or before January 1, 2021, the course shall include instruction on both of the following: (I) The elements of knowledge described in paragraph (1) of subdivision (b) of Section 113947 that are consistent with recommendations from a nationally organized allergy organization. (II) Safe handling food practices for major food allergens, as defined in Section 113820.5, as they relate to food preparation activities that occur at a food facility, including, but not limited to, training on the avoidance of allergen cross-contamination. (B) The course and examination is designed to be completed within approximately two and one-half hours.During a review of [name] High School unofficial Transcripts, dated 6/6/1996, the transcripts indicated the DS, while in the 12th grade, was enrolled in a course titled Restaurant Careers for two semesters and completed 30 units. During a review of the Valley Regional Occupational Program (ROP) course outline, revised 2/2023, indicated the course targeted job titles of chefs and head cooks, and was designed for students in grades 9-12. The course description indicated that it was intended to expose students to the culinary arts profession. The course competencies indicated that students would acquire the knowledge necessary to complete a ServSafe exam and obtain a California Food Handler Card. The course certification was identified as a ServSafe certification. During a review of Dietary Manager Job Description, dated 2023, indicated, required qualifications minimum requirements include one of the following: certification as a dietary manager, certification as a food service manager, has similar national certification for food service management and safety from a national certifying body, has an associate's or higher degree in food service management or in hospitality, if the course of study includes food service or restaurant management from an accredited institution of higher learning, has 2 or more years experience in position of director of food and nutrition services in a nursing facility setting and has completed a course of study and management, by no later than 10/1/2023, that includes topics integral to managing dietary operations including but not limited to foodborne illness, sanitation procedures, and food purchasing/receiving.must also meet State requirements for food service managers or dietary managers.During a review of the facilities policy and procedure (P&P) titled, License Verification, dated 2025, the P&P indicated, All personnel that require a license or certification shall be verified through the appropriate issuing agency.the human resources director or designee is responsible for maintaining and ensuring the validity and current status of individual certification/licensure.an individual will not be employed and or/will be terminated from employment if a. the individual has lost licensure/certification for any reason.any licensed/certified employee is responsible for submitting verification of licensure/certification renewal to human resources prior to expiration.

Based on observation, interview and record review the facility failed to ensure the food preparation sink was equipped with a required air gap to prevent contamination, when the food preparation sink was observed without an air gap, creating the potential for backflow and contamination of food and food-contact surfaces.This failure had the potential to affect 40 of 41 residents who received meals prepared in the facility. During an observation on 9/30/25 at 8:16a.m. in the kitchen, the one-compartment sink located next to Fridge 2 was observed with beans soaking. During an interview on 1/6/26 at 12:51p.m. with Kitchen Staff (KS) 1, KS 1 stated the small, one-compartment sink was used as the food preparation sink. KS 1 indicated the two-compartment sink was used only as a backup if the dishwasher was not functioning. KS 1 stated she was unsure what an air gap was but stated the piping to the sink had not been altered. During an interview on 1/7/26 at 3:08p.m. with the Dietary Supervisor (DS), the DS stated an air gap was intended to prevent contamination of food if the sink were to overflow. The DS was unsure if an airgap was required and believed the facility may have a waiver. During a concurrent observation and interview on 1/8/26 at 10:25a.m. with the Registered Dietitian (RD) and DS, both confirmed the one-compartment sink in the kitchen was used as the food preparation sink and did not have an air gap. During an interview on 1/9/26 at 9:28a.m. with the Administrator (ADM), the ADM stated an air gap was required, and should have been present. During a review of professional reference titled, FDA Food Code 2022, section 5-402.11 Backflow Prevention, (A) A direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. (B) Equipment and fixtures used for food preparation or utensil washing must be installed with an air gap or air brake as required to prevent backflow of sewage into the equipment.

Based on observation, interview and record review the facility failed to ensure garbage was stored and disposed of in a manner that prevented unsanitary conditions when 3 of 3 outdoor dumpsters were observed with lids open and one dumpster was overflowing.This failure had the potential to attract pests, create offensive odors and negatively impact food safety and the overall sanitary environment of the facility. During an observation on 1/6/26 at 12:44 p.m. the facility's dumpsters located behind the building were observed with all three lids in the open position. One dumpster contained overflowing boxes, which prevented the lid from closing securely. During an interview on 1/6/26 at 12:51 p.m. with Kitchen Staff (KS) 1, KS1 stated the lids of the dumpsters were required to remain closed at all times to prevent pests. During an interview on 1/7/26 at 3:08p.m. with the Dietary Supervisor (DS), the DS stated the dumpsters were required to remain closed at all times and the surrounding area should be kept clear to prevent unwanted pests. The DS stated the facility's location next to agricultural orchards placed the facility at increased risk for pests. During an interview on 1/9/26 at 9:28a.m. with the Administrator (ADM), the ADM stated her expectation was for the dumpster lids to remain closed at all times for infection control purposes and the dumpsters should not be overflowing. During a review of the facility's policy and procedure (PNP), titled, Disposal of Garbage and Refuse dated 12/18/2025, the PNP indicated, .dumpsters shall be kept covered when not being loaded.surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.

Number of residents sampled: 4Number of residents cited: 1Based on observation, interview and record review, the facility failed to ensure professional standards of practice and the facility's policies and procedures were followed for one of four sampled residents (Resident 46) when Resident 46's psychotropic medication (psychoactive drugs that alter brain chemistry to treat mental illness) brexpiprazole (used to treat Alzheimer's disease- disease characterized by a progressive decline in mental abilities) ordered on 12/7/25, was not available for administration and was documented in the Electronic Medication Administration Record (EMAR- a digital system that replaces paper charts to streamline and secure the process of giving medications to patients) as administered on 12/10/25, 12/18/25, 12/19/25, 1/5/26 and 1/6/26. The EMAR for the medication was documented as refused on 12/8/25, 12/12/25 and 12/13/25 when the medication was not available for administration on those datesThis failure resulted in Resident 46 not receiving the physician ordered medication and not achieving the intended therapeutic outcome. During a review of Resident 46's admission Record [AR-a document containing resident profile information], dated 1/8/26, the AR indicated resident 46 was admitted to the facility on [DATE] with diagnoses which included depression (persistent sadness, loss of interest, and changes in sleep, appetite, and energy that interfere with daily life), Alzheimer's Disease and dementia (a progressive state of decline in mental abilities). During a review of Resident 46's Minimum Data Set (MDS- resident assessment tool which indicates physical and cognitive abilities), dated 11/15/25, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 4 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 46 had severe cognitive impairment. During a medication observation on 1/7/26 at 8:17 a.m. with Licensed Vocational Nurse (LVN) 1 outside of Resident 46's room, LVN 1 prepared Resident 46 medications. LVN 1 stated Resident 46's psychotropic medication was not available and was still waiting for pharmacy to deliver the medication. LVN 1 stated she would contact pharmacy to follow up on the medication. Resident 46 was observed sitting up in her wheelchair inside her room next to her bed. Resident 46 was alert, verbally responsive, and appropriately dressed. During a concurrent interview and record review on 1/7/26 at 2:55 p.m. with LVN 1, Resident 46's EMAR dated 1/2026 was reviewed. LVN 1 stated the checkmark in the EMAR indicated the medication was administered and nine (9) indicated Other/See Nurse Notes. LVN 1 stated she did not know why there was a checkmark documented on 1/5/26 and 1/6/26 in the EMAR, LVN 1 stated medication was not available because the pharmacy had not delivered the medication. LVN 1 stated, the medication was still being processed and the pharmacy was waiting for Resident 46's insurance approval LVN 1 stated she did not notify Resident 46's physician the medication was unavailable. LVN 1 statedI notified the Director of Nursing (DON) and the Administrator today. LVN 1 stated she was not sure if the DON contacted the physician. During an interview on 1/8/26 at 9:25 a.m. with the Director of Nursing (DON), the DON stated Resident 46's brexpiprazole medication was ordered by the Psychiatric-Mental Health Nurse Practitioner (PMHNP). The DON stated she discussed the cost of medication with the PMHNP because Resident 46's insurance did not cover the cost. The DON stated the PMHNP did not want to change the medication and rewrote the order stating Resident 46's insurance should approve it. However, the insurance did not approve the medication. The DON stated the PMHNP instructed nursing staff to place the medication on-hold until insurance approval was obtained. The DON stated she did not recall discussing the medication with the primary physician for recommendation and did not contact the pharmacist for an alternative equivalent medication. The DON reviewed Resident 46's EMAR for December 2025 and January 2026. The DON stated licensed nurses documented the medication was administered on 12/10/25, 12/18/25, 12/19/25, 1/5/26 and 1/6/26. DON stated the medication was documented as refused on 12/8/25, 12/12/25 and 12/13/25. The DON stated the documentation of both administered and refused was inaccurate because the medication was not available. The DON stated her expectation was to verify medications availability before documenting administration or refusal. During a concurrent interview and record review on 1/8/26 at 10:05 a.m. with LVN 2, LVN 2 reviewed Resident 46's EMAR dated 12/1/25 through12/31/25 and 1/1/2026 through 1/31/26. LVN 2 stated she signed the December EMAR indicating she administered the medication on 12/18/25 and signed the January 2026 EMAR indicating she administered the medication on 1/6/26. LVN 2 stated she was not aware of the documentation error and stated, I was just told today. LVN 2 stated she did not recall contacting the physician regarding the medication not available and did not contact the pharmacy to follow up on the medication. LVN 2 stated, I should have been more attentive to what I was doing. LVN 2 stated it was an error to document the medication was administered when it was not. During a concurrent interview and record review on 1/8/26 at 10:48 a.m. with LVN 3, Resident 46 EMAR was reviewed, LVN 3 stated she documented she administered Resident 46's brexpiprazole on 1/6/26. LVN 3 stated she documented the medication as administered and did not realize the medication was not available. LVN 3 stated she was notified by the DON today that she documented the medication incorrectly in the EMAR. LVN 3 stated the brexpiprazole medication was ordered by the PMHNP LVN 3 stated she notified the PMHNP and the medication order was rewritten and faxed to the pharmacy, but Resident 46's insurance did not approve the medication. LVN 3 stated she did not recall notifying the primary physician to let him know the medication was not covered by Resident 46's insurance. During a review of facility's document titled, Charge Nurse Job Description, dated 2023, the Job Description indicated, .Ensures that policies and procedures are complied with by nursing personnel assigned . Prepares and administers medications as per physicians' orders and observed for adverse effects . Ensures that there is adequate stock of medications, supplies, equipment and notifies appropriate personnel of needs . During a review of facility's policy and procedure (P&P) titled, Medication Administration, General Guideline, dated 9/18, The P&P indicated, . Medications are administered in accordance with written orders of the prescriber . Verify medication is correct three (3) times before administering the medication. a. When pulling medication package from med cart. b. When dose is prepared. c. Before dose is administered . Documentation: 1. The individual who administers the medication dose, records the administration on the residents EMAR immediately following the medication being given . 2. If a dose of a regularly scheduled medication is withheld, refused, or given at other than the scheduled time . an explanatory note is entered . During a review of facility's policy and procedure (P&P) titled, Medication Orders Non-Controlled Medication Orders, dated 12/12, the P&P indicated, .The prescriber should be contacted by nursing when delivery of a medication will be delayed or the medication is not available . Non-emergency medication orders; The first dose of medication is scheduled to be given after the next regularly scheduled pharmacy delivery to the nursing care center . During a review of facility's policy and procedure (P&P) titled, Documentation of Medication Administration, dated 2001, the P&P indicated, .A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (MAR) . Documentation of medication administration includes, as a minimum: .reason(s) why a medication was withheld, not administered, or refused . During a review of the professional reference (PR), found on https://www.ncbi.nlm.nih.gov/books/NBK519065/ an article titled, Medication Dispensing Errors and Prevention, dated 2/12/24, the PR indicated, .Types of Medication Errors: Prescribing, Omission, Wrong time, Unauthorized medication, Improper dose, Wrong dose prescription or wrong dose preparation, Administration errors such as incorrect route of administration, administering the drug to the wrong patient, extra dose, or wrong rate, Monitoring errors such as failing to take into account the patient's liver and renal function, failing to document allergy or potential for drug interaction, Compliance errors such as not following protocol or rules established for dispensing and prescribing medications.

Number of residents sampled: 6Number of residents cited: 2Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility's medication error rate was 9.68 percent. There were 31 opportunities for errors and three medication errors occurred for three of six sampled residents (Resident 5 and Resident 46) when:1.Licensed Vocational Nurse (LVN)1 did not follow Resident 46's physician's order of multivitamins when she administered multivitamin with minerals to Resident 46 on 1/7/26. This failure had the potential for Resident 46 to develop adverse reaction to medication that was not prescribed to her which could result in serious health condition.2.LVN 1 did not follow Resident 5's physician's order of senna-docusate (used to prevent/treat constipation) when she administered senna and a routine inhaler (a small handheld medical device that delivers medicine as a mist or spray directly to the lungs for treating respiratory conditions like asthma) medication Advair HFA (used for the treatment of breathing problems in patients with asthma) was not available to administer to Resident 5 on 1/7/26.These failures resulted in the potential for Resident 5 to experience shortness of breath and constipation which could lead to more serious health condition. 1. During an observation on 1/7/26 at 8:17 a.m. with LVN 1, outside of Resident 46's room, LVN 1 prepared Resident 46's medications including multivitamin with minerals. LVN 1 crushed the medications and added apple sauce in the medication cup and administered to Resident 46. During a review of Resident 46's admission Record [AR-a document containing resident profile information], dated 1/8/26, the AR indicated resident 46 was admitted to the facility on [DATE] with diagnoses which included depression (persistent sadness, loss of interest, and changes in sleep, appetite, and energy that interfere with daily life), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). During a review of Resident 46's Minimum Data Set (MDS- resident assessment tool which indicates physical and cognitive abilities), dated 11/15/25, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 4 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 46 had severe cognitive impairment. During a concurrent interview and record review on 1/7/26 at 2:55 p.m. with LVN 1, Resident 46 Electronic Medication Administration Record (EMAR-an electronic daily documentation record used by licensed nurse to document medications and treatments given to a resident), dated 1/2026 was reviewed. The EMAR indicated, .Multivitamin Oral Tablet (Multiple Vitamin) Give 1 (one) tablet by mouth one time a day for Supplement. Start Date 10/14/23. LVN 1 stated she signed Resident 46's EMAR on 1/7/26 indicating she administered multivitamin to Resident 46. LVN 1 stated, I administered multivitamin with minerals because it is the only over the counter medication available for us to administer, it is the same medication. LVN 1 refused to answer possible side effects to Resident 46 when administered with the wrong medication. During a concurrent interview and record review on 1/8/26 at 10:10 a.m. with LVN 2, Resident 46 medication physician's orders was reviewed. LVN 2 stated Resident 46's order was multivitamin and not multiple vitamin with minerals. LVN 2 stated, Medications are over the counter but are not the same. LVN 2 stated Resident 46 could develop allergic reactions to the medication. LVN 2 stated the physician order has to be followed. During an interview on 1/8/26 at 10:50 a.m. with LVN 3, LVN 3 stated Resident 46's medication physician's order should be followed as ordered LVN 3 stated Resident 46 may develop allergic reaction to a medication administered not ordered by her physician. 2. During an observation and interview on 1/7/26 at 8:21 a.m. with LVN 1, outside of resident 5's room. LVN 1 prepared Resident 5's 8 a.m. medications including senna (stool softener). LVN 1 stated Resident 5's routine [brand name] inhaler was not available to administer. LVN 1 crushed Resident 5's medications and added apple sauce in the medication cup. LVN 1 stated Resident 5 was hard of hearing and had to write on a white board to communicate with Resident 5. During a review of Resident 5's admission Record, dated 1/8/26, the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnoses which included asthma (narrowing of the small airways in the lungs making it hard to breath), shortness of breath and constipation (infrequent bowel movements and stools are hard, dry, lumpy, and difficult or painful to pass).During a review of Resident 5's MDS dated [DATE], the MDS indicated a BIMS of 13 which indicated Resident 5 had no cognitive impairment.During concurrent interview and record review on 1/7/26 at 3:05 p.m. with LVN 1, Resident 5's EMAR dated 1/2026 was reviewed. The EMAR indicated, .(brand name) inhalation Aerosol 115-21 MCG/ACT [micrograms per actuation] 1 puff inhale orally one time a day . Start date 8/8/25 .Senna-Docusate Sodium Oral Tablet . Give two [2] tablet by mouth every morning and at bedtime for constipation. Start Date 4/4/25 . LVN 1 stated she administered senna to Resident 5 because it was the only over the counter medication available. LVN 1 refused to answer whether both medications are the same. LVN 1 refused to answer possible consequences of Resident 5 not receiving the right medication. LVN 1 stated Resident 5's [brand name] inhaler was a routine medication and should have been available to administer. LVN 1 stated Resident 5 could develop respiratory problem because of the medication not available and not administered as ordered by the physician. LVN 1 stated licensed nurses are responsible in making sure all routine medications are available to administer to residents and to follow up with the pharmacy.During an interview on 1/8/25 at 10:05 a.m. with LVN 2, LVN stated Resident 5's medication order should be followed as ordered by her physician. LVN 2 stated Resident 45 may not be getting the result needed if not administered the right medication. LVN 2 stated routine medications should be available to residents because they need the medication. LVN 2 stated Resident 5 needed her inhaler to prevent her from having respiratory problems. LVN 2 stated Resident 5 has asthma and she needed her inhaler to prevent respiratory complications.During a concurrent interview and record review on 1/8/26 at 10:55 a.m. with LVN 3, Resident 5's EMAR was reviewed. LVN 3 stated she worked on 1/6/26 and she administered Resident 5's inhaler. LVN 3 stated she signed the EMAR on 1/6/26 because she administered the inhaler medication to Resident 5. LVN 3 stated Resident 5's inhaler was routine and should be available to administer as ordered by the physician to prevent Resident 5 from getting respiratory complications. LVN 3 stated Resident 5 should have been administered the Senna-docusate as ordered by the physician. LVN 3 stated Senna and Senna -docusate are not the same medications. LVN 3 stated Resident 5 could develop constipation because she was not given the medication ordered by her physician. During an interview on 6/9/26 at 12:42 p.m. with the Director of Nursing (DON), the DON stated her expectation was for routine medications to be readily available to administer to residents. The DON stated licensed nurses should have called pharmacy when a routine medication was not available. The DON stated licensed nurses during medication administration should be following the medication physician's order and administering the correct medication. The DON stated her expectation was for licensed nurses to compare medication order and the medication at hand making sure medications are the same to prevent medication error. The DON stated medication errors are harmful to residents which could potentially be debilitating to residents and may end up in the acute hospital. During a review of facility's policy and procedure (P&P) titled, Medication Administration, General Guideline, dated 2007, the P&P indicated, . Prior to administration, review and confirm medication order for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label . Medications are administered in accordance with written orders of the prescriber .Verify medication is correct three (3) times before administering the medication .During a review of facility's policy and procedure (P&P) titled, Medication Ordering and Receiving From Pharmacy Provider, Ordering and Receiving non-Controlled Medications, dated 1/20, the P&P indicated, .All medications should be reordered in advanced by writing medication names and prescription number . and faxing or otherwise transmitting the order to the pharmacy . Timely delivery of new medications is required so that medication is not delayed . During a review of the professional reference (PR), found on https://www.ncbi.nlm.nih.gov/books/NBK519065/ an article titled, Medication Dispensing Errors and Prevention, dated 2/12/24, the PR indicated, .Types of Medication Errors: Prescribing, Omission, Wrong time, Unauthorized medication, Improper dose, Wrong dose prescription or wrong dose preparation, Administration errors such as incorrect route of administration, administering the drug to the wrong patient, extra dose, or wrong rate, Monitoring errors such as failing to take into account the patient's liver and renal function, failing to document allergy or potential for drug interaction, Compliance errors such as not following protocol or rules established for dispensing and prescribing medications.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review, the facility failed to ensure proper storage and disposal of medications and biologicals in accordance with facility policy and procedures when:1.Two expired medications were found in one of one medication rooms. This failure had the potential for residents to receive medication that no longer had the desired efficacy with the potential to slow healing, and or relieve pain and discomfort.2. Station 1's medication cart, contained Resident 21's lactulose (used to treat constipation) medication with label different from the medication's physician order in the Electronic Medication Administration Order (Electronic Medication Administration Record (EMAR- an electronic daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 1/2026.This failure placed Resident 21 at risk of not receiving the physician's prescribed dose which could lead to serious health condition. 1.During a concurrent observation and record review on 1/8/26 at 11:10 a.m. with Director of Nurses (DON), in the Medication Storage Room, a bottle of Simethicone (a medication to ease gas symptoms) 80 milligrams (MG – unit of measurement), with an expiration date of 12/2024 and an injectable vial of Dulaglutide (a medication to treat high blood sugar) 1.5 MG with an expiration date of 10/15/25. The DON stated that expired medications are to be destroyed following the policy on destruction of medications. Expired medications may not have the same strength and not benefit the resident. During an interview on 1/9/26 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated all expired meds should be removed from the medication carts and medication so as not to give them to the residents. Expired meds could have unwanted side effects and may no longer have the same efficacy resulting in the resident not receiving the full effect of the medication. During a review of the facility's policy and procedure titled, Destruction of Unused Drugs, dated 12/18/25, indicated, .All unused, or expired drugs shall be disposed of in accordance with state laws and regulations . 2.During a review of Resident 21's admission Record [AR- a document containing resident profile information], dated 1/8/26, the AR indicated Resident 21 was readmitted to the facility on [DATE] with diagnoses which included depression (persistent sadness, loss of interest, and changes in sleep, appetite, and energy), anxiety (persistent, excessive, and uncontrolled worry or fear about everyday situations) and heart failure. During a review of Resident 21's Order Summary Report[OSR], dated 1/9/26, The OSR indicated, .Lactulose Oral Solution 10 GM[gram-unit of measurement]/15ML [milliliter-unit of measurement] Give 45 ml by mouth three times a day for Constipation related to QUADRIPLEGIA [paralysis from the neck down, including legs, and arms, usually due to a spinal injury] . During an observation on 1/7/26 at 8:51 a.m. with Licensed Vocational Nurse (LVN) 1 outside of Resident 21's room. LVN 1 observed preparing Resident 21's prescribed medication including lactulose. LVN 1 poured 45 ml of lactulose in a medicine cup and administered to Resident 21. Resident 21's lactulose medication bottle with direction to administer 30ml. During a concurrent interview and record review on 1/7/26 at 2:55 p.m. with LVN 1, LVN 1 reviewed Resident 21's medication orders and stated Resident 21's lactulose order was 45 ml three times a day. LVN 1 stated she followed Resident 21's physician order in the EMAR. LVN 1 stated she looked at the lactulose medication bottle prior to preparing medication and did not realize the medication direction was different from the medication direction in the EMAR. LVN 1 refused to answer what she could have done when a medication bottle direction was different from the medication direction in the EMAR. During an interview on 1/8/26 at 10:17 a.m. with LVN 2, LVN 2 stated it was the responsibility of the licensed nurse receiving a medication order to notify pharmacy of new orders. LVN 2 stated for medication direction changes in dose and frequency, put a change of direction sticker on the bottle of medication or the bubble pack (blister pack) until pharmacy send us medication with the new label. LVN 2 stated not placing a change of direction sticker was a potential for medication error, not following the physician order and resident not achieving the intended therapeutic outcome. During an interview on 1/8/26 at 11:20 a.m. with LVN 3, LVN 3 stated it was the responsibility of the licensed nurse administering medications to contact physician when a prescribed medication direction label was different from the medication direction in the EMAR to prevent medication error. LVN 3 stated the nurse receiving the medication order was responsible in contacting the pharmacy to let them know of the new order. LVN 3 stated to place a change of direction sticker on the medication bottle or medication blister pack while waiting for the new medication with the correct label and to avoid medication error. During an interview on 1/9/26 at 12:53 p.m. with the Director of Nursing (DON), the DON stated, I expect licensed nurses to notify pharmacy of new prescribed medication dose and frequency and put a sticker on medication bottles and blister pack. The DON stated licensed nurses should be comparing prescribed medication orders in the EMAR and the medication bottle or blister pack available to avoid medication error. The DON stated, Medication error could result in harm to residents, and we do not want that to happen. During a review of facility's policy and procedure (P&P) titled, Medications and Medication Labels, dated 5/16, the P&P indicated, .a. If the prescriber's directions for use change of the label is inaccurate, the nurse may place a direction change, change of order-check chart or similar label on the container indicating there is a change in directions for use, taking care not to cover important label information. b. When such a direction change label appears on the container, the medication nurse checks the resident's medication administration record (MAR) or the prescriber's order for current information. 7. If directions for use change, the provider pharmacy is informed prior to next refill of the prescription so the new container will show an accurate label .

