Every finding on record at Westside Oaks Rehabilitation & Nursing Center

Based on a review of facility and resident records, staff interviews, a review of the facility's policies titled Quality Assessment and Performance Improvement (QAPI) Policy and Risk Management, and a review of QAPI meeting documentation, the facility failed to have an effective QAPI process that used adverse event data and safety information related to smoking and oxygen use, to identify a Root Cause Analysis (RCA) and develop relevant performance improvement activities to prevent similar future events. Resident #1, with a known history of smoking in his room while using oxygen, was again found smoking in his room while using oxygen. His nasal cannula ignited and he sustained second-degree facial burns and respiratory distress requiring emergent transport to an acute care hospital burn unit for treatment. Resident #1 and three other residents (#2, #3 and #4) were known to keep cigarettes and lighters on their person or in their rooms, and two of the four (Residents #1 and #2) were oxygen-dependent and were known to smoke in their rooms. Despite direct observations by staff and leadership, as well as leadership's awareness of these residents' dangerous behavior, the facility failed to develop measures needed to ensure the safety and protection of these and other residents at risk. The facility had 45 residents who smoked at the time of the survey. Immediate Jeopardy (IJ) at a scope and severity of L (widespread) was identified at 10:45 AM on 3/30/26.On 2/27/26, Immediate Jeopardy began.On 4/1/26 at 5:45 PM, the Administrator was notified of the IJ determination. IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on 4/1/26.The findings include:Cross reference F600, F609, F689, and F835During a facility tour on 3/30/26 at 9:58 AM, three residents were observed sitting in their wheelchairs inside the facility near the designated smoking area door waiting for staff to open the door for their scheduled smoking period at 10:00 AM. Certified Nursing Assistant (CNA) A, assigned to supervise the residents who smoked, opened the door leading to the designated smoking area (back porch) at 10:00 AM. CNA A did not provide the three residents with smoking materials; all three residents had cigarettes and lighters already in their possession. At 10:16 AM, all three residents left the designated smoking area and re-entered the facility without providing their smoking materials to CNA A for storage in the smoking area locked cart.Another tour of the facility on 3/30/26 at 10:45 AM revealed that the same three residents who had not relinquished their smoking materials to CNA A in the designated smoking area at 10:16 AM were assigned to rooms [ROOM NUMBERS]. room [ROOM NUMBER] (Residents #2 and #4) and room [ROOM NUMBER] (Resident #3) had Oxygen in Use/No Smoking signs posted on the door frames outside of the rooms.1.A review of Resident #1's medical record revealed that he was admitted to the facility on [DATE], was transferred to an acute care hospital on 2/27/26 and was re-admitted on [DATE]. His diagnoses included chronic obstructive pulmonary disease (COPD - constriction of the airways and difficulty breathing) with acute exacerbation (sudden, severe worsening); alcohol abuse; noncompliance with other medical treatment and regimen; difficulty in walking; dysphagia (difficulty swallowing); anxiety disorder and mood disorder.A nursing note authored by Registered Nurse (RN) E on 2/27/26 revealed that she heard Certified Nursing Assistant (CNA) B scream that Resident #1's oxygen tubing was on fire and entered the room to find the nasal cannula tubing burning, a cigarette on the floor, and smoke spreading throughout the room. The nurse paged a Code Red (an intercom announcement indicating a fire or smoke emergency alerting staff to activate fire safety protocols) and obtained a fire extinguisher while another staff member called 911. RN E then provided care to the resident.A Change in Condition form, completed by RN F on 2/27/26 at 10:35 PM, noted that Resident #1's oxygen tubing caught fire while he was smoking in his room, resulting in burns to his nose and right cheek with pain rated at a 4 on a scale of zero through 10 with 10 being the worst possible pain. He was documented with increased confusion, general weakness, dizziness, unsteadiness, and labored, rapid breathing. His oxygen saturation was 98% on room air, he was a full code, and primary care was notified on 2/27/26 at 10:42 PM with orders to send him to the emergency room. Emergency Medical Services (EMS)/911 was called, and family was notified.A review of the resident's active physician's orders revealed that on 2/28/26, a physician's order was placed to send the resident to the Emergency Department (ED) for evaluation and treatment.A review of the February 2026 medication administration record (MAR) and treatment administration record (TAR) revealed that Resident #1's oxygen was delivered continuously via nasal cannula at 2 LPM according to the nurses' documentation of task completion from 2/1/26 - 2/27/26. The MAR/TAR included documentation of Resident #1's hospital/ED (Emergency Department) transfer on 2/28/26 at 12:54 AM.A review of hospital records revealed that on 2/27/26, Resident #1, diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and receiving oxygen via a nasal cannula at the nursing home, lit a cigarette and sustained superficial partial thickness burns of his face with a concern for inhalation injury. He required intubation during transport for airway protection and was accepted by the trauma/burn team. On 2/28/26 at 4:59 AM, he was documented as intubated and sedated, with soot in the nares (nostrils) and oropharynx (throat), and superficial partial thickness burns to the bridge of the nose and right cheek. An interview was conducted with Resident #1 on 3/30/26 at 9:51 AM. He was observed lying in bed, awake, wearing his nasal cannula with oxygen flowing at 3 liters per minute (LPM). When he was asked about his 2/27/26 incident, he stated he smoked a cigarette in his room while wearing oxygen via nasal cannula, the cannula ignited, and he sustained burns to his face that required emergent transport to the hospital. When asked if he had been educated about the facility's smoking policy prior to the event, he stated he had received education, but he was a 72 year old man and would smoke whenever he wanted to. When asked whether he kept his cigarettes and lighter in his room or provided them to the certified nursing assistant (CNA) supervising smokers in the designated smoking area, he stated he did not give his supplies to staff but always kept all of his smoking materials with him. When asked if he had smoked in his room prior to the 2/27/26 incident, he stated he had previously smoked in the bathroom of his room (room [ROOM NUMBER]), and in room [ROOM NUMBER]. When asked if nursing staff rounded frequently to check on/supervise the residents in his room, he stated he barely saw anyone come into his room prior to the incident. When asked if he continued to smoke after the 2/27/26 incident, he stated he quit smoking after that event. When he was asked how he obtained his cigarettes and lighters, he stated he would ask other residents to purchase cigarettes and lighters for him or have a personal friend bring them to him. When asked if he informed staff that he had cigarettes and a lighter on his person, he stated he never did. When asked if he knew he was violating the facility's policy, he stated he was aware but did not care. When asked if staff had requested that he relinquish his smoking supplies to them for proper storage, he stated he never gave them anything.Further review of Resident #1's medical record revealed the following nursing notes:A nursing note dated 9/25/24 at 2:24 PM revealed that Resident #1 was observed smoking cigarettes in his room while connected to his oxygen concentrator. The nurse provided education and informed the resident that smoking in the room, especially while on oxygen, was prohibited and posed a serious safety risk to him and other residents. The nurse then contacted law enforcement to assist with the situation. There was no documented evidence verifying that the nurse requested that the resident relinquish his smoking materials or that she confiscated them.A nursing behavior note dated 9/25/24 at 2:59 PM revealed that the writer noticed a smell of cigarette smoke. She went inside Resident #1's room and found him smoking with his nasal cannula on and oxygen flowing. Resident #1 was asked to extinguish his cigarette, and he put it into a beer can between his feet. Seven beer cans were also found in a trash bag under his bedside table. When staff requested that he relinquish his cigarettes and beer, he refused, became belligerent, and insisted he paid for them. The unit manager and the Director of Nursing (DON) were notified, and law enforcement was called. When law enforcement arrived, the resident denied smoking in the building, stated he did not care about others' safety, and insisted he would keep his cigarettes. He ultimately surrendered five cigarettes from a carton to the officer, who gave them to the nurse and indicated it was a civil matter, advising the unit manager to review the facility's smoking policy and consider discharge options. The DON was briefed on the situation.A nursing note dated 10/19/25 at 3:00 PM revealed that the nurse observed Resident #1 smoking in his room with his oxygen turned off. The nurse noted that education was provided and the DON was notified. The nurse documented the failed attempt to confiscate the resident's smoking materials due to his refusal.A review of Resident #1's active care plans revealed a care plan dated 11/7/23 with a focus area for a risk for complications with respiratory status related to COPD and a requirement for the use of oxygen. The goal was that the resident would display optimal breathing patterns daily through the next review date. The interventions did not include oxygen therapy safety interventions.Resident #1 was care-planned on 10/8/24 with the following focus areas:Behaviors and smoking inside the building with a goal to decrease risk factors of harming himself or others secondary to his behaviors through the next 30 days.He was care-planned for smoking. The goal was that he would not smoke without supervision through the review date. Interventions included notification of the nurse immediately if it was suspected that Resident #1 was violating the smoking policy; The resident required supervision while smoking; The resident was to be educated about the facility's smoking policy and the dangers of smoking in his room. The most recent revision of the interventions was completed on 2/26/25.A review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. He was documented as independent with activities of daily living (ADLs).A review of the resident's medical record revealed that on 3/25/26, Resident #1 saw his primary care provider (PCP) for a follow-up after his hospital discharge. The PCP's notes indicated that Resident #1 presented to the hospital on 2/27/26 for respiratory failure, facial and inhalation burns. Her notes also indicated that Resident #1 was intubated and admitted to the ICU (Intensive Care Unit). 2. On 3/30/26 at 10:00 AM, Resident #2 was observed entering the designated smoking area. Resident #2 did not obtain cigarettes or a lighter from the CNA supervising residents in the smoking area. He agreed to an interview at 10:02 AM. When asked if he received his cigarettes and lighter from the CNA, he stated he always kept his cigarettes and lighter on his person. He removed a pack of cigarettes and a lighter from his left front pants pocket and placed them on the table. When asked if he had received education or information about the facility's rules regarding smoking/smoking safety, he stated he had but he was afraid the staff would steal his cigarettes and lighter if he let them store the smoking supplies. When asked how he obtained his supplies, he stated when he went out on a leave of absence (LOA), he purchased cigarettes and lighters and kept them. He said he intentionally did not disclose to staff that he was in possession of cigarettes and a lighter when he returned from LOA. When he was asked how long he had been keeping smoking supplies on his person, he stated he had done so since he was admitted to the facility. When he was asked if he was oxygen dependent, he stated he wore oxygen mostly at night and as needed; he did not wear it all the time. Resident #2 said that on 2/27/26 at approximately 9:30 PM to 10:00 PM, Resident #1 was smoking in his room when Resident #1's oxygen ignited and burned his face. Resident #2 stated Resident #1 constantly smoked in his room, including in the bathroom, while wearing his oxygen. Resident #2 further stated he was also a smoker who depended on oxygen therapy and that he had previously smoked inside his own room, but that he did not use his oxygen when he went into the bathroom to smoke. He stated he maintained all of his smoking supplies, including cigarettes and lighters, with him at all times. When asked why he did not provide his smoking supplies to the CNA supervising smokers in the designated smoking area today, he stated he was afraid staff would steal them. He said he was familiar with the facility's smoking policy and acknowledged that he knew he was in violation of the policy. He stated the nurses and CNAs sometimes checked on him every few hours, but on most days, he did not see them at all. He said he was able to leave the facility independently and went to the corner store to purchase cigarettes and lighters when he ran out. When he was asked if staff had requested that he surrender his smoking supplies to them for proper storage, he stated they had, but he would not give them his cigarettes or lighter because they will steal them.On 3/30/26 at 10:16 AM, Resident #2 was observed going back inside the facility without providing his smoking materials to the CNA for storage in the designated smoking area locked cart.A review of Resident #2's medical record revealed he was admitted to the facility on [DATE] with diagnoses including COPD with acute exacerbation, wheezing, and alcohol abuse.A review of the resident's Quarterly MDS assessment, dated 3/30/26, revealed that Resident #2 had a BIMS score of 15 out of 15 possible points, indicating intact cognition. He was documented as independent with ADLs.A review of Resident #2's active physician's orders revealed an order dated 5/14/24 for Oxygen at 2L (two liters per minute) per nasal cannula as needed.A review of the resident's active care plans revealed the following focus areas:[Resident #2] prefers to smoke. The care plan was initiated on 10/17/23 with revisions on 7/1/25 and 3/30/26. The goal was to remain a safe smoker through the next review date on 4/8/26. A second goal of review smoking policy with resident was initiated on 3/30/26 with a target date of 4/8/26. The second goal was set after the survey began. Interventions initiated on 10/17/23 included encouraging the resident to follow safe smoking guidelines; to explain the smoking policy to the resident; to keep smoking products in a locked cart, and to notify the charge nurse immediately if it was suspected that the resident had violated the facility's smoking policy. None of these interventions had been revised since 10/17/23. On 3/30/26, a new intervention was initiated (after the surveyor's arrival): review smoking policy, educate not to smoke in the room. Under the care plan interventions on three occasions (10/4/24, 10/7/25 and 3/29/26), the following was noted, Resident given a smoking policy reminder and re-educated regarding not smoking inside the building. Under the intervention dated 10/4/24, initiation and revision dates were also documented as 3/31/26. [Resident #2] is/has the potential to be physically aggressive towards others and is known to refuse daily care r/t (related to) poor impulse control. The care plan was initiated on 11/11/23 with a goal that he will not harm self or others through the review date.Resident #2 was also care planned for his use of oxygen therapy related to a diagnosis of COPD (initiated 11/21/23) and impaired vision (initiated 7/12/24). A review of Resident #2's progress notes from 9/19/24 through 3/31/26 revealed no documented evidence of the resident's noncompliance with the facility's smoking policy.A review of Resident #2's Smoking Evaluations, dated 7/10/23, 10/17/23, 2/17/24, 3/2/26, and 3/30/26, revealed that Resident #2 was deemed a safe smoker and did not require supervision. According to the facility's policy, smoking evaluations were to be conducted upon admission, quarterly, annually, and if there was significant change in the resident's condition. Resident #2 signed his smoking agreement on 1/16/2025. 3. On 3/30/26 at 10:00 AM, Resident #3 was observed entering the designated smoking area. She did not obtain cigarettes or a lighter from the CNA supervising residents in the smoking area. Resident #3 agreed to an interview at 10:08 AM. She stated she was oxygen dependent and she smoked but she emphasized that she did not smoke while wearing her oxygen or inside her room. The smoking porch was the only place she went to smoke. When asked if she received her cigarettes and lighter from the CNA, she stated she did not and that she kept her cigarettes and lighter in her black purse. She further stated she did not give her smoking supplies to staff because she did not trust them and was afraid someone would steal her cigarettes or lighter. She stated she had been educated about smoking safety and was aware of the facility's smoking policy. She knew she was not supposed to keep cigarettes and a lighter on her person but continued to do so due to fear of theft, stating, I am [AGE] years old. If I want to keep my cigarettes and lighter in my purse, I will. She stated she had kept cigarettes and a lighter on her person for as long as she could remember. She obtained them when she went out on LOA with her family, and did not inform staff that she had cigarettes and a lighter when she returned from LOA. She stated she used oxygen when needed at night and had not and would not smoke in her room or while wearing oxygen. She stated she knew that Residents #1 and #2 had been caught smoking many times in the past and that they used to talk about smoking in their rooms while in the designated smoking area. She stated nursing staff usually took a long time to come to her room and would typically come into her room only two to three times a day while she was awake. She said that although the facility had provided education and reminders not to smoke inside, residents continued to smoke inside every day. She stated staff had requested that she relinquish her smoking supplies to them for proper storage, but she has always refused. During the interview Resident #3 removed one pack of cigarettes and a lighter from her black purse. At the conclusion of the interview, Resident #3 placed the pack of cigarettes and lighter back into her black purse and entered the facility at 10:16 AM without providing her smoking supplies to the supervising CNA. She then entered her room (room [ROOM NUMBER]) with the cigarettes and lighter still in her possession.A review of Resident #3's medical record revealed that she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including COPD, chronic diastolic (congestive) heart failure (CHF - the heart does not pump blood efficiently, leading to fatigue, fluid buildup in the lungs/tissues and shortness of breath), shortness of breath, and nicotine dependence.A review of the resident's Quarterly MDS assessment, dated 3/19/26, revealed that Resident #3 had a BIMS score of 13 out of 15 possible points, indicating intact cognition. She was documented as independent with some ADLs, but she required partial to substantial assistance with dressing, toileting, personal hygiene, and wheelchair mobility.A review of Resident #3's medical record revealed an active physician's order, dated 11/14/23, for Oxygen at 2 liters via nasal cannula - as needed for shortness of breath.A review of Resident #3's active care plan revealed the following focus areas:Resident #3 had a care plan focus area for smoking that was initiated on 4/18/23 with the goal that she would not suffer injury from unsafe smoking practice through the next review date. Interventions initiated on 4/18/23 included: Instruct resident about smoking risks and hazards and about smoking cessation aids that are available; instruct resident about the facility policy on smoking: locations, times, safety concerns; monitor oral hygiene and notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Interventions initiated on 4/17/24 included: Assist with removing O2 (oxygen) during smoking times prn (as needed) and observe clothing and skin for signs of cigarette burns. On 3/31/26, after the start of the survey, a new intervention was added: Resident will sign a smoking agreement upon admission, which remains in effect throughout the stay. Upon any smoking-related infraction, the resident will be re-educated on the established smoking agreement/policy and safety expectations. A formal warning will be issued, documented, and reviewed with the resident, with acknowledgement obtained when possible. Continued noncompliance will result in progressive warnings in accordance with facility policy, up to and including initiation of the discharge process.Further review of the resident's care plans revealed that she was care planned for impaired vision (initiated on 10/13/23), noncompliance with care (initiated on 1/19/26), and use of oxygen therapy (initiated on 6/15/24)related to a diagnosis of COPD.A review of Resident #3's progress notes from 9/19/24 through 3/31/26 revealed no documented evidence of the resident's noncompliance with the facility's smoking policy.A review of the scanned documents in the resident's electronic medical record revealed that Resident #3 had not been issued any Smoking Notices for non-compliance with the facility's smoking policy.A review of Resident #3's Smoking Evaluations dated 10/17/23, 2/18/24 and 3/2/26 revealed the following: On 10/17/23, Resident #3 was deemed a safe smoker who did not require supervision. On 2/18/24, the evaluation's Summary of Evaluation indicated that the resident was a safe smoker, but it did not specify whether or not she required supervision (not answered in the assessment). The smoking evaluation dated 3/2/26 revealed in the Summary of Evaluation that Resident #3 was deemed a safe smoker, but she required supervision. The Quarterly Review section of the same evaluation dated 3/2/26 revealed that the resident was a safe smoker and did not require supervision while smoking. Per the facility's policy, smoking evaluations were to be conducted upon admission, quarterly, annually, and if there was significant change in condition. Resident #3 signed her smoking contract on 2/20/2025. 4. On 3/30/26 at 10:00 AM, Resident #4 was observed entering the designated smoking area. He did not obtain cigarettes or a lighter from the CNA supervising residents in the smoking area. He did not agree to an interview in the designated smoking area but stated he would agree to an interview after he finished smoking.On 3/30/26 at 10:16 AM, Resident #4 went back inside the facility without providing his smoking materials to the CNA for storage in the designated smoking area locked cart.During an interview with Resident #4 on 3/30/26 at 11:49 AM in his room, he stated he was Resident #1's roommate at the time Resident #1 sustained facial burns during a smoking accident at night. He stated Resident #1 smoked in the room multiple times a day while wearing oxygen. He further stated both Resident #1 and Resident #2 smoked in the bathroom and that Resident #2 did not wear his oxygen when smoking but Resident #1 always smoked while wearing his oxygen. Resident #4 stated he was also a smoker but did not use oxygen. He stated he kept his cigarettes and lighter on his person and produced two packs of cigarettes from his left pants pocket and a lighter from his right pants pocket. (photographic evidence obtained) Resident #4 stated the nursing staff were delayed in rounding and typically came into the room once in the early morning, once at lunchtime, and once again at dinner. He said he barely saw nursing staff come into the room to check on residents. He said the facility had educated residents about the smoking policy, but that most of the residents who smoked did not listen to or follow the policy. When asked why he kept his cigarettes and lighter on his person instead of providing them to the CNA supervising smokers in the designated smoking area, Resident #4 stated, Just like everyone else, we don't want people stealing our stuff. Resident #4 stated he knew he was not supposed to keep cigarettes and lighters in his room and he acknowledged that he was in violation of the facility's smoking policy. When asked if staff had requested that he surrender his smoking supplies to them for proper storage, he stated they had asked him a few times, but he refused. Resident #4 declined to continue with the interview, stating he wanted to go outside to smoke again. The interview was concluded.A review of Resident #4's medical record revealed an admission date of 7/25/25 with diagnoses including anxiety disorder, major depressive disorder and schizoaffective disorder. Further review of the record revealed that Resident #4 was a current smoker and was not oxygen dependent.Resident #4 was the former roommate of Resident #1, an oxygen-dependent resident who smoked until 2/27/26, and was the current roommate of Resident #2, an oxygen-dependent resident who smoked.The resident's Quarterly MDS assessment, dated 1/28/26, revealed a BIMS score of 15 out of 15 possible points, indicating intact cognition. He was documented as independent with ADLs.A review of Resident #4's active care plan revealed the following focus areas:Resident prefers to smoke. (initiated on 3/2/26 after the 2/27/26 incident involving Resident #1) The goal was that he would safely smoke in the designated smoking area at designated smoking times through the next review date. Interventions initiated on 3/2/26 included Explain smoking policy to resident. Keep smoking products in locked cart. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. An intervention initiated on 3/31/26 (after the start of the survey) read: Resident will sign a smoking agreement upon admission, which remains in effect throughout the stay. Upon any smoking-related infraction, the resident will be re-educated on the established smoking agreement/policy and safety expectations. A formal warning will be issued, documented, and reviewed with the resident, with acknowledgement obtained when possible. Continued noncompliance will result in progressive warnings in accordance with facility policy, up to and including initiation of the discharge process. Another focus area for Resident #4 was for antipsychotic therapy for a diagnosis of psychosis (initiated on 7/27/25).A review of Resident #4's active physician's orders revealed an order dated 9/5/25 for May go LOA (leave of absence) and to therapeutic visits (including facility events) with responsible party and medications.A review of Resident #4's progress notes from 9/19/24 through 3/31/26 revealed no documented evidence of the resident's noncompliance with the facility's smoking policy.A review of the scanned documents in the resident's electronic medical record revealed that Resident #4 was not issued any Smoking Notices for non-compliance with the facility's smoking policy.A review of Resident #4's Smoking Evaluation, dated 3/2/26, revealed that Resident #4 was deemed a safe smoker and did not require supervision. Resident #4 was admitted on [DATE] and his first smoking evaluation was not completed until 3/2/26, after the 2 27/26 incident involving Resident #1. Per the facility's policy, smoking evaluations were to be conducted upon admission, quarterly, annually, and if there was a significant change in condition. Resident #4 signed the facility's smoking agreement on 7/25/25. On 3/30/26 at 10:35 AM, an interview was conducted with Certified Nursing Assistant (CNA) A. CNA A stated the CNAs routinely supervised the designated smoking area and were expected to issue and collect residents' smoking supplies and monitor their safety. CNA A stated most residents who were smokers refused to relinquish their cigarettes and lighters and kept them on their person or in their rooms. CNA A stated she notified the nurse, Assistant Director of Nursing (ADON) or DON when residents refused to surrender their smoking supplies, but nothing happens, and that both the Administrator and DON had long been aware that residents retained smoking materials without enacting effective corrective action. CNA A stated staff training on the smoking policy and oxygen safety was limited to folders left at the nurses' station with a sign in sheet. No formal, in person instruction or confirmation of understanding was completed. She stated residents were only periodically reminded in resident council not to smoke inside or keep supplies in their rooms or on their person, with no changes made to the facility's policy or practice despite ongoing noncompliance. CNA A stated Resident #1 burned his face in February (2026) after repeatedly smoking in his room while on oxygen and that staff, the Administrator and the DON all knew he had been smoking in his room for a long time. CNA A also stated Resident #2, Resident #1's oxygen dependent roommate, also smoked in his room. CNA A stated she personally saw both Residents #1 and #2 smoking in their room during the week of and the week before the burn incident. CNA A confirmed that both residents kept their smoking supplies in their room and stated she did not attempt to confiscate the supplies because of their history of aggression. CNA A stated instead, the facility's leadership was informed of their behaviors without knowing whether any follow up action was taken.On 3/30/26 at 3:00 PM, an interview was conducted with CNA D who stated this morning, 3/30/26 at about 8:30 AM, she observed Resident #2 (Resident #1's former roommate and an oxygen dependent resident) smoking in the bathroom inside his room, and immediately notified the Unit Manager, who then informed the DON. When asked if she confiscated Resident #2's smoking materials, she replied that she did not attempt to take Resident #2's cigarettes or lighter because prior attempts had led to verbal and a threat of physical aggression. She stated when residents refused to surrender smoking materials, she reported it to the Unit Manager or the DON. When asked about training and education related to the smoking policy and safety of oxygen dependent residents, she stated she did not recall receiving specific or formal education on the smoking policy, smoking safety, or oxygen therapy safety, explaining that training mainly consisted of reading folders at the nurses' station and signing a sign in sheet. She added that there was inconsistent enforcement by leadership as residents continued to hide smoking materials and smoke in their rooms.On 3/30/26 at 3:07 PM, an interview was conducted with CNA B. She stated she had previously seen Resident #1 smoking in his room and had told the DON several times, including having seen him smoke in his room about six times during the week of the burn accident. She stated the DON does not do anything about it. She confirmed that she did not attempt to confiscate Resident #1's cigarettes or lighter because he became aggressive and hid the smoking supplies. She said she recalled some past training on smoking safety but no formal training after the 2/27/26 incident specific to smoking, the smoking policy, or oxygen therapy safety. She stated the facility had not implemented new measures or interventions to prevent oxygen dependent residents from smoking inside despite ongoing noncompliance. She stated, Nothing is done about it.On 3/30/26 at 3:40 PM, an interview was conducted w

Based on a review of facility and resident records, facility job descriptions, policies and procedures, and interviews with residents, staff and medical professionals, the facility's Administration failed to provide oversight of the facility in a manner that ensured necessary interventions, including adequate supervision and sufficient safeguards, were in place to prevent avoidable accidents, by failing to ensure that CNAs A, B, D, RN E and the DON implemented the facility's Smoking/Vaping policy to prevent four oxygen dependent residents (#1, #2, #3 and #4) out of four residents reviewed for smoking, from storing cigarettes and lighters in their rooms, and to prevent two oxygen-dependent residents (#1 and #2) from smoking in their rooms while oxygen was in use. This failure resulted in Resident #1 sustaining second-degree facial burns and respiratory distress after his nasal cannula ignited while he smoked in his room, requiring emergency transfer to a local acute care hospital and subsequent transfer to a burn unit for treatment.Resident #1 was identified on 9/25/24 as unsafely smoking in his room while receiving oxygen. Two nursing notes on 9/25/24, and notes dated 9/5/25, 10/19/25 and 2/27/26 revealed that Resident #1 was found smoking in his room. On 2/27/26, Registered Nurse (RN) E observed Resident #1 smoking in his bathroom at 12:00 PM. She did not retrieve his cigarettes or lighter but notified the Director of Nursing (DON). On 2/27/26 at 10:24 PM, Certified Nursing Assistant (CNA) B observed Resident #1 smoking in his room while she was providing care to his roommate. When CNA B saw Resident #1's nasal cannula ignite, she immediately notified RN F. Code Red (an intercom announcement indicating a fire or smoke emergency alerting staff to activate fire safety protocols) was activated and 911 was called for emergency transport to an acute care hospital for treatment. CNA B stated on 3/30/26 at 3:07 PM that she witnessed Resident #1 smoking in his room six times during the week of the event. She notified the DON but stated she did not collect the resident's smoking supplies due to his aggressive behavior. Staff were aware of Resident #1's unsafe behavior and safety needs but did not take necessary action to avoid actual harm to the resident.Facility Administration, while aware of a longstanding problem with residents who smoked not adhering to the facility's Smoking/Vaping policy, failed to ensure the implementation of that policy to prevent residents who smoked, particularly oxygen dependent smokers, from smoking in their rooms or possessing smoking materials. The Administration also failed to initiate a timely, effective, facility wide corrective action plan, following the 2/27/26 event, that addressed system failures regarding resident assessments for smoking risk, supervision practices and environmental safety controls. As a result, residents who smoked continued to retain cigarettes and lighters, smoked inside the facility (including in rooms of oxygen dependent residents), and smoked unsupervised in non designated areas, resulting Resident #1 sustaining a serious injury and leaving all residents at continued risk for serious injury, harm, impairment, or death.Immediate Jeopardy (IJ) at a scope and severity of L (widespread) was identified at 10:45 AM on 3/30/26.On 2/27/26, Immediate Jeopardy began.On 4/1/26 at 5:45 PM, the Administrator was notified of the IJ determination. IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on 4/1/26.The findings include:Cross reference F600, F609, F689, and F867During a facility tour on 3/30/26 at 9:58 AM, three residents were observed sitting in their wheelchairs inside the facility near the designated smoking area door waiting for staff to open the door for their scheduled smoking period at 10:00 AM. Certified Nursing Assistant (CNA) A, assigned to supervise the residents who smoked, opened the door leading to the designated smoking area (back porch) at 10:00 AM. CNA A did not provide the three residents with smoking materials; all three residents had cigarettes and lighters already in their possession. At 10:16 AM, all three residents left the designated smoking area and re-entered the facility without providing their smoking materials to CNA A for storage in the smoking area locked cart.Another tour of the facility on 3/30/26 at 10:45 AM revealed that the same three residents who had not relinquished their smoking materials to CNA A in the designated smoking area at 10:16 AM were assigned to rooms [ROOM NUMBERS]. room [ROOM NUMBER] (Residents #2 and #4) and room [ROOM NUMBER] (Resident #3) had Oxygen in Use/No Smoking signs posted on the door frames outside of the rooms.1.A review of Resident #1's medical record revealed that he was admitted to the facility on [DATE], was transferred to an acute care hospital on 2/27/26 and was re-admitted on [DATE]. His diagnoses included chronic obstructive pulmonary disease (COPD - constriction of the airways and difficulty breathing) with acute exacerbation (sudden, severe worsening); alcohol abuse; noncompliance with other medical treatment and regimen; difficulty in walking; dysphagia (difficulty swallowing); anxiety disorder and mood disorder.A nursing note authored by Registered Nurse (RN) E on 2/27/26 revealed that she heard Certified Nursing Assistant (CNA) B scream that Resident #1's oxygen tubing was on fire and entered the room to find the nasal cannula tubing burning, a cigarette on the floor, and smoke spreading throughout the room. The nurse paged a Code Red (an intercom announcement indicating a fire or smoke emergency alerting staff to activate fire safety protocols) and obtained a fire extinguisher while another staff member called 911. RN E then provided care to the resident.A Change in Condition form, completed by RN F on 2/27/26 at 10:35 PM, noted that Resident #1's oxygen tubing caught fire while he was smoking in his room, resulting in burns to his nose and right cheek with pain rated at a 4 on a scale of zero through 10 with 10 being the worst possible pain. He was documented with increased confusion, general weakness, dizziness, unsteadiness, and labored, rapid breathing. His oxygen saturation was 98% on room air, he was a full code, and primary care was notified on 2/27/26 at 10:42 PM with orders to send him to the emergency room. Emergency Medical Services (EMS)/911 was called, and family was notified.A review of the resident's active physician's orders revealed that on 2/28/26, a physician's order was placed to send the resident to the Emergency Department (ED) for evaluation and treatment.A review of the February 2026 medication administration record (MAR) and treatment administration record (TAR) revealed that Resident #1's oxygen was delivered continuously via nasal cannula at 2 LPM according to the nurses' documentation of task completion from 2/1/26 - 2/27/26. The MAR/TAR included documentation of Resident #1's hospital/ED (Emergency Department) transfer on 2/28/26 at 12:54 AM.A review of hospital records revealed that on 2/27/26, Resident #1, diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and receiving oxygen via a nasal cannula at the nursing home, lit a cigarette and sustained superficial partial thickness burns of his face with a concern for inhalation injury. He required intubation during transport for airway protection and was accepted by the trauma/burn team. On 2/28/26 at 4:59 AM, he was documented as intubated and sedated, with soot in the nares (nostrils) and oropharynx (throat), and superficial partial thickness burns to the bridge of the nose and right cheek. An interview was conducted with Resident #1 on 3/30/26 at 9:51 AM. He was observed lying in bed, awake, wearing his nasal cannula with oxygen flowing at 3 liters per minute (LPM). When he was asked about his 2/27/26 incident, he stated he smoked a cigarette in his room while wearing oxygen via nasal cannula, the cannula ignited, and he sustained burns to his face that required emergent transport to the hospital. When asked if he had been educated about the facility's smoking policy prior to the event, he stated he had received education, but he was a 72 year old man and would smoke whenever he wanted to. When asked whether he kept his cigarettes and lighter in his room or provided them to the certified nursing assistant (CNA) supervising smokers in the designated smoking area, he stated he did not give his supplies to staff but always kept all of his smoking materials with him. When asked if he had smoked in his room prior to the 2/27/26 incident, he stated he had previously smoked in the bathroom of his room (room [ROOM NUMBER]), and in room [ROOM NUMBER]. When asked if nursing staff rounded frequently to check on/supervise the residents in his room, he stated he barely saw anyone come into his room prior to the incident. When asked if he continued to smoke after the 2/27/26 incident, he stated he quit smoking after that event. When he was asked how he obtained his cigarettes and lighters, he stated he would ask other residents to purchase cigarettes and lighters for him or have a personal friend bring them to him. When asked if he informed staff that he had cigarettes and a lighter on his person, he stated he never did. When asked if he knew he was violating the facility's policy, he stated he was aware but did not care. When asked if staff had requested that he relinquish his smoking supplies to them for proper storage, he stated he never gave them anything.Further review of Resident #1's medical record revealed the following nursing notes:A nursing note dated 9/25/24 at 2:24 PM revealed that Resident #1 was observed smoking cigarettes in his room while connected to his oxygen concentrator. The nurse provided education and informed the resident that smoking in the room, especially while on oxygen, was prohibited and posed a serious safety risk to him and other residents. The nurse then contacted law enforcement to assist with the situation. There was no documented evidence verifying that the nurse requested that the resident relinquish his smoking materials or that she confiscated them.A nursing behavior note dated 9/25/24 at 2:59 PM revealed that the writer noticed a smell of cigarette smoke. She went inside Resident #1's room and found him smoking with his nasal cannula on and oxygen flowing. Resident #1 was asked to extinguish his cigarette, and he put it into a beer can between his feet. Seven beer cans were also found in a trash bag under his bedside table. When staff requested that he relinquish his cigarettes and beer, he refused, became belligerent, and insisted he paid for them. The unit manager and the Director of Nursing (DON) were notified, and law enforcement was called. When law enforcement arrived, the resident denied smoking in the building, stated he did not care about others' safety, and insisted he would keep his cigarettes. He ultimately surrendered five cigarettes from a carton to the officer, who gave them to the nurse and indicated it was a civil matter, advising the unit manager to review the facility's smoking policy and consider discharge options. The DON was briefed on the situation.A nursing note dated 10/19/25 at 3:00 PM revealed that the nurse observed Resident #1 smoking in his room with his oxygen turned off. The nurse noted that education was provided and the DON was notified. The nurse documented the failed attempt to confiscate the resident's smoking materials due to his refusal.A review of Resident #1's active care plans revealed a care plan dated 11/7/23 with a focus area for a risk for complications with respiratory status related to COPD and a requirement for the use of oxygen. The goal was that the resident would display optimal breathing patterns daily through the next review date. The interventions did not include oxygen therapy safety interventions.Resident #1 was care-planned on 10/8/24 with the following focus areas:Behaviors and smoking inside the building with a goal to decrease risk factors of harming himself or others secondary to his behaviors through the next 30 days.He was care-planned for smoking. The goal was that he would not smoke without supervision through the review date. Interventions included notification of the nurse immediately if it was suspected that Resident #1 was violating the smoking policy; The resident required supervision while smoking; The resident was to be educated about the facility's smoking policy and the dangers of smoking in his room. The most recent revision of the interventions was completed on 2/26/25.A review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. He was documented as independent with activities of daily living (ADLs).A review of the resident's medical record revealed that on 3/25/26, Resident #1 saw his primary care provider (PCP) for a follow-up after his hospital discharge. The PCP's notes indicated that Resident #1 presented to the hospital on 2/27/26 for respiratory failure, facial and inhalation burns. Her notes also indicated that Resident #1 was intubated and admitted to the ICU (Intensive Care Unit). 