Number of residents sampled: 4Number of residents cited: 1Based on interview and record review, the facility failed to ensure Minimum Data Set Assessment (MDS-assessment of physical and psychological function needs) accurately reflected resident's health and function for one of four sampled residents (Resident 21) when Resident 21's use of lorazepam (medication uses for anxiety) was inaccurately coded in the MDS assessment dated [DATE].This failure had the potential to result in Resident 21's care needs not being met and the potential risk for adverse medication reactions not be monitored. During a review of Resident 21's admission Record [AR- a document with personal identification and medical information], dated 1/8/26, the AR indicated Resident 21 was re-admitted to the facility on [DATE] with diagnoses which included anxiety (feeling of worry, fear or unease, often triggered by stress, that helps cope with challenges by creating focus and energy), depression (persistent sadness, loss of interest, and changes in sleep, appetite and energy) and mood disorder (persistent emotional state, causing extreme sadness or highs often with swings between them, significantly disrupting daily life, functioning, and relationship). During a review of Resident 21's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 11/15/25, the MDS indicated a Brief Interview for Mental Status (BIMS- an assessment of cognitive function) score of 14 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 21 had no cognitive impairment. During a concurrent interview and record review on 1/9/26 at 8:38 a.m. with Minimum Data Set Nurse (MDSN), the MDSN reviewed Resident 21's MDS assessment dated [DATE] Section N (Medications). The MDSN stated Resident 21 was taking medications for anxiety but Section N was not marked. The MDSN stated she did not code Resident 21 was taking medication for anxiety and she should have marked Section N. The MDSN stated it was her responsibility to ensure MDS assessment was accurate. The MDSN stated, I have to make sure I captured the right data because we utilize the data for payments and has to be done the right way. During an interview on1/9/26 at 1:25 p.m. with the Director of Nursing (DON), the DON stated her expectation regarding MDS assessment was To ensure assessments are accurate to ensure the right care was provided to residents to move on to the next level. The DON stated each staff member completing an MDS assessments are responsible for ensuring accuracy of their own assessments. During an interview on 1/9/26 at 1:55 p.m. with the Administrator (ADM), the ADM stated her expectation was for MDS assessment to be accurate and data to be transmitted to Centers for Medicare and Medicaid Services (CMS-federal agency that runs Medicare, Medicaid, and the Children's Health Insurance Program) on time. The ADM stated each staff member completing the MDS assessment are responsible for ensuring the accuracy of their own assessments. During a review of facility's policy and procedure (P&P) titled Resident Assessment-RAI dated 2025, the P&P indicated, The facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences .The assessment will include at least the following: .Disease diagnosis and health conditions . Medications . During a review of professional reference titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.19.1 10/24, indicated, .Identify Diagnoses: The disease conditions in this section require a physician-documented diagnosis . in the last 60 days . Check the following information sources in the medical record for the last 7 [seven] days to identify active diagnoses: transfer documents, physician progress notes, recent history . medication sheets, doctor's orders .

Number of residents sampled: 4Number of residents cited: 2Based on interview and record review, the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASARR-a federal requirement to ensure residents with mental disorder or intellectual disorder or intellectual disabilities are not appropriately placed in a nursing home) were completed and the state mental health authority or stated intellectual disability authority was notified promptly after a significant change of condition for two of four sampled residents (Resident 21 and Resident 46).This failure had a potential risk for Resident 21 and Resident 46 not to have received the appropriate services related to their mental health needs. During a review of Resident 21's admission Record [AR- a document containing resident profile information], dated 1/8/26, the AR indicated Resident 21 was readmitted to the facility on [DATE] with diagnoses which included depression (persistent sadness, loss of interest, and changes in sleep, appetite, and energy), anxiety (persistent, excessive, and uncontrolled worry or fear about everyday situations) and heart failure. During a review of Resident 21's Order Summary Report[OSR], dated 1/9/26, The OSR indicated, .Duloxetine HCl [hydrochloride] [used to treat depression] Oral Capsule Delayed Release Sprinkle 30 MG[milligram-unit of measurement] . Order Date: 12/06/25, Start Date; 12/06/25 . Lorazepam [used to treat anxiety] Oral Tablet 0.5 MG . Start Date: 12/13/25, Start Date 12/14/25 . Mirtazapine [used to treat depression] Oral tablet 15 MG . Start Date: 1/9/26, Start Date: 1/9/26 . During a review of Resident 21's PASARR Level I screening Report, dated 9/12/23, the PASARR level I indicated, .Negative Level I Screening Indicates a Level II Mental Health Evaluation is Not Required . During a review of Resident 46's AR dated 1/8/26, the AR indicated Resident 46 was admitted to the facility with diagnoses which included depression, Alzheimer's disease (disease characterized by a progressive decline in mental abilities) and dementia (progressive decline in mental abilities). During a review of Resident 46's OSR, dated 1/9/26, the OSR indicated , .Mirtazapine Oral Tablet 15 MG (Mirtazapine) Give 1 [one] tablet by mouth in the evening . Start Date: 1/12/25, Start Date: 1/12/25 . During a concurrent interview and record review on 1/9/26 at 8:50 a.m. with Minimum Data Set Nurse (MDSN), the MDSN stated she started working at the facility in 10/2025 and she was responsible in reviewing PASARR screening for residents. The MDSN stated PASARR screening are completed for new admission, readmission, and when there was a change in condition, including the initiation of psychotropic medication. The MDSN reviewed Resident 21's PASARR level I dated 9/12/23 and stated, at the time of admission, Resident 21 did not have diagnosis of mental disorder, such as depression, and was not prescribed any psychotropic medication. Resident 21 was re-admitted to the facility on [DATE] and was prescribed lorazepam on 12/13/25, mirtazapine 1/9/26 and duloxetine 12/06/25. The MDSN stated a new PASARR level I screening should have been completed following Resident 21's readmission and initiation pf psychotropic medications, but the record revealed no evidence a PASSAR Level I screening was completed. During a concurrent interview and record review on 1/9/26 at 9:05 a.m. with MDSN, the MDSN reviewed Resident 46's PASARR level 1 dated 9/29/23. The MDSN stated Resident 46 was diagnosed with major depression on 12/5/23. The MDSN stated a new PASARR level I screening should have been completed following this diagnosis but there was no evidence in the record that a PASARR level I screening was completed. The MDSN stated Resident 46 started on mirtazapine on 1/12/25 and a new PASARR level I screening should have been completed but there was none. The MDSN stated she did not remember completing any PASARR level I screening since she started working in the facility. During an interview on 1/9/26 at 1:20 p.m. with the Director of Nursing (DON), the DON stated PASARR Level I screening are completed at the acute hospital and sent to the facility as part of resident's record. The DON stated her expectation was to make sure all residents who require a PASARR Level I screening have an updated assessment completed. The DON stated she will be working with the MDSN and other licensed nurses to ensure PASARR level 1 screening are completed when a change in a resident's condition occurred. During an interview on 1/9/26 at 2:10 p.m. with the Administrator (ADM), the ADM stated PASARR Level I are completed in the acute hospital and are sent to the facility upon resident's admission. The ADM stated the admission coordinator made sure a PASARR Level I screening was completed prior to resident admission to the facility.During a review of facility's policy and procedure (P&P) titled, Resident Assessment-Coordination with PASARR Program, revised dated 12/16/25, the P&P indicated, .All applicants to this facility will be screened for serious mental disorder s or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening . Any residents who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Example include: a. A resident who exhibit s behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR .

Based on observation, interview, and record review, the facility failed to ensure a nurse staffing data was posted in a visible location for residents, families, and visitors. This failure did not allow the residents and their families to access important information about the facility staffing levels, which could affect their ability to make informed decisions about safety and quality of care provided. During a concurrent observation and record review on 1-8-26 at 12:30 p.m., with the facility's administrator (ADM), outside of the business office, the nurse staffing data was not displayed. The ADM stated that the nurse staffing data belongs in the empty clear folder that is taped to the outside of the window. The business office is to place the nurse staffing data for the day inside the clear plastic folder so that it is visible for residents and visitors to see as they first enter the facility. The ADM stated there was no reason for the nurse staffing not to be posted.During a review of the facility's policy and procedure titled, Nurse Staffing Posting Information, dated 12/18/25, indicated, . nurse staffing readily available in a readable format to residents, staff and visitors at any given time. the nurse staffing sheet will be posted on a daily basis . at the beginning of each shift .

Number of residents sampled: 6Number of residents cited: 2 Based on observation, interview and record review, the facility failed to provide pharmaceutical services which ensured appropriate administration of medications to meet residents needs for two of six sampled residents (Resident 46 and Resident 5) when Resident 46's psychotropic (medications that alter brain chemistry to affect mood, thoughts, and behavior) medication brexpiprazole (used to treat Alzheimer's Disease-a disease characterized by a progressive decline in mental abilities) and Resident 5's inhaler (a small, handheld medical device that delivers medicine as a mist or spray directly to the lungs for treating respiratory conditions like asthma) medication fluticasone propionate/salmeterol (used for treatment of breathing problems in patients with asthma) were not available to administer on 1/7/25.These failures resulted in Resident 46 and Resident 5 not receiving their routine medications, which could have led to serious health conditions. During a concurrent observation and interview on 1/7/26 at 8:17 a.m. with Licensed Vocational Nurse (LLVN)1 outside Resident 46's room, LVN 1 prepared Resident 46's medications. LVN 1 stated Resident 46's brexiprazole medication was not available for administration. Resident 46 was observed sitting in her wheelchair inside her room next to her bed. Resident 46 was alert, verbally responsive, and appropriately dressed. During a review of Resident 46's admission Record [AR-a document containing resident profile information], dated 1/8/26, the AR indicated Resident 46 was admitted to the facility on [DATE] with diagnoses which included depression (persistent sadness, loss of interest, and changes in sleep, appetite, and energy that interfere with daily life), Alzheimer's Disease and dementia (a progressive state of decline in mental abilities). During a review of Resident 46's Minimum Data Set (MDS- resident assessment tool which indicates physical and cognitive abilities), dated 11/15/25, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 4 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 46 had severe cognitive impairment. During a review of Resident 46's Electronic Medication Administration Record (EMAR-an electronic daily documentation record used by licensed nurse to document medications and treatments given to a resident), dated 12/2025. The EMAR indicated, . Brexpiprazole Oral tablet 0.5 MG [milligram-unit of measurement] (Brexpiprazole) Give one (1) tablet by mouth in the morning . Start Date 12/07/25 . During a concurrent observation and interview on 1/7/26 at 8:21 a.m. with LVN 1, outside of Resident 5's room. LVN 1 prepared Resident 5's medication. LVN 1 stated Resident 5's routine inhaler was not available for administration. Resident 5 was observed lying in bed with the head of the bed elevated and working on her crosswords puzzles. Resident 5 looked up when LVN 1 touched her shoulder. LVN 1 stated Resident 5 was hard of hearing and communication required writing on a white board. During a review of Resident 5's admission Record, dated 1/8/26, the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnoses which included asthma (narrowing of the small airways in the lungs making it hard to breath), shortness of breath and constipation (infrequent bowel movements and stools are hard, dry, lumpy, and difficult or painful to pass). During a review of Resident 5's EMAR dated 1/2026, the EMAR indicated, . [brand name] HFA [hydrofluoroalkane-non-ozone-depleting chemicals used as propellants in aerosol inhalant] 115-21 MCG/ACT [micrograms/actuation] (Fluticasone-Salmetrol) one (1) puff orally one time a day related to COUGH VARIANT ASTHMA . rinse mouth with water and spit back into cup after use Start Date 08/08/2025 . During an interview on 1/7/26 at 2:38 p.m. with LVN 1, LVN 1 stated it was the responsibility of all nurses to ensure routine medications were available for administration to residents. LVN 1 stated she checked the medication room and the medication cart for Resident 5's inhaler, but it was not available, so she faxed pharmacy to send the medication. LVN 1 stated Resident 46's medication was not available to administer because, according to the pharmacy, medication was still being processed. LVN 1 stated she did not remember notifying the physician Resident 46's prescribed medication was unavailable since it was ordered. LVN 1 stated she was not sure when the psychotropic medication had been ordered.During an interview on 1/8/26 at 10:08 a.m. with LVN 2, LVN 2 stated all licensed nurses are responsible for ordering medication refills. LVN 2 stated medication refills are faxed to pharmacy when medication supplies is less than a week and staff follow up with the pharmacy as needed. LVN 2 stated all routine medications should be available for administration to residents to ensure no doses are missed, which could result in residents becoming seriously ill.During an interview on 1/8/26 at 10:15 a.m. with LVN 3, LVN 3 stated Nurses are responsible for ensuring routine medications are available to administer to residents. LVN 3 stated medications are ordered from pharmacy when supplies are running low to prevent residents from missing doses. LVN 3 stated residents needs their medications, and if not administered, it could affect their health making residents sicker. During an interview on 1/9/26 at 1:05 p.m. with the Director of Nursing (DON), the DON stated her expectation was for the licensed nurses to ensure routine medications are available to administer to residents. The DON stated licensed nurses should call pharmacy for new medications and to ensure all medications are available. The DON stated missed doses could negatively affect a residents health, and depending on the medications, it could result in diminished breathing, uncontrolled pain, or worsening of mental health conditions . During a review of facility's document titled, Charge Nurse Job Description, dated 2023, the Job Description indicated, .Ensures that policies and procedures are complied with by nursing personnel assigned . Prepares and administers medications as per physicians' orders and observed for adverse effects . Ensures that there is adequate stock of medications, supplies, equipment and notifies appropriate personnel of needs . During a review of facility's policy and procedure (P&P) titled, Medication Orders Non-Controlled Medication Orders, dated 12/12, the P&P indicated, .The prescriber should be contacted by nursing for direction when delivery of a medication will be delayed or the medication is not available . Non-emergency medication orders: The first dose of medication is scheduled to be given after the next regularly scheduled pharmacy delivery to the nursing care center . During a review of facility's policy and procedure (P&P) titled, Medication Ordering and Receiving From Pharmacy Provider Ordering and Receiving Non-Controlled Medications, dated 1/20, the P&P indicated, . all medications shall be reordered in advance by writing in the medication name and prescription number or applying the peel-off bar coded label from the prescription label on the reorder sheet and faxing or otherwise transmitting the order to the pharmacy. All medication order, changes or discontinuation must be communicated to the pharmacy, timely . Timely delivery of new orders is required so that medication order is not delayed . A medication order form is also used to notify the provider pharmacy of changes in dosage, directions for use, discontinuation, etc, of new medications .

Number of residents sampled: 4Number of residents cited: 1Based on observation, interview, and record review, the facility failed to ensure food preferences were accommodated for one of four sampled residents (Resident 16) when Resident 16's standing physician order for strawberry shake was not served to Resident 16 during lunch on 9/30/25. This failure had the potential risk to result in Resident 16 not meeting nutritional needs, which could lead to unplanned weight loss. During a concurrent interview and record review on 9/30/25 at 12:20 p.m. in the dining room, Resident 16 was sitting in her wheelchair with her lunch tray positioned in front of her. Resident 16's lunch tray did not include a strawberry health shake. Certified Nursing Assistant (CNA) 1, was observed seated next to Resident 16 and assisting with lunch. CNA 1 stated Resident 16 needed assistance with meals to ensure adequate intake and prevent weight loss. CNA 1 reviewed Resident 16's meal ticket and stated, There should be a milk shake with her meal tray. CNA 1 stated she was not sure why Resident 16 had an order for milk shake. CNA 1 stated, Health shakes are ordered for residents experiencing weight loss. CNA 1 stated Resident 16 could experience further weight loss when the ordered health shake was not given as ordered by the physician. During a review of Resident 16's admission Record [AR-a document containing resident profile information], dated 1/8/26, the AR indicated, Resident 16 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), hemiplegia (complete paralysis) and hemiparesis (weakness or partial paralysis) and muscle weakness. During a review of Resident 14's meal ticket, dated 9/30/25, the meal ticket indicated, .Diet Order: National Dysphagia 2 (Mechanical Soft), Regular, -Fluids-Regular (Thin) Liquids . Standing Orders: >four [4] ounces [oz- unit of measurement] carton Ready Care Strawberry Shake . During an interview on 1/8/26 at 1:43 p.m. with CNA 2, CNA 2 stated during mealtimes in the dining room, certified nursing assistants ensure residents' hands are cleaned and residents'' are ready for lunch. CNA 2 stated fluids, including water and juices, are provided to residents. CNA 2 stated once the meal cart was brought in the dining room, licensed nurses checked the meal trays, and CNAs then deliver the food tray to residents. CNA 2 stated, We are supposed to compare the food with the meal ticket to ensure the food matches the meal ticket order. CNA 2 stated nutritional supplements, such as health shakes, are ordered for residents with poor appetite and experiencing weight loss. CNA 2 stated, We have to make sure residents received the health shake as ordered to prevent weight loss. During an interview on 1/8/26 at 1:10 p.m. with the Dietary Supervisor (DS), the DS stated she has worked at the facility as the DS for four years. The DS stated she maintains a list of residents with orders for milk shake. The DS stated milk shakes are labeled with resident names. The DS stated, We placed all the health shakes in a tray and pushed in the dining room before meals, The DS stated CNAs are responsible for ensuring residents' received their milkshakes The DS stated health shakes are ordered for residents experiencing weight loss and to support wound healing. The DS stated residents with milk shake orders could experience weight loss and delayed wound healing if the milkshakes are not provided to residents as ordered. During an interview on 1/9/26 at 1:14 p.m. with the Director of Nursing (DON), the DON stated, I expect residents with orders for health shakes be served as ordered. The DON stated health shakes have extra nutrients and are ordered for residents experiencing weight loss. The DON stated residents may experience weight loss if they do not serve health shakes as ordered. The DON stated, We want to prevent any further weight loss for all residents. The DON stated nursing staff should ensure to check and compare the meal trays and the meal ticket when serving residents and communicating with the dietary staff any missing items in the meal tray.During a review of facility's document titled, Certified Nursing Assistant Job Description, dated 2023, the Job Description indicated, .Coordinates dining room services at assigned meal times, including se-up and clean-up, meal tray delivery, feeding assistance, and documentation of meal intake. Delivers nutritional supplements to residents at assigned times and provides assistance as necessary to ensure intake . During review of facility's policy and procedure (P&P) titled, Resident Food Preferences, revised 7/17, the P&P indicated, .The dietician and nursing staff, assisted by the physician, will identify any nutritional issues and dietary recommendations . The dietitian will discuss with the resident or representative the rationale of any prescribed diet .The food service department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks .

Number of residents sampled: 4Number of residents cited: 2Based on observation, interview, and record review, the facility failed to ensure adaptive equipment was provided for two of four sampled residents (Resident 14 and Resident 16) when:1.During a meal observation in the dining room on 9/30/25, Rehabilitative Nursing Assistant (RNA) used plastic straws instead of spoon for Resident 14's liquids.This failure had the potential for Resident 14 to aspirate while drinking fluids.2.Resident 16 was not provided sippy cup on her meal tray during lunch on 9/30/25. This failure had the potential to limit Resident 16's ability to drink independently and safely. 1.During a concurrent observation and interview on 9/30/25 at 12:12 p.m. in the dining room, Resident 14 was observed seated in a geriatric chair (large, padded, reclining room with wheels, designed for individuals with limited mobility, offering comfort and support for relaxing, dining or medical procedures) assisted by RNA with his meals. Resident 14's drinks of water and juice was thickened, and plastic straws was placed in each drink. Resident 14's meal ticket indicated, Liquids by spoon no straws. RNA stated it was her first time to assisting Resident 14 and she did not know not to use a straw for Resident 14's drinks. RNA stated she should have read Resident 14's meal ticket and followed the instruction not to use a straw. RNA stated Resident 14 could aspirate from using a strawReview of Resident 14's meal ticket indicated, Notes: 1:1 Feeder Liquids by spoon no straws.Review of Resident 14's admission Record [AR-a document containing resident profile information], dated 1/8/26, the AR indicated, Resident 14 was admitted to the facility on [DATE] with diagnoses which included dehydration (body uses or loses more fluids than it takes in), dementia (a progressive state of decline in mental abilities) and adult failure to thrive (gradual and unexplained decline in older adult's physical and mental health marked by symptoms like poor appetite and weight loss).During an interview on 1/9/26 at 1:20 p.m. with Dietary Supervisor (DS), the DS stated use of straws was not recommended for residents who are at high risk of aspiration. The DS stated residents who are ordered to not use straws are unable to safely suck fluids through them. The DS stated, Using a straw could cause residents to aspirate. 2.During a concurrent observation and interview on 9/30/25 at 12:20 in the dining room, Resident 16 was observed sitting in a wheelchair assisted by Certified Nursing Assistant (CNA) 1 with her meals. Resident 16's drinks were in a regular cups without handles. CNA 1 stated, I thought she only used sippy cup when in bed. CNA 1 reviewed Resident 16's meal ticket and stated the order should have been followed and placed all of Resident's 16's fluids in a sippy cup. CNA 1 stated not providing Resident 16 with a sippy cup for her drinks could affect her ability to drink independently and safely. Review of Resident 16's meal ticket indicated, Adap [Adaptive] Equip [Equipment]: Sippy Cup During a review of Resident 16's admission Record [AR-a document containing resident profile information], dated 1/8/26, the AR indicated, Resident 16 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), hemiplegia (complete paralysis) and hemiparesis (weakness or partial paralysis) and muscle weakness. During an interview on 1/8/26 at 1:15 p.m. with DS, The DS stated dietary staff placed all the sippy cups in the dining room prior to each meals. The DS stated the CNAs in the dining room are responsible in ensuring residents with orders for sippy are provided with a sippy cup. The DS stated sippy cups are ordered for residents because they are easier to hold and allow residents to drink independently. The DS stated they have enough sippy cups for residents who needed them. During an interview on 1/8/26 1:55 p.m. with CNA 2, CNA 2 stated she helps in the dining room to ensure residents are ready for their meals and provide assistance to residents during meals. CNA 2 stated sippy cups are provided to residents with orders to use them with their drinks. CNA 2 stated sippy cups makes it easier for residents to hold and drink independently. CNA 2 stated regular cups do not have handles and residents could spill their drinks on themselves and not drink at all. CNA 2 stated meal trays do not include straws, the staff assisting residents picked up the straws if needed. CNA 2 stated staff must read the meal ticket and follow the orders. CNA 2 stated using a straw on resident when the meal ticket indicated not to use a straw could result in resident chocking and aspirating fluid. During an interview on 1/9/26 at 1:35 p.m, with the Director of Nursing (DON), the DON stated, Depending on the reason for the order, it can be detrimental to the resident. The DON stated sippy cups are important because it help residents hold the cup with better control and prevent from drinking too fast or too much, which could lead to aspiration. The DON stated her expectation was for nursing staff to ensure they are checking meal trays and comparing meal tickets. The DON stated nursing staff are expected to ensure any adaptive equipment ordered for residents are provided and to follow meal ticket directions. During a review of facility's policy and procedure (P&P) titled, Adaptive Feeding Equipment, dated 12/18/25, the P&P indicated, Residents requiring assistance in feeding are potential candidates for a restorative dining program pr adaptive utensil use, as determined by the occupational therapist . The resident may, depending on the rehabilitative potential . train in the use of adaptive feeding equipment . The dietary department should be notified of residents needing adaptive feeding equipment . Appropriate utensils should be placed on the resident's food tray, at each meal, and returned to the dietary department, on the food tray, for sanitization .

Based on observation and interview during the survey period from 9/30/25 through 1/9/26, the facility failed to ensure each bedroom accommodated no more than four residents (rooms [ROOM NUMBERS]). This failure had the potential to adversely affect care provided to residents in room [ROOM NUMBER] and 14.During an observation on 9/30/25 through 1/9/26, in room [ROOM NUMBER] and 14, the two resident bedrooms had more than four residents. Each room met the required needs of the residents, as well as the square footage. Closet and storage space were adequate. Bedside stands were available. There were sufficient room for nursing care to be provided to the residents. Wheelchair and toilet facilities were accessible. The health and safety of residents would not be adversely affected by the continuance of this waiver. Room Number Number of Beds Square footage4 8 735.19 14 8 732.52 Recommend waiver continue in effect.

Based on observation, interview and record review during the survey period of 9/30/25 to 1/9/2026, the facility failed to provide the minimum of at least 80 square feet per resident in multiple rooms (Rooms 1, 6, 8, 10, 11 and 16). This failure had the potential for residents not to have reasonable accommodations for privacy or adequate space for care to be rendered. During a concurrent observation and interview on 1/9/25, at 12:47 P.m., with the Maintenance Supervisor (MS), an environmental tour was conducted. The MS measured six rooms and stated the rooms did not meet the minimum square footage of 80 square feet per resident. These rooms were as follows: Room Number: Square Feet: Number of Residents room [ROOM NUMBER] 145.96 2 bedsroom [ROOM NUMBER] 312.0 4 bedsroom [ROOM NUMBER] 159.17 2 bedsroom [ROOM NUMBER] 147.17 2 bedsroom [ROOM NUMBER] 147.25 2 bedsroom [ROOM NUMBER] 300.9 4 beds During the observations made on 9/30/25 to 1/9/26, the residents had reasonable amount of privacy. Closets and storage space were adequate, bedside stands were available. There was sufficient room for nursing to provide care and for residents to ambulate. Toilet facilities and wheelchairs were accessible. The waiver will not adversely affect the health and safety of residents. Recommend waiver continue in effect.

Based on interviews and record reviews, the facility failed to ensure residents were treated with dignity and respect for one of seven residents (Resident 1) when two Certified Nurse Assistants (CNA 2, CNA 3) spoke loudly and disrespectfully to Resident 1 and accused her of taking her roommate's remote control and adjusting the television to face Resident 1.This failure placed Resident 1 at potential risk for emotional distress, depression, mental instability, and decline in overall health. During an interview on 11/25/25 at 9:38 a.m., Resident 1 reported two CNAs (CNA 2, CNA 3) accused her of turning her roommate's TV and taking the remote control. Resident 1 stated the CNAs spoke loudly and angrily, calling her a liar, which she found unprofessional and hurtful. During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 11/25/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses: type 2 diabetes mellitus (DM2-- a condition where your body does not use a hormone that helps move sugar from your blood into your cells for energy properly), protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function ), other stimulant abuse, bipolar disorder (,a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to lows (depression or depressive episode)), major depressive disorder (persistent feeling of sadness and loss of interest), post-traumatic stress disorder (extreme fear during or after witnessing or experiencing potentially traumatic events, such as war, accidents, natural disasters or sexual violence), chronic pain syndrome. During a review of Resident 1's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 9/17/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had no cognitive impairment. During an interview on 11/25/25 at 10:46 a.m. with CNA 1, CNA 1 stated staff should not yell at residents to preserve their dignity. CNA 1 stated residents deserve to be treated with respect and yelling could make them feel belittled or depressed. During an interview on 11/25/25 at 11:54 a.m. with the Administrator (ADM), the ADM stated on 11/11/25 around 7:30 p.m., the Director of Staff Development (DSD) informed her two CNAs argued with Resident 1 and were immediately suspended. The ADM stated he interviewed alert residents who stated they heard arguing but could not identify who was involved. The ADM stated he interviewed Licensed Vocational Nurse (LVN 5), who witnessed the incident. The ADM stated LVN 5 reported CNA 2 and CNA 3 argued with Resident 1 and behaved inappropriately. The ADM stated CNA 2 and CNA 3 had final written warnings due to misconduct. The ADM stated CNA 2 and CNA 3 were terminated on 11/17/25.During an interview on 11/25/25, at 12:09 p.m. with the Registered Nurse (RN), the RN stated it was unacceptable for staff to yell at residents. The RN stated staff members must act appropriately and address the needs of the residents. The RN stated if a resident were to yell at staff, it would still be inappropriate for staff to respond by yelling at the resident. The RN stated the residents have a right to be treated with respect and dignity. During an interview on 11/25/25 at 1:45 p.m. with the Director of Nursing (DON), the DON stated staff must maintain residents' dignity and safety and should not raise their voices when speaking to residents. The DON stated raising one's voice when speaking to residents could cause emotional distress, lead residents to refuse food, or diminish their trust in staff. During a phone interview on 12/2/25, at 3:25 p.m. with CNA 2, CNA 2 stated Resident 1 took her roommate's television (TV) remote control and turned the TV away from her roommate's view to face herself. CNA 2 stated she and CNA 3 went to Resident 1's room, retrieved the remote, and redirected the television towards the roommate's view. CNA 2 stated Resident 1 told LVN 5 what happened and accused CNA 2 and CNA 3 of lying. CNA 2 stated they did not respond to the accusation. CNA 2 stated yelling at residents was never acceptable and all residents should be treated with dignity and respect. CNA 2 stated treating residents poorly could lead to depression or decline in residents' health. During a phone interview on 12/2/25 at 3:47 p.m. with CNA 3, CNA 3 stated she and CNA 2 entered Resident 1's room and found the roommate's TV positioned towards Resident 1. CNA 3 stated they repositioned the TV to face the roommate. CNA 3 stated while attending to the roommate's needs, Resident 1 yelled at her for moving the TV. CNA 3 stated she attempted to explain to Resident 1the need for privacy for the roommate, but Resident 1 continued arguing. CNA 3 stated she asked Resident 1 to quiet down because other residents were sleeping. CNA 3 stated she reported the incident to LVN 5, who asked Resident 1 to return to her room. CNA 3 stated staff should speak to residents respectfully and calmly to maintain their dignity and avoid causing emotional distress or depression. During a phone interview on 12/3/25 at 10:15 a.m. with LVN 5, LVN 5 stated staff should always speak respectfully to residents. LVN 5 stated using a disrespectful tone could place residents at risk for emotional distress, mental instability and decline in health. LVN 5 stated she witnessed CNA 2 and CNA 3 yelling at Resident 1 at the nursing station. LVN 5 stated Resident 1 reported I heard they were texting (ADM), but they were giving false information. LVN 5 stated CNA 2 and CNA 3 made statement such as, I'm not going to stop because at the end of the day, I could lose my job.the family didn't want you to use the TV.we are not liars, you are lying. LVN 5 stated the CNAs were inappropriate and disruptive. During a phone interview on December 3, 2025, at 3:13 p.m. with the ADM, the ADM stated she interviewed Resident 1, CNA 2, CNA 3, LVN 5, and the alert residents living in the same hallway as the incident. The ADM stated the alert residents heard Resident 1 yelling but could not identify other voices. The ADM stated Resident 1 argued back and forth with CNA 2 and CNA 3. During a concurrent interview and record review on 12/10/2 at 1:17 p.m. with the Infection Preventionist (IP), the facility's policy and procedure (P&P) titled, Promoting/Maintaining Resident Dignity, Dated 2025 was reviewed. The P&P indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident's rights.10. Speak respectfully to residents. IP stated staff should communicate with residents professionally, avoiding yelling or scolding. The IP stated residents have the right to express themselves, and staff should not raise their voice or belittle them. IP stated staff should refrain from arguing with residents, respecting their right to disagree, as this can affect their dignity. IP stated the staff are visitors in the residents' home, it is crucial to maintain their dignity and ensure they feel safe. IP stated the failure of staff to treat residents with respect may lead to emotional distress and potentially trigger depression. During a review of the facility's P&P titled, Resident Rights, dated 12/17/24, the policy indicated the resident has a right to be treated with respect and dignity.

Based on observations, interviews, and record reviews, the facility failed to protect residents' rights and ensure they were free from misappropriation of property, medications were administered as prescribed, and controlled drugs were properly accounted for and discarded according to facility's policy and procedure for two of three sampled residents (Resident 5 and Resident 6) when License Vocational Nurse (LVN) 5 diverted controlled medications (drugs regulated by law for potential abuse, addiction, or dependence) prescribed for Resident 5 and Resident 6 for personal use and failed to properly document, discard discontinued medications according to facility's policies and procedures. These failures resulted in Resident 5 and Resident 6 not receiving their prescribed medications as ordered which placed them at risk for inadequate pain management and anxiety. During an interview on 11/25/25 at 12:09 p.m. with Registered Nurse (RN), the RN stated controlled substances were stored in the controlled substance drawer of the medication cart. The RN stated the facility had two medication carts; one located at each nursing station. Each medication cart had one controlled substance key which was maintained by the assigned Licensed Nurse (LN). The RN stated during shift change, two LNs would audit the controlled substances medications by reviewing the Controlled Substance Record (log used to document the actual pill count of controlled substance) and conduct a physical count of the total number of pills. The RN stated after verifying the record and count were accurate, both LNs signed the controlled substance records. The RN stated when a resident was discharged from the facility, the LN placed unused controlled substance medications in the discontinued section of the controlled substance drawer. The RN stated the LN was responsible for handing off discontinued controlled substances to the Director of Nursing (DON) when available. The RN stated upon transfer of discontinued controlled substances, the DON and the LN reviewed the discontinued controlled substance medication record, verified the total number of discontinued pills and both signed the controlled substance record after confirming the count was accurate. The RN stated if discrepancies were identified between the controlled substance record and the actual pill count, the LN would review the controlled substance record line items to identify the discrepancy. The RN stated if the discrepancy could not be resolved, the LN notifies the DON, Medical Director (MD), and the Administrator (ADM) for further investigation. During an interview on 11/25/25 at 12:40 p.m. with LVN 1, LVN 1 stated the LNs were responsible for managing and documenting controlled substances from the pharmacy through administration and discontinuation by physician order. LVN 1 stated controlled substances were stored in a secure medication cart, which included a separate locked drawer designated for controlled substances. LVN 1 stated only the nurse assigned to the nursing station-maintained possession of the key to the controlled substance drawer. LVN 1 stated when a controlled substance was administered, the LN signed the Controlled Drug Record, removed the bubble pack from the locked drawer, removed the prescribed dose, administered the medication to the resident, and documents the administration on the Medication Administration Record (MAR). LVN 1 stated the LN would verify the pill count and document on the Controlled Drug Record match the remaining quantity in the bubble packs. LVN 1 stated upon resident's discharged , all controlled drug substances should be delivered to the DON. LVN 1 stated licensed nurse give the controlled substance record and discontinued bubble packs to the DON for review and verification. LVN 1 stated after the pill count was verified, both the DON and the LN signed the controlled substance record, and the DON secured the discontinued controlled substance for destruction. LVN 1 stated if the DON was not available to receive discontinued controlled substances, the controlled substances were stored in the discontinued section of the controlled substance drawer inside the medication cart, and two LNs verified the controlled substance count at each change of shift until the DON was available for transfer. During a concurrent interview and record review on 11/25/25 at 1:45 p.m. with the DON, the facility's document titled Shift Change Controlled Substance Inventory Log, dated 11/14/25 was reviewed. The Shift Change Controlled Substance Inventory Log indicated Resident 5's oxycodone 5 mg quantity was zero. The DON stated Resident 5 was discharged home on [DATE]. The DON stated Resident 5's two bubble packs of Oxycodone (medication used to relieve pain) 5 mg (milligram- unit of measurement) remained in the controlled substance drawer after discharge. The DON stated on 11/14/25, LVN 5 documented on the Shift Change Controlled Substance Inventory Log (log used to document counts of controlled substance bubble packs) a count of zero for Resident 5's Oxycodone 5 mg, which indicated the bubble packs were emptied. The DON stated on 11/17/25, LVN 3 discovered Resident 5's two bubble packs of Oxycodone 5 mg were missing from the controlled substance drawer during shift change controlled substance count with LVN 4. The DON stated LVN 3 notified both her and the ADM of the suspected drug diversion on 11/17/25. The DON stated after interviewing LVN 5, she became aware LVN 5 had removed the corresponding sheet from the Controlled Substance Record Log and removed the two bubble packs of oxycodone 5 mg from the controlled substance drawer, resulting in the medication being untraceable. The DON stated LVN 5 admitted to taking Resident 5's two bubble packs of oxycodone 5 mg, each containing 30 pills. The DON stated she notified law enforcement and the facility pharmacy. The DON stated Resident 5 was discharged on 11/8/25 and the two bubble packs of oxycodone should have been given to her by the LN but was not done. The DON stated the facility's policy and procedure for Controlled Substance Administration & Accountability was not followed. During a record review on 11/25/25 at 2:59 p.m. with the DON, Resident 5's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes) and Medication Administration Record (MAR) were reviewed. The AR, dated 11/25/25 indicated Resident 5 was admitted on [DATE] and discharged on 11/8/25 and had a history of muscle weakness, difficulty walking, alcoholic liver with ascites (liver damage cause by alcohol, with fluid buildup in your abdomen causing swelling), liver failure, encephalopathy (the liver is not working well enough such as filtering toxins, causing a condition affecting the brain that can cause confusion), Type 2 Diabetes Mellitus (a condition where your body does properly use insulin, leading to high blood sugar), alcoholic dependence(a condition in which a person has difficulty stopping alcohol use) and had spinal surgery on 9/7/25. The MAR indicated Resident 5 had a physician order for Oxycodone 5 mg as follows: give one tablet by mouth every four hours as needed for moderate pain and give two tablets by mouth every four hours as needed for severe pain. During a phone interview on 12/2/25 at 2:15 p.m. with LVN 3, LVN 3 stated she discharged Resident 5 on 11/8/25. LVN 3 stated Resident 5 had three bubble packs of oxycodone 5 mg on the day of discharge, one partially used bubble pack containing 25 pills and two unopened bubble packs containing 30 pills each. LVN 3 stated the physician ordered the 25 pills to be sent home with Resident 5 and discontinued the two unopened bubble packs. LVN 3 stated the two discontinued bubble packs were stored in the controlled substance drawer of the medication cart but in a separate compartment designated for discontinued medications, to be included in the shift change controlled substance audit. LVN 3 stated on 11/14/25, during the morning shift, she completed the shift change controlled substance count with LVN 5. LVN 3 stated at that time, the two discontinued oxycodone bubble packs were present in the separate compartment in the controlled substance drawer, and verified the controlled substances were accounted for. LVN 3 stated on 11/17/25, during her morning shift, she completed the shift- change control substance count with LVN 6, no discrepancies were identified, as the discontinued oxycodone bubble packs were in the separate compartment and were not immediately recognized as missing. LVN 3 stated later during her shift, she noticed that the two discontinued bubble packs were missing. LVN 3 stated during the end-of-shift controlled substance count with LVN 4, the incoming nurse, The absence of the two bubble packs was confirmed, and LVN 3 and LVN 4 notified the DON and ADM of the missing medications and potential drug diversion. LVN 3 stated when a resident is discharged , the LN was supposed to notify the DON, and the LN and the DON are responsible for removing the controlled medication from the controlled substance drawer for proper destruction. During a phone interview on 12/3/25 at 10:15 a.m. with LVN 5, LVN 5 stated when controlled substances were discontinued, the LN would leave it in the controlled substance drawer until the DON was notified and could remove the medication for proper destruction. LVN 5 stated the LNs were responsible for notifying the DON when discontinued controlled substances need to be removed. LVN 5 stated she was aware of Resident 5's two bubble packs of oxycodone in the controlled substance drawer. LVN 5 stated she documented zero count in the Shift Change Controlled Substance Inventory Log, removed the corresponding sheet from the Controlled Substance Record Log and removed the two bubble packs of oxycodone 5 mg from the controlled substance drawer, rendering the medication untraceable. During a phone interview on 12/3/25 at 1:44 p.m. with the Pharmacy Nurse Consultant (PNC), the PNC stated discontinued controlled substances should have been destroyed according to the facility's narcotic destruction protocol. The PNC stated the facility should maintain a section for discontinued medications and the LNs were supposed to give discontinued controlled substances to the DON for disposal after a resident's discharge. During a phone interview on 12/3/25 at 2:22 p.m. with the Pharmacy Consultant (PHARM), the PHARM stated discontinued controlled substances should have been handed off to the DON as soon as possible. The PHARM stated if the DON was not available, the LN should continue to count the controlled substance during shift change until they could be handed off to the DON. The PHARM stated the facility was required to monitor the number of controlled medications, and each LN was required to verify every narcotic on the log matched the actual number of medications locked in the controlled substance drawer. During a review of Resident 6's AR, dated 11/25/25, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses: fracture (a partial or complete break in a bone) of unspecified bone in left wrist, hyperlipidemia (high cholesterol), chronic pain syndrome, osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). During a review of Resident 6's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 10/10/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 12 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 6 had moderate cognitive impairment. During a concurrent interview and record review on 12/10/25 at 12:38 p.m. with the Infection Preventionist (IP), Resident 6's MAR dated 11/2025 and the Controlled Drug Record dated 10/23/25 were reviewed. The MAR indicated Hydrocodone-APAP [Acetaminophen] 10-325 (medication used to relieved pain): Give 1 tablet by mouth every four hours as needed for pain. The Controlled Drug Record indicated the Hydrocodone-APAP 10-325 had been signed out multiple times by LVN 5 for Resident 6 on 11/15/25 at 2 p.m., 11/15/25 at 6:19 p.m., 11/15/25 at 6:19 p.m., 11/15/25 at 10:11 p.m., 11/15/25 at 10:11 p.m., 11/16/25 at 1:30 p.m., and 11/16/25 at 6 p.m. The IP stated none of these administrations were Documented the MAR. The IP stated after the prior drug diversion was identified, the facility became aware of the out of sequence entries on the Controlled Drug Record. The IP stated the drug diversion concerns for Residents 6 was reported to the DON. During a phone interview on 12/16/25 at 1:15 p.m. with the PHARM, the PHARM stated it was important for the facility to ensure accurate controlled substance audits to prevent possible drug diversion. The PHARM stated drug diversion could place a resident at risk of not receiving their prescribed pain medication, which could result in uncontrolled pain, decreased quality of life, delayed healing, or a prolonged length of stay. During a concurrent phone interview and record review on 12/10/25 at 11:15 a.m. with the DON, the Controlled Substance Administration & Accountability P&P dated 12/17/24 were reviewed. The P&P indicated, 1.j. The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. The DON stated she audits the controlled substances daily Monday through Friday since the drug diversion incident on 11/17/25. The DON stated she does not perform controlled substance audits on Saturday and Sunday. The DON stated she would resume controlled substance audits on Monday and would review Saturday and Sunday at that time. During a professional reference review retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC3538481/ titled, Diversion of Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention, dated 7/2012, the professional reference review indicated, .healthcare workers who are diverting drugs from the health care facility workplace pose a risk to their patients, their employers, their co-workers, and themselves. It is essential that all health care institutions have a robust system in place to identify and investigate suspected diversion as rapidly and efficiently as possible and that they implement policies and procedures that enable a standardized and effective response to confirmed diversion. Drug diversion by healthcare workers violates the core value that the needs of the patient come first. Clearly, if we are to optimize our approach to inpatient drug diversion and its consequences, we must look at such diversion not as a victimless act but as a multiple-victim crime .