2. On 3/30/26 at 10:00 AM, Resident #2 was observed entering the designated smoking area. Resident #2 did not obtain cigarettes or a lighter from the CNA supervising residents in the smoking area. He agreed to an interview at 10:02 AM. When asked if he received his cigarettes and lighter from the CNA, he stated he always kept his cigarettes and lighter on his person. He removed a pack of cigarettes and a lighter from his left front pants pocket and placed them on the table. When asked if he had received education or information about the facility's rules regarding smoking/smoking safety, he stated he had but he was afraid the staff would steal his cigarettes and lighter if he let them store the smoking supplies. When asked how he obtained his supplies, he stated when he went out on a leave of absence (LOA), he purchased cigarettes and lighters and kept them. He said he intentionally did not disclose to staff that he was in possession of cigarettes and a lighter when he returned from LOA. When he was asked how long he had been keeping smoking supplies on his person, he stated he had done so since he was admitted to the facility. When he was asked if he was oxygen dependent, he stated he wore oxygen mostly at night and as needed; he did not wear it all the time. Resident #2 said that on 2/27/26 at approximately 9:30 PM to 10:00 PM, Resident #1 was smoking in his room when Resident #1's oxygen ignited and burned his face. Resident #2 stated Resident #1 constantly smoked in his room, including in the bathroom, while wearing his oxygen. Resident #2 further stated he was also a smoker who depended on oxygen therapy and that he had previously smoked inside his own room, but that he did not use his oxygen when he went into the bathroom to smoke. He stated he maintained all of his smoking supplies, including cigarettes and lighters, with him at all times. When asked why he did not provide his smoking supplies to the CNA supervising smokers in the designated smoking area today, he stated he was afraid staff would steal them. He said he was familiar with the facility's smoking policy and acknowledged that he knew he was in violation of the policy. He stated the nurses and CNAs sometimes checked on him every few hours, but on most days, he did not see them at all. He said he was able to leave the facility independently and went to the corner store to purchase cigarettes and lighters when he ran out. When he was asked if staff had requested that he surrender his smoking supplies to them for proper storage, he stated they had, but he would not give them his cigarettes or lighter because they will steal them.On 3/30/26 at 10:16 AM, Resident #2 was observed going back inside the facility without providing his smoking materials to the CNA for storage in the designated smoking area locked cart.A review of Resident #2's medical record revealed he was admitted to the facility on [DATE] with diagnoses including COPD with acute exacerbation, wheezing, and alcohol abuse.A review of the resident's Quarterly MDS assessment, dated 3/30/26, revealed that Resident #2 had a BIMS score of 15 out of 15 possible points, indicating intact cognition. He was documented as independent with ADLs.A review of Resident #2's active physician's orders revealed an order dated 5/14/24 for Oxygen at 2L (two liters per minute) per nasal cannula as needed.A review of the resident's active care plans revealed the following focus areas:[Resident #2] prefers to smoke. The care plan was initiated on 10/17/23 with revisions on 7/1/25 and 3/30/26. The goal was to remain a safe smoker through the next review date on 4/8/26. A second goal of review smoking policy with resident was initiated on 3/30/26 with a target date of 4/8/26. The second goal was set after the survey began. Interventions initiated on 10/17/23 included encouraging the resident to follow safe smoking guidelines; to explain the smoking policy to the resident; to keep smoking products in a locked cart, and to notify the charge nurse immediately if it was suspected that the resident had violated the facility's smoking policy. None of these interventions had been revised since 10/17/23. On 3/30/26, a new intervention was initiated (after the surveyor's arrival): review smoking policy, educate not to smoke in the room. Under the care plan interventions on three occasions (10/4/24, 10/7/25 and 3/29/26), the following was noted, Resident given a smoking policy reminder and re-educated regarding not smoking inside the building. Under the intervention dated 10/4/24, initiation and revision dates were also documented as 3/31/26. [Resident #2] is/has the potential to be physically aggressive towards others and is known to refuse daily care r/t (related to) poor impulse control. The care plan was initiated on 11/11/23 with a goal that he will not harm self or others through the review date.Resident #2 was also care planned for his use of oxygen therapy related to a diagnosis of COPD (initiated 11/21/23) and impaired vision (initiated 7/12/24). A review of Resident #2's progress notes from 9/19/24 through 3/31/26 revealed no documented evidence of the resident's noncompliance with the facility's smoking policy.A review of Resident #2's Smoking Evaluations, dated 7/10/23, 10/17/23, 2/17/24, 3/2/26, and 3/30/26, revealed that Resident #2 was deemed a safe smoker and did not require supervision. According to the facility's policy, smoking evaluations were to be conducted upon admission, quarterly, annually, and if there was significant change in the resident's condition. Resident #2 signed his smoking agreement on 1/16/2025. 3. On 3/30/26 at 10:00 AM, Resident #3 was observed entering the designated smoking area. She did not obtain cigarettes or a lighter from the CNA supervising residents in the smoking area. Resident #3 agreed to an interview at 10:08 AM. She stated she was oxygen dependent and she smoked but she emphasized that she did not smoke while wearing her oxygen or inside her room. The smoking porch was the only place she went to smoke. When asked if she received her cigarettes and lighter from the CNA, she stated she did not and that she kept her cigarettes and lighter in her black purse. She further stated she did not give her smoking supplies to staff because she did not trust them and was afraid someone would steal her cigarettes or lighter. She stated she had been educated about smoking safety and was aware of the facility's smoking policy. She knew she was not supposed to keep cigarettes and a lighter on her person but continued to do so due to fear of theft, stating, I am [AGE] years old. If I want to keep my cigarettes and lighter in my purse, I will. She stated she had kept cigarettes and a lighter on her person for as long as she could remember. She obtained them when she went out on LOA with her family, and did not inform staff that she had cigarettes and a lighter when she returned from LOA. She stated she used oxygen when needed at night and had not and would not smoke in her room or while wearing oxygen. She stated she knew that Residents #1 and #2 had been caught smoking many times in the past and that they used to talk about smoking in their rooms while in the designated smoking area. She stated nursing staff usually took a long time to come to her room and would typically come into her room only two to three times a day while she was awake. She said that although the facility had provided education and reminders not to smoke inside, residents continued to smoke inside every day. She stated staff had requested that she relinquish her smoking supplies to them for proper storage, but she has always refused. During the interview Resident #3 removed one pack of cigarettes and a lighter from her black purse. At the conclusion of the interview, Resident #3 placed the pack of cigarettes and lighter back into her black purse and entered the facility at 10:16 AM without providing her smoking supplies to the supervising CNA. She then entered her room (room [ROOM NUMBER]) with the cigarettes and lighter still in her possession.A review of Resident #3's medical record revealed that she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including COPD, chronic diastolic (congestive) heart failure (CHF - the heart does not pump blood efficiently, leading to fatigue, fluid buildup in the lungs/tissues and shortness of breath), shortness of breath, and nicotine dependence.A review of the resident's Quarterly MDS assessment, dated 3/19/26, revealed that Resident #3 had a BIMS score of 13 out of 15 possible points, indicating intact cognition. She was documented as independent with some ADLs, but she required partial to substantial assistance with dressing, toileting, personal hygiene, and wheelchair mobility.A review of Resident #3's medical record revealed an active physician's order, dated 11/14/23, for Oxygen at 2 liters via nasal cannula - as needed for shortness of breath.A review of Resident #3's active care plan revealed the following focus areas:Resident #3 had a care plan focus area for smoking that was initiated on 4/18/23 with the goal that she would not suffer injury from unsafe smoking practice through the next review date. Interventions initiated on 4/18/23 included: Instruct resident about smoking risks and hazards and about smoking cessation aids that are available; instruct resident about the facility policy on smoking: locations, times, safety concerns; monitor oral hygiene and notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Interventions initiated on 4/17/24 included: Assist with removing O2 (oxygen) during smoking times prn (as needed) and observe clothing and skin for signs of cigarette burns. On 3/31/26, after the start of the survey, a new intervention was added: Resident will sign a smoking agreement upon admission, which remains in effect throughout the stay. Upon any smoking-related infraction, the resident will be re-educated on the established smoking agreement/policy and safety expectations. A formal warning will be issued, documented, and reviewed with the resident, with acknowledgement obtained when possible. Continued noncompliance will result in progressive warnings in accordance with facility policy, up to and including initiation of the discharge process.Further review of the resident's care plans revealed that she was care planned for impaired vision (initiated on 10/13/23), noncompliance with care (initiated on 1/19/26), and use of oxygen therapy (initiated on 6/15/24)related to a diagnosis of COPD.A review of Resident #3's progress notes from 9/19/24 through 3/31/26 revealed no documented evidence of the resident's noncompliance with the facility's smoking policy.A review of the scanned documents in the resident's electronic medical record revealed that Resident #3 had not been issued any Smoking Notices for non-compliance with the facility's smoking policy.A review of Resident #3's Smoking Evaluations dated 10/17/23, 2/18/24 and 3/2/26 revealed the following: On 10/17/23, Resident #3 was deemed a safe smoker who did not require supervision. On 2/18/24, the evaluation's Summary of Evaluation indicated that the resident was a safe smoker, but it did not specify whether or not she required supervision (not answered in the assessment). The smoking evaluation dated 3/2/26 revealed in the Summary of Evaluation that Resident #3 was deemed a safe smoker, but she required supervision. The Quarterly Review section of the same evaluation dated 3/2/26 revealed that the resident was a safe smoker and did not require supervision while smoking. Per the facility's policy, smoking evaluations were to be conducted upon admission, quarterly, annually, and if there was significant change in condition. Resident #3 signed her smoking contract on 2/20/2025. 4. On 3/30/26 at 10:00 AM, Resident #4 was observed entering the designated smoking area. He did not obtain cigarettes or a lighter from the CNA supervising residents in the smoking area. He did not agree to an interview in the designated smoking area but stated he would agree to an interview after he finished smoking.On 3/30/26 at 10:16 AM, Resident #4 went back inside the facility without providing his smoking materials to the CNA for storage in the designated smoking area locked cart.During an interview with Resident #4 on 3/30/26 at 11:49 AM in his room, he stated he was Resident #1's roommate at the time Resident #1 sustained facial burns during a smoking accident at night. He stated Resident #1 smoked in the room multiple times a day while wearing oxygen. He further stated both Resident #1 and Resident #2 smoked in the bathroom and that Resident #2 did not wear his oxygen when smoking but Resident #1 always smoked while wearing his oxygen. Resident #4 stated he was also a smoker but did not use oxygen. He stated he kept his cigarettes and lighter on his person and produced two packs of cigarettes from his left pants pocket and a lighter from his right pants pocket. (photographic evidence obtained) Resident #4 stated the nursing staff were delayed in rounding and typically came into the room once in the early morning, once at lunchtime, and once again at dinner. He said he barely saw nursing staff come into the room to check on residents. He said the facility had educated residents about the smoking policy, but that most of the residents who smoked did not listen to or follow the policy. When asked why he kept his cigarettes and lighter on his person instead of providing them to the CNA supervising smokers in the designated smoking area, Resident #4 stated, Just like everyone else, we don't want people stealing our stuff. Resident #4 stated he knew he was not supposed to keep cigarettes and lighters in his room and he acknowledged that he was in violation of the facility's smoking policy. When asked if staff had requested that he surrender his smoking supplies to them for proper storage, he stated they had asked him a few times, but he refused. Resident #4 declined to continue with the interview, stating he wanted to go outside to smoke again. The interview was concluded.A review of Resident #4's medical record revealed an admission date of 7/25/25 with diagnoses including anxiety disorder, major depressive disorder and schizoaffective disorder. Further review of the record revealed that Resident #4 was a current smoker and was not oxygen dependent.Resident #4 was the former roommate of Resident #1, an oxygen-dependent resident who smoked until 2/27/26, and was the current roommate of Resident #2, an oxygen-dependent resident who smoked.The resident's Quarterly MDS assessment, dated 1/28/26, revealed a BIMS score of 15 out of 15 possible points, indicating intact cognition. He was documented as independent with ADLs.A review of Resident #4's active care plan revealed the following focus areas:Resident prefers to smoke. (initiated on 3/2/26 after the 2/27/26 incident involving Resident #1) The goal was that he would safely smoke in the designated smoking area at designated smoking times through the next review date. Interventions initiated on 3/2/26 included Explain smoking policy to resident. Keep smoking products in locked cart. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. An intervention initiated on 3/31/26 (after the start of the survey) read: Resident will sign a smoking agreement upon admission, which remains in effect throughout the stay. Upon any smoking-related infraction, the resident will be re-educated on the established smoking agreement/policy and safety expectations. A formal warning will be issued, documented, and reviewed with the resident, with acknowledgement obtained when possible. Continued noncompliance will result in progressive warnings in accordance with facility policy, up to and including initiation of the discharge process. Another focus area for Resident #4 was for antipsychotic therapy for a diagnosis of psychosis (initiated on 7/27/25).A review of Resident #4's active physician's orders revealed an order dated 9/5/25 for May go LOA (leave of absence) and to therapeutic visits (including facility events) with responsible party and medications.A review of Resident #4's progress notes from 9/19/24 through 3/31/26 revealed no documented evidence of the resident's noncompliance with the facility's smoking policy.A review of the scanned documents in the resident's electronic medical record revealed that Resident #4 was not issued any Smoking Notices for non-compliance with the facility's smoking policy.A review of Resident #4's Smoking Evaluation, dated 3/2/26, revealed that Resident #4 was deemed a safe smoker and did not require supervision. Resident #4 was admitted on [DATE] and his first smoking evaluation was not completed until 3/2/26, after the 2 27/26 incident involving Resident #1. Per the facility's policy, smoking evaluations were to be conducted upon admission, quarterly, annually, and if there was a significant change in condition. Resident #4 signed the facility's smoking agreement on 7/25/25. On 3/30/26 at 10:35 AM, an interview was conducted with Certified Nursing Assistant (CNA) A. CNA A stated the CNAs routinely supervised the designated smoking area and were expected to issue and collect residents' smoking supplies and monitor their safety. CNA A stated most residents who were smokers refused to relinquish their cigarettes and lighters and kept them on their person or in their rooms. CNA A stated she notified the nurse, Assistant Director of Nursing (ADON) or DON when residents refused to surrender their smoking supplies, but nothing happens, and that both the Administrator and DON had long been aware that residents retained smoking materials without enacting effective corrective action. CNA A stated staff training on the smoking policy and oxygen safety was limited to folders left at the nurses' station with a sign in sheet. No formal, in person instruction or confirmation of understanding was completed. She stated residents were only periodically reminded in resident council not to smoke inside or keep supplies in their rooms or on their person, with no changes made to the facility's policy or practice despite ongoing noncompliance. CNA A stated Resident #1 burned his face in February (2026) after repeatedly smoking in his room while on oxygen and that staff, the Administrator and the DON all knew he had been smoking in his room for a long time. CNA A also stated Resident #2, Resident #1's oxygen dependent roommate, also smoked in his room. CNA A stated she personally saw both Residents #1 and #2 smoking in their room during the week of and the week before the burn incident. CNA A confirmed that both residents kept their smoking supplies in their room and stated she did not attempt to confiscate the supplies because of their history of aggression. CNA A stated instead, the facility's leadership was informed of their behaviors without knowing whether any follow up action was taken. When asked why she did not notify the nursing/management staff immediately after Residents #2, #3 and #4 returned inside with their smoking supplies this morning, she replied t

Based on a review of facility and resident records, resident and staff interviews, and a review of the facility policy titled Smoking/Vaping, the facility failed to ensure residents received adequate supervision and sufficient safeguards to prevent avoidable accidents, by failing to ensure that CNAs A, B, D, RN E and the DON implemented the facility's Smoking/Vaping policy to prevent four oxygen dependent residents (#1, #2, #3 and #4) out of four residents reviewed for smoking, from storing cigarettes and lighters in their rooms, and to prevent two oxygen-dependent residents (#1 and #2) from smoking in their rooms while oxygen was in use. This failure resulted in Resident #1 sustaining second-degree facial burns and respiratory distress after his nasal cannula ignited while he smoked in his room, requiring emergency transfer to a local acute care hospital and subsequent transfer to a burn unit for treatment.Resident #1 was identified on 9/25/24 as unsafely smoking in his room while receiving oxygen. Two nursing notes on 9/25/24, and notes dated 9/5/25, 10/19/25 and 2/27/26 revealed that Resident #1 was found smoking in his room. On 2/27/26, Registered Nurse (RN) E observed Resident #1 smoking in his bathroom at 12:00 PM. She did not retrieve his cigarettes or lighter but notified the Director of Nursing (DON). On 2/27/26 at 10:24 PM, Certified Nursing Assistant (CNA) B observed Resident #1 smoking in his room while she was providing care to his roommate. When CNA B saw Resident #1's nasal cannula ignite, she immediately notified RN F. Code Red (an intercom announcement indicating a fire or smoke emergency alerting staff to activate fire safety protocols) was activated and 911 was called for emergency transport to an acute care hospital for treatment. CNA B stated on 3/30/26 at 3:07 PM that she witnessed Resident #1 smoking in his room six times during the week of the event. She notified the DON but stated she did not collect the resident's smoking supplies due to his aggressive behavior. Staff were aware of Resident #1's unsafe behavior and safety needs but did not take necessary action to avoid actual harm to the resident.The facility failed to effectively implement its Smoking/Vaping policy to prevent residents who smoked, particularly oxygen dependent smokers, from smoking in their rooms or possessing smoking materials. As a result, residents who smoked continued to retain cigarettes and lighters, smoked inside the facility (including in rooms of oxygen dependent residents), and smoked unsupervised in non designated areas, leaving all residents at continued risk for serious injury, harm, impairment, or death.Immediate Jeopardy (IJ) at a scope and severity of K (pattern) was identified at 10:45 AM on 3/30/26.On 2/27/26, Immediate Jeopardy began.On 4/1/26 at 5:45 PM, the Administrator was notified of the IJ determination. IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on 4/1/26.The findings include:Cross reference F600, F835, and F867During a facility tour on 3/30/26 at 9:58 AM, three residents were observed sitting in their wheelchairs inside the facility near the designated smoking area door waiting for staff to open the door for their scheduled smoking period at 10:00 AM. Certified Nursing Assistant (CNA) A, assigned to supervise the residents who smoked, opened the door leading to the designated smoking area (back porch) at 10:00 AM. CNA A did not provide the three residents with smoking materials; all three residents had cigarettes and lighters already in their possession. At 10:16 AM, all three residents left the designated smoking area and re-entered the facility without providing their smoking materials to CNA A for storage in the smoking area locked cart.Another tour of the facility on 3/30/26 at 10:45 AM revealed that the same three residents who had not relinquished their smoking materials to CNA A in the designated smoking area at 10:16 AM were assigned to rooms [ROOM NUMBERS]. room [ROOM NUMBER] (Residents #2 and #4) and room [ROOM NUMBER] (Resident #3) had Oxygen in Use/No Smoking signs posted on the door frames outside of the rooms.1.A review of Resident #1's medical record revealed that he was admitted to the facility on [DATE], was transferred to an acute care hospital on 2/27/26 and was re-admitted on [DATE]. His diagnoses included chronic obstructive pulmonary disease (COPD - constriction of the airways and difficulty breathing) with acute exacerbation (sudden, severe worsening); alcohol abuse; noncompliance with other medical treatment and regimen; difficulty in walking; dysphagia (difficulty swallowing); anxiety disorder and mood disorder.A nursing note authored by Registered Nurse (RN) E on 2/27/26 revealed that she heard Certified Nursing Assistant (CNA) B scream that Resident #1's oxygen tubing was on fire and entered the room to find the nasal cannula tubing burning, a cigarette on the floor, and smoke spreading throughout the room. The nurse paged a Code Red (an intercom announcement indicating a fire or smoke emergency alerting staff to activate fire safety protocols) and obtained a fire extinguisher while another staff member called 911. RN E then provided care to the resident.A Change in Condition form, completed by RN F on 2/27/26 at 10:35 PM, noted that Resident #1's oxygen tubing caught fire while he was smoking in his room, resulting in burns to his nose and right cheek with pain rated at a 4 on a scale of zero through 10 with 10 being the worst possible pain. He was documented with increased confusion, general weakness, dizziness, unsteadiness, and labored, rapid breathing. His oxygen saturation was 98% on room air, he was a full code, and primary care was notified on 2/27/26 at 10:42 PM with orders to send him to the emergency room. Emergency Medical Services (EMS)/911 was called, and family was notified.A review of the resident's active physician's orders revealed that on 2/28/26, a physician's order was placed to send the resident to the Emergency Department (ED) for evaluation and treatment.A review of the February 2026 medication administration record (MAR) and treatment administration record (TAR) revealed that Resident #1's oxygen was delivered continuously via nasal cannula at 2 LPM according to the nurses' documentation of task completion from 2/1/26 - 2/27/26. The MAR/TAR included documentation of Resident #1's hospital/ED (Emergency Department) transfer on 2/28/26 at 12:54 AM.A review of hospital records revealed that on 2/27/26, Resident #1, diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and receiving oxygen via a nasal cannula at the nursing home, lit a cigarette and sustained superficial partial thickness burns of his face with a concern for inhalation injury. He required intubation during transport for airway protection and was accepted by the trauma/burn team. On 2/28/26 at 4:59 AM, he was documented as intubated and sedated, with soot in the nares and oropharynx, and superficial partial thickness burns to the bridge of the nose and right cheek. An interview was conducted with Resident #1 on 3/30/26 at 9:51 AM. He was observed lying in bed, awake, wearing his nasal cannula with oxygen flowing at 3 liters per minute (LPM). When he was asked about his 2/27/26 incident, he stated he smoked a cigarette in his room while wearing oxygen via nasal cannula, the cannula ignited, and he sustained burns to his face that required emergent transport to the hospital. When asked if he had been educated about the facility's smoking policy prior to the event, he stated he had received education, but he was a 72 year old man and would smoke whenever he wanted to. When asked whether he kept his cigarettes and lighter in his room or provided them to the certified nursing assistant (CNA) supervising smokers in the designated smoking area, he stated he did not give his supplies to staff but always kept all his smoking materials with him. When asked if he had smoked in his room prior to the 2/27/26 incident, he stated he had previously smoked in the bathroom of his room (room [ROOM NUMBER]), and in room [ROOM NUMBER]. When asked if nursing staff rounded frequently to check on/supervise the residents in his room, he stated he barely saw anyone come into his room prior to the incident. When asked if he continued to smoke after the 2/27/26 incident, he stated he quit smoking after that event. When he was asked how he obtained his cigarettes and lighters, he stated he would ask other residents to purchase cigarettes and lighters for him or have a personal friend bring them to him. When asked if he informed staff that he had cigarettes and a lighter on his person, he stated he never did. When asked if he knew he was violating the facility's policy, he stated he was aware but did not care. When asked if staff had requested that he relinquish his smoking supplies to them for proper storage, he stated he never gave them anything.A review of Resident #1's active care plans revealed a care plan dated 11/7/23 with a focus area for a risk for complications with respiratory status related to COPD and a requirement for the use of oxygen. The goal was that the resident would display optimal breathing patterns daily through the next review date. The interventions did not include oxygen therapy safety interventions.Resident #1 was care-planned on 10/8/24 with the following focus areas:Behaviors and smoking inside the building with a goal to decrease risk factors of harming himself or others secondary to his behaviors through the next 30 days.He was care-planned for smoking. The goal was that he would not smoke without supervision through the review date. Interventions included notification of the nurse immediately if it was suspected that Resident #1 was violating the smoking policy; The resident required supervision while smoking; The resident was to be educated about the facility's smoking policy and the dangers of smoking in his room. The most recent revision of the interventions was completed on 2/26/25.A review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. He was documented as independent with activities of daily living (ADLs).2. On 3/30/26 at 10:00 AM, Resident #2 was observed entering the designated smoking area. Resident #2 did not obtain cigarettes or a lighter from the CNA supervising residents in the smoking area. He agreed to an interview at 10:02 AM. When asked if he received his cigarettes and lighter from the CNA, he stated he always kept his cigarettes and lighter on his person. He removed a pack of cigarettes and a lighter from his left front pants pocket and placed them on the table. When asked if he had received education or information about the facility's rules regarding smoking/smoking safety, he stated he had but he was afraid the staff would steal his cigarettes and lighter if he let them store the smoking supplies. When asked how he obtained his supplies, he stated when he went out on a leave of absence (LOA), he purchased cigarettes and lighters and kept them. He said he intentionally did not disclose to staff that he was in possession of cigarettes and a lighter when he returned from LOA. When he was asked how long he had been keeping smoking supplies on his person, he stated he had done so since he was admitted to the facility. When he was asked if he was oxygen dependent, he stated he wore oxygen mostly at night and as needed; he did not wear it all the time. Resident #2 said that on 2/27/26 at approximately 9:30 PM to 10:00 PM, Resident #1 was smoking in his room when Resident #1's oxygen ignited and burned his face. Resident #2 stated Resident #1 constantly smoked in his room, including in the bathroom, while wearing his oxygen. Resident #2 further stated he was also a smoker who depended on oxygen therapy and that he had previously smoked inside his own room, but that he did not use his oxygen when he went into the bathroom to smoke. He stated he maintained all of his smoking supplies, including cigarettes and lighters, with him at all times. When asked why he did not provide his smoking supplies to the CNA supervising smokers in the designated smoking area today, he stated he was afraid staff would steal them. He said he was familiar with the facility's smoking policy and acknowledged that he knew he was in violation of the policy. He stated the nurses and CNAs sometimes checked on him every few hours, but on most days, he did not see them at all. He said he was able to leave the facility independently and went to the corner store to purchase cigarettes and lighters when he ran out. When he was asked if staff had requested that he surrender his smoking supplies to them for proper storage, he stated they had, but he would not give them his cigarettes or lighter because they will steal them.On 3/30/26 at 10:16 AM, Resident #2 was observed going back inside the facility without providing his smoking materials to the CNA for storage in the designated smoking area locked cart.A review of Resident #2's medical record revealed he was admitted to the facility on [DATE] with diagnoses including COPD with acute exacerbation, wheezing, and alcohol abuse.A review of the resident's Quarterly MDS assessment, dated 3/30/26, revealed that Resident #2 had a BIMS score of 15 out of 15 possible points, indicating intact cognition. He was documented as independent with ADLs.A review of Resident #2's active physician's orders revealed an order dated 5/14/24 for Oxygen at 2L (two liters per minute) per nasal cannula as needed.A review of the resident's active care plans revealed the following focus areas:[Resident #2] prefers to smoke. The care plan was initiated on 10/17/23 with revisions on 7/1/25 and 3/30/26. The goal was to remain a safe smoker through the next review date on 4/8/26. A second goal of review smoking policy with resident was initiated on 3/30/26 with a target date of 4/8/26. The second goal was set after the survey began. Interventions initiated on 10/17/23 included encouraging the resident to follow safe smoking guidelines; to explain the smoking policy to the resident; to keep smoking products in a locked cart, and to notify the charge nurse immediately if it was suspected that the resident had violated the facility's smoking policy. None of these interventions had been revised since 10/17/23. On 3/30/26, a new intervention was initiated (after the surveyor's arrival): review smoking policy, educate not to smoke in the room. Under the care plan interventions on three occasions (10/4/24, 10/7/25 and 3/29/26), the following was noted, Resident given a smoking policy reminder and re-educated regarding not smoking inside the building. Under the intervention dated 10/4/24, initiation and revision dates were also documented as 3/31/26. [Resident #2] is/has the potential to be physically aggressive towards others and is known to refuse daily care r/t (related to) poor impulse control. The care plan was initiated on 11/11/23 with a goal that he will not harm self or others through the review date.Resident #2 was care planned for his use of oxygen therapy related to a diagnosis of COPD (initiated 11/21/23) and impaired vision (initiated 7/12/24). A review of Resident #2's progress notes from 9/19/24 through 3/31/26 revealed no documented evidence of the resident's noncompliance with the facility's smoking policy.A review of Resident #2's Smoking Evaluations, dated 7/10/23, 10/17/23, 2/17/24, 3/2/26, and 3/30/26, revealed that Resident #2 was deemed a safe smoker and did not require supervision. According to the facility's policy, smoking evaluations were to be conducted upon admission, quarterly, annually, and if there was significant change in the resident's condition. Resident #2 signed his smoking agreement on 1/16/2025. 3. On 3/30/26 at 10:00 AM, Resident #3 was observed entering the designated smoking area. She did not obtain cigarettes or a lighter from the CNA supervising residents in the smoking area. Resident #3 agreed to an interview at 10:08 AM. She stated she was oxygen dependent and she smoked but she emphasized that she did not smoke while wearing her oxygen or inside her room. The smoking porch was the only place she went to smoke. When asked if she received her cigarettes and lighter from the CNA, she stated she did not and that she kept her cigarettes and lighter in her black purse. She further stated she did not give her smoking supplies to staff because she did not trust them and was afraid someone would steal her cigarettes or lighter. She stated she had been educated about smoking safety and was aware of the facility's smoking policy. She knew she was not supposed to keep cigarettes and a lighter on her person but continued to do so due to fear of theft, stating, I am [AGE] years old. If I want to keep my cigarettes and lighter in my purse, I will. She stated she had kept cigarettes and a lighter on her person for as long as she could remember. She obtained them when she went out on LOA with her family, and did not inform staff that she had cigarettes and a lighter when she returned from LOA. She stated she used oxygen when needed at night and had not and would not smoke in her room or while wearing oxygen. She stated she knew that Residents #1 and #2 had been caught smoking many times in the past and that they used to talk about smoking in their rooms while in the designated smoking area. She stated nursing staff usually took a long time to come to her room and would typically come into her room only two to three times a day while she was awake. She said that although the facility had provided education and reminders not to smoke inside, residents continued to smoke inside every day. She stated staff had requested that she relinquish her smoking supplies to them for proper storage, but she has always refused. During the interview Resident #3 removed one pack of cigarettes and a lighter from her black purse. At the conclusion of the interview, Resident #3 placed the pack of cigarettes and lighter back into her black purse and entered the facility at 10:16 AM without providing her smoking supplies to the supervising CNA. She then entered her room (room [ROOM NUMBER]) with the cigarettes and lighter still in her possession.A review of Resident #3's medical record revealed that she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including COPD, chronic diastolic (congestive) heart failure (CHF - the heart does not pump blood efficiently, leading to fatigue, fluid buildup in the lungs/tissues and shortness of breath), shortness of breath, and nicotine dependence.A review of the resident's Quarterly MDS assessment, dated 3/19/26, revealed that Resident #3 had a BIMS score of 13 out of 15 possible points, indicating intact cognition. She was documented as independent with some ADLs, but she required partial to substantial assistance with dressing, toileting, personal hygiene, and wheelchair mobility.A review of Resident #3's medical record revealed an active physician's order, dated 11/14/23, for Oxygen at 2 liters via nasal cannula - as needed for shortness of breath.A review of Resident #3's active care plan revealed the following focus areas:Resident #3 had a care plan focus area for smoking that was initiated on 4/18/23 with the goal that she would not suffer injury from unsafe smoking practice through the next review date. Interventions initiated on 4/18/23 included: Instruct resident about smoking risks and hazards and about smoking cessation aids that are available; instruct resident about the facility policy on smoking: locations, times, safety concerns; monitor oral hygiene and notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Interventions initiated on 4/17/24 included: Assist with removing O2 (oxygen) during smoking times prn (as needed) and observe clothing and skin for signs of cigarette burns. On 3/31/26, after the start of the survey, a new intervention was added: Resident will sign a smoking agreement upon admission, which remains in effect throughout the stay. Upon any smoking-related infraction, the resident will be re-educated on the established smoking agreement/policy and safety expectations. A formal warning will be issued, documented, and reviewed with the resident, with acknowledgement obtained when possible. Continued noncompliance will result in progressive warnings in accordance with facility policy, up to and including initiation of the discharge process.Further review of the resident's care plans revealed that she was care planned for impaired vision (initiated on 10/13/23), noncompliance with care (initiated on 1/19/26), and use of oxygen therapy (initiated on 6/15/24)related to a diagnosis of COPD.A review of Resident #3's progress notes from 9/19/24 through 3/31/26 revealed no documented evidence of the resident's noncompliance with the facility's smoking policy.A review of the scanned documents in the resident's electronic medical record revealed that Resident #3 had not been issued any Smoking Notices for non-compliance with the facility's smoking policy.A review of Resident #3's Smoking Evaluations dated 10/17/23, 2/18/24 and 3/2/26 revealed the following: On 10/17/23, Resident #3 was deemed a safe smoker who did not require supervision. On 2/18/24, the evaluation's Summary of Evaluation indicated that the resident was a safe smoker, but it did not specify whether or not she required supervision (not answered in the assessment). The smoking evaluation dated 3/2/26 revealed in the Summary of Evaluation that Resident #3 was deemed a safe smoker, but she required supervision. The Quarterly Review section of the same evaluation dated 3/2/26 revealed that the resident was a safe smoker and did not require supervision while smoking. Per the facility's policy, smoking evaluations were to be conducted upon admission, quarterly, annually, and if there was significant change in condition. Resident #3 signed her smoking contract on 2/20/2025. 4. On 3/30/26 at 10:00 AM, Resident #4 was observed entering the designated smoking area. He did not obtain cigarettes or a lighter from the CNA supervising residents in the smoking area. He did not agree to an interview in the designated smoking area but stated he would agree to an interview after he finished smoking.On 3/30/26 at 10:16 AM, Resident #4 went back inside the facility without providing his smoking materials to the CNA for storage in the designated smoking area locked cart.During an interview with Resident #4 on 3/30/26 at 11:49 AM in his room, he stated he was Resident #1's roommate at the time Resident #1 sustained facial burns during a smoking accident at night. He stated Resident #1 smoked in the room multiple times a day while wearing oxygen. He further stated both Resident #1 and Resident #2 smoked in the bathroom and that Resident #2 did not wear his oxygen when smoking but Resident #1 always smoked while wearing his oxygen. Resident #4 stated he was also a smoker but did not use oxygen. He stated he kept his cigarettes and lighter on his person and produced two packs of cigarettes from his left pants pocket and a lighter from his right pants pocket. (photographic evidence obtained) Resident #4 stated the nursing staff were delayed in rounding and typically came into the room once in the early morning, once at lunchtime, and once again at dinner. He said he barely saw nursing staff come into the room to check on residents. He said the facility had educated residents about the smoking policy, but that most of the residents who smoked did not listen to or follow the policy. When asked why he kept his cigarettes and lighter on his person instead of providing them to the CNA supervising smokers in the designated smoking area, Resident #4 stated, Just like everyone else, we don't want people stealing our stuff. Resident #4 stated he knew he was not supposed to keep cigarettes and lighters in his room and he acknowledged that he was in violation of the facility's smoking policy. When asked if staff had requested that he surrender his smoking supplies to them for proper storage, he stated they had asked him a few times, but he refused. Resident #4 declined to continue with the interview, stating he wanted to go outside to smoke again. The interview was concluded.A review of Resident #4's medical record revealed an admission date of 7/25/25 with diagnoses including anxiety disorder, major depressive disorder and schizoaffective disorder. Further review of the record revealed that Resident #4 was a current smoker and was not oxygen dependent.Resident #4 was the former roommate of Resident #1, an oxygen-dependent resident who smoked until 2/27/26, and was the current roommate of Resident #2, an oxygen-dependent resident who smoked.The resident's Quarterly MDS assessment, dated 1/28/26, revealed a BIMS score of 15 out of 15 possible points, indicating intact cognition. He was documented as independent with ADLs.A review of Resident #4's active care plan revealed the following focus areas:Resident prefers to smoke. (initiated on 3/2/26 after the 2/27/26 incident involving Resident #1) The goal was that he would safely smoke in the designated smoking area at designated smoking times through the next review date. Interventions initiated on 3/2/26 included Explain smoking policy to resident. Keep smoking products in locked cart. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. An intervention initiated on 3/31/26 (after the start of the survey) read: Resident will sign a smoking agreement upon admission, which remains in effect throughout the stay. Upon any smoking-related infraction, the resident will be re-educated on the established smoking agreement/policy and safety expectations. A formal warning will be issued, documented, and reviewed with the resident, with acknowledgement obtained when possible. Continued noncompliance will result in progressive warnings in accordance with facility policy, up to and including initiation of the discharge process. Resident #4 was care planned for antipsychotic therapy for a diagnosis of psychosis (initiated on 7/27/25).A review of Resident #4's active physician's orders revealed an order dated 9/5/25 for May go LOA (leave of absence) and to therapeutic visits (including facility events) with responsible party and medications.A review of Resident #4's progress notes from 9/19/24 through 3/31/26 revealed no documented evidence of the resident's noncompliance with the facility's smoking policy.A review of the scanned documents in the resident's electronic medical record revealed that Resident #4 was not issued any Smoking Notices for non-compliance with the facility's smoking policy.A review of Resident #4's Smoking Evaluation, dated 3/2/26, revealed that Resident #4 was deemed a safe smoker and did not require supervision. Resident #4 was admitted on [DATE] and his first smoking evaluation was not completed until 3/2/26, after the 2 27/26 incident involving Resident #1. Per the facility's policy, smoking evaluations were to be conducted upon admission, quarterly, annually, and if there was a significant change in condition. Resident #4 signed the facility's smoking agreement on 7/25/25. On 3/30/26 at 3:07 PM, an interview was conducted with CNA B. She stated she worked from 2:45 PM until 11:15 PM on 2/27/26 and was in the room caring for Resident #1's roommate when at around 10:15 PM, she smelled cigarette smoke, saw Resident #1 smoking and then his nasal cannula caught on fire. She stated she immediately called the nurse, who entered with a fire extinguisher, put out the fire, assessed Resident #1, called 911, and had him transported by EMS (emergency medical services) to the hospital at around 10:45 PM. She stated she had previously seen Resident #1 smoking in his room and had told the DON several times, including having seen him smoke in his room about six times during the week of the burn accident. She stated the DON does not do anything about it. She confirmed that she did not attempt to confiscate Resident #1's cigarettes or lighter because he became aggressive and hid the smoking supplies. When asked about the frequency of resident rounding, she stated CNA rounding was not consistently done every two hours due to the workload, and there was limited supervision. She said she recalled some past training on smoking safety but no formal training after the 2/27/26 incident specific to smoking, the smoking policy, or oxygen therapy safety. She stated the facility had not implemented new measures or interventions to prevent oxygen dependent residents from smoking inside despite ongoing noncompliance. She stated, Nothing is done about it.On 3/30/26 at 3:40 PM, an interview was conducted with Licensed Practical Nurse (LPN) C who stated she was familiar with Resident #1. She said she had not personally seen him smoking in his room but frequently noticed a strong cigarette odor coming from the room (room [ROOM NUMBER]) and believed that he was smoking in the room. She stated other staff also told her that Resident #1 and his roommate (Resident #2) had been seen smoking in the bathroom inside their room. She stated this morning at around 8:30 AM, CNA D informed her that Resident #2 had been observed smoking in the bathroom and she had reported it to the DON. LPN C stated there had always been a problem with residents hiding cigarettes, lighters, and smoking in their rooms despite the facility's rules. When asked if the facility had attempted to implement any new interventions to prevent residents from smoking inside the facility, she said she was not aware of any new interventions. She stated she had completed past in service education on the smoking policy, smoking safety, and oxygen therapy safety, and that staff tried to complete rounds at least every two hours but oftentimes could not round timely due to their excessive workload.On 3/30/26 at 3:59 PM, an interview was conducted with Registered Nurse (RN) E who stated she was familiar with Resident #1 and personally witnessed Resident #1 smoking in his room. She reported that on 2/27/26 at around 12:00 PM, she observed Resident #1 smoking inside his room. When asked whether she retrieved cigarettes or a lighter from him at that time, she stated she did not see any cigarettes or lighter on his person or in plain view, and believed he had hidden his smoking materials, as he did not surrender them when asked. RN E stated Resident #1 had been seen smoking in his room on prior occasions and that staff had reported these incidents to her and to the DON. When asked if she reported incidents to the DON, she stated that anytime a staff member reported an incident, the DON was notified immediately. When asked whether the facility had implemented any new interventions specifically to prevent oxygen-dependent residents from smoking in their rooms, she stated she was not aware of any new internal changes directed at oxygen dependent smokers after these events. When asked about training, she stated that the majority of the staff received reading material or education after the incident, but she could not recall any focused, formal training specifically addressing smoking safety and oxygen therapy safety beyond what had been provided previously. When asked if she believed that the training provided had been effective, she replied that it had not been effective. She added that most of the training was just a folder with information and a sign-in sheet that the staff had to review and sign. When asked if formal training was ever provided, she stated, rarely. When asked if formal training was provided related to the Smoking Policy after Resident #1's incident, she replied, No.On 3/30/26 at 4:03 PM, an interview was conducted with the DON who stated he was notified at around 10:00 PM on 2/27/26 that Resident #1 had been smoking in his room while on oxygen, that his nasal cannula caught fire and partially melted, and that staff responded to the alarm by turning off the oxygen, assessing the resident, calling 911, and involving the fire department and EMS, who ultimately transported the resident to the hospital. He stated Resident #1 had previously been caught smoking in his room multiple times, received repeated education, and three to four written smoking policy notices. He st

Based on a review of facility and resident records, resident and staff interviews, and a review of the facility's policies titled Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI), and Smoking/Vaping, the facility failed to protect the residents' right to be free from neglect/deprivation of services by Certified Nursing Assistants (CNAs) A, B, D, Registered Nurse (RN) E and the Director of Nursing (DON). The facility failed to ensure sufficient safeguards and supervision to protect the residents' right to be free from neglect, by failing to ensure that CNAs A, B, D, RN E and the DON implemented the facility's Smoking/Vaping policy to prevent four oxygen dependent residents (#1, #2, #3 and #4) out of four residents reviewed for smoking, from storing cigarettes and lighters in their rooms, and to prevent two oxygen-dependent residents (#1 and #2) from smoking in their rooms while oxygen was in use. This failure resulted in Resident #1 sustaining second-degree facial burns and respiratory distress after his nasal cannula ignited while he smoked in his room, requiring emergency transfer to a local acute care hospital and subsequent transfer to a burn unit for treatment.Resident #1 was identified on 9/25/24 as unsafely smoking in his room while receiving oxygen. Two nursing notes on 9/25/24, and notes dated 9/5/25, 10/19/25 and 2/27/26 revealed that Resident #1 was found smoking in his room. On 2/27/26, Registered Nurse (RN) E observed Resident #1 smoking in his bathroom at 12:00 PM. She did not retrieve his cigarettes or lighter but notified the Director of Nursing (DON). On 2/27/26 at 10:24 PM, Certified Nursing Assistant (CNA) B observed Resident #1 smoking in his room while she was providing care to his roommate. When CNA B saw Resident #1's nasal cannula ignite, she immediately notified RN F. Code Red (an intercom announcement indicating a fire or smoke emergency alerting staff to activate fire safety protocols) was activated and 911 was called for emergency transport to an acute care hospital for treatment. CNA B stated on 3/30/26 at 3:07 PM that she witnessed Resident #1 smoking in his room six times during the week of the event. She notified the DON but stated she did not collect the resident's smoking supplies due to his aggressive behavior. Staff were aware of Resident #1's unsafe behavior and safety needs but did not take necessary action to avoid actual harm to the resident.The facility failed to effectively implement its Smoking/Vaping policy to prevent residents who smoked, particularly oxygen dependent smokers, from smoking in their rooms or possessing smoking materials. As a result, residents who smoked continued to retain cigarettes and lighters, smoked inside the facility (including in rooms of oxygen dependent residents), and smoked unsupervised in non designated areas, leaving all residents at continued risk for serious injury, harm, impairment, or death.Immediate Jeopardy (IJ) at a scope and severity of K (pattern) was identified at 10:45 AM on 3/30/26.On 2/27/26, Immediate Jeopardy began.On 4/1/26 at 5:45 PM, the Administrator was notified of the IJ determination. IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on 4/1/26.The findings include:Cross reference F689, F835, and F867During a facility tour on 3/30/26 at 9:58 AM, three residents were observed sitting in their wheelchairs inside the facility near the designated smoking area door waiting for staff to open the door for their scheduled smoking period at 10:00 AM. Certified Nursing Assistant (CNA) A, assigned to supervise the residents who smoked, opened the door leading to the designated smoking area (back porch) at 10:00 AM. CNA A did not provide the three residents with smoking materials; all three residents had cigarettes and lighters already in their possession. At 10:16 AM, all three residents left the designated smoking area and re-entered the facility without providing their smoking materials to CNA A for storage in the smoking area locked cart.Another tour of the facility on 3/30/26 at 10:45 AM revealed that the same three residents who had not relinquished their smoking materials to CNA A in the designated smoking area at 10:16 AM were assigned to rooms [ROOM NUMBERS]. room [ROOM NUMBER] (Residents #2 and #4) and room [ROOM NUMBER] (Resident #3) had Oxygen in Use/No Smoking signs posted on the door frames outside of their rooms.1.A review of Resident #1's medical record revealed that he was admitted to the facility on [DATE], was transferred to an acute care hospital on 2/27/26 and was re-admitted on [DATE]. His diagnoses included chronic obstructive pulmonary disease (COPD - constriction of the airways and difficulty breathing) with acute exacerbation (sudden, severe worsening); alcohol abuse; noncompliance with other medical treatment and regimen; difficulty in walking; dysphagia (difficulty swallowing); anxiety disorder and mood disorder.A nursing note authored by Registered Nurse (RN) E on 2/27/26 revealed that she heard Certified Nursing Assistant (CNA) B scream that Resident #1's oxygen tubing was on fire and entered the room to find the nasal cannula tubing burning, a cigarette on the floor, and smoke spreading throughout the room. The nurse paged a Code Red (an intercom announcement indicating a fire or smoke emergency alerting staff to activate fire safety protocols) and obtained a fire extinguisher while another staff member called 911. RN E then provided care to the resident.A Change in Condition form, completed by RN F on 2/27/26 at 10:35 PM, noted that Resident #1's oxygen tubing caught fire while he was smoking in his room, resulting in burns to his nose and right cheek with pain rated at a 4 on a scale of zero through 10 with 10 being the worst possible pain. He was documented with increased confusion, general weakness, dizziness, unsteadiness, and labored, rapid breathing. His oxygen saturation was 98% on room air, he was a full code, and primary care was notified on 2/27/26 at 10:42 PM with orders to send him to the emergency room. Emergency Medical Services (EMS)/911 was called, and family was notified.A review of the resident's active physician's orders revealed that on 2/28/26, a physician's order was placed to send the resident to the Emergency Department (ED) for evaluation and treatment.A review of the February 2026 medication administration record (MAR) and treatment administration record (TAR) revealed that Resident #1's oxygen was delivered continuously via nasal cannula at 2 LPM according to the nurses' documentation of task completion from 2/1/26 - 2/27/26. The MAR/TAR included documentation of Resident #1's hospital/ED (Emergency Department) transfer on 2/28/26 at 12:54 AM.A review of hospital records revealed that on 2/27/26, Resident #1, diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and receiving oxygen via a nasal cannula at the nursing home, lit a cigarette and sustained superficial partial thickness burns of his face with a concern for inhalation injury. He required intubation during transport for airway protection and was accepted by the trauma/burn team. On 2/28/26 at 4:59 AM, he was documented as intubated and sedated, with soot in the nares (nostrils) and oropharynx (throat), and superficial partial thickness burns to the bridge of the nose and right cheek. An interview was conducted with Resident #1 on 3/30/26 at 9:51 AM. He was observed lying in bed, awake, wearing his nasal cannula with oxygen flowing. When he was asked about his 2/27/26 incident, he stated he smoked a cigarette in his room while wearing oxygen via nasal cannula, the cannula ignited, and he sustained burns to his face that required emergent transport to the hospital. When asked if he had been educated about the facility's smoking policy prior to the event, he stated he had received education, but he was a 72 year old man and would smoke whenever he wanted to. When asked whether he kept his cigarettes and lighter in his room or provided them to the certified nursing assistant (CNA) supervising smokers in the designated smoking area, he stated he did not give his supplies to staff but always kept all of his smoking materials with him. When asked if he had smoked in his room prior to the 2/27/26 incident, he stated he had previously smoked in the bathroom of his room (room [ROOM NUMBER]), and in room [ROOM NUMBER]. When asked if nursing staff rounded frequently to check on/supervise the residents in his room, he stated he barely saw anyone come into his room prior to the incident. When asked if he continued to smoke after the 2/27/26 incident, he stated he quit smoking after that event. When he was asked how he obtained his cigarettes and lighters, he stated he would ask other residents to purchase cigarettes and lighters for him or have a personal friend bring them to him. When asked if he informed staff that he had cigarettes and a lighter on his person, he stated he never did. When asked if he knew he was violating the facility's policy, he stated he was aware but did not care. When asked if staff had requested that he relinquish his smoking supplies to them for proper storage, he stated he never gave them anything.Further review of Resident #1's medical record revealed the following nursing notes:A nursing note dated 9/25/24 at 2:24 PM revealed that Resident #1 was observed smoking cigarettes in his room while connected to his oxygen concentrator. The nurse provided education and informed the resident that smoking in the room, especially while on oxygen, was prohibited and posed a serious safety risk to him and other residents. The nurse then contacted law enforcement to assist with the situation. There was no documented evidence verifying that the nurse requested that the resident relinquish his smoking materials or that she confiscated them.A nursing behavior note dated 9/25/24 at 2:59 PM revealed that the writer noticed a smell of cigarette smoke. She went inside Resident #1's room and found him smoking with his nasal cannula on and oxygen flowing. Resident #1 was asked to extinguish his cigarette, and he put it into a beer can between his feet. Seven beer cans were also found in a trash bag under his bedside table. When staff requested that he relinquish his cigarettes and beer, he refused, became belligerent, and insisted he paid for them. The Unit Manager and the Director of Nursing (DON) were notified, and law enforcement was called. When law enforcement arrived, the resident denied smoking in the building, stated he did not care about others' safety, and insisted he would keep his cigarettes. He ultimately surrendered five cigarettes from a carton to the officer, who gave them to the nurse and indicated it was a civil matter, advising the Unit Manager to review the facility's smoking policy and consider discharge options. The DON was briefed on the situation.A nursing note dated 10/19/25 at 3:00 PM revealed that the nurse observed Resident #1 smoking in his room with his oxygen turned off. The nurse noted that education was provided and the DON was notified. The nurse documented the failed attempt to confiscate the resident's smoking materials due to his refusal.Resident #1 was care-planned on 10/8/24 with the following focus areas:Behaviors and smoking inside the building with a goal to decrease risk factors of harming himself or others secondary to his behaviors through the next 30 days.He was care-planned for smoking. The goal was that he would not smoke without supervision through the review date. Interventions included notification of the nurse immediately if it was suspected that Resident #1 was violating the smoking policy; The resident required supervision while smoking; The resident was to be educated about the facility's smoking policy and the dangers of smoking in his room. A review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. He was documented as independent with activities of daily living (ADLs). 2. On 3/30/26 at 10:00 AM, Resident #2 was observed entering the designated smoking area. Resident #2 did not obtain cigarettes or a lighter from the CNA supervising residents in the smoking area. He agreed to an interview at 10:02 AM. When asked if he received his cigarettes and lighter from the CNA, he stated he always kept his cigarettes and lighter on his person. He removed a pack of cigarettes and a lighter from his left front pants pocket and placed them on the table. When asked if he had received education or information about the facility's rules regarding smoking/smoking safety, he stated he had but he was afraid the staff would steal his cigarettes and lighter if he let them store the smoking supplies. When asked how he obtained his supplies, he stated when he went out on a leave of absence (LOA), he purchased cigarettes and lighters and kept them. He said he intentionally did not disclose to staff that he was in possession of cigarettes and a lighter when he returned from LOA. When he was asked how long he had been keeping smoking supplies on his person, he stated he had done so since he was admitted to the facility. When he was asked if he was oxygen dependent, he stated he used oxygen mostly at night and as needed; he did not use it all the time. Resident #2 said that on 2/27/26 at approximately 9:30 PM to 10:00 PM, Resident #1 was smoking in his room when Resident #1's oxygen ignited and burned his face. Resident #2 stated Resident #1 constantly smoked in his room, including in the bathroom, while wearing his oxygen. Resident #2 further stated he was also a smoker who depended on oxygen therapy and that he had previously smoked inside his own room, but that he did not use his oxygen when he went into the bathroom to smoke. He stated he maintained all of his smoking supplies, including cigarettes and lighters, with him at all times. When asked why he did not provide his smoking supplies to the CNA supervising smokers in the designated smoking area today, he stated he was afraid staff would steal them. He said he was familiar with the facility's smoking policy and acknowledged that he knew he was in violation of the policy. He stated the nurses and CNAs sometimes checked on him every few hours, but on most days, he did not see them at all. He said he was able to leave the facility independently and went to the corner store to purchase cigarettes and lighters when he ran out. When he was asked if staff had requested that he surrender his smoking supplies to them for proper storage, he stated they had, but he would not give them his cigarettes or lighter because they will steal them.On 3/30/26 at 10:16 AM, Resident #2 was observed going back inside the facility without providing his smoking materials to the CNA for storage in the designated smoking area locked cart.A review of Resident #2's medical record revealed he was admitted to the facility on [DATE] with diagnoses including COPD with acute exacerbation, wheezing, and alcohol abuse.A review of the resident's Quarterly MDS assessment, dated 3/30/26, revealed that Resident #2 had a BIMS score of 15 out of 15 possible points, indicating intact cognition. He was documented as independent with ADLs.A review of Resident #2's active physician's orders revealed an order dated 5/14/24 for Oxygen at 2L (two liters per minute) per nasal cannula as needed.A review of the resident's active care plans revealed the following focus areas:[Resident #2] prefers to smoke. The care plan was initiated on 10/17/23 with revisions on 7/1/25 and 3/30/26. The goal was to remain a safe smoker through the next review date on 4/8/26. A second goal of review smoking policy with resident was initiated on 3/30/26 with a target date of 4/8/26. The second goal was set after the survey began. Interventions initiated on 10/17/23 included encouraging the resident to follow safe smoking guidelines; to explain the smoking policy to the resident; to keep smoking products in a locked cart, and to notify the charge nurse immediately if it was suspected that the resident had violated the facility's smoking policy. None of these interventions had been revised since 10/17/23. On 3/30/26, a new intervention was initiated (after the surveyor's arrival): review smoking policy, educate not to smoke in the room. Under the care plan interventions on three occasions (10/4/24, 10/7/25 and 3/29/26), the following was noted, Resident given a smoking policy reminder and re-educated regarding not smoking inside the building. Under the intervention dated 10/4/24, initiation and revision dates were also documented as 3/31/26. [Resident #2] is/has the potential to be physically aggressive towards others and is known to refuse daily care r/t (related to) poor impulse control. The care plan was initiated on 11/11/23 with a goal that he will not harm self or others through the review date.Resident #2 was also care planned for his use of oxygen therapy related to a diagnosis of COPD (initiated 11/21/23) and impaired vision (initiated 7/12/24). A review of Resident #2's progress notes from 9/19/24 through 3/31/26 revealed no documented evidence of the resident's noncompliance with the facility's smoking policy.A review of Resident #2's Smoking Evaluations, dated 7/10/23, 10/17/23, 2/17/24, 3/2/26, and 3/30/26, revealed that Resident #2 was deemed a safe smoker and did not require supervision. According to the facility's policy, smoking evaluations were to be conducted upon admission, quarterly, annually, and if there was significant change in the resident's condition. Resident #2 signed his smoking agreement on 1/16/2025. 