Based on observations, interviews and record review, the facility failed to maintain accurate controlled substance records, documentation and reconciliation in accordance with facility's policies and procedures for two of three sampled residents (Resident 5, 6) when the license nurses (LNs) failed to accurately document and account Resident 5 and Resident 6 controlled substance on the Controlled Drug Records and Medication Administration Record to accurately reflect the controlled substance disposition or resident administration.These failures resulted in the facility's delayed detection of controlled substances diversion for Residents 5 and 6, and placed residents at potential risk for medication errors, untreated pain, and overdose, compromising residents' safety and quality of care. During an interview on 11/25/25 at 12:09 p.m. with the Registered Nurse (RN), The RN stated when controlled substances were delivered, the licensed nurse (LN) checked the medications against the pharmacy manifest to ensure the resident name, medication name, dose, and instructions for use matched the physician's order. The RN stated after verifying, the LN and delivery person signed the manifest, which was filed at the nurse's station. The RN stated LNs recorded the received controlled substances on the Shift Change Control Substance Inventory Log. The RN stated each shift change, two LNs counted the pills in the narcotic drawer and compared them to the records. The RN stated if there was a discrepancy, the LN's reviewed documentation to identify and correct errors, and if it could not be resolved, the LNs notified the Director of Nursing (DON) and the Administrator (ADM). The RN's stated controlled substances required close monitoring because too much medication could cause drowsiness or overdose, placing residents at risk.During an interview on 11/25/25 at 1:45 p.m. with the DON, the DON stated when controlled substances were delivered to the facility, the pharmacy would deliver it directly to the LN. The DON stated the LN would verify with the delivery staff what was received, ensure the bubble packs were intact, and nothing was missing. The DON stated once the controlled substances were verified against the manifest, physician order and the bubble pack label, the LN and delivery staff would sign the manifest. The DON stated the LN would place the controlled substances in the double locked drawer of the medication cart. The DON stated the Controlled Drug Record was stored in a binder and the Shift Change Controlled Substance Inventory Log would be updated with the addition of the pharmacy delivery. The DON stated when the LN prepared to administer controlled substances, the LN should verify the count on the Controlled Drug Record and the bubble pack contents matched. The DON stated the LN should document the date, time and dose of the medication given on the Controlled Drug Record in the binder and in the MAR. The DON stated during shift change, the LN would verify the Shift Change Controlled Substance Inventory Log's recorded total sheets (bubble packs) at the end of the shift would match the number of bubble packs in the controlled substance drawer. The DON stated that LNs would compare the Controlled Drug Record's pill count with the number of pills in the bubble packs in the controlled substance drawer.During a review of Resident 5's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 11/25/25, the AR indicated Resident 5 admitted on [DATE], discharged [DATE] and had a history of muscle weakness, difficulty walking, alcoholic liver with ascites (a buildup of fluid in your abdomen causing a swollen belly), liver failure, encephalopathy (a disturbance of brain function that causes confusion, memory loss and coma in severe cases), Type 2 Diabetes Mellitus (a condition where your body does not use a hormone that helps move sugar from your blood into your cells for energy properly), alcoholic dependence and had spinal surgery on 9/7/25.During a review of Resident 5's Order Summary (OS) dated 9/23/25, the OS indicated oxycodone hydrocholoride (HCl) (drugs used to treat pain) Oral Tablet 5 mg Give 2 tablet by mouth every 4 hours as needed for severe pain.oxycodone HCl Oral Tablet 5 mg Give 1 tablet by mouth every 4 hours as needed for moderate pain.During a review of Resident 5's Controlled Drug Records dated 10/25/25, undated and 11/8/25, and the MAR dated [DATE], the Controlled Drug Record indicated Oxycodone HCL 5 mg Tablet Give 1 Tablet by mouth every 4 hours as needed for moderate pain, Give 2 tablets for severe pain. The MAR indicated Pain: monitor for presence of pain every shift using scale 0-10. 0=No pain, 1-3=mild pain, 4-6=moderate pain, 7-9=severe pain, 10 =very severe/horrible/worst pain .Oxycodone 2 tablets by mouth every 4 hours as needed for severe pain. The Controlled Drug Record indicated oxycodone HCL was removed from the controlled drug drawer on 11/3/25 at 9 p.m., 11/4/25 at 1:34 p.m., 4:43 p.m., 9:44 p.m., and 11/5/25 at 6 a.m., and 7:37 p.m., 11/6/25 at 4:10 a.m., 7:55 a.m., 3:27 p.m., and 7:55 p.m., and 11/7/25 12:45 a.m. These medications removals were not documented on the MAR, and no corresponding record indicating refusal, wastage, or return.During a review of Resident 5's Controlled Drug Records dated 10/25/25, undated and 11/8/25, and the MAR dated [DATE], the Controlled Drug Record indicated Oxycodone HCL 5 mg Tablet Give 1 Tablet by mouth every 4 hours as needed for moderate pain, Give 2 tablets for severe pain. The MAR indicated Pain: monitor for presence of pain every shift using scale 0-10. 0=No pain, 1-3=mild pain, 4-6=moderate pain, 7-9=severe pain, 10 =very severe/horrible/worst pain .Oxycodone 2 tablets by mouth every 4 hours as needed for severe pain. The Controlled Drug Record indicated oxycodone HCL was removed from the controlled drug drawer on 11/3/25 at 9 p.m., 11/4/25 at 1:34 p.m., 4:43 p.m., 9:44 p.m., and 11/5/25 at 6 a.m., and 7:37 p.m., 11/6/25 at 4:10 a.m., 7:55 a.m., 3:27 p.m., and 7:55 p.m., and 11/7/25 12:45 a.m. These medications removals were not documented on the MAR, and no corresponding record indicating refusal, wastage, or return.During a review of Resident 6's AR, dated 11/25/25, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses: fracture (a partial or complete break in a bone) of unspecified bone in left wrist, hyperlipidemia (high cholesterol), chronic pain syndrome, osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), age related osteoporosis (bones get weak and brittle, like a sponge with big holes, making them easy to break), fracture of T9-T10 vertebra (a broken bone in your mid-upper back), multiple broke right ribs, fractured coccyx (broken tailbone), and lower end of left radius fracture (broken wrist). During a concurrent interview and record review on 12/3/25 at 1:44 p.m. with the Pharmacy Nurse Consultant (PNC), the facility pharmacy 2nd Quarter Nurse Consulting Services Audit dated 5/20/25 were reviewed. The Medication Administration Observation Report indicated the controlled drug log was not signed in a timely manner. The PNC stated her role was to observe and audit medication administration process, perform medication cart, medication storage and treatment cart audits, and provide in-services to the facility staff when requested. The PNC stated she would report the audit findings to the DON during the exit interview.During an interview on 12/3/25 at 2:22 p.m. with the Pharmacy Consultant (PHARM), the PHARM stated his duties included teaching staff to handle controlled substances, ensuring correct counts in each cart, and making sure staff do not leave their shift if there was a discrepancy. The PHARM stated the facility had an end-to-end system in place, upon receipt of a delivery, the LN signed the receipt, documented administration, and handed discontinued controlled substances to the DON until they were destroyed in the presence of the pharmacist. The PHARM stated each nurse must verify every single controlled substance on the log matches what was locked in the controlled substance drawer. During a concurrent interview and record review on 12/10/25 at 11:12 a.m. with the DON, the facility's policy and procedure (P&P) titled, Controlled Substance Administration & Accountability dated 12/17/24 was reviewed. The P&P indicated .1. f. All controlled substances (Schedule II, III, IV, V) are accounted for in one of the following ways.ii. All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided.1. g. In all cases, the dose noted on the usage form.must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record. 1.h. The Controlled Drug Record .serves the dual purpose of recording both narcotic disposition and patient administration. 1.j. The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source of documenting any patient-specific narcotic dispensed from the pharmacy.10. Discrepancy Resolution: a. Any discrepancy in the count of controlled substances or disposition of the narcotic keys is resolved by the end of the shift during which it was discovered.c. Resolution can be achieved by review of dispensing and administration records and consulting with all staff with access. D. additional reports may be available from the pharmacy. E. any discrepancies which cannot be resolved must be reported immediately as follows: I. Notify the DON, charge nurse, or designee and the pharmacy; ii. Complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted; iii. The don, charge nurse, or designee must also report any loss of controlled substances where theft is suspected to the appropriate authorities such as local law enforcement, Drug Enforcement Agency, State Board of Nursing, State Board of Pharmacy and possibly the State Licensure Board for Nursing Home Administrators. F. Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies. The DON stated that all medication administration must be recorded on the MAR. The DON stated controlled substance administration should match the MAR. The DON stated it was important to document in the MAR, so staff know what medication was administered or refused. The DON stated failing to document medication administration on the MAR could lead to a resident receiving an extra dose. The DON stated that unnecessary medication could worsen a resident's chronic conditions or cause an overdose, potentially leading to death.During a concurrent interview and record review on 12/12/25 at 2:26 p.m., with the DON, Resident 6's Controlled Drug Record dated 10/23/25 and the MAR dated [DATE], the Controlled Drug Record indicated Hydrocodone-APAP 10-325 Give 1 Tablet by mouth every 4 hours as needed for pain, the MAR indicated Hydrocodone-Acetaminophen Oral Tablet 10-325 mg Give 1 tablet by mouth every 4 hours as needed for moderate to severe pain 4-10 start date 9/22/25 11:15 and discontinue (DC) date 11/21/25 16:49, The Controlled Drug Record indicated hydrocodone acetaminophen was removed from the controlled drug drawer on the following times: 11/15/25 at 21:40, 11/16/25 at 13:20,11/16/25 at 18:00, 11/15/25 at 14:00, 11/15/25 at 18:19, and 11/15/25 at 22:11. These medications removals were not documented on the MAR, and no corresponding record indicating refusal, wastage, or return. The Shift Change Controlled Drug Inventory Log Revealed multiple and accurate count computations. On 11/7/25 the controlled substance sheets (medication bubble packs) count began at 67; two sheets were added, and four sheets were subtracted. The correct ending count should have been 65; however, 66 was documented. On 11/9/25, the count began at 65; one sheet was added and two were subtracted. The correct ending count should have been 64; however, 65 was documented. On 11/10/25, the count began at 65 with no additions or subtractions, yet the ending count was documented as 64. On 11/14/25, the count began at 63; three sheets and three sheets were subtracted. The correct ending count should have remained 63; however, 57 was documented. On 11/16/25, the count began at 51; one sheet was added and three were subtracted. The correct ending count should have been 49; however, 51 was documented. The DON stated the controlled drug inventory calculation were inaccurate. The DON stated it was her responsibility to conduct controlled drug audits and she did not perform the audits as required. During an interview on 12/16/25 at 1:15 p.m. with the PHARM, the PHARM stated the Shift Change Controlled Substance Inventory Log and the Controlled Drug Record should not contain calculation inaccuracies. The PHARM stated shift change controlled substance audits were intended to identify potential diversion by staff. The PHARM stated if controlled substances were diverted, residents would be at risk for uncontrolled pain, which could negatively impact their quality of life and prolong the residents' stay.

Based on interviews, and record reviews the facility failed to ensure residents were free from unnecessary medications administration for three of three sampled residents (Resident 1, 5, and 6) when license nurses (LN) assessed Resident 1, Resident 5, and Resident 6's pain levels as mild to moderate and administered pain medications prescribed for severe pain, not in accordance with the physician's order. These failures had the potential to place Resident 1, Resident 5, and Resident 6 at risk for over-medication, respiratory distress, impaired cognition, falls, and inadequate pain control. During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 11/25/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which includes type 2 diabetes mellitus (DM2-- a condition where the body has trouble controlling blood sugar levels, causing blood sugar to become high) and chronic pain syndrome. During a review of Resident 1's Medication Administration Record (MAR), the MAR indicated physician order for Hydrocodone-Acetaminophen [medication used to treat pain] 5-325 mg [milligrams- unit of measurements] give 1 tablet by mouth every 8 hours as needed for moderate to severe pain and Tramadol [medication use to treat pain] HCL [hydrochloride] 50 mg give one tablet by mouth every 6 hours as needed for moderate to severe pain. The MAR indicated Resident 1 received Hydrocodone Acetaminophen 5/325 mg on 11/4/25 at 12:06 a.m. for a reported pain level 3 out of 10. Tramadol 50mg was administered on 11/4/25 at 9:38 p.m., 11/6/25 at 3:11 a.m., 11/7/25 at 8:30 a.m., 11/8/25 at 9:03 a.m., and 11/28/25 at 11;36 a.m., for a reported pain level of 3 out of 10. During a review of Resident 5's AR, dated 11/25/25, the AR indicated Resident 5 was admitted on [DATE], discharged [DATE]. Resident 5 had a history of muscle weakness, difficulty walking, alcoholic liver with ascites (a buildup of fluid in your abdomen causing a swollen belly), liver failure, encephalopathy (a disturbance of brain function that causes confusion, memory loss and coma in severe cases), and had spinal surgery on 9/7/25. During a review of Resident 5's Order Summary (OS) dated 9/23/25, the OS indicated oxycodone [medication used to treat pain] HCl Oral Tablet 5 mg Give 2 tablet by mouth every 4 hours as needed for severe pain.oxycodone HCl Oral Tablet 5 mg Give 1 tablet by mouth every 4 hours as needed for moderate pain. During a review of Resident 5's MAR dated [DATE], the MAR indicated Pain: monitor for presence of pain every shift using scale 0-10. 0=No pain, 1-3=mild pain, 4-6=moderate pain, 7-9=severe pain, 10 =very severe/horrible/worst pain. The MAR indicated oxycodone 2 tablets by mouth every 4 hours as needed for severe pain and was administered on 11/2/15 at 5:15 p.m., 11/3/25 at 1:56 a.m., 11/3/25 at 7:52 a.m., 11/3/25 at 12:44 p.m., 11/4/25 at 3 a.m., 11/4/25 at 8:04 a.m., 11/5/25 at 1:50 a.m., 11/6/25 at 12 a.m., and 11/7/25 at 4:34 a.m. for a reported pain level ranging from 3 out of 10 and 4 out of 10, indicating the pain oxycodone was given for pain below the physician ordered severity level. During a review of Resident 6's AR, dated 11/25/25, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses which included fracture (a partial or complete break in a bone) of unspecified bone in left wrist, , chronic pain syndrome, osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), age related osteoporosis (is a condition where the bones become weak and brittle, , making them easy to break), fracture of T9-T10 [ninth and tenth thoracic] vertebra (a broken bone in your mid-upper back), multiple rib fractures, fractured coccyx (broken tailbone), and a fracture of the distal left radius (broken wrist). During a review of Resident 6's MAR, the MAR indicated that Resident 6 was prescribed: Hydrocodone-Acetaminophen Oral Tablet 10-325 mg Give 1 tablet by mouth every 4 hours as needed for moderate to severe pain 4-10 start date 9/22/25 11:15 and discontinue [DC] date 11/21/25 16:49, and Hydrocodone-Acetaminophen Oral Tablet 10-325 mg Give 1 tablet by mouth every 4 hours as needed for severe pain 7-10 Start Date 11/22/25 14:27, and Hydrocodone-Acetaminophen Oral Tablet 10-325 mg Give 1 tablet by mouth two times a day for severe pain 7-10 for 10 days start date 11/25/25 16:00. The MAR indicated Resident 6 was administered: Hydrocodone-Acetaminophen 10/325 give 1 tablet every 4 hours as needed for moderate to severe pain 4-10 Start date 9/22/25 11:15, DC Date 11/21/25 16:49 on:o 11/12/25 5:26 a.m. for pain 3/10 Hydrocodone-Acetaminophen 10/325 give 1 tablet every 4 hours as needed for severe pain 7-10, Start date 11/22/25 14:27:o 11/24/25 09:37 for pain 6/10o 11/25/25 04:09 for pain 4/10o 11/25/25 08:25 for pain 6/10o 11/27/25 01:46 for pain 5/10o 11/28/25 03:47 for pain 3/10 o 12/6/25 16:58 for pain 5/10 During a phone interview on 12/2/25 at 2:15 p.m. with the Licensed Vocational Nurse (LVN) 3, LVN 3 stated PRN (pro re nata meaning as needed) pain medication orders are written using a 0-10 pain scale, which identifies mild pain (1-3), moderate pain (4-7), and severe pain (8-10), with specific medications ordered for each level of pain severity. LVN 3 stated the LN was responsible for assessing the resident's pain score and administering the physician ordered pain medication corresponding to the resident's level of pain. LVN 3 stated the importance of administering PRN pain medications in accordance with physician's order was necessary to effectively manage residents' pain. LVN 3 stated failure to follow physician's orders could result in unmanage pain, negative impact on residents' daily functioning, or place residents at risk for overmedication. During a phone interview on 12/3/25 at 10:15 a.m. with LVN 5, LVN 5 stated for PRN pain medication administration, the LN would review the MAR to verify the timing of the last administered dose prior to giving the medication. LVN 5 stated the LN should administer the pain medication according to the resident's assessed pain level and as prescribed. LVN 5 stated if the resident reported moderate pain, the LN would administer pain medication specifically ordered for moderate pain. LVN 5 stated it was important to administer pain medication as prescribed and failure to administer pain medication according to physician's order could place residents at risk for medication errors, including potential overdose. During a concurrent interview and record review on 12/10/25 at 10:47 a.m. with the IP, Resident 5's MAR dated [DATE] was reviewed. The MAR indicated Pain: monitor for presence of pain every shift using scale 0-10. 0=No pain, 1-3=mild pain, 4-6=moderate pain, 7-9=severe pain, 10 =very severe/horrible/worst pain, Tylenol 325 mg give 2 tab by mouth every 8 hours as needed for mild pain, Oxycodone 5mg give 1 tablets by mouth every 4 hours as needed for moderate pain and Oxycodone 5mg give 2 tablets by mouth every 4 hours as needed for severe pain. The MAR indicated Resident 5 was administered Oxycodone 5mg give 2 tablets for severe pain on: 11/2/25 05:15 for pain 4/10 (moderate pain) by LVN 1 11/3/25 01:56 for pain 3/10 (mild pain) by LVN 6 11/3/25 07:52 for pain 4/10 (moderate pain) by LVN 1 11/3/25 12:44 for pain 4/10 (moderate pain) by LVN 1 11/4/25 03:00 for pain 4/10 (moderate pain) by LVN 6 11/4/25 08:04 for pain 4/10 (moderate pain) by LVN 1 11/5/25 01:50 for pain 4/10 (moderate pain) by LVN 6 11/6/25 00:00 for pain 4/10 (moderate pain) by LVN 6 11/7/25 04:34 for pain 3/10 (mild pain) by LVN 6The IP stated that pain levels of 3 and 4 were not severe (7-10), and Resident 5 did not receive the appropriate medication. IP stated Resident 5 should have received Tylenol for mild pain 3/10 and oxycodone 5mg 1 tab for moderate pain 4/10. IP stated LVN 1 and LVN 6 who were assigned to Resident 5 did not follow the physician's order. IP stated the importance of administering medication as prescribed by the physician to avoid overmedication. IP stated overmedication could lead to serious harm, such as respiratory distress, since narcotics could suppress breathing, potentially causing a resident to experience a medical emergency and even death. During a concurrent interview and record review on 12/10/25 at 11:58 a.m. with LVN 1, Resident 5's MAR dated [DATE] was reviewed. The MAR indicated Pain: monitor for presence of pain every shift using scale 0-10. 0=No pain, 1-3=mild pain, 4-6=moderate pain, 7-9=severe pain, 10 =very severe/horrible/worst pain. The MAR indicated LVN 1 administered Oxycodone 5mg give 2 tablets by mouth every 4 hours as needed for severe pain on: 11/2/25 05:15 for pain 4/10 (moderate pain) 11/3/25 07:52 for pain 4/10 (moderate pain) 11/3/25 12:44 for pain 4/10 (moderate pain) 11/4/25 08:04 for pain 4/10 (moderate pain) LVN 1 stated the medication administered was not the correct dose per the pain scale score. LVN 1 stated based on the pain scale, the resident should not have been administered two tablets. LVN 1 stated if a resident reports a lower pain score, the LN should not administer the higher dose of pain medication. LVN 1 stated if a resident required any as needed pain medication, the LN would ask the resident for the pain level, based on the pain level the nurse would review the MAR to determine the appropriate medication to administer. LVN 1 stated it was important for the LN to adhere to the pain scale to prevent residents from taking unnecessary medication. LVN 1 stated a higher-than-necessary medication dose could place the resident at risk of an overdose. During a phone interview on 12/16/25 at 1:15 p.m. with the PHARM, the PHARM stated the facility should have a pain scale clearly associated with mild, moderate, and severe pain to ensure the decision of which medication to administer was guided by the physician orders rather than left to individual nurse judgement. The PHARM stated PRN medications should be administered by the physician's order to ensure proper pain management and avoid unnecessary medications. The PHARM stated failure to follow physician orders and unnecessary medication administration could lead to drowsiness, respiratory distress or respiratory depression and death. During a phone interview on 12/17/25 at 1:21 p.m. with the DON and ADM, the DON stated she expected the LN to follow the physician's orders when administering PRN pain medication. The DON stated the LN must assess the resident's pain score and match the pain score to the physician's corresponding pain medication order. The DON stated it was important to follow the physician's order to ensure residents receive the correct medication and are not administered unnecessary medications. The DON stated the risk of administering unnecessary medication could result in drug dependency in residents. During a review of the facility's P&P titled, Medication Administration dated 12/17/24, the P&P indicated .10. Ensure that the six rights of medication administration are followed: a. right resident, b. Right drug, c. Right dosage.f. Right documentation. During a review of the facility's policy and procedure titled, Pain Management, dated 12/17/2024, the P&P indicated Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.Pain Assessment: 2.c, Asking the patient to rate the intensity of his/her pain using a numerical scale.2.i. current prescribed pain medications, dosage and frequency.Pain Management and Treatment.7. Pharmacological interventions will follow a systematic approach for selecting medication and dosages to treat pain.7. a. Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate analgesic therapy for pain. 7.e. Use lower doses of medication initially and titrate slowly upward until comfort is achieved.7. j. Facility staff will notify the practitioner, if the resident's pain is not controlled by the current regimen. During a review of the facility's P&P titled, PRN Medications dated 12/17/24, the P&P indicated adequate indications for use refers to the identified, documented clinical rational for administering a medication that is based upon an assessment of the resident's condition.adequate indication for use means that the medication administered is consistent with.clinical practice guidelines, clinical standards of practice.Policy Explanation and Compliance Guidelines:.3. When administering a PRN medication: a. Verify physician's order for the medication, b. Document the reason voiced by the resident and/or assessment findings.that verify the reason for the prescribed indication for the medication, c. Document the time of administration. During a review of professional reference review retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC9039188/pdf/fphar-13-759998.pdf National Library of Medicine titled, Practical Considerations of PRN Medicines Management: An Integrative Systematic Review, dated 4/12/22 indicated .Pro re nata (PRN), when required, or as needed is defined as the prescription and administration of medications based on the immediate patients' needs instead of prescheduled administration times. the nurse responsibility to administer PRN medications based on the patient health condition after receiving the physician's prescription order (Dorks et al., 2019). Improper prescription and administration of PRN medications can cause medication interactions, adverse drug reactions (ADRs), overuse and abuse (Davies et al., 2007; Vaismoradi et al., 2018) .