3. On 3/30/26 at 10:00 AM, Resident #3 was observed entering the designated smoking area. She did not obtain cigarettes or a lighter from the CNA supervising residents in the smoking area. Resident #3 agreed to an interview at 10:08 AM. She stated she was oxygen dependent and she smoked but she emphasized that she did not smoke while wearing her oxygen or inside her room. The smoking porch was the only place she went to smoke. When asked if she received her cigarettes and lighter from the CNA, she stated she did not and that she kept her cigarettes and lighter in her black purse. She further stated she did not give her smoking supplies to staff because she did not trust them and was afraid someone would steal her cigarettes or lighter. She stated she had been educated about smoking safety and was aware of the facility's smoking policy. She knew she was not supposed to keep cigarettes and a lighter on her person but continued to do so due to fear of theft, stating, I am [AGE] years old. If I want to keep my cigarettes and lighter in my purse, I will. She stated she had kept cigarettes and a lighter on her person for as long as she could remember. She obtained them when she went out on LOA with her family, and did not inform staff that she had cigarettes and a lighter when she returned from LOA. She stated she used oxygen when needed at night and had not and would not smoke in her room or while wearing oxygen. She stated she knew that Residents #1 and #2 had been caught smoking many times in the past and that they used to talk about smoking in their rooms while in the designated smoking area. She stated nursing staff usually took a long time to come to her room and would typically come into her room only two to three times a day while she was awake. She said that although the facility had provided education and reminders not to smoke inside, residents continued to smoke inside every day. She stated staff had requested that she relinquish her smoking supplies to them for proper storage, but she had always refused. During the interview Resident #3 removed one pack of cigarettes and a lighter from her black purse. At the conclusion of the interview, Resident #3 placed the pack of cigarettes and lighter back into her black purse and entered the facility at 10:16 AM without providing her smoking supplies to the supervising CNA. She then entered her room (room [ROOM NUMBER]) with the cigarettes and lighter still in her possession.A review of Resident #3's medical record revealed that she was admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses including COPD, chronic diastolic (congestive) heart failure (CHF - the heart does not pump blood efficiently, leading to fatigue, fluid buildup in the lungs/tissues and shortness of breath), shortness of breath, and nicotine dependence.A review of the resident's Quarterly MDS assessment, dated 3/19/26, revealed that Resident #3 had a BIMS score of 13 out of 15 possible points, indicating intact cognition. She was documented as independent with some ADLs, but she required partial to substantial assistance with dressing, toileting, personal hygiene, and wheelchair mobility.A review of Resident #3's medical record revealed an active physician's order, dated 11/14/23, for Oxygen at 2 liters via nasal cannula - as needed for shortness of breath.A review of Resident #3's active care plan revealed the following focus areas:Resident #3 had a care plan focus area for smoking that was initiated on 4/18/23 with the goal that she would not suffer injury from unsafe smoking practice through the next review date. Interventions initiated on 4/18/23 included: Instruct resident about smoking risks and hazards and about smoking cessation aids that are available; instruct resident about the facility policy on smoking: locations, times, safety concerns; monitor oral hygiene and notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Interventions initiated on 4/17/24 included: Assist with removing O2 (oxygen) during smoking times prn (as needed) and observe clothing and skin for signs of cigarette burns. On 3/31/26, after the start of the survey, a new intervention was added: Resident will sign a smoking agreement upon admission, which remains in effect throughout the stay. Upon any smoking-related infraction, the resident will be re-educated on the established smoking agreement/policy and safety expectations. A formal warning will be issued, documented, and reviewed with the resident, with acknowledgement obtained when possible. Continued noncompliance will result in progressive warnings in accordance with facility policy, up to and including initiation of the discharge process.Further review of the resident's care plans revealed that she was care planned for impaired vision (initiated on 10/13/23), noncompliance with care (initiated on 1/19/26), and use of oxygen therapy (initiated on 6/15/24) related to a diagnosis of COPD.A review of Resident #3's progress notes from 9/19/24 through 3/31/26 revealed no documented evidence of the resident's noncompliance with the facility's smoking policy.A review of the scanned documents in the resident's electronic medical record revealed that Resident #3 had not been issued any Smoking Notices for noncompliance with the facility's smoking policy.A review of Resident #3's Smoking Evaluations dated 10/17/23, 2/18/24 and 3/2/26 revealed the following: On 10/17/23, Resident #3 was deemed a safe smoker who did not require supervision. On 2/18/24, the evaluation's Summary of Evaluation indicated that the resident was a safe smoker, but it did not specify whether or not she required supervision (not answered in the assessment). The smoking evaluation dated 3/2/26 revealed in the Summary of Evaluation that Resident #3 was deemed a safe smoker, but she required supervision. The Quarterly Review section of the same evaluation dated 3/2/26 revealed that the resident was a safe smoker and did not require supervision while smoking. Per the facility's policy, smoking evaluations were to be conducted upon admission, quarterly, annually, and if there was significant change in condition. Resident #3 signed her smoking agreement on 2/20/2025. 4. On 3/30/26 at 10:00 AM, Resident #4 was observed entering the designated smoking area. He did not obtain cigarettes or a lighter from the CNA supervising residents in the smoking area. He did not agree to an interview in the designated smoking area but stated he would agree to an interview after he finished smoking.On 3/30/26 at 10:16 AM, Resident #4 went back inside the facility without providing his smoking materials to the CNA for storage in the designated smoking area locked cart.During an interview with Resident #4 on 3/30/26 at 11:49 AM in his room, he stated he was Resident #1's roommate at the time Resident #1 sustained facial burns during a smoking accident at night. He stated Resident #1 smoked in the room multiple times a day while wearing oxygen. He further stated both Resident #1 and Resident #2 smoked in the bathroom and that Resident #2 did not wear his oxygen when smoking but Resident #1 always smoked while wearing his oxygen. Resident #4 stated he was also a smoker but did not use oxygen. He stated he kept his cigarettes and lighter on his person and produced two packs of cigarettes from his left pants pocket and a lighter from his right pants pocket. (photographic evidence obtained) Resident #4 stated the nursing staff were delayed in rounding and typically came into the room once in the early morning, once at lunchtime, and once again at dinner. He said he barely saw nursing staff come into the room to check on residents. He said the facility had educated residents about the smoking policy, but that most of the residents who smoked did not listen to or follow the policy. When asked why he kept his cigarettes and lighter on his person instead of providing them to the CNA supervising smokers in the designated smoking area, Resident #4 stated, Just like everyone else, we don't want people stealing our stuff. Resident #4 stated he knew he was not supposed to keep cigarettes and lighters in his room and he acknowledged that he was in violation of the facility's smoking policy. When asked if staff had requested that he surrender his smoking supplies to them for proper storage, he stated they had asked him a few times, but he refused. Resident #4 declined to continue with the interview, stating he wanted to go outside to smoke again. A review of Resident #4's medical record revealed an admission date of 7/25/25 with diagnoses including anxiety disorder, major depressive disorder and schizoaffective disorder. Further review of the record revealed that Resident #4 was a current smoker and was not oxygen dependent.Resident #4 was the former roommate of Resident #1, an oxygen-dependent resident who smoked until 2/27/26, and was the current roommate of Resident #2, an oxygen-dependent resident who smoked.The resident's Quarterly MDS assessment, dated 1/28/26, revealed a BIMS score of 15 out of 15 possible points, indicating intact cognition. He was documented as independent with ADLs.A review of Resident #4's active care plan revealed the following focus areas:Resident prefers to smoke. (initiated on 3/2/26 after the 2/27/26 incident involving Resident #1) The goal was that he would safely smoke in the designated smoking area at designated smoking times through the next review date. Interventions initiated on 3/2/26 included Explain smoking policy to resident. Keep smoking products in locked cart. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. An intervention initiated on 3/31/26 (after the start of the survey) read: Resident will sign a smoking agreement upon admission, which remains in effect throughout the stay. Upon any smoking-related infraction, the resident will be re-educated on the established smoking agreement/policy and safety expectations. A formal warning will be issued, documented, and reviewed with the resident, with acknowledgement obtained when possible. Continued noncompliance will result in progressive warnings in accordance with facility policy, up to and including initiation of the discharge process. Another focus area for Resident #4 was for antipsychotic therapy for a diagnosis of psychosis (initiated on 7/27/25).A review of Resident #4's active physician's orders revealed an order dated 9/5/25 for May go LOA (leave of absence) and to therapeutic visits (including facility events) with responsible party and medications.A review of Resident #4's progress notes from 9/19/24 through 3/31/26 revealed no documented evidence of the resident's noncompliance with the facility's smoking policy.A review of the scanned documents in the resident's electronic medical record revealed that Resident #4 was not issued any Smoking Notices for non-compliance with the facility's smoking policy.A review of Resident #4's Smoking Evaluation, dated 3/2/26, revealed that Resident #4 was deemed a safe smoker and did not require supervision. Resident #4 was admitted on [DATE] and his first smoking evaluation was not completed until 3/2/26, after the 2 27/26 incident involving Resident #1. Per the facility's policy, smoking evaluations were to be conducted upon admission, quarterly, annually, and if there was a significant change in condition. Resident #4 signed the facility's smoking agreement on 7/25/25. On 3/30/26 at 10:35 AM, an interview was conducted with Certified Nursing Assistant (CNA) A who supervised the designated smoking area. CNA A stated the CNAs routinely supervised the designated smoking area and were expected to issue and collect residents' smoking supplies and monitor their safety. CNA A stated most residents who were smokers refused to relinquish their cigarettes and lighters and kept them on their person or in their rooms. CNA A stated she notified the nurse, Assistant Director of Nursing (ADON) or DON when residents refused to surrender their smoking supplies, but nothing happens, and that both the Administrator and DON had long been aware that residents retained smoking materials without enacting effective corrective action. CNA A stated staff training on the smoking policy and oxygen safety was limited to folders left at the nurses' station with a sign in sheet. No formal, in person instruction or confirmation of understanding was completed. She stated residents were only periodically reminded in resident council not to smoke inside or keep supplies in their rooms or on their person, with no changes made to the facility's policy or practice despite ongoing noncompliance. CNA A stated Resident #1 burned his face in February (2026) after repeatedly smoking in his room while on oxygen and that staff, the Administrator and the DON all knew he had been smoking in his room for a long time. CNA A also stated Resident #2, Resident #1's oxygen dependent roommate, also smoked in his room. CNA A stated she personally saw both Residents #1 and #2 smoking in their room during the week of and the week before the burn incident. CNA A confirmed that both residents kept their smoking supplies in their room and stated she did not attempt to confiscate the supplies because of their history of aggression. CNA A stated instead, the facility's leadership was informed of their behaviors without knowing whether any follow up action was taken. When asked why she did not notify the nursing/management staff immediately after Residents #2, #3 and #4 returned inside with their smoking supplies this morning, she replied that she could not leave the designated smoking area but would notify the appropriate staff as soon as there were no residents in the smoking area.On 3/30/26 at 3:00 PM, an interview was conducted with CNA D who stated she was scheduled to work on 2/27/26 but had called out that day. She stated on 3/30/26 (this morning) at about 8:30 AM, she observed Resident #2 (Resident #1's former roommate and oxygen dependent resident) smoking in the bathroom inside his room, and immediately notified the Unit Manager, who then informed the DON. When asked if she confiscated Resident #2's smoking materials, she replied that she did not attempt to take Resident #2's cigarettes or lighter because prior attempts had led to verbal and a threat of physical aggression. She stated when residents refused to surrender smoking materials, she reported it to the Unit Manager or the DON. When asked about resident rounding, she stated that while staff conducted rounds, they were not frequent enough to prevent residents from smoking in their rooms. When asked about training and education related to the smoking policy and

Based on a review of facility documents, resident and staff interviews, and a review of the facility's policy titled Adverse Incident Reporting, the facility failed to ensure the timely reporting of an adverse incident for one (Resident #1) of four residents reviewed. The facility failed to report an adverse incident that occurred on 2/27/26 in which Resident #1 sustained second degree facial burns and respiratory distress after smoking in his room while on oxygen, requiring his transfer to an acute care facility burn unit for treatment.The findings include: An interview was conducted with Resident #1 on 3/30/26 at 9:51 AM. He was observed lying in bed, awake, wearing his nasal cannula with oxygen flowing. When he was asked about his 2/27/26 incident, he stated he smoked a cigarette in his room while wearing oxygen via nasal cannula, the cannula ignited, and he sustained burns to his face that required transport to the hospital. A review of Resident #1's record revealed that he was admitted to the facility on [DATE], was transferred to an acute care hospital on 2/27/26 and was readmitted on [DATE]. Resident #1 sustained second-degree facial burns and respiratory distress after his nasal cannula ignited while he was smoking in his room while receiving oxygen. His diagnoses included chronic obstructive pulmonary disease (COPD - constriction of the airways and difficulty breathing) with acute exacerbation (sudden, severe worsening); alcohol abuse; noncompliance with other medical treatment and regimen; difficulty in walking; dysphagia (difficulty swallowing); anxiety disorder and mood disorder.A review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. He was documented as independent with activities of daily living (ADLs).A review of hospital records revealed that on 2/27/26, Resident #1, diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and receiving oxygen via a nasal cannula at the nursing home, lit a cigarette and sustained superficial partial thickness burns of his face with a concern for inhalation injury. He required intubation during transport for airway protection and was accepted by the trauma/burn team. On 2/28/26 at 4:59 AM, he was documented as intubated and sedated, with soot in the nares and oropharynx, and superficial partial thickness burns to the bridge of the nose and right cheek. On 3/30/26 at 11:02 AM, the Administrator offered a copy of the facility's Reportable log for the Month of: [DATE] for review. She wrote on the paper the following: 0 (zero) for Feb [Administrator's name]. (photographic evidence obtained) A review of the log revealed that there were no adverse incidents reported in the month of February 2026. When the Administrator was asked to confirm that there were no adverse incidents during the month of February 2026, she confirmed there were none.On 3/30/26 at 3:40 PM, the Administrator offered a copy of the Ad Hoc Quality Assurance and Performance Improvement Meeting dated 2/27/26 for review. The reason for the meeting was noted as Resident smoking in the room. The Data section of the Ad Hoc form stated, Resident smoking in the room with oxygen in place, sustaining second degree burn on the face.An interview was conducted with the Director of Nursing (DON) on 3/30/26 at 4:03 PM. When asked about the incident involving Resident #1 on 2/27/26, he stated he was notified the night of 2/27/26, around 10:00 PM, that Resident #1 had been smoking in his room while on oxygen, and that the nasal cannula had caught fire, with parts of the cannula melting on the floor. The DON stated staff heard the fire alarm, responded to the room, turned off the oxygen, assessed the resident, and called 911. The fire department responded to assess the environment for damage and safety, and EMS (Emergency Medical Services) evaluated Resident #1. The DON states Resident #1 initially refused transport, stating he felt okay, but due to the oxygen use and visible burns around his nose, EMS ultimately transported him to the hospital.An interview was conducted with the Administrator on 3/30/26 at 4:42 PM. When she was asked about the incident involving Resident #1 on 2/27/26, she stated she first became aware of the 2/27/26 incident involving Resident #1 when the Nursing Supervisor called her at approximately 9:30 PM that evening because she was unable to reach the DON. The Nursing Supervisor reported that Resident #1 had caught himself on fire after attempting to smoke in his room while on oxygen, shortly after returning from the designated smoking area. The Administrator stated she instructed the Nursing Supervisor to complete a full change in condition assessment, including a thorough skin assessment, document the findings, notify the physician, and call 911. She stated she then contacted the DON, relayed the information, and directed him to follow up with the Nursing Supervisor. The DON called the Nursing Supervisor as soon as he was notified. When asked if she notified the Agency for Health Care Administration (AHCA) of this incident by submitting a report, she replied that she did not. She stated she consulted with the Regional Clinical Consultant (RCC) who assisted with evaluations, education, and timelines related to the event, and with the Chief Executive Officer (CEO) on 2/27/26. The Administrator stated she was advised by the RCC and CEO to not report it at this time. The Administrator clarified that they did not explicitly tell her never to report the incident, but they also did not direct her to submit a report. When asked about her understanding of the reporting requirements, the Administrator stated that she believed this incident should have been reported. She further stated that a state survey team arrived on 3/2/26 for the facility's annual survey, and as a result, the reporting of the incident was put on the back burner.During a follow-up interview with the DON on 4/1/26 at 8:10 AM, he confirmed that the 2/27/26 incident involving Resident #1 was not reported to the Agency for Health Care Administration (AHCA) and stated that after reviewing the facility's policy, it should have been reported.An interview was conducted with the CEO on 4/1/26 at 5:26 PM. When asked whether an adverse incident report had been submitted for the 2/27/26 incident in which Resident #1 sustained facial burns after his oxygen nasal cannula ignited while he was smoking in his room, she stated an adverse incident report had not been submitted. When asked to explain why the facility did not submit a report, she stated they did not suspect abuse or neglect and while gathering information about the incident, It felt like the incident did not meet the requirement to submit a report. The CEO was presented with the facility's policy titled Adverse Incident Reporting and she was asked to review the definition of adverse incident, specifically item #7, which read, Any condition that required the transfer of the resident within or outside the center to a unit providing a more acute level of care due to the adverse incident, rather than the resident's condition prior to the adverse incident. After reviewing the policy, the CEO acknowledged that the 2/27/26 incident involving Resident #1 met the definition of an adverse incident and should have been reported. She confirmed that the facility failed to submit the required report.A review of the facility's policy and procedure titled Adverse Incident Reporting (dated 8/22/22), revealed:Policy:Florida Statute 400.147 requires the reporting of Adverse Incidents to the Agency for Health Care Administration.Incidents, accidents and unusual occurrences shall be promptly reported to the Administrator or designee via the Center reporting policy and procedure. The Administrator or designee shall immediately notify the Director of Operations/Corporate Nurse Consultant of any Adverse incidents. The Director of Operations/Corporate Nurse Consultant shall review all Adverse Incident Reports prior to submission.For purposes of reporting to the Agency under this section, the term Adverse Incident means:An event over which center personnel could exercise control, and which is associated in whole or in part with the Center's intervention, rather than the condition for which such intervention occurred, and which results in one of the following:7. Any condition that required the transfer of the resident, within or outside the Center, to a unit providing a more acute level of care due to the adverse incident, rather than the resident's condition prior to the adverse incident.The Center will take timely corrective action to ensure resident safety.

Based on review of staff records, and interviews conducted with the Administrator, the facility, which is licensed for 180 beds, failed to ensure the full-time social worker was qualified, and failed to verify educational requirements were met, with the potential to negatively impact the overall health, safety, and quality of life to all 172-residents present during the recertification survey.The findings include:On 3/05/2025 at 1:37 PM, a personnel record review was conducted for the Social Services Director (SSD) that revealed she did not have a bachelor's degree in social work, or a similar human services field.During an interview with the Administrator on 03/05/2026 at 1:49 PM, she reported having problems with the SSD's performance, and after she was promoted, a request for a copy of her master's degree in social work, transcripts, and her social worker license was made, but was never provided. The Administrator further reported that she asked the SSD to go home and get her degree and credentials during the recertification survey, and at the time of exit from the survey after 6:30 PM, the Administrator confirmed that the SSD never returned to the facility or contacted her.

Based on observations, interviews, record reviews, and a review of facility policies and procedures, the facility failed to ensure that eight (Residents #5, #34, #11, #166, #91, #19, #82, and #159) of 73 sampled residents received appropriate ADL (activities of daily living) care necessary to maintain good grooming, by failing to ensure fingernails were clean/trimmed/clipped, hair was shampooed, and/or facial hair was removed. The findings include: 1.An interview was conducted on 3/2/2026 at 9:20 AM with Resident #5. He was observed sitting up in bed watching TV. The resident's hair was oily and disheveled. The resident stated he did not know the last time he received a shower or complete bed bath. He raised his hand to show his nails which were visibly stained, uneven and jagged. He stated he was receiving Hospice services and that in the past, they bathed him; however, they had not done so for quite some time. He stated he would like to get a real shower. I'm so nasty. I feel like my skin is crawling. He stated he only had one arm and one leg, and that staff were not turning and repositioning him every two hours as they should. Another observation of Resident #5 was made on 3/5/2026 at 11:13 AM. The resident had been moved to a new room. He was sitting up in bed, and his hair was oily and slicked back against his head in clumps. The resident stated he was wheeled in his bed to the new room and that he still had not received a shower. He stated his nails were still nasty while holding up his hand to show them. His nails were dark in color with debris underneath them. A review of Resident #5's medical record revealed and admission date of 6/30/23 with the most recent readmission on [DATE]. His diagnoses included cerebral infarction; major depressive disorder; acquired absence of left shoulder; atherosclerotic heart disease; non-pressure chronic ulcer of left heel and mid foot with fat layer exposed; pressure ulcer of sacral region - stage III; post-traumatic stress disorder (PTSD); peripheral vascular disease (PVD), and embolism and thrombosis of superficial veins of left lower extremity. A review of Resident #5's minimum data set (MDS) assessment , dated 1/30/2026, revealed adequate hearing/vision requiring no corrective lenses; clear speech; understands and is understood. He scored 14 out of 15 possible points on his brief interview for mental status (BIMS), indicating intact cognition. He had impairment on one side of both upper and lower extremities and required a wheelchair for mobility. He was independent with eating and dependent for toilet hygiene, oral hygiene, shower/bathe self, upper/lower body dressing and personal hygiene. He was always incontinent of bladder/bowel. A review of the resident's active care plan revealed: Impaired skin integrity - left foot ulcer/gangrene. PVD (peripheral vascular disease) present. Requires assistance with the completion of his ADLs related to (r/t) cerebral infarction, depression, absence of left shoulder, PTSD (post-traumatic stress disorder) and muscle weakness. Date Initiated: 12/10/2024 Revision on: 09/23/2025 [Resident #5] will maintain current level of function through the review date. Date Initiated: 12/10/2024 Revision on: 09/30/2025 Target Date: 05/11/2026. Assist with ADLs as needed. Date Initiated: 01/16/2025. Bathing preference is a bed bath. Date Initiated: 01/16/2025 Revision on: 01/16/2025. An interview was conducted on 3/05/2026 at 12:31 PM with Licensed Practical Nurse (LPN) M who stated she was familiar with Resident #5. She stated he was on Hospice and that he did not refuse care. She stated she was not aware that the resident had a Hospice CNA. She was asked about the resident's shower schedule. She provided his shower schedule and shower sheets (1/3/26; 1/6/26& 2/7/26). She stated the facility staff were responsible for giving him baths and performing all ADL care. She stated the resident was compliant with care and could make his needs known. He loved to drink lots of water (and soda) which would cause him to wet a lot. She stated he would call for help when he wanted to be changed. She confirmed that the documentation on the shower sheets she had provided for review indicated that no baths had been documented since 2/2/2026. An interview was conducted on 3/05/2026 at 12:34 PM with LPN L who stated the resident had been assigned to her for more than six months. She stated he was sent out to the hospital in December 2025 and when he returned in January 2026, he was moved to another room and assigned to then assigned to LPN M. She stated there was a time when the resident was assigned a Hospice CNA (certified nursing assistant) who came in and provided baths/showers. She stated the resident was out of the facility in an in-patient Hospice facility for a period of time before he returned to the facility. She stated he was able to make his needs known and had no complaints. He would call for assistance when he needed to be changed. She stated he had no behaviors. An interview was conducted on 3/4/2026 at 2:39 PM with Staff Developer (SD) Q who stated when an individual was hired, they attended a two-day training session. They had to perform competencies related to their duties which included hands-on demonstrations. She provided instructions to the CNAs about how to complete the bathing task. The information was also provided on their staffing sheet. She stated when a new hire was a new CNA, she had them demonstrate how to perform a resident bath using a life-sized mannequin. She had them do it then she showed them how it should be done. She stated if there were any concerns with how they were performing the task, she would address them at that time. She stated the CNAs should be shaving the residents as required, adding that female residents should not have facial hair. She added that some of the women were self-conscious about having facial hair and that privacy in this matter was important. She stated the CNAs could perform this task for women in the privacy of their rooms stating it would be based on the resident's preference. Staff were responsible for cleaning the residents' fingernails. They should go under their nails with a Q-tip or washcloth. This should be done when they were washing the residents' arms during their baths. If debris remained and additional cleaning of the nails was required, staff were to soak the resident's hands in water and clean their nails again. She stated all of the information that she provided to the surveyor was included in the staff education, adding that return demonstration on the life-sized mannequin was required. If a resident could not make their needs known, then staff should be taking the initiative to perform the appropriate care. A review of the facility's CNA shower schedule revealed that Resident #5 was scheduled for weekly showers on Mondays, Wednesdays, and Fridays during the 11 PM to 7 AM shift. (Photographic evidence obtained) LPN M , previously assigned to Resident #5, could only provide documentation that the resident received a bath/shower on 1/3/2026, 1/6/2026 and 2/7/2026. (Photographic evidence obtained) 2.On 3/2/2026 at 12:13 PM, Resident #34 was observed lying in bed. She had thick, black hair growing along her chin. On 3/3/2026 at 2:03 PM, Resident #34 was observed watching TV with other residents in the dining/activity room on the first floor of the facility. Activities staff were present. Resident #34 was observed wringing and chewing her top and the thick, black chin hair remained on the resident's chin. On 3/4/2026 at 11:27 AM, Resident #34 was observed with other residents seated in the dining/activities room on the first floor of the facility. Thick, black hair remained along the resident's chin line. An interview was conducted on 3/5/2026 with LPN N at 10:00 AM. She stated she was familiar with Resident #34. The resident received her showers as scheduled without refusals. She stated staff may not have been documenting them accurately, but the resident was showered routinely due to her age and extreme personal hygiene concerns. She provided facility Shower Sheets and Skin Check forms for Resident #34. Based on the information provided, Resident #34 received a shower on 2/3/26, 2/10/2026, 2/14/2026, 2/16/2026, 2/20/2026, 2/21/2026, 2/24/2026, and 2/27/2026. None of the forms indicated specific services performed, such as shaving. When asked the last time Resident #34 was shaved, LPN N was unable to answer the question. She responded repeatedly with, She gets her showers. She gets her showers. She gets them. She has to. A review of the facility's CNA Shower Schedule revealed that Resident #34 was scheduled for weekly showers on Tuesdays, Thursdays and Saturdays during the 7 AM to 3 PM shift. (Photographic evidence obtained) 3.On 03/02/2026 at 12:02 PM, Resident #11 was observed resting in bed. His fingernails were elongated with brown matter underneath some of the nails on his left hand. His right hand was partially contracted and therefore observation of his fingernails was obstructed. He was asked if he had any use of his right hand. He stated, No. He was asked if he was right-handed or left-handed. He stated, Right. He was asked if he was able to feed himself with his left hand. He stated, Yes. He was asked if the staff cared for his fingernails. He could not recall. He was asked if he wanted his fingernails trimmed. He replied, Yes. On 03/05/2026 at 9:56 AM, Resident #11 was observed resting in bed. His fingernails were elongated with brown matter under some of the nails on his left hand. His right-hand fingernails could only be partially observed as his hand was closed. On 03/05/2026 at 10:05 AM, an interview was conducted with CNA G. She was asked who was responsible for providing fingernail care for the residents. She confirmed that the CNAs usually did fingernail care, but that all nursing staff could provide fingernail care to the residents. She was asked how often fingernail care was provided. She stated, They usually do fingernails on Sundays because that's the day we don't have any showers scheduled, but we can do it whenever it's needed. She was asked to observe Residents #11 and #91 (#11's roommate) and determine whether or not they needed fingernail care. She confirmed that both residents needed fingernail care. A review of Resident #11's medical record revealed an admission on [DATE] with diagnoses including hemiplegia/hemiparesis following a cerebral infarction (stroke) affecting the resident's right, dominant side. A review of the Quarterly MDS (minimum date set) assessment dated [DATE], revealed the resident's BIMS (Brief Interview for Mental Status) score was 7 out of 15 possible points, indicating severe cognitive impairment. He was independent with eating and dependent with toileting, personal hygiene, bed mobility and transfers. A review of the active care plan revealed the following focus areas: FOCUS: The resident has an ADL/self-care performance deficit r/t (related to) cerebral infarction affecting right side Date Initiated: 12/11/2024 Revision on: 04/28/2025. Goal: The resident will maintain current level of function through the review date. Date Initiated: 12/11/2024 Revision on: 01/30/2026 Target Date: 04/06/2026. Interventions: Assist with ADLs as needed. Date Initiated: 12/24/2024, Personal Hygiene - Dependent Date Initiated: 12/11/2024 Revision on: 02/18/2026, Shower and Bathe - Dependent Date Initiated: 12/11/2024 Revision on: 02/18/2026. 4.On 03/03/2026 at 10:10 AM, Resident #166 was observed resting in bed. The fingernails on his left hand were elongated with brown matter underneath. He was asked if he wanted his fingernails trimmed and he replied, Yes, but I'm going to be leaving soon to go to dialysis. On 03/05/2026 at 9:54 AM, Resident #166 was observed resting in bed. The fingernails on his left hand were elongated with brown matter underneath. He was asked if the staff had offered him fingernail care and he confirmed they had not. On 03/05/2026 at 10:57 AM, an interview was conducted with LPN F who was asked to observe the resident's fingernails. She was asked if she believed Resident #166 needed fingernail care. She confirmed that the resident needed fingernail care. She confirmed that any nursing staff member could provide fingernail care whenever it was needed. A record review revealed that Resident #166 was admitted to the facility on [DATE] with diagnoses including hemiplegia/hemiparesis following a nontraumatic subarachnoid hemorrhage affecting his left dominant side. A review of the Quarterly MDS, dated [DATE], revealed that the resident had a BIMS score of 15 out of 15 possible points, indicating intact cognition. He was independent with eating and dependent with toileting and personal hygiene. A review of the care plan revealed the following focus areas: FOCUS: Resident has an ADL self-care performance deficit r/t ESRD (end-stage renal disease), hemiplegia/hemiparesis, depression, diabetes, and dependence on renal dialysis. Date Initiated: 12/10/2024 Revision on: 08/09/2025. Goal: The resident will maintain current level of function through the review date. Date Initiated: 12/10/2024 Revision on: 02/10/2026 Target Date: 05/08/2026. Interventions: Assist with ADLs as needed. Date Initiated: 12/24/2024, Bathing preference (bed bath) Date Initiated: 12/24/2024 Revision on: 12/24/2024. Personal Hygiene - Dependent Date Initiated: 12/10/2024. 5.On 03/02/2026 at 12:05 PM, Resident #91 was observed sitting up on the side of his bed watching television. His fingernails were elongated with brown matter underneath the nails on his left hand. The resident's right hand was contacted, and observation of his fingernails was obstructed. He was asked if the staff cared for his fingernails. He stated, Nobody. He was asked if he wanted fingernail care. He stated, Yes, but nobody is doing nails around here. On 03/05/2026 at 9:57 AM, Resident #91 was observed resting in bed. His fingernails were elongated with brown matter underneath the nails on his left hand. He was asked if he had refused fingernail care. He confirmed that he did not refuse care. A record review revealed that Resident #91 was admitted on [DATE] with diagnoses including hemiplegia/hemiparesis following a cerebral infarction (stroke) affecting his left non-dominant side. A review of the admission MDS, dated [DATE], revealed that the resident had a BIMS score of 14/15, indicating intact cognition. He had no identified behaviors. He required supervision or touching assistance with eating and partial/moderate assistance with toileting and personal hygiene. A review of the care plan revealed the following focus areas: FOCUS: Resident requires assistance with completion of his functional abilities' r/t recent CVA (stroke), cellulitis and CKD (chronic kidney disease - stage 3. Date Initiated: 12/01/2025 Revision on: 12/01/2025. Goal: Resident's needs will be met. Date Initiated: 12/01/2025 Revision on: 01/30/2026 Target Date: 03/10/2026. Interventions: Assist with ADLs as needed. Date Initiated: 12/01/2025, Eating - Supervision/Touching assist Date Initiated: 12/01/2025 Revision on: 12/01/2025. Personal Hygiene - Partial/Mod assist Date Initiated: 12/01/2025 Revision on: 12/01/2025. Shower and Bathe Self - Substantial/Max assist Date Initiated: 12/01/2025 Revision on: 12/01/2025. 