Based on interview and record review, the facility failed to notify the residents responsible party (RP- an individual who has the authority to act on behalf of the patient)/family/emergency contact of a change in condition for two of three sampled residents (Resident 1, 6) when Resident 1 experienced seizures (abnormal electrical activity in the brain) and Resident 6 reported chest pain and were transferred to acute care hospital. This failure had the potential to result in Resident 1 and Resident 6's RP/family/emergency contact being unaware of the acute health conditions, hospital transfers, and treatment decisions, which could negatively impact continuity of care and right to have their representatives involved in care decisions. During a concurrent interview and record review on 8/22/25 at 1:41 p.m. with the Director of Nursing (DON) in the DON office, Resident 1's Situation Background Assessment Recommendation Form (SBAR-a tool used to improve the clarity and efficiency of information exchange) form dated 8/17/25 was reviewed. The SBAR indicated Resident 1 had active seizures lasting 3 to 4 minutes. The physician was notified on 8/17/25 at 5:30 a.m. and ordered to send Resident 1 to the acute hospital for further evaluation. The SBAR indicated on 8/17/25 at 5:30 a.m. Resident 1 was notified he was being transferred to the acute care hospital. The DON stated the RP should have been notified when a resident had a change of condition and transferred to the acute hospital. The DON stated the facility did not notify Resident 1's RP when he had changed of condition and was transferred to acute care hospital. The DON stated the license nurse should have called Resident 1's RP unless Resident 1 does not want his RP to be notified. The DON stated the documentation did not indicate Resident 1 declined to have his family notified of the acute care hospital transfer. During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/22/25, the AR indicated Resident 1 was a [AGE] year old male, admitted to the facility on [DATE] with diagnoses: left middle cerebral artery infarction (a blood clot to a major blood vessel on the left side of the brain that control the ability to use ones senses, move and language), muscle weakness, dysphagia (difficulty swallowing), type 2 diabetes mellitus (DM2- a condition where your body does not use a hormone that helps move sugar from your blood into your cells for energy properly), hallucinogen (drugs used for their ability to alter human perception and mood) abuse, cerebral edema (swelling of the brain), essential hypertension (abnormally high blood pressure that's not the result of a medical condition), and atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart and increase the risk of stroke and heart failure). During a concurrent interview and record review on 8/22/25 at 1:58 p.m. with the DON in the DON office, Resident 6's SBAR Communication Form dated 8/5/25 and the AR dated 8/22/25 were reviewed. The SBAR indicated on 8/5/25 at 11:30 a.m. Resident 6 had chest pain. The physician was notified on 8/5/25 at 11:30 a.m. and ordered the nurse to administer medication and transfer Resident 6 to the acute care hospital if the medication was not effective. Resident 6 received two medication doses for chest pain without effect and Resident 6 was transferred to the acute care hospital. Resident 6 was his own RP, and his mother was the emergency contact. The DON stated the facility did not have to notify Resident 6's emergency contact of the transfer to the acute care hospital because Resident 6 was his own RP. During a review of Resident 6's AR, dated 8/22/25, the AR indicated Resident 6 was a[AGE] year old male, admitted to the facility on [DATE] with diagnoses: anemia in chronic kidney disease (a condition in which your blood has a lower-than-normal amount of red blood cells that carry oxygen from your lungs to the rest of your body), severe protein-calorie malnutrition a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), atherosclerotic ( hardening of your arteries) heart disease without angina pectoris (chest pain), ischemic cardiomyopathy ( the heart's decreased ability to pump blood properly), other pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung), asthma (a chronic lung disease caused by inflammation and muscle tightening around the airways making it hard to breathe), pleural effusion (the buildup of excess fluid between the layers of the pleura outside your lungs), and end stage renal disease (permanent kidney failure that requires a regular course of dialysis or a kidney transplant).During an interview on 8/22/25 at 1:20 p.m. with the Administrator (ADM) in the ADM office, the ADM stated the RP or Emergency Contact should have been notified when residents have a change of condition and transferred to the acute care hospital regardless of resident's mental status. During a phone interview n 8/27/25 at 8:52 a.m. with the Licensed Vocational Nurse (LVN), the LVN stated the RP/family/emergency contact should have been notified when a resident had a change of condition and transferred to the acute care hospital. The LN stated it was important to notify the RP/family/emergency contact so they would know of the resident's change of condition and allow the ability to visit or contact the residents at the hospital. The LN stated the risk of not notifying the RP/family/emergency contact could result in delayed care or worsened medical condition if the hospital required consent for procedures and the RP/family/emergency contact were unaware resident had a change of condition and in the hospital. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2/2021, the P&P indicated, .4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: .b. there is a significant change in the resident's physical, mental, or psychosocial status; e. it is necessary to transfer the resident to a hospital/treatment center.5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.During a review of the facility's P&P titled, Transfer and Discharge (including AMA), dated 12/17/24, the P&P indicated, .12. Emergency Transfers/Discharges-initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified) .g. Provide a notice of transfer.to the resident and representative as indicated.

Based on observation, interview, and record review, the facility failed to ensure seven of 13 sampled residents (Residents 10, 11, 13, 25, 32, 33, and 36) received diabetic (disease in which the body's ability to produce or respond to the hormone insulin is impaired) management care in accordance with professional standards of practice when: 1. Resident 10 did not have a baseline (starting point) hemoglobin A1C (HBA1c- test tells you your average level of blood sugar over the past two to three months; the target A1c level for people with diabetes is usually less than 7% [percent]. The higher the hemoglobin A1c, the higher the risk of having complications related to diabetes) obtained upon admission to the skilled nursing facility (SNF), licensed nurses (LNs) did not notify the physician when Resident 10 exhibited consistent elevated blood sugars, and the interdisciplinary team (IDT-approach involves team members from different disciplines working collaboratively, with a common purpose, to set goals, and make decisions and share sources and responsibilities) failed to assess Resident 10's consistent elevated blood sugars; 2. Resident 11 did not have a baseline HBA1c obtained upon admission to the SNF, Resident 11 was on a regular diet, LNs did not notify the physician when Resident 11 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 11's consistent elevated blood sugars; 3. Resident 13 did not have a baseline HBA1c obtained upon admission to the SNF, LNs did not notify the physician when Resident 13 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 13' consistent elevated blood sugars; 4. Resident 25 did not have a baseline HBA1c obtained upon admission to the SNF, Resident 25 was on a regular diet, LNs did not notify the physician when Resident 25 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 25's consistent elevated blood sugars; 5. Resident 32 was on a regular diet, LNs did not notify the physician when Resident 32 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 32's consistent elevated blood sugars; 6. Resident 33 did not have a baseline HBA1c obtained upon admission to the SNF, Resident 33 was on a regular diet, LNs did not notify the physician when Resident 33 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 33's consistent elevated blood sugars; and 7. Resident 36 did not have a baseline HBA1c obtained upon admission to the SNF, LNs did not notify the physician when Resident 36 exhibited consistent elevated blood sugars, and the IDT failed to assess Resident 36's consistent elevated blood sugars. Because of the serious potential harm to Residents 10, 11, 13, 25, 32, 33, and 36 due to not following professional standards of practice with care of residents with diabetes (a disease in which your blood glucose, or blood sugar, levels are too high) in obtaining a baseline HBA1c upon admission, four of the seven residents were on a regular diet and not a consistent carbohydrate diet (the focus of the diet is eating the same amount of carbohydrates every day; this helps keep your blood sugar, or glucose, levels stable), licensed nurses did not notify the physician when residents presented with consistent elevated blood sugars and the IDT did not assess the consistent elevated blood sugars, an Immediate Jeopardy (IJ-a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) situation was called on 5/14/21 at 3:44 p.m. under Code of Federal Regulations (CFR) 483.25 Quality of Care (F684) with the Director of Operations, Administrator (ADM), Director of Nursing (DON), Director of Social Services (DSS), and the Minimum Data Set Consultant (MDSC). The IJ template was provided to the ADM. The facility submitted an acceptable IJ Plan of Removal (Version 3) on 5/17/21, at 8:55 a.m. The IJ Plan of Removal included but was not limited to the following: 1) Immediate training to LNs, Certified Nursing Assistants (CNAs), and IDT on diabetes management. 2) Immediate training to dietary staff on consistent carbohydrate diet. 3) Obtaining baseline HBA1c levels on all 17 diabetic residents. 4) IDT review all 17 residents with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 5) IDT including physician evaluate residents with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 5) Create a system for the IDT to review and manage diabetic residents' blood sugar levels and HBA1c and follow up as required. The components of the IJ Plan of Removal was validated through observations, interviews, and record review. The IJ was removed on 5/18/21 at 3:54 p.m. with the Director of Operations, ADM, DON, and the Nurse Consultant. These failures resulted in Resident 11 to experience headache and dizziness and had the potential for Residents 10, 11, 13, 25, 32, 33, and 36 to continue to have elevated blood sugars not assessed and had the potential for life-threatening complications/conditions. Findings: 1. During a review of Resident 10's Admission Record (AR-document that gives a resident's information at a quick glance) undated, the AR indicated, .admitted [DATE] .diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 10's Laboratory Report dated 3/3/21, the Laboratory Report indicated .GLYCOHGB (A1c) .Abnormal Summary .7.3 H [high] . During a review of Resident 10's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The blood sugar results from 11:30 a.m. ranged from 118 mg/dl to 195 mg/dl. The blood sugar results 4:30 p.m. ranged from 110 mg/dl to 255 mg/dl. During a review of Resident 10's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The blood sugar results from 11:30 a.m. ranged from 116 mg/dl to 207 mg/dl. The blood sugar results from 4:30 p.m. ranged from 111 mg/dl to 245 mg/dl. During a review of Resident 10's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The blood sugar results from 11:30 a.m. ranged from 130 mg/dl to 188 mg/dl. The blood sugar results 4:30 p.m. ranged from 147 mg/dl to 279 mg/dl. During a review of Resident 10's Order Summary Report dated 2/11/21, the Order Summary indicted, .Carbohydrate Controlled diet . During an interview on 5/10/21, at 8:04 a.m., with Resident 10, Resident 10 stated he was on a diabetic diet and he was not getting the correct foods. Resident 10 stated no one from the facility had discussed his diet with him. During a concurrent interview and record review with the Dietary Service Manager (DSM) on 5/11/21 at 12:20 p.m. the facility's document titled, Spring Cycle Menus dated 5/10/21 was reviewed. The facility Menu indicated, .Regular .Oatmeal 4 oz (ounces- units of measurement) .Pancakes 1 (quantity) .Oven Roasted Potatoes 1/4 cup .Pasta bean soup 4 oz .Egg salad sandwich 1 .CCHO (controlled carbohydrate diet) .Oatmeal 4 oz .Pancakes 1 .Oven Roasted Potatoes 1/4 cup .Pasta Bean Soup 4 oz .Egg salad sandwich 1. The DSM stated the cooks followed the menu's portion sizes. The DSM validated the portion sizes of the regular and controlled carbohydrate diet were the same. During an interview on 5/13/21 at 3:12 p.m., with the DSM, the DSM stated his expectation was for the nursing staff to inform him when residents had consistent elevated blood sugars so he could work with residents on their diet. The DSM stated he had no training on diabetes or blood sugar control. The DSM stated Registered Dietitian (RD) 1, should have been onsite at the facility when she evaluated residents. The DSM stated he would have expected RD 1 to assist him in planning meals for diabetic residents with consistent elevated blood sugars. During an interview on 5/13/21 at 3:52 p.m., with the DON, the DON stated her expectation was for the LNs to notify her [DON] when residents had consistent elevated blood sugars. The DON stated the expectation was for the LNs to call the physician when the blood sugar was over 400 mg/dl. The DON stated the physician would give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the DSM should have been involved when the residents' blood sugars were elevated. The DON stated she aware the residents' blood sugars were an issue. The DON stated she should have followed up with the residents' diets. The DON stated the RD was not called or was informed of the elevated blood sugars. The DON was unable to verbalize and explain the role of the RD and the oversight the RD provided to the facility. During a telephone interview on 5/14/21, at 3:21 p.m., with the Medical Director (MD), the MD validated he was the primary physician for Residents 10, 11, 13, 25, 32, 33, and 36. The MD stated he conducted facility visits once a month and he expected the LNs to notify him when the blood sugars were high, if the LNs had questions, and to discuss the care of diabetes management. The MD stated his expectation was for the LNs to provide him a list of the residents along with their elevated blood sugars to determine what the next steps were. Resident 10, 11, 13, 25, 32, 33, and 36's blood sugars readings for March, April and May 2021 were shared with the MD. The information of the residents' blood sugars readings was consistently over 150 mg/dl. The MD stated when an individual reviewed the residents' blood sugars, it looked like they are high and they were definitely high. The MD stated he was not aware diabetic residents had asked for a change from regular diet to controlled carbohydrate diet, the MD stated nursing staff did not bring this to his attention. The MD stated the facility should have made an effort to help get the residents' diet changed. The MD stated physicians are not physically present in the facility during the residents' admission, so he depended on what the nurses informed him. The MD stated he wrote the residents' diet orders based on the information he received from the nursing staff. The MD stated residents can experience acute (new) and chronic (long term) changes in their blood sugars. The facility should have considered a referral to an endocrinologist (a medical practitioner qualified to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MD stated if residents were in the facility for long term care, a baseline HBA1c should have been ordered upon admission. The MD stated the registered dietitian should have been engaged in residents' diabetic management. During an interview on 5/16/21, at 12:20 pm, with Resident 10, Resident 10 stated .I get carbs and too much salt . During an interview on 5/17/21, at 4:20 p.m., with Registered Dietitian (RD) 2, RD 2 stated it was her first day in this facility. RD 2 stated the facility had called her on Friday (5/14/21) and she was made aware of the IJ situation at the facility because diabetic residents had uncontrolled blood sugars, and the RD, physician, and IDT had not assessed the elevated glucose (sugar) levels. RD 2 stated the facility asked her why diabetic residents were not on a controlled carbohydrate diet. RD 2 stated residents needed nursing intervention and communication to the DON and physician. RD 2 stated her expectation was for the facility to notify her if the residents' blood sugars were consistently high. RD 2 stated her expectation of the facility staff was to be informed if they the HBA1c and blood sugars were elevated. RD 2 stated, I definitely need to be in the loop. RD 2 stated the facility should have reviewed the residents' charts to see if anything changed with their meal percentages (intake of food), infection, changes, and review the HBA1c to review trends. RD 2 stated she talked to the ADM and informed him there was no communication system between the facility and the RD [RD 2]. RD 2 stated communication system needed to be improved. RD 2 stated she followed the American Diabetes Association (ADA) standards. During an interview on 5/19/21, at 9:47 a.m., with the Social Worker (SW), the SW stated she distributed the snacks from the snack cart to the residents. The SW stated that the residents could choose from common items on the snack cart, such as chips, cookies, and bananas. The SW stated nursing staff had not brought up the topic of diabetic residents and what snacks diabetic resident could or could not have. During a concurrent interview and record review on 5/19/21 at 10:21 a.m., with the DON, Residents 10, 11, 13, 25, 32, 33, and 36's blood sugars dated March, April and May 2021 were reviewed. The DON stated the facility system that was in place (communication of blood sugars) was not working. The DON reviewed Residents 10, 11, 13, 25, 32, 33, and 36's blood sugars and validated the blood sugars were consistently elevated and should have been communicated to the physician. The DON stated LNs had not communicated to her [DON], the CNAs, DSM, RD or the physician regarding the consistent elevated blood sugars. The DON stated the physician was not notified by the LNs of the consistent elevated blood sugars and the physician should have been notified. The DON reviewed Residents 10, 11, 13, 25, 32, 33, and 36's medical records and validated there were no IDT notes to address the residents' blood sugars. The DON stated the RD should have educated diabetic residents on the consistent carbohydrate diet and explained the differences between a regular diet and a consistent carbohydrate diet. During a review of the facility's policy and procedure (P&P) titled, Diabetes Management Guideline revised December 2015, the P&P indicated, Guidelines statement: All residents will have appropriate treatment and services to manage their Diabetes .Admission Assessments .Residents with diabetes are at very high risk for skin breakdown. Risks include vascular wounds (When there's reduced blood flow, skin and tissues in the affected areas are deprived of oxygen and nutrients, these areas will become irritated and form an open wound), pressure ulcers, infection and delayed healing .Recent lab values- A1C .Daily Observation by all staff should include: nutritional intake, glucose control .The American Diabetes Association states that the ideal goal for adults with diabetes is to achieve glucose levels between 70 and 130 mg/dl before meals, and less than 180 two hours after starting a meal, with a glycated hemoglobin (A1C) level less than 7 percent . [CONDITION(S)]: is common cause of illness and is the cause of secondary complications of the disease. Common signs and symptoms: .More frequent urination, incontinence, increased fatigue, unexplained weight loss, new vision problems, decreased mental function, confusion .Advanced Signs and Complications: .Poorly healing wounds, incisions, tingling, burning, numbness, persistent infections, dehydration, vomiting, renal dysfunction, cardiac symptoms .Nutrition .Maintaining health and promoting quality of life are two goals of nutritional care of the resident with Diabetes. The registered dietitian will complete a nutritional assessment upon admission and make changes as needed to food plans. The food plan and nutritional goals focus on the daily intake of carbohydrates, fats, protein and soluble fiber for those with diabetes. The Consistent Carbohydrate diet (Con CHO) is designed for individuals with a stable diabetes condition. A liberalized diet can enhance both the quality of life and nutritional status (relaxing the original diet prescriptions meant to control disease states like diabetes) .In caring for an individual with diabetes .b. Regularly review the meal plans and medication list of your residents .Monitoring/Compliance: The following elements are in place for the center to demonstrate satisfactory compliance with the guide: MD notification parameters in place .[CONDITION(S)] . Review patterns of blood glucose levels and communicate to physician .Communicate with physician if: Blood Glucose > (greater) 300 [mg/dl] . During a professional reference review of the American Diabetes Association retrieved from https://care.diabetesjournals.org/content/39/2/308 on 5/26/21, titled, Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association dated February 2016, the professional reference indicated, Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost . Several organizations have developed diabetes guidelines for patients living in LTC settings. Almost all of these guidelines emphasize the need to individualize care goals and treatments related to diabetes, the need to avoid sliding scale insulin (SSI) as a primary means of regulating blood glucose, and the importance of providing adequate training and protocols to LTC staff who may be operating without the presence of a practitioner for prolonged periods .[CONDITION(S)] . persistent [CONDITION(S)] increases the risk of dehydration, electrolyte abnormalities (imbalance of minerals in the body), urinary incontinence, dizziness, falls, and hyperglycemic hyperosmolar syndrome (occurs when a person's blood sugar levels are too high for a long period, leading to severe dehydration and confusion) .Improving Nutrition Health . a consistent carbohydrate meal plan that allows for a wide variety of food choices (e.g., general diet) may be more beneficial for both nutritional needs and glycemic control in patients with type 1 diabetes (is a chronic condition in which the pancreas produces little or no insulin) or type 2 diabetes on mealtime insulin .Diabetes Management During Transitions of Care . At the time of admission to a facility, transitional care documentation should include the current meal plan, activity levels, prior treatment regimen, prior self-care education, laboratory tests (including A1C, lipids [family of organic compounds, composed of fats and oils], and renal function), hydration status, and previous episodes of [CONDITION(S)] (low blood sugar) (including symptoms and patient's ability to recognize and self-treat) .Integration of Diabetes Management Into LTC Facilities .Recommendation . Patients admitted to LTC facilities are not seen daily by a practitioner. Because of this reality, successful diabetes care needs to include a dedicated interprofessional team. This team may be composed of practitioners (physicians, nurse practitioners, and physician assistants), registered nurses, licensed practical/vocational nurses, certified nursing assistants, diabetes educators, dietitians, food service managers, consultant pharmacists, physical therapists, and/or social workers . In order to assess and improve facility-wide management of diabetes directed by multiple practitioners, the facility leadership (e.g., the director of nursing, nurse managers, medical director, and consultant pharmacist) should collect data and trends and plan strategies to improve selected process or outcome indicators relevant to diabetes management. These could include sharing data with managerial staff, providing staff education, and planning a performance improvement project. In general, the facility medical leadership and nursing administration have the opportunity to develop and implement patient care policies that can facilitate optimal management of the older patient with diabetes and to coordinate efforts with the multidisciplinary team. Nursing leadership training programs for nurses working in LTC facilities that include skills in diabetes management can also help to improve quality of care offered to patients in these facilities .Figures & Tables .Table 6 - specific situations needing attention in patients with diabetes in LTC setting .glucose meter readings >300 mg/dl during all or part of 2 consecutive day .Confirm high glucose value by laboratory test .Evaluate nutritional intake . 2. During a review of Resident 11's AR undated, the AR indicated, .admitted [DATE] .diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .[CONDITION(S)] .Long Term (Current) Use of Insulin . Resident 11 was admitted on [DATE] from a general acute care hospital. During a review of Resident 11's Laboratory Report from the acute care hospital dated 8/28/2020 (prior to admission to the skilled nursing facility), the Laboratory Report indicated .HGBA1c .6.3 . [goal is less than 7 for diabetics] . During a review of Resident 11's Laboratory Report dated 5/5/21, the Laboratory Report indicated .GLYCOHGB (A1c) .Abnormal Summary .10.5 H [high] . During a review of Resident's 11's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation and interview, on 5/10/21, at 11:45 a.m., in Resident 11's room, Resident 11 was observed in bed with his eyes closed and his left hand pressed against the left side of his head. Resident 11 stated he was diabetic, and he got too much pasta. Resident 11 stated his blood sugar was high, sometimes it was over 400 mg/dl. Resident 11 stated he experienced a headache and was dizzy. Resident 11 stated he requested a diabetic diet from nursing staff but continued to receive a regular diet. During a concurrent observation and interview, on 5/10/21, at 12:35 p.m., in Resident 11's room, Resident 11 sat on the side of bed eating lunch. Resident 11's lunch tray included: rice, pasta, green beans and pinto beans. Resident 11 stated he ate the green beans and pinto beans but did not want the rice and pasta. Resident 11 stated his blood sugar was 371 before lunch. During a concurrent observation and interview, on 5/10/21, at 4:09 p.m., in Resident 11's room, Resident 11 stated when he was in the hospital (prior to admission to the SNF), .They [hospital] gave me a diabetic diet and my blood sugars were not high. During an interview on 5/12/21 at 8:55 a.m., with the DSM, the DSM stated Resident 11 was on a regular diet. During a review of Resident 11's Order Summary Report dated 2/11/21, the Order Summary indicted, .Regular Diet . During an interview on 5/11/21, at 11:30 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she had just assisted Resident 11 in ambulating with a walker from his room to the dining room for lunch. CNA 1 stated Resident 11 did Really good, but he was dizzy. CNA 1 stated Resident 11 complained of being dizzy when he walked to the dining room. During a review of Resident 11's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 5/11/21, at 1:10 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the physician was notified when blood sugars were over 400 mg/dl. LVN 3 stated she did not notify the physician when the blood sugars were over 300 mg/dl, two or more consecutive days. LVN 3 stated RD 1 did not receive notification of Resident 11's blood sugars that were over 300 mg/dl two or more consecutive days. During a concurrent observation and interview on 5/12/21 at 12:30 p.m. with LVN 4 during the noon medication pass, Resident 11 was observed. LVN 4 obtained Resident 11's blood sugar, the result was 325 mg/dl. Resident 11 stated he needed help from the surveyors to assist with his blood sugars and diet. Resident 11 stated he told the facility to stop feeding him carbs like pasta, corn and bread. Resident 11 stated his blood sugar reading in the morning was 400 mg/dl. LVN 4 did not respond to Resident 11's comments. When LVN 4 was asked if she was going to intervene with Resident 11's blood sugar, LVN 4 stated because it was under 400 mg/dl, she did not need to call the physician. LVN 4 stated, .His blood sugar is hard to control, he is always eating the wrong food . During a telephone interview on 5/12/21, at 2:55 p.m., with RD 1, RD 1 stated Resident 11 was on a regular diet and she had not received any notification Resident 11 had requested a controlled carbohydrate diet. RD 1 stated she was unaware Resident 11's blood sugars were consistently over 300 mg/dl. RD 1 stated, Thanks for letting me know. During an interview on 5/13/21 at 1:10 p.m., with the DSM, the DSM stated, No one ever mentioned his [Resident 11] blood sugars . During an interview on 5/13/21 at 3:12 p.m., with the DSM, the DSM stated his expectation was for the nursing staff to inform him when residents had consistent elevated blood sugars so he could work with residents on their diet. The DSM stated he had no training on diabetes or blood sugar control. The DSM stated RD 1, should have been onsite at the facility when she evaluated residents. The DSM stated he would have expected RD 1 to assist him in planning meals for diabetic residents with consistent elevated blood sugars. During an interview on 5/13/21 at 3:52 p.m., with the DON, the DON stated her expectation was for the LNs to notify her [DON] when residents had consistent elevated blood sugars. The DON stated the expectation was for the LNs to call the physician when the blood sugar was over 400 mg/dl. The DON stated the MD would give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated she was unaware of 11's request for a diet change from a regular diet to a consistent carbohydrate diet. The DON stated the DSM should have been involved when the residents' blood sugars were elevated. The DON stated she aware the residents' blood sugars were an issue. The DON stated she should have followed up with the residents' diets. The DON stated the RD was not called or was informed of the elevated blood sugars. The DON was unable to verbalize and explain the role of the RD and the oversight the RD provided to the facility. During a telephone interview on 5/14/21, at 3:21 p.m., with the MD, the MD validated he was the primary physician for Residents 10, 11, 13, 25, 32, 33, and 36. The MD stated he conducted facility visits once a month and he expected the LNs to notify him when the blood sugars were high, if the LNs had questions, and to discuss the care of diabetes management. The MD stated his expectation was for the LNs to provide him a list of the residents along with their elevated blood sugars to determine what the next steps were. Resident 10, 11, 13, 25, 32, 33, and 36's blood sugars readings for March, April and May 2021 were shared with the MD. The information of the residents' blood sugars readings was consistently over 150 mg/dl. The MD stated when an individual reviewed the residents' blood sugars, it looked like they are high and they were definitely high. The MD stated he was not aware diabetic residents had asked for a change from regular diet to controlled carbohydrate diet, the MD stated nursing staff did not bring this to his attention. The MD stated the facility should have made an effort to help get the residents' diet changed. The MD stated physicians are not physically present in the facility during the residents' admission, so he depended on what the nurses informed him. The MD stated he wrote the residents' diet orders based on the information he received from the nursing staff. The MD stated residents can experience acute and chronic changes in their blood sugars. The facility should have considered a referral to an endocrinologist for the chronic elevated blood sugars. The MD stated if residents were in the facility for long term care, a baseline HBA1c should have been ordered upon admission. The MD stated the registered dietitian should have been engaged in residents' diabetic management. During an interview on 5/17/21, at 4:20 p.m., with RD 2, RD 2 stated it was her first day in this facility. RD 2 stated the facility had called her on Friday (5/14/21) and she was made aware of the IJ situation at the facility because diabetic residents had uncontrolled blood sugars, and the RD, physician, and IDT had not assessed the elevated glucose levels. RD 2 stated the facility asked her why diabetic residents were not on a controlled carbohydrate diet. RD 2 stated residents needed nursing intervention and communication to the DON and physician. RD 2 stated her expectation was for the facility to notify her if the residents' blood sugars were consistently high. RD 2 stated her expectation of the facility staff was to be informed if they the HBA1c and blood sugars were elevated. RD 2 stated, I definitely need to be in the loop. RD 2 stated the facility should have reviewed the residents' charts to see if anything changed with their meal percentages (intake of food), infection, changes, and review the HBA1c to review trends. RD 2 stated she talked to the ADM and informed him there was no communication system between the facility and the RD [RD 2]. RD 2 stated communication system needed to be improved. RD 2 stated she followed the American Diabetes Association (ADA) standards. During an interview on 5/19/21, at 9:47 a.m., with the SW, the SW stated she distributed the snacks from the snack cart to the residents. The SW stated that the residents could choose from common items on the snack cart, such as chips, cookies, and bananas. The SW stated nursing staff had not brought up the topic of diabetic residents and what snacks diabetic resident could or could not have. During a concurrent interview and record review on 5/19/21 at 10:21 a.m., with the DON, Residents 10, 11, 13, 25, 32, 33, and 36's blood sugars dated March, April and May 2021 were reviewed. The DON stated the facility system that was in place (communication of blood sugars) was not working. The DON reviewed Residents 10, 11, 13, 25, 32, 33, and 36's blood sugars and validated the blood sugars were consistently elevated and should have been communicated to the physician. The DON stated LNs had not communicated to her [DON], the CNAs, DSM, RD or the physician regarding the consistent elevated blood sugars. The DON stated the physician was not notified by the LNs of the consistent elevated blood sugars and the physician should have been notified. The DON reviewed Residents 10, 11, 13, 25, 32, 33, and 36's medical records and validated there were no IDT notes to address the residents' blood sugars. The DON stated the RD should have educated diabetic residents on the consistent carbohydrate diet and explained the differences between a regular diet and a consistent carbohydrate diet. During a review of Resident 11's Order Summary Report dated 2/9/21, the Order Summary Report indicated, Insulin [brand name] Solution 100 UNIT/ML, inject as per sliding scale, (sliding scale refers to the progressive increase of the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges). Give subcutaneously (into the skin) before meals and at bedtime: 150 - 200 = 2 unit 201 - 250 = 4 units 251 - 300 = 6 units 301 - 350 = 8 units 351 - 400 = 10 units - if >400 notify MD On 5/7/21, Insulin [brand name] Solutions 11 UNIT/ML increased to: 150 - 200 = 4 units 201 _ 250 = 6 units 301 _ 350 = 10 units 352 - 400 = 12 units - if >400 notify MD During a review of Resident 11's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The bl[TRUNCATED]

Based on observation, interview, and record, review the facility failed to provide care in accordance with professional standards of practice, comprehensive person-centered care plan, and the residents' choices to ensure smoking residents remained safe for two of three sampled residents (Resident 1 and Resident 3) when the facility was aware of the unsafe smoking habits of Residents 1 and 3 and the repeated behavior of concealing smoking paraphernalia and smoking unsupervised. The risky smoking behaviors exhibited by Resident 1 and Resident 3 were not sufficiently addressed and care-planned to keep the residents safe. This failure resulted in Resident 1 smoked unsupervised with his oxygen equipment attached on 6/2/19, caught his face on fire and suffered second [MEDICAL CONDITION] his face and hands. Because of these failures and the identified serious actual harm sustained by Resident 1 while he smoked unsupervised and the potential serious harm to Resident 3 and the other residents of the facility, an Immediate Jeopardy Situation (IJ) was called on 6/5/19 at 3:20 p.m., with the facility Administrator (ADM), Administrator in Training (AIT), Director of Nurses (DON), and Registered Nurse Clinical of Operations (RNCO). The facility submitted an acceptable IJ Removal Plan on 6/7/19, at 10:32 a.m., to address the process for the completion of timely smoking assessments, frequency of smoking assessments, care planning needs of residents who smoke, and supervision requirement needed for residents who smoked. The components of the IJ Removal Plan were validated as implemented and the IJ situation was removed on 6/7/19 at 5:04 p.m., with the ADM, DON and the RNCO. Findings: During an observation of Resident 1, on 6/4/19, at 9:39 a.m., Resident 1 was sleeping and did not respond when his name was called while he laid in bed. Resident 1 wore a nasal cannula (oxygen tubing- device used to deliver supplemental oxygen ) attached to an oxygen concentrator (a device which concentrates ambient air to provide higher oxygen concentration) that delivered supplemental oxygen at two liters per minute. Resident 1's face appeared red, swollen, and scaly, with patches of yellow crust on his right cheek and nose. Resident 1's mustache and beard were singed and blackened. During an interview with Resident 1, on 6/4/19, at 9:41 a.m., Resident 1 stated on 6/2/19 he went out to smoke without informing staff beforehand. Resident 1 stated he lit his cigarette outside in the smoking area two days ago (6/2/19) and blew up. Resident 1 stated on 6/2/19 he smoked with his oxygen still on and staff were not nearby. Resident 1 stated he always kept a couple of cigarettes and a lighter inside a drawer located in his room. Resident 1 stated there were certain times the residents were allowed to go out to smoke but he was unaware of the smoking scheduled times. Resident 1 stated he began to smoke many years ago and smoked up to one pack of cigarettes per day. Resident 1 stated he did not have anything else to do while he was in the facility and smoking was an activity he looked forward to. Resident 1 stated the facility smoking schedule did not meet his smoking need and he often craved to smoke more. Resident 1 stated he would sneak a cigarette whenever he could because he was limited on the number of times he could smoke. During an observation on 6/4/19, at 9:50 a.m., in Resident 1's room, the activity calendar board and in the facility smoking area, there were no signs posted to indicate the facility smoking times. 1. During a review of the clinical record for Resident 1, the clinical document titled, Admission Record (a document with background information) undated, indicated Resident 1 had the following Diagnoses: [REDACTED]. to function properly). During a review of Resident 1's Minimum Data Set (MDS) assessment (an evaluation of memory recall and care needs) dated 4/2/19, indicated Resident 1 had long and short term memory impairment. During a review of Resident 1's Physician order [REDACTED]. During a concurrent interview and record review with Certified Nursing Assistant (CNA) 1, on 6/4/19, at 10:03 a.m., she reviewed the facility Smoking Schedule undated and stated resident smoking times were scheduled for 9:30 a.m., 11 a.m., 1 p.m., 3 p.m., and 6 p.m. CNA 1 stated she and all facility staff were aware Resident 1 was a smoker because he would frequently keep one or two cigarettes inside his bed side drawer in his room. CNA 1 stated she never asked Resident 1 about the cigarettes he kept inside the drawer in his room. CNA 1 stated Resident 1 was alert and oriented and was able to make his needs known. CNA 1 stated she was aware Resident 1 did not like to abide by the facility smoking schedule, he would try to smoke more than the scheduled five times. CNA 1 stated the facility staff would remind Resident 1 of the smoking schedule and remind him that he could not smoke more than five times which often resulted in Resident 1's agitation and bouts of anger. CNA 1 stated Resident 1 was taken to the smoking area by staff on the scheduled smoking times and often would be found an hour later smoking alone and unsupervised in the smoking area. CNA 1 stated, About a month ago (Resident 1) was outside smoking unsupervised and the Licensed Vocational Nurse (LVN) and Director of Staff Development (DSD) were notified. CNA 1 stated she was not aware of the conversation the LVN and DSD had with Resident 1 and was not made aware if interventions were started to ensure Resident 1's unsupervised smoking was addressed. CNA 1 stated Resident smoked unsupervised on several occasions but did not recall the dates and times. CNA 1 stated she would observe Resident 1 remove his own nasal cannula and walk outside to the smoking area. CNA 1 stated she viewed Resident 1's unsupervised smoking as a normal occurrence because everyone in the facility was aware of his risky smoking behavior. During a concurrent interview and record review with LVN 1, on 6/4/19, at 10:33 a.m., she reviewed Resident 1's electronic clinical record and stated Resident 1 was admitted to the facility on [DATE]. LVN 1 stated Resident 1 had cognitive impairment and did not follow the smoking rules. LVN 1 stated Resident 1 did not follow the smoking schedule and would smoke at nonscheduled times. LVN 1 stated Resident 1 was found smoking while unsupervised on two occasions. LVN 1 stated Resident 1 was found smoking on 5/6/19, and could not recall the date of the second time he was found smoking while unsupervised. LVN 1 stated on 5/6/19, Resident 1 was placed on alert charting (monitoring required to be completed and documented by nursing staff every shift for a duration of 72 hours). LVN 1 stated the purpose of the 72-hour monitor/alert charting was for licensed nurses to document Resident 1's whereabouts and his smoking activity. LVN 1 stated she could not recall if interventions were implemented to address Resident 1's need for supervision while he smoked. LVN 1 stated Resident 1's smoking evaluations were supposed to be completed upon admission and on a quarterly basis. LVN 1 reviewed Resident 1's clinical record and stated the smoking assessment dated [DATE], was left incomplete. LVN 1 reviewed the clinical record and could not find Resident 1's smoking assessment due in (MONTH) (2019). LVN 1 stated the first smoking assessment for Resident 1 was completed on 6/3/19, 24 hours after the unsupervised smoking incident that resulted in Resident 1's facial burns. LVN 1 stated Resident 1 required oxygen 24 hours a day 7 days a week for his Chronic Obstructive [MEDICAL CONDITION] Disorder (chronic obstruction of lung airflow that interferes with normal breathing) and shortness of breath. LVN 1 stated he was educated that he could not go outside (to smoke) with his oxygen on. During a review of the clinical record for Resident 1, the Smoking Evaluation dated 12/24/18, at 10:27 p.m., was left blank in the following sections [NAME] (smoking) History . B. Cognition . C. Physical (ability) . D. reviewed the policy related to smoking times and storage or smoking material with resident. During an interview with the DON, on 6/4/19, at 1:15 p.m., she reviewed the electronic clinical record and stated Resident 1 was admitted on [DATE] on hospice (end of life care). The DON stated Resident 1 requested to be admitted to a facility that allowed smoking. The DON stated Resident 1's smoking evaluation was not completed and should have been completed within 24 hours following his admission to the facility in order to identify Resident 1's safety risks of oxygen use and smoking during the times he smoked. During a review of the clinical record for Resident 1, the Care Plan dated 12/25/18, indicated interventions, Remove supplemental oxygen device prior to entering designated smoking area .patient not to have cigarettes or smoking material on person .observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outsides sources. Immediately inform facility management . complete smoking safety assessment per living center policy . Assist (Resident 1) to and from designated smoking area . During a concurrent interview and record review with the DON, on 6/4/19, at 1:24 p.m., she reviewed Resident 1's Progress Notes dated 12/29/18 at 2:01 p.m., and stated the incident on 12/29/18 was Resident 1's first incident where he concealed smoking paraphernalia inside the facility. The DON stated on 12/29/18 Resident 1 had a pack of cigarettes in his nightstand next to his bed even though he had a cigarette during the smoke break. The DON stated the interdisciplinary team (IDT) (a group composed of a nurse, social service designee, activity designee, other appointed staff) did not meet after the pack of cigarettes were found in Resident 1 room while he had oxygen in use. The DON stated the IDT did not address Resident 1's need for safety during smoking, and his care plan was not followed or updated to reflect additional interventions to keep him safe. During a concurrent interview and record review with the DON, on 6/4/19, at 1:35 p.m., she reviewed Resident 1's Progress Notes dated 1/13/19, at 11:11 p.m. The DON stated Resident 1 was seen by a CNA coming out of his restroom with a cloud of cigarette smoke following him and a strong smell of smoke. The DON stated there were cigarette ashes found on the window seal of the restroom. The DON stated Resident 1's care plan was not revised to indicate new strategies for safety or interventions to provide supervision. During a concurrent interview and record review with the DON, on 6/4/19, at 1:45 p.m., she reviewed Resident 1's Progress Notes dated 2/8/19, at 2:46 p.m. The DON stated Resident 1 was found with three packs of cigarettes in his possession. The DON stated Resident 1 was not put on alert charting following the unauthorized possession of cigarettes and the IDT did not meet to discuss his safety or need for supervision. The DON stated Resident 1's care plan was not updated to reflect strategies or interventions for safety and for supervision. During a concurrent interview and record review with the DON, on 6/4/19, at 1:55 p.m., she reviewed Resident 1's Progress Notes dated 5/6/19, at 7:30 p.m. The DON stated Resident 1 was outside smoking during a non-smoking time and without staff to provide supervision. The DON stated Resident 1 was placed on 72-hour alert charting following the incident. The DON stated the IDT did not meet to discuss the need for safety and supervision and did not update the care plan to reflect strategies or implement interventions for safety and for supervision. During a concurrent interview and record review with the DON, on 6/4/19, at 2:05 p.m., she reviewed Resident 1's Progress Notes dated 6/2/19, at 1:50 p.m. The DON stated a visiting family member (VFM) of another resident saw when Resident 1 caught his face on fire while he smoked unsupervised in the designated smoking area. The DON stated the VFM alerted the staff inside the facility when Resident 1's face caught on fire. The DON stated Resident 1 was in the outside smoking area with a portable oxygen tank and without staff supervision. The DON stated Resident 1 was sent to the hospital emergency room for evaluation of his facial and hand burns. During an interview with VFM, on 6/4/19, at 3:32 p.m., she stated, on 6/2/19 around noon time, after she walked out of the facility and gotten into her car, she noticed Resident 1 and two other males underneath the canopy smoking area. VFM stated she initially saw when Resident 1 rubbed his face and fanned it with his hands. VFM stated she saw Resident 1's face on fire. VFM stated she got out of her car and ran inside the facility to get help for Resident 1. VFM stated she did not see staff from the facility outside in the smoking area during the time Resident 1 caught his face on fire. During an interview with the ADM, on 6/4/19, at 3:50 p.m., she stated Resident 1 was on continuous oxygen for his shortness of breath and [MEDICAL CONDITION] and was not allowed to smoke with his oxygen on. The ADM stated she had not spoken to Resident 1 about his risky and unsafe behaviors involving his smoking prior to the incident when he burned his face. The ADM stated she was not made aware of Resident 1's behavior of noncompliance with the smoking policy. The ADM stated she was not always in the facility and expected the AIT to notify her of any risky behavior exhibited by any resident. During an interview with the AIT, on 6/4/19, at 5:36 p.m., she stated she was aware of Resident 1's smoking and unsafe behavior. The AIT stated she explained the facility smoking rules to Resident 1 and told him he could only smoke during the designated smoking times (five times a day). The AIT stated Resident 1 was placed on alert charting and monitoring for three days on 1/13/19, following an unscheduled and unsupervised smoking incident. The AIT stated the 72-hour monitor was to determine if Resident 1 was following the facility smoking rules or not. The AIT stated if there were no incidents of unsupervised smoking during the 3 days the facility nursing staff would stop monitoring. The AIT stated if the nursing staff witnessed an incident of unsupervised smoking, the staff was expected to come up with an intervention. The AIT stated the smoking care plan for Resident 1 was not updated after the incident on 1/13/19 and should have been updated with new safety interventions after every incident of unsupervised smoking or non-compliance with the smoking policy. During an interview with the Activities Director (AD), on 6/4/19, at 6:01 p.m., she stated Resident 1 would go outside to smoke. The AD stated the expectation for Resident 1 was for him to leave his wheelchair inside the building by the front door entrance, then walk outside to the designated smoking area. The AD stated staff knew he wanted to smoke. The AD stated Resident 1 should have known to not take the oxygen tank with him when he would smoke. During an interview with the Social Services Director (SSD), on 6/5/19, at 9:47 a.m., she stated smoking evaluations were required to be completed by nurses at the time of admission to the facility and on a quarterly basis. The SSD stated the facility admitted Resident 1 with the awareness he smoked. The SSD stated she was aware Resident 1 would have smoking paraphernalia on his possession. The SSD stated she was trying to figure what interventions to put in place to alert staff how they would be able to keep Resident 1's smoking paraphernalia from his possession. The SSD stated each time Resident 1 was found with smoking paraphernalia he would state he was not aware of the smoking paraphernalia or how it ended up in his room. The SSD stated she was informed on 1/4/19 by Resident 1's daughter about the time when he was found smoking inside his room in a previous skilled nursing facility. The SSD stated Resident 1 had known history of unsafe and unsupervised risky smoking behaviors prior to being admitted to the facility. The SSD stated she initiated a care plan which indicated his behaviors of noncompliance with the smoking policy but the interventions were not followed by the staff and/or Resident 1. During a concurrent interview and record review with the SSD, on 6/5/19, at 9:58 a.m., she reviewed Resident 1's care plan dated 1/4/19 and stated the intervention she added to the care plan dated 1/4/19 was to check Resident 1's room as needed for smoking paraphernalia and remind him not to keep smoking paraphernalia at his bedside. The SSD stated she would check Resident 1's belongings for smoking paraphernalia at times. The SSD stated she reviewed and discussed the smoking policy with Resident 1 on 1/16/19 to remind him of the smoking policy rules after the incident on 1/13/19. During a review of Resident 1's clinical record, the care plan dated 1/4/19, indicated, I sometimes have behaviors which include noncompliant with smoking policy. I have a (history) of attempting to smoke in my room .My behavior will stop with staff interventions . Attempt intervention before my behaviors begin .Please remind me not to keep cigarettes and lighters with me at my bedside table . Check (as needed) if I have items at my bedside. During an interview with the SSD, on 6/5/19, at 9:55 a.m., she stated the IDT met on 1/16/19 to formulate a smoking contract agreement with Resident 1. The SSD stated the smoking contract was a form which indicated the rules of the facility's smoking policy. The SSD stated the smoking contract was meant as a reminder of the smoking policy for Resident 1. The SSD stated Resident 1 signed the contract which indicated he understood the smoking policy. The SSD stated the contract was discussed and signed with him (Resident 1) and the AIT and the DON. The SSD stated the contract was not followed by Resident 1. The SSD stated additional interventions included to consider his discharge from the facility if he remained noncompliant with the smoking policy. The SSD stated the IDT met with him and the Ombudsman (an advocate for skilled nursing facility residents) on 3/27/19 and discussed his noncompliance with the smoking policy. The SSD stated he was reminded of the smoking schedule and the requirement for him to comply with the smoking policy. The SSD stated the facility had not considered offering a smoking secession program. The SSD stated the IDT had not considered completing a smoking assessment to quantify how often Resident 1 would have wanted to smoke in order to reduce his risky behavior of smoking unsupervised. During a review of Resident 1's untitled document dated 1/16/19, indicated, (Resident 1) will follow all smoking policies, including: Not smoking unsupervised. Participating in the five scheduled smoke breaks at his preference (9:30, 11:30, 1:30, 3:30, 6:30) these times are subject to change and resident will be notified. Not smoking with oxygen on or near any oxygen tank. Not smoking inside the facility at any time. (Resident 1) is expected to follow the living center's directions for the safety of himself and others around him. We agree to the terms of this behavior contract as set forth above. The untitled document was signed by the AIT, the SSD, DON and Resident 1. During a review of Resident 1's clinical record titled, Care Conference dated 3/27/19, indicated, Care conference with resident's daughter, (Resident 1), ombudsman, hospice team, and DON. Resident was explained the rules of facility regarding cigarettes, smoking and lighters. (Resident 1) agreed that he has cigarettes on hand and will no longer keep cigarettes. (Resident 1) agreed to follow rules of facility. (Resident 1) will smoke at regular smoking breaks . During an interview with the DON, on 6/5/19, at 11:29 a.m., she stated Resident 1 wanted to smoke and would do anything to smoke. She was unaware of what additional interventions to implement for Resident 1's continued behavior of unsupervised and unsafe smoking. The DON stated she felt the interventions in the care plan of contacting the families, providing education to the residents and families on the smoking policy, placing the residents on alert charting and searching rooms for smoking paraphernalia was sufficient to keep residents safe. During an interview with the Director of Staff Development (DSD), on 6/5/19, at 3:41 p.m., she stated on 6/2/19 at 10:58 a.m., she observed Resident 1 wheeling himself out of the facility along with Resident 2. The DSD stated Resident 1 would usually leave his wheelchair inside the facility and walk out to the smoking area. The DSD stated she did not think Resident 1 was going to lite up and smoke with his oxygen when she witnessed Resident 1 going outside with Resident 2. The DSD stated around 11 a.m., she was notified Resident 1 was on fire by VFM. The DSD stated Resident 1 was sitting in wheelchair facing away from her. The DSD stated Resident 1's face was no longer on fire, his nasal cannula was melted on the floor and the portable oxygen tank was still on. The DSD stated Resident 1 was having difficulty breathing. The DSD stated Resident 1 was immediately taken inside the facility to his room. The DSD stated Resident 1's lips, tongue and facial hair were blackened from the fire and his hands were red from extinguishing the fire. The DSD stated Resident 1 complained of pain and requested pain medication. The DSD stated she observed an empty packet of cigarettes on Resident 1's bedside table. The DSD stated Resident 1 was then sent to the Acute Care Hospital (ACH). During a review of Resident 1's untitled acute care hospital clinical record dated 6/2/19, at 11:37 a.m., indicated, Chief Complaint .Burn Face .Comment (Resident 1) with [MEDICAL CONDITION] right [MEDICAL CONDITION] trying to smoke his cigarette with his home oxygen in his nares (nose) . During an interview with the Rehabilitative Nursing Assistant (RNA), on 6/6/19, at 3 p.m., she stated she would take the smoking residents to smoke from Monday to Friday at 9:30 a.m., 11 a.m., 1 p.m., 3 p.m. The RNA stated other staff were assigned to take the residents to smoke at 6 p.m. and on the weekends. The RNA stated she would first ask the smoking residents if they wanted to go smoke, then get the smoking supplies from the nurse's station and then she would collect the smoking aprons. The RNA stated she would take the residents outside and put smoking aprons on them and light each cigarette for them; once they were done smoking she would put it in the metal cigarettes bud disposal container. The RNA stated she was unaware if residents were able to have a second cigarette if requested. The RNA stated smoking residents were allowed to smoke only five times a day. 2. During an interview with Resident 3, on 6/4/19 at 3:33 p.m., he stated he smoked over a pack of cigarettes per day prior to his facility admission. Resident 3 stated he was never asked by the facility staff if he wanted to smoke more than five times per day. Resident 3 stated he was not allowed to smoke outside of the scheduled smoking times. Resident 3 stated he would go out of the facility and purchase his own cigarette boxes. During a concurrent interview and record review with the DON, on 6/5/19, at 8:01 a.m., she reviewed Resident 3's, Admission Record and stated Resident 3 was admitted on [DATE], and had a [DIAGNOSES REDACTED]. supervision when he was on facility property smoking. During a concurrent interview and clinical record review for Resident 3, the MDS assessment dated [DATE], indicated Resident 3 had long and short term memory impairment. The DON confirmed Resident 3 had been identified on the MDS assessment as having cognitive impairment and stated Resident 3 would have poor safety awareness. During a review of the clinical record for Resident 3, the Smoking Evaluation dated 8/21/18, at 4:35 p.m., indicated Resident 3 was a smoker, he did not want to quit smoking and was left with an incomplete entry under, referral made to a physician for smoking cessation. The assessment indicated Resident 3 smoked three to four times per day and had no smoking related incidents. The assessment indicated Resident 3 did not have confusion, he had the ability to make himself understood, could verbalize or demonstrate an understanding of the living center's smoking policy, the smoking times and designated smoking areas. The assessment indicated Resident 3 remained alert during his smoking sessions and he had the ability to communicate his need for help if lit materials fell on him. The assessment indicated he did not have tremors. The assessment indicated Resident 3 was able to extinguish his own cigarette. The assessment had not indicated if Resident 3 complied with the smoking policy and it had not indicated if Resident 3 required supervision during smoking. During a record review of Resident 3's clinical record, the Care Plan dated 8/22/18, indicated, Patient not to have cigarettes or smoking material on person . During a review of the clinical record for Resident 3, the Smoking Evaluation dated 12/8/18, at 11:41 a.m., indicated documented assessment entries were identical to the assessment completed on 8/21/18. The assessment had not indicated whether or not Resident 3 complied with the smoking policy and it had not indicated if Resident 3 required supervision during smoking. During a concurrent interview and record review with the DON, on 6/5/19, at 8:01 a.m., she reviewed Resident 3's Progress Notes dated 1/22/19, at 10:47 p.m. The DON stated the document indicated the licensed nurse smelled cigarette smoke in Resident 3's room. The DON stated when Resident 3 was questioned by the licensed nurse he stated he was taking an extra smoke. The DON stated Resident 3's care plan was not updated by the licensed nurse following the unsupervised incident of smoking inside the facility. The DON stated the IDT had not met to discuss the incident of unsupervised smoking inside the facility. During a concurrent interview and record review with the DON, on 6/5/19, at 8:09 a.m., she reviewed Resident 3's Progress Notes dated 4/16/19, at 10:45 p.m. The DON stated Resident 3 was discovered by the CNA's smoking outside on the side of the building when he was unable to sleep. The DON stated the IDT had not met to discuss the incident or safety intervention. During a review of the clinical record for Resident 3, the Smoking Evaluation dated 4/16/19, at 11:45 p.m., indicated Resident 3 smoked five to nine times per day. The assessment did not indicate if Resident 3 complied with the smoking policy and did not indicate if Resident 3 required supervision during smoking sessions. The assessment did not indicate Resident 3 was found smoking in a non-smoking area on 4/16/19 unsafely smoking. During a concurrent interview and record review with the DON, on 6/5/19, at 8:15 a.m., she reviewed Resident 3's Progress Notes dated 4/18/19, at 9:59 p.m. The DON stated Resident 3 was discovered smoking in the back of the building because he did not want to smoke with other residents. The DON stated the IDT did not meet to discuss the incident of not following the facility smoking policy and the unsupervised unsafe smoking. During a concurrent interview and record review with the DON, on 6/5/19, at 8:24 a.m., she reviewed Resident 3's Progress Notes dated 5/2/19, at 1 a.m. The DON stated Resident 3 was discovered smoking in a non-designated smoking area. The DON stated the care plan was not updated with new interventions and the IDT had not met to discuss the safety risks of not following the facility smoking policy. During a concurrent interview and record review with the DON, on 6/5/19, at 8:34 a.m., she reviewed Resident 3's Progress Notes dated 5/7/19, at 7:12 p.m. The DON stated Resident 3 was found smoking outside of the facility and unsupervised. The DON stated Resident 3's care plan was not updated with new interventions and the IDT had not met to discuss the incident. During a concurrent interview and record review with the DON, on 6/5/19, at 8:48 a.m., she reviewed Resident 3's Progress Notes dated 5/11/19, at 4:37 p.m. The DON stated a CNA observed Resident 3 handing out cigarettes to Resident 1 and Resident 2 in the outside smoking area. The DON stated by the time staff came out all three residents were smoking without supervision. The DON stated the care plan for Resident 3 was not updated with new interventions for safety and supervision. During a concurrent interview and record review with the DON, on 6/5/19, at 8:57 a.m., she reviewed Resident 3's Progress Notes dated 5/12/19, at 9:41 a.m. The DON stated Resident 3 was witnessed by a CNA smoking outside in the back of the building unsupervised. The DON stated the care plan was not updated and the IDT did not meet to discuss the risks of not following the facility smoking policy. During a concurrent interview and record review with the DON, on 6/5/19, at 9:07 a.m., she reviewed Resident 3's Progress Notes dated 5/23/19, at 8:16 a.m. The DON stated Resident 3 was smoking outside and was told to put the cigarette out and he did. The DON stated the care plan was not updated and the IDT had not met to discuss the risks of not following the smoking policy. During a concurrent interview and record review with the DON, on 6/5/19, at 9:12 a.m., she reviewed Resident 3's Progress Notes dated 6/2/19, at 1:09 p.m. The DON stated Resident 3 had a packet of cigarettes inside his walker's storage area. During an interview with the DON, on 6/5/19, at 9:19 a.m., she reviewed the electronic clinical record Progress Notes dated 6/3/19, at 11:53 p.m. The DON stated Resident 3 was found with a packet of cigarettes in his room in addition to three 25-ounce beer cans. During an interview with the SSD on 6/5/19, at 9:47 a.m., she stated a smoking contract was completed on 5/13/19 for Resident 3. The DSD stated the day-to-day business practice for residents who smoke was for staff to gather the smoking paraphernalia from the nurses and then go offer residents the opportunity to go out to smoke. During a review of Resident 3's untitled document dated 5/13/19, indicated, (Resident 3) will follow .Not smoking unsupervised. Participating in the five scheduled smoke breaks at his preference (9:30, 11:30, 1:30, 3:30, 6:30) these times are subject to change and resident will be notified. Not smoking with oxygen on or near any oxygen tank. Not smoking inside the facility at any time. (Resident 3) is expected to follow the living center's directions for the safety of himself and others around him. We agree to the terms of this behavior contract as set forth above. The untitled document was signed by the AIT, the SSD, the DON and Resident 3. During review of the undated facility smoking schedule, the schedule indicated there were three residents who smoked. The schedule indicated the five scheduled smoking times which were 9:30 a.m., 11 a.m., 1 p.m., 3 p.m., and 6 p.m. The facility policy and procedure titled, Smoking and Tobacco Use Guideline dated 12/17/16, indicated, . Residents of (SNF) are permitted to smoke in the designated area only .Residents may smoke only at the designated times . Smoking will be supervised by a staff member . Residents wh

Based on observation, interview and record review, the facility failed to evaluate and analyze hazards and risks for residents who smoked and implement interventions of safety and supervision for two of three sampled residents (Resident 1 and Resident 3) when: 1. Resident 1 had a known history of unsupervised smoking and concealed his smoking paraphernalia. Resident 1's smoking habit was not assessed to address his history, frequency, amount and safety needs for smoking. The facility's smoking schedule frequency and the degree of supervision for Resident 1 was insufficient to keep him safe. Resident 1 engaged in risky behavior of smoking without supervision and sustained second [MEDICAL CONDITION] his face during an episode of unsupervised smoking when Resident 1 wore an oxygen cannula (tubing attached to an oxygen tank) attached to an oxygen source during an episode of smoking, ignited. 2. Resident 3 was not provided supervision while smoking after Resident 3 had witnessed smoking incidents inside the facility. The facility was aware of Resident 3's non-compliance with the policy and procedure of smoking during designated smoking times when he smoked in his restroom and outside during non-designated smoking times. The facilty failed to designate supervised smoking for Resident 3 and interventions to help with Resident 3's non-compliance. Because of these failures and the identified serious harm sustained by Resident 1 while he smoked unsupervised and the potential serious harm to Resident 3 and the other residents of the facility, an Immediate Jeopardy Situation (IJ) was called on 6/5/19 at 3:20 p.m., with the facility Administrator (ADM), Administrator in Training (AIT), Director of Nurses (DON), and Registered Nurse Clinical of Operations (RNCO). The facility submitted an acceptable IJ Removal Plan on 6/7/19, at 10:32 a.m., to address the process for the completion of timely smoking assessments, frequency of smoking assessments, care planning needs of residents who smoke, and supervision requirement needed by residents who smoked. The IJ Removal Plan was validated and implemented to address and outline steps to follow when encountering residents who were non-compliant with facility smoking schedules, followed by individualization of smoking needs, care planning responsibilities and supervision requirements. The IJ situation was removed on 6/7/19 at 5:04 p.m., with the ADM, DON and the RNCO. Findings: 1. During an observation of Resident 1 on 6/4/19, at 9:39 a.m., Resident 1 was sleeping and did not respond when his name was called while lying in bed. Resident 1 wore a nasal cannula (tubing by which oxygen was received) attached to an oxygen concentrator (a device which concentrates ambient air to provide higher oxygen concentration) and delivered supplemental oxygen at two liters per minute (rate of flow). Resident 1's face was red, swollen, and scaly, with patches of yellow crust on his right cheek and nose. Resident 1's mustache and beard were singed and blackened. During an interview with Resident 1, on 6/4/19, at 9:41 a.m., Resident 1 stated on 6/2/19 he had not alerted any of the staff he was going outside to smoke (6/2/19). Resident 1 stated he lit his cigarette outside in the smoking area two days ago and blew up. Resident 1 stated on 6/2/19 he smoked with his oxygen on and without staff present. Resident 1 stated he always kept a couple of cigarettes and a lighter inside a drawer located in his room. Resident 1 stated he was unaware of the scheduled smoking times. Resident 1 stated he began to smoke many years ago and smoked up to one pack of cigarettes per day. Resident 1 stated the facility smoking schedule did not meet his smoking need and he often craved to smoke more. Resident 1 stated he would sneak a cigarette whenever he could because he was limited on the number of times per day he could smoke. During an observation on 6/4/19, at 9:50 a.m., there were no signs posted to indicate the facility smoking times in Resident 1's room, the activity calendar board and in the facility smoking area. During a review of the clinical record for Resident 1, the clinical document titled, Admission Record (a document with background information) undated, indicated Resident 1 had the following Diagnoses: [REDACTED]. Resident 1's Minimum Data Set (MDS) assessment (an evaluation of memory recall and care needs) dated 4/2/19, indicated Resident 1 had long and short term memory impairment. During a review of Resident 1's Physician order [REDACTED]. During a concurrent interview with Certified Nursing Assistant (CNA) 1, on 6/4/19, at 10:03 a.m., she stated the smoking times were 9:30 a.m., 11 a.m., 1 p.m., 3 p.m., and 6 p.m. CNA 1 stated she was familiar with Resident 1. CNA 1 stated staff were aware Resident 1 was a smoker because he would frequently keep one or two cigarettes inside his drawer. CNA 1 stated she never asked Resident 1 about the cigarettes he kept inside the drawer. CNA 1 stated Resident 1 was alert and oriented without cognitive impairment and was able to make his needs known. CNA 1 stated Resident 1 did not like to abide by the facility smoking schedule. CNA 1 stated the facility staff would remind Resident 1 of the smoking schedule which often resulted in agitating and angering Resident 1. CNA 1 stated Resident 1 was taken to the smoking area by staff on the scheduled smoking times and would be found an hour later smoking alone and unsupervised in the smoking area. CNA 1 stated, About a month ago (Resident 1) was outside smoking unsupervised and the Licensed Vocational Nurse (LVN) and Director of Staff Development (DSD) were notified. CNA 1 stated she could not recall the exact date Resident 1 was found smoking while unsupervised. CNA 1 stated Resident smoked unsupervised on several occasions but did not recall the dates and times. During a concurrent interview and record review with LVN 1, on 6/4/19, at 10:33 a.m., she reviewed Resident 1's electronic clinical record and stated Resident 1 was admitted to the facility on [DATE]. LVN 1 stated Resident 1 was alert and oriented without cognitive impairment and was able to make his needs known. LVN 1 stated Resident 1 did not follow the smoking schedule and would smoke during nonscheduled smoking times. LVN 1 stated Resident 1 was found smoking while unsupervised on two occasions. LVN 1 stated Resident 1 was found smoking, unsupervised, on 5/6/19, and could not recall the date of the second time he was found smoking while unsupervised. LVN 1 stated on 5/6/19, Resident 1 was placed on alert charting (monitoring required to be completed and documented by nursing staff every shift for a duration of 72 hours). LVN 1 stated the purpose of the 72-hour monitor/alert charting was for licensed nurses to document Resident 1's whereabouts and his smoking activity. LVN 1 stated she could not recall if there were interventions made to address Resident 1's need for supervision while he smoked. LVN 1 stated Resident 1's smoking evaluations were supposed to be completed upon admission and on a quarterly basis. LVN 1 stated Resident 1's smoking assessment should have been completed on admission and three months later. LVN 1 reviewed Resident 1's clinical record and stated the smoking assessment dated [DATE], was left incomplete. LVN 1 reviewed the clinical record and could not find Resident 1's smoking assessment which was due in (MONTH) (2019). LVN 1 stated the first smoking assessment for Resident 1 was completed on 6/3/19, 24 hours after the unsupervised smoking incident that resulted in Resident 1's facial burns. During an interview with the DON, on 6/4/19, at 1:15 p.m., she reviewed the electronic clinical record and stated Resident 1 was admitted on [DATE] on hospice (end of life care) services. The DON stated Resident 1 requested to be admitted to a facility that allowed smoking. The DON stated Resident 1's smoking evaluation was not completed and should have been completed within 24 hours following his admission to the facility in order to identify Resident 1's safety requirement during the times he smoked. During a review of the clinical record for Resident 1, the Smoking Evaluation dated 12/24/18, at 10:27 p.m., the record was left blank and incomplete. During a review of the clinical record for Resident 1, the Care Plan dated 12/25/18, indicated, Remove supplemental oxygen device prior to entering designated smoking area .patient not to have cigarettes or smoking material on person .observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outsides sources. Immediately inform facility management . complete smoking safety assessment per living center policy . Assist (Resident 1) to and from designated smoking area . During a concurrent interview and record review with the DON, on 6/4/19, at 1:24 p.m., she reviewed Resident 1's Progress Notes dated 12/29/19, at 2:01 p.m., and stated Resident 1 had a pack of cigarettes on his nightstand next to his bed even though he had a cigarette during the smoke break. The DON stated the interdisciplinary team (IDT) (a group composed of a nurse, social service designee, activity designee, other appointed staff) did not meet after the pack of cigarettes were found on Resident 1's nightstand. The DON stated the IDT did not address Resident 1's need for safety and supervision during smoking, and his care plan was not updated to reflect additional interventions to keep him safe. During a concurrent interview and record review with the DON, on 6/4/19, at 1:35 p.m., she reviewed Resident 1's Progress Notes dated 1/13/19, at 11:11 p.m. The DON stated Resident 1 was seen by a CNA coming out of his restroom followed by a cloud of cigarette smoke and odor. The DON stated there were cigarette ashes found on the window seal of the restroom. The DON stated Resident 1 was placed on alert charting for 72 hours. The DON stated Resident 1's care plan was not revised to indicate new strategies for safety or interventions. During a concurrent interview and record review with the DON, on 6/4/19, at 1:45 p.m., she reviewed Resident 1's Progress Notes dated 2/8/19, at 2:46 p.m. The DON stated Resident 1 was found with three packs of cigarettes in his possession. The DON stated the IDT did not meet to discuss his safety or need for supervision. The DON stated Resident 1's care plan was not updated to reflect strategies for safety and for supervision. During a concurrent interview and record review with the DON, on 6/4/19, at 1:55 p.m., she reviewed Resident 1's Progress Notes dated 5/6/19, at 7:30 p.m. The DON stated Resident 1 was outside smoking during a non-smoking time and without staff supervision. The DON stated the IDT did not meet to discuss his need for safety and supervision and did not update his care plan to reflect strategies for safety and for supervision. During a concurrent interview and record review with the DON, on 6/4/19, at 2:05 p.m., she reviewed Resident 1's Progress Notes dated 6/2/19, at 1:50 p.m. The DON stated a visiting family member (VFM) of another resident saw the incident when Resident 1 caught his face on fire while he smoked unsupervised. The DON stated the VFM alerted the staff inside the facility when Resident 1's face caught on fire. The DON stated Resident 1 was in the outside smoking area with a portable oxygen tank on and without staff present. The DON stated Resident 1 required to be sent out to the acute care hospital for an evaluation and treatment of [REDACTED]. During an interview with VFM, on 6/4/19, at 3:32 p.m., she stated, on 6/2/19 around noon time, after she walked out of the facility and gotten into her car, she noticed Resident 1 and two others were underneath the canopy smoking area. VFM stated there was a person on a motorized wheelchair, and a male who stood near Resident 1. VFM stated she initially saw when Resident 1 rubbed his face and fanned it with his hands. VFM stated she saw Resident 1's face on fire. VFM stated she got out of her car and ran inside the facility to get help for Resident 1. VFM stated she did not see staff from the facility outside in the smoking area during the time Resident 1 caught his face on fire. During an interview with the ADM, on 6/4/19, at 3:50 p.m., she stated Resident 1 was on continuous oxygen and was not allowed to smoke with his oxygen on. The ADM stated she did not talk to Resident 1 about his risky and unsafe behaviors involving his smoking prior to the incident when he burned his face. The ADM stated she was not made aware of Resident 1's behavior of noncompliance with the smoking policy. The ADM stated she was not always in the facility and expected the AIT to notify her of any risky behavior exhibited by any resident. During an interview with the AIT, on 6/4/19, at 5:36 p.m., she stated she was aware of Resident 1's smoking and unsafe behavior. The AIT stated she explained the facility smoking rules to Resident 1 and told him he could only smoke during the designated smoking times. The AIT stated Resident 1 was placed on alert charting and monitored for three days on 1/13/19, following an unscheduled and unsupervised smoking incident. The AIT stated the 72-hour monitor was to determine whether or not Resident 1 was following the facility smoking rules. The AIT stated if there were no incidents of unsupervised smoking during the 3 days of monitoring the facility nursing staff would stop the alert charting. The AIT stated if the nursing staff witnessed an incident of unsupervised smoking, the staff would then come up with an intervention. The AIT stated the smoking care plan for Resident 1 was not updated after the incident on 1/13/19 and should have been updated after every incident of unsupervised smoking or non-compliance with the smoking policy. During an interview with the Social Services Director (SSD), on 6/5/19, at 9:47 a.m., she stated smoking evaluations were required to be completed by nurses at the time of admission to the facility and on a quarterly basis. The SSD stated the facility admitted Resident 1 with the awareness he smoked. The SSD stated she reviewed and discussed the smoking policy with the residents and their families if staff alerted her a resident was not compliant with the smoking policy. The SSD stated she was alerted on 1/4/19 by Resident 1's daughter about the time when he was found smoking inside his room in a previous skilled nursing facility. The SSD stated she initiated a care plan which indicated his behaviors of noncompliance with the smoking policy. During a review of Resident 1's care plan dated 1/4/19, indicated, I sometimes have behaviors which include noncompliant with smoking policy. I have a history of attempting to smoke in my room .My behavior will stop with staff interventions . During an interview with the SSD, on 6/5/19, at 9:55 a.m., she stated the IDT met on 1/16/19 to formulate a smoking agreement (contract) with Resident 1. The SSD stated the smoking contract was a form which indicated the rules of the facility's smoking policy. The SSD stated the smoking contract was meant as a reminder of the smoking policy for Resident 1. The SSD stated Resident 1 signed the contract which indicated he understood the smoking policy. The SSD stated the contract was discussed and signed with him (Resident 1) and the AIT and the DON. The SSD stated the contract was not followed by Resident 1. The SSD stated the IDT met with him and the Ombudsman (an advocate for skilled nursing facility residents) on 3/27/19 and discussed his noncompliance with the smoking policy. The SSD stated he was reminded of the smoking schedule and the requirement for him to comply with the smoking policy. The SSD stated the facility had not considered offering a smoking secession program. The SSD stated the IDT had not considered completing a smoking assessment to quantify how often Resident 1 would have wanted to smoke in order to reduce his risky behavior of smoking unsupervised. During a review of Resident 1's untitled document dated 1/16/19, indicated, (Resident 1) will follow all smoking policies, including: Not smoking unsupervised. Participating in the five scheduled smoke breaks at his preference (9:30, 11:30, 1:30, 3:30, 6:30) these times are subject to change and resident will be notified. Not smoking with oxygen on or near any oxygen tank. Not smoking inside the facility at any time. (Resident 1) is expected to follow the living center's directions for the safety of himself and other around him. We agree to the terms of this behavior contract as set forth above. The contract was signed by the AIT, the SSD, and the DON and by Resident 1. During a review of Resident 1's clinical record titled, Care Conference dated 3/27/19, indicated, Care conference with resident's daughter, (Resident 1), ombudsman, hospice team, and DON. Resident was explained the rules of facility regarding cigarettes, smoking and lighters. (Resident 1) agreed that he has cigarettes on hand and will no longer keep cigarettes. (Resident 1) agreed to follow rules of facility. (Resident 1) will smoke at regular smoking breaks . During an interview with the DON on 6/5/19, at 11:29 a.m., she stated Resident 1 wanted to smoke and would do anything to smoke. She was uncertain what additional interventions to implement for Resident 1's continued behavior of unsupervised and unsafe smoking. The DON stated she felt the interventions of contacting the families, providing education to the residents and families on the smoking policy, placing the residents on alert charting and searching rooms for smoking paraphernalia was sufficient. During an interview with the DSD, on 6/5/19, at 3:41 p.m., she stated on 6/2/19 at 10:58 a.m., she observed Resident 1 wheeling himself out of the facility. The DSD stated Resident 1 would usually leave his wheelchair inside the facility and walk out to the smoking area. The DSD stated she did not think Resident 1 was going to lite up and smoke when she saw Resident 1 going outside with Resident 2. The DSD stated around 11 a.m., she was notified Resident 1 was on fire by a VFM. The DSD stated Resident 1 was sitting in wheelchair facing away from her. The DSD stated Resident 1's face was no longer on fire, his nasal cannula was melted on the floor and the portable oxygen tank was still on. The DSD stated Resident 1 was having difficulty breathing. The DSD stated Resident 1 was immediately taken inside to his room. The DSD stated Resident 1's lips, tongue and facial hair were blackened from the fire and his hands were red from extinguishing the fire. The DSD complained of pain and requested pain medication. The DSD stated she observed an empty packet of cigarettes on Resident 1's bedside table. The DSD stated Resident 1 was then transferred to the Acute Care Hospital (ACH). During an interview with the SSD on 6/5/19, at 9:47 a.m., she stated a smoking contract was completed on 1/16/19 for Resident 1. The SSD stated the day-to-day business practice for residents who smoke was for staff to gather the smoking paraphernalia from the nurses and then go offer residents the opportunity to go out to smoke. During review of Resident 1's untitled acute care hospital clinical record emergency room record, dated 6/2/19, at 11:37 a.m., indicated, Chief Complaint .Burn Face .Comment (Resident 1) with [MEDICAL CONDITION] right [MEDICAL CONDITION] trying to smoke his cigarette with his home oxygen in his nares . 2. During an interview with Resident 3, on 6/4/19 at 3:33 p.m., he stated he smoked over a pack of cigarettes per day prior to his facility admission. Resident 3 stated he was never asked by the facility staff if he wanted to smoke more than five times per day. Resident 3 stated he was not allowed to smoke outside of the scheduled smoking times. Resident 3 stated he would go out of the facility and purchase his own cigarette boxes. During a concurrent interview and record review with the DON, on 6/5/19, at 8:01 a.m., she reviewed Resident 3's, Admission Record and stated Resident 3 was admitted on [DATE], and had a [DIAGNOSES REDACTED]. Resident 3's MDS assessment dated [DATE], indicated Resident 3 had long and short term memory impairment. During a review of the clinical record for Resident 3, the Smoking Evaluation dated 8/21/18, at 4:35 p.m., indicated Resident 3 was a smoker, he did not want to quit smoking. The record had an incomplete entry under, Referral made to a physician for smoking cessation. The assessment indicated Resident 3 smoked three to four times per day and had no smoking related incidents. The assessment indicated Resident 3 did not have confusion, he had the ability to make himself understood, could verbalize or demonstrate an understanding of the living center's smoking policy, the smoking times and designated smoking areas. The assessment indicated Resident 3 remained alert during his smoking sessions and he had the ability to communicate his need for help if lit materials fell on him. The assessment indicated he did not have tremors. The assessment indicated Resident 3 was able to extinguish his own cigarette. The assessment had not indicated if Resident 3 complied with the smoking policy and it had not indicated if Resident 3 required supervision during smoking. During a concurrent interview and record review of Resident 3's clinical record, the Care Plan dated 8/22/18, indicated, Patient not to have cigarettes or smoking material on person . During a review of the clinical record for Resident 3, the Smoking Evaluation dated 12/8/18, at 11:41 a.m., indicated documented assessment entries were identical to the assessment completed on 8/21/18. The assessment had not indicated if Resident 3 complied with the smoking policy and it had not indicated if Resident 3 required supervision during smoking. During a concurrent interview and record review with the DON, on 6/5/19, at 8:01 a.m., she reviewed Resident 3's Progress Notes dated 1/22/19, at 10:47 p.m. The DON stated the document indicated the licensed nurse smelled cigarette smoke in Resident 3's room. The DON stated when Resident 3 was questioned by the licensed nurse he stated he was taking an extra smoke. The DON stated Resident 3's care plan was not updated by the licensed nurse following the unsupervised incident of smoking inside the facility. The DON stated the IDT had not met to discuss the incident of unsupervised smoking inside the facility. During a concurrent interview and record review with the DON, on 6/5/19, at 8:09 a.m., she reviewed Resident 3's Progress Notes dated 4/16/19, at 10:45 p.m. The DON stated Resident 3 was discovered by the CNA's smoking outside on the side of the building when he was unable to sleep. The DON stated the IDT had not met to discuss the incident. During a review of the clinical record for Resident 3, the Smoking Evaluation dated 4/16/19 at 11:45 p.m., indicated Resident 3 smoked five to nine times per day. The assessment had not indicated if Resident 3 complied with the smoking policy and did not indicate if Resident 3 required supervision during smoking sessions. The assessment did not indicate Resident 3 was found smoking in a non-smoking area on 4/16/19. During a concurrent interview and record review with the DON, on 6/5/19, at 8:15 a.m., she reviewed Resident 3's Progress Notes dated 4/16/19, at 9:59 p.m. The DON stated Resident 3 was discovered smoking in the back of the building because he did not want to smoke with other residents. The DON stated the IDT did not meet to discuss the incident of unsupervised smoking. During a concurrent interview and record review with the DON, on 6/5/19, at 8:24 a.m., she reviewed Resident 3's Progress Notes dated 5/2/19, at 1 a.m. The DON stated Resident 3 was discovered smoking in a non-designated smoking area at that time. The DON stated the care plan was not updated and the IDT had not met to discuss the incident in efforts to implement interventions. During a concurrent interview and record review with the DON, on 6/5/19, at 8:34 a.m., she reviewed Resident 3's Progress Notes dated 5/7/19, at 7:12 p.m. The DON stated Resident 3 was found smoking on his own outside of the facility. The DON stated Resident 3's care plan was not updated and the IDT had not met to discuss the incident. During a concurrent interview and record review with the DON, on 6/5/19, at 8:48 a.m., she reviewed Resident 3's Progress Notes dated 5/11/19, at 4:37 p.m. The DON stated a CNA observed Resident 3 handing out cigarettes to Resident 1 in the outside smoking area. The DON stated by the time staff came out residents were smoking without supervision. The DON stated the care plan for Resident 3 was not updated with new interventions for safety and supervision. During a concurrent interview and record review with the DON, on 6/5/19, at 8:57 a.m., she reviewed Resident 3's Progress Notes dated 5/12/19, at 9:41 a.m. The DON stated Resident 3 was witnessed by a CNA smoking outside in the back of the building unsupervised. The DON stated the care plan was not updated and the IDT did not meet to discuss the incident in efforts to implement interventions. During a concurrent interview and record review with the DON, on 6/5/19, at 9:07 a.m., she reviewed Resident 3's Progress Notes dated 5/23/19, at 8:16 a.m. The DON stated Resident 3 was smoking outside and was told to put the cigarette out and he did. The DON stated the care plan was not updated and the IDT had not met to discuss the incident in an effort to implement interventions. During a concurrent interview and record review with the DON, on 6/5/19, at 9:12 a.m., she reviewed Resident 3's Progress Notes dated 6/2/19, at 1:09 p.m. The DON stated Resident 3 had a packet of cigarettes inside his walker's storage area. During an interview with the DON, on 6/5/19, at 9:19 a.m., she reviewed the electronic clinical record Progress Notes dated 6/3/19, at 11:53 p.m. The DON stated Resident 3 was found with a packet of cigarettes in his room. During an interview with the SSD on 6/5/19, at 9:47 a.m., she stated a smoking contract was completed on 5/13/19 for Resident 3. The SSD stated the day-to-day business practice for residents who smoke was for staff to gather the smoking paraphernalia from the nurses and then go offer residents the opportunity to go out to smoke. During a review of Resident 3's untitled document dated 5/13/19, indicated, (Resident 3) will follow .Not smoking unsupervised. Participating in the five scheduled smoke breaks at his preference (9:30, 11:30, 1:30, 3:30, 6:30) these times are subject to change and resident will be notified. Not smoking with oxygen on or near any oxygen tank. Not smoking inside the facility at any time. (Resident 3) is expected to follow the living center's directions for the safety of himself and others around him. We agree to the terms of this behavior contract as set forth above. The contract was signed by the AIT, the SSD, and the DON and Resident 3. During review of the undated facility smoking schedule, the schedule indicated there were three residents who smoked. The schedule indicated the five scheduled smoking times which were 9:30 a.m., 11 a.m., 1 p.m., 3 p.m., and 6 p.m. The facility policy and procedure titled, Smoking and Tobacco Use Guideline dated 12/17/16, indicated, . Residents of (SNF) are permitted to smoke in the designated area only .Residents may smoke only at the designated times . Smoking will be supervised by a staff member . Residents who smoke must be able to do so safely. periodic assessment evaluates the individual's ability to smoke safely in a supervised setting . Assessment of all residents will occur on admission, quarterly, and with significant changes in condition . smoking is supervised per policy.

Based on observation, resident and staff interview and clinical record and administrative document review, the facility failed to provide a safe, functional and sanitary environment for residents, staff and public when there was a sewage backflow, foul odor, and a plumbing leak due to a broken plumbing pipe. The bathroom toilet between Rooms 2 and 3 was not available for one month due to the sewage leakage. The facility's failure to ensure the correction of the sewage leak placed the residents at risk for potential harm due to the hazardous waste leakage. Immediate Jeopardy (IJ) was identified at 2/21/13 at 4:53 p.m.and the Administrator was notified. Findings: On 2/15/13 California Department of Public Health was in receipt of a complaint #CA 660 that alleged the following: Resident 1's restroom commode and sink had been out of order for over a month with a sign placed over the toilet. The Complainant stated the odor was really bad. The facility provided an invoice dated 1/21/13 from a plumbing company. There was a "smell in Rm 3, toilet keeps backing up...Video inspect line found bad pipe aprox. 9' from closet flange, unable to video beyond this point...line is under water." The facility provided a second invoice dated 2/1/13 from a different plumbing company. "Recommend call a Haz mat company to clean under building of waste water (grey water), and a flooring company to make a access on supflooring to get below building for plumbing company to get a proper proposal together and for Haz mat company to access to clean and disenfect area." There was no documented evidence the facility acted upon the recommendations. On 2/20/13 at 2:40 p.m. during a tour of the facility, it was observed there was a vent between Rooms 2 and 3 with a distinctive foul odor coming from the vent. There was also an foul odor noted coming from Nurse's Station 2 vent. On 2/20/13 at 2:48 p.m., during an interview Resident 2 stated, that the toilet between Rooms 2 and 3 was unusable. Resident 2 stated the nearest restroom for her to use was in Room 4. According to the Minimum Data Set (MDS) assessment (tool used to determine the resident's abilities) dated 2/17/13 identified the resident as being cognitive, alert and oriented. On 2/20/13 at 3:10 p.m., during interview LN 1 stated he knew the toilet between Rooms 2 and 3 had a problem but the maintenance man could not fix it. LN 1 stated, "there was a sewage problem...this is an old building." On 2/20/13 at 3:15 p.m., during an interview at the Nurse's Station 2, LN 2 stated there were floor vents around the building connected underground. LN 2 indicated the vent located at the nurse's station (where the odor was coming from) which was covered partially by a trash can. On 2/20/13 at 3:30 p.m., during an interview, the Maintenance Supervisor ( MS) stated sometime on the first week of January, the toilet and the floor in the bathroom between Rooms 2 and 3 were flooded when the toilet had clogged up. The MS stated, since then they had tried to do everything to fix it. They had tried to use a snake line several times to unclog it. They also had installed a new toilet bowl hoping it would solve the problem, but it did not. They finally turned off the water supply to the toilet and sink. The MS stated he had been in contact with their Regional Director of Facilities Maintenance at their corporate office about the problem on 2/20/13. On 2/20/13 at 3:40 p.m. during an interview, the Administrator (ADM) stated, the plumbing company had been contacted but they did not want to do the job because of the "hazardous waste." The ADM stated the plumbing company wanted the hazardous waste to be treated first and an open access to the flooring. The ADM and MS stated they she did not agree and did not like the idea of opening up the cement floor. The ADM and MS were interviewed, if the facility chose not to approve what would be their plan to resolve the hazardous waste problem? The ADM stated eventually they would have to do it and the corporate office would help them. On 2/20/13 at 4:15 p.m. during a telephone interview, the Complainant stated on 1/15/13, she observed the bathroom in Room 3A where Res 1 was staying had a sink full of black water that smelled so bad and the toilet had the toilet cover down with an orange cone on top. On 2/22/13 environmental specialist indicated the "crawl space has sewage." The specialist indicated he was at risk for respiratory problems during the clean up as indicated in the contract. On 2/22/13 at 9:10 a.m., an onsite observation was made by the Office of Statewide Health Planning and Development (OSHPD) representative. His Construction Advisory Report dated 2/22/13 included the following: "Patient rooms two and three and the staff break room are affected by this plumbing leak. The leak was caused by loose drain line supports...were compromised in the affected area which removed the slope and allowed water to pool in the drain pipe, resulting in accelerated corrosion in the affected area...The affected fixtures include patient rooms 2 and 3 and the ice-maker and hand wash sink in the break room." The OSHPD representative recommended "placing negative pressure air machine on crawl space, and suggested hiring an Industrial Hygienist to certify the affected area clean after mitigation has been completed." A recommendation was also made that the sewer be capped, negative air maintained, and/or clean up complete before restrictions be lifted. On 2/22/13 at 3:11 p.m., IJ was abated with the Administrator when the facility provided an acceptable plan and evidence that the sewage leak had been stopped (to prevent potential backflow of sewage), a plumbing contractor was onsite to do clean up of the sewage spillage, and the water to the affected area was shut off. On 2/27/13 at 9:45 p.m. during an interview in Resident 1's room (3B), Resident 1's personal caregiver (PC) stated, since the day Resident 1 was admitted to the facility (1/9/13), the bathroom smelled and clogged. There was a potty chair in the bathroom for Resident 1's use. The PC stated, she visited Resident 1 on 2/15/13 at 9 a.m. and saw Resident 1 eating breakfast in her room. The PC stated she asked Resident 1 why she was eating in her room where the smell was so bad? She stated Resident 1 replied, "The food tray was left in my room, so I ate here." On 2/27/13 at 10 a.m. during an interview in Room 7C, Resident 5 stated on 12/24/12 and 12/25/12, the toilet at Room 2A (which she previously occupied) was clogged and the smell was so unpleasant. Resident 5 stated, "I have to put up with this, because this was the only facility where I can live." The facility's undated policy and procedure on Infection Control indicated ..." To maintain a safe sanitary, and comfortable environment for personnel, residents, visitors and the general public..."