6.On 03/02/2026 at 12:55 PM, Resident #19 was observed sitting up at bedside with elongated jagged fingernails with brown matter underneath the nails on his left hand. A record review revealed that Resident #19 was admitted on [DATE] with diagnoses including encephalopathy, anxiety, depression, generalized muscle weakness, a need for assistance with personal care and hydrocephalus. A review of the Quarterly MDS assessment dated [DATE], revealed a BIMS score of 07/15, indicating severe cognitive impairment. No behaviors were indicated and the resident was noted independent with eating, toileting and personal hygiene tasks. A Care Plan review revealed the following focus problem: FOCUS: Resident has an ADL deficit related to deconditioning following hospitalization, date initiated: 03/27/2025, revision date: 08/27/2025. Goal: The resident will improve current level of self ADL care through the review date. Date initiated: 03/27/2025, revision date: 06/05/2025, target date: 03/06/2026. Interventions: Assist with ADLs as needed, initiated 03/27/2025, Personal hygiene: supervision/touching assistance, initiated 03/27/2025, revision date: 12/06/2025, Shower/Bath: supervision/touching assistance, initiated 03/27/2025, revision date: 12/06/2025. A review of pertinent progress notes revealed that the resident was documented as refusing medications on 3/3/26, 2/25, 2/24, 2/23, 2/19 and 2/18/2026. There was no documentation during this timeframe that indicated refusal of ADL care, specifically fingernail care. On 02/13/2026, a Psychiatry Encounter note documented that the residents received no psych meds. As per collected information and interview, it appears that the patient is at baseline with no acute symptoms or behaviors. There was no documentation indicating that the resident refused ADL care. On 03/03/2026 at 9:53 AM, an interview was conducted with Registered Nurse (RN) A. She was asked how often the residents received grooming care and what the grooming care consisted of. She confirmed that grooming was provided to the residents weekly and consisted of hair care, nail care, haircuts, and sometimes the staff would paint the ladies' toenails. She was asked how often fingernail care was provided and what the facility's process was if the resident refused fingernail care. She confirmed that fingernail care was provided by the nursing staff on the weekends and if the residents refused fingernail care the staff was to educate them on the importance of care. 7.On 03/03/26 at 10:27 AM, Resident #82 was observed resting in bed with thickened, rigid, and overgrown fingernails on both hands that were extending approximately 1/2 inch beyond the nailbed. (Photographic evidence obtained) The resident said he did not like his fingernails so long and was afraid he may scratch himself. He explained that staff had not offered to assist him by trimming his nails. On 03/04/26 at 1:35 PM, another observation was made of Resident #82's fingernails. The nails on both hands remained thickened, rigid, overgrown, and extending approximately 1/2 inch beyond the nailbed. (Photographic evidence obtained) A review of Resident #82's medical record revealed that he was admitted on [DATE] with diagnoses including type 2 diabetes mellitus, human immunodeficiency virus (HIV), unsteadiness on feet, muscle weakness (generalized), other reduced mobility, need for assistance with personal care, hypertension, acquired absence of left leg below knee, acquired absence of right leg above knee, and a pressure ulcer of the sacral region - stage 2. A review of the MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 possible points, indicating moderate cognitive impairment. The resident was not documented with indicators of psychosis, physical or verbal behavioral symptoms directed towards others, or rejection of care. He was noted as requiring supervision for hygiene as well as partial assistance for personal hygiene. A review of Resident #82's care plan, revised on 02/05/26, revealed a focus area indicating that the resident had an ADL performance deficit related to bilateral amputee, cognitive issues and a need for assistance with daily care tasks. Interventions included that personal hygiene required partial assistance. 8.On 03/03/26 at 9:42 AM, Resident #159 was observed in his room thickened, rigid, and overgrown fingernails on both hands that extended approximately ¾ inch beyond the nailbed. (Photographic evidence obtained) The resident explained that he did not like his fingernails so long and staff had not offered to help trim his fingernails. On 03/04/26 at 1:00 PM, another observation was made of Resident #159's fingernails, which looked the same as they had on 03/03/26 at 9:42 AM. (Photographic evidence obtained). A review of Resident #159's medical record revealed an admission on [DATE] and diagnoses including diabetes mellitus with diabetic neuropathy, hemiplegia/hemiparesis following cerebral infarction (stroke) affecting left non-dominant side, acquired absence of eye, absolute glaucoma, left eye, muscle weakness (generalized), other reduced mobility, need for assistance with personal care, and frontal lobe and executive function deficit following cerebral infarction. A review of an MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 possible points, indicating moderate cognitive impairment. There were no indicators of psychosis, no physical or verbal behavioral symptoms directed towards others, and no rejection of care noted. The resident's functional abilities were assessed as requiring supervision and/or touching assistance. A review of Resident #159's active care plan (dated 02/20/26), revealed that the resident required assistance with completing his ADLs related to adult failure to thrive, hemiplegia/ hemiparesis following cerebral infarction and absence of his left eye. The goal noted that the resident's needs would be met. Interventions included that the resident required assistance with ADLs. Personal hygiene required supervision and/or touching assistance. On 03/04/26 at 2:39 PM, an interview was conducted with CNA T, who reported that she had been employed by the facility for one month. She verified the following resident's nails were too long – Residents in rooms/beds 19B, 36D, 40C, 49B, 52A and 52D. She stated received ADL training during orientation. She said if she observed a resident with long nails, she would ask the resident if they would like their nails trimmed. If the resident was independent for grooming, specifically nail care, she would provide the resident with nail clippers and a nail file. On 03/04/26 at 3:00 PM, an interview was conducted CNA U, who stated she had been employed by the facility since 02/25/25 and received ADL training during orientation. She explained that if she saw a resident with long, jagged or soiled nails, she would ask the resident if they wanted their nails trimmed. She would proceed to gather supplies, including nail clippers and nail files located in the supply room. If the resident was confined to bed, she would provide nailcare at bedside. If the resident was in a chair, she would provide nailcare chairside. She would then document nailcare in the resident's chart. A review of the facility's policy and procedure titled Activities of Daily Living (ADLs) Maintain Abilities (Date: January 2024), revealed: Procedure: 3. The facility will provide care and services for the following activities of daily living: a. Hygiene-bathing, dressing, grooming, and oral care. 4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interviews and record reviews, the facility failed to provide accurate Preadmission Screening and Resident Reviews (PASRRs) for seven (Residents #23, #62, #63, #65, #76, #101, and #167) of eight residents sampled for PASRRs and identified with a mental disorder (MD) and/or intellectual disability (ID), and failed to ensure that the residents were properly evaluated and received care and services in a setting appropriate for their needs. The findings include:1.A review of Resident #23's medical record revealed an admission date of 5/8/2025 with the latest readmission on [DATE]. His diagnoses included generalized anxiety disorder (5/12/2025), schizophrenia (5/08/2025), brief psychotic disorder (5/12/2025), major depressive disorder (5/12/2025), and alcohol abuse (5/8/2025).A review of the resident's active care plan revealed focus areas including:7/8/2025: [Resident #23] has potential for impaired or inappropriate behaviors r/t Dementia: AEB (as evidenced by) refusing blood pressure, cognitive loss, ineffective coping skills.9/5/2025: [Resident #23] has had a history of past traumatic events/histories with anxiety, crying, isolation, nightmares, sleeplessness, acting fears, voice of upsetting, withdrawal, refusal of treatments/activities, etc., that has the potential to affect care while at facility.8/16/2025: [Resident #23] is an elopement risk/wanderer r/t (related to) brief psychotic disorder Impaired safety awareness.A review of the resident's PASRR, dated 4/22/2025, revealed that no MDs and/or IDs for the resident were identified. (Photographic evidence obtained) 2.A review of Resident #62's medical record revealed an admission on [DATE] with her latest readmission on [DATE].Her diagnoses included dementia with other behavioral disturbance (10/01/2022 and 5/23/2025); bipolar disorder (11/14/2025 and 1/10/2023); major depressive disorder (5/23/2025); anxiety disorder (5/23/2025).A review of the resident's active care plan revealed focus areas including:4/17/2023: Behavioral - [Resident #62] is at risk for socially inappropriate/disruptive behavioral symptoms.2/16/2024: [Resident #62] is/has potential to be verbally aggressive towards other residents r/t dementia and mental/emotional illness.4/22/2024: [Resident #62] has potential to be physically aggressive r/t dementia.7/09/2025: [Resident #62] has behaviors - resident exhibits obsessive behaviors over roommate, leading to potential conflict and care disruption.8/19/2025: [Resident #62] is an elopement risk r/t dementia.A review of the PASRR dated 3/11/2024 revealed that no MDs and/or IDs for the resident were documented. (Photographic evidence obtained) 3.A review of Resident #63's medical record revealed an admission date of 5/1/2024. Her diagnoses included depression (5/1/2024); psychosis ( 5/1/2024); anxiety disorder (5/1/2024); dementia with other behavioral disturbance (5/1/2024); major depressive disorder (5/23/2024), and anxiety disorder (5/23/2024).A review of the resident's active care plan revealed focus areas including:7/03/2025: [Resident #63] exhibits s/s (signs and symptoms) of behaviors related to eating paper. She has also been found to have other non-food items (condiment packet) in her mouth.9/20/2024: [Resident #63] is an elopement risk/wanderer r/t dementia, disoriented to place, impaired safety awareness. Resident wanders aimlessly.2/12/2026: [Resident #63] shows signs of delirium AEB (as evidenced by) inattention and disorganized thinking. She also has diagnoses of frontotemporal neurocognitive disorder, dementia, mood disorder and anxiety.A review of the PASRR dated 10/22/2024 revealed no documented MDs and/or IDs. (Photographic evidence obtained) 4.A of Resident #65's medical record revealed an admission date of 9/14/2023 with the most recent readmission on [DATE].Diagnoses included: major depressive disorder (5/23/2025); dementia (5/23/2025); psychotic disturbance, mood disturbance, and anxiety (5/23/2025), and bipolar disorder (9/19/2023).A review of the active care plan revealed focus areas including:7/08/2025: Potential for impaired or inappropriate behaviors r/t cognition and ineffective impulse control AEB inappropriate urination putting self on floor/tipping wheelchair backwards shaving self without assistance.7/03/2025: Resident exhibits s/s of BPSD (behavioral and psychological symptoms of dementia) or sexually inappropriate behaviors.5/13/2025: The resident has behaviors of sitting on the floor, crawling or putting himself on his knees.10/17/2024: Potential for impaired or inappropriate behaviors r/t (non-compliant to care): AEB Stress.9/27/2023: The resident has impaired cognitive function/dementia or impaired thought processes r/t Difficulty making decisions, Impaired decision making, Short term memory lossA review of the PASRR dated 8/24/2023 revealed that none of the resident's identified MDs or IDs were documented. (Photographic evidence obtained) 5.A review of Resident #76's medical record revealed an admission on [DATE] with the most recent readmission on [DATE].Her diagnoses included bipolar disorder (11/02/2023); dementia, psychotic disturbance, mood disturbance, and anxiety (11/03/2025); depression (11/03/2023), and major depressive disorder (05/23/2025).A review of the resident's active care plan revealed focus areas including:4/17/2024: [Resident #76] makes disruptive sounds/grunting. Potential for impaired or inappropriate behaviors r/t bipolar disorder and cognitive/communication deficit.12/11/2024: [Resident #76] has an ADL (activities of daily living) self-care performance deficit r/t bipolar disorder, dementia, muscle weakness.7/23/2025: Potential for impaired or inappropriate behaviors r/t cognitive impairment.11/17/2025: [Resident #76] has little or no community life involvement r/t bipolar disorder, dementia and major depressive disorder.11/24/2023: [Resident #76] has behaviors: disruptive sounds.A review of the PASRR dated 11/2/2023 revealed that none of the resident's identified MDs or IDs were documented. (Photographic evidence obtained)6.A review of Resident #101's medical record revealed an admission date of 8/25/2023.His diagnoses included schizoaffective disorder, bipolar type (8/25/2023); alcohol abuse (8/25/2023); major depressive disorder (9/20/2023); anxiety disorder (5/23/2025); alcohol dependence (5/23/2025); anxiety disorder (8/25/2023).A review of the active care plan (Date initiated: 09/11/2023) revealed focus areas including:[Resident #101] has potential for impaired or inappropriate behaviors r/t dementia with cognitive decline, AEB ineffective impulse control, insufficient safety awareness, history of elopement.[Resident #101] has impaired cognition and/or impaired thought processes r/t mental illness.The resident is/has potential to be verbally aggressive towards others r/t depression and mood disorder.The resident is an elopement risk/wanderer r/t dementia.[Resident #101] has impaired cognitive function/dementia or impaired thought processes r/t dementia with a history of alcohol abuse.A review of the PASRR dated 8/22/2023 revealed that the identified MDs/IDs for Resident #101 were not documented. (Photographic evidence obtained) 7.A review of Resident #167's medical record revealed an admission on [DATE] with the most recent readmission on [DATE].Her diagnoses included depression (5/31/2022); dementia, psychotic disturbance, mood disturbance, and anxiety (7/18/2020); bipolar disorder (1/25/2021); major depressive disorder (5/23/2025); anxiety disorder (5/23/2025); bipolar disorder (5/23/2025), and major depressive disorder (7/19/2020).A review of the active care plan revealed focus areas including:9/04/2025: Resident has a history of anxiety and withdrawal that has the potential to affect care while at facility - Trauma Informed Care.4/18/2023: [Resident #167] has a behavior problem r/t sexual behaviors and inappropriate sexual comments. Refuses medications. The resident attempted to expose herself to others. [Resident #167] will bite and kick at staff when she is agitated.8/18/2025: The resident is an elopement risk/wanderer r/t dementia.A review of the PASRR dated 5/28/2021 revealed that none of the identified MDs/IDs for Resident #167 were documented. (Photographic evidence obtained) An interview was conducted on 3/4/2026 at 11:55 AM with the Social Services Director (SSD) who stated she had been employed as the SSD for more than a year. She further stated she was supposed to have two assistants; however, she had not had one since occupying the position. She stated she assisted the Director of Nursing (DON) with the PASRRs. The DON usually completed the PASRRs, as he was the only person with a log-in. She stated she checked the PASRRs upon resident admission. She and the DON reviewed them. She stated she looked for non provisional to see if they met the skilled criteria. She stated she, the DON, and the Assistant Director of Nursing (ADON) checked the forms to ensure all of the necessary diagnoses were included. The PASRRs were reviewed daily in the morning meeting. She stated there were no additional audits of the forms. They were only reviewed at admission. If the resident had a change in condition which identified an MD/ID, the Unit Manager would be responsible for reporting it.An interview was conducted on 3/4/2026 at 1:40 PM with the DON who stated he was responsible for checking the PASRRs in the morning meeting when there were new admissions. He stated they checked to see if it was not a provisional admission. He stated assisted with the Level II PASRRs if they were required. He sent them out for the Level II. He stated the clinical team was responsible for ensuring all pertinent diagnoses were listed. He completed a new PASRR if corrections were necessary. He stated the resident's History and Physical from the hospital was used to confirm the MDs/IDs. When asked if the information was reviewed during a resident's stay for any updates/corrections, he stated audits were performed; however, he did not provide any documentation to verify this during the course of the survey. He stated if a resident had a new MD/ID, it would be updated in the resident's chart and a new PASRR would be completed. The psychiatric provider would notify him if a resident had a newly identified MD/ID. Again, he stated that a new PASRR would be completed if that occurred.A follow-up interview was conducted on 3/05/2026 at 12:48 PM with the DON. The PASRRs for Resident's #23, #62, #63, #65, #76, #101 and #167 were individually reviewed with the DON. He consulted the electronic medical record for each resident. He confirmed the PASRRs provided to the survey team were all that were available for each of the residents. As he compared the PASRRs to the residents' documented diagnoses, he confirmed that the PASRRs were inaccurate. He confirmed that diagnoses were excluded from each of the residents' PASRRs. He stated the SSD would have been responsible for identifying this so that he could update the PASRRs with the proper diagnoses. The facility's policy, Preadmission Screening (PASSAR / PASSR) (Effective 6/2025), revealed:Policy: It is the policy of the center to follow the Federal and State regulations with regard to pre-screening residents with a mental disorder and individuals with intellectual disability for individuals requiring more than 30 days in the Center. Procedure: 1. A level II PASSR must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, or a suspicion or diagnosis of serious mental illness, intellectual disability, or both. A PASSR level II may only be terminated by a PASSR Level II Evaluator.2. Mental illness diagnoses added after admission should have a PASSR Level II completed again to ensure proper screening.3. Recommendations from the Level II PASSR should be reviewed and added to the plan of care.

Based on observations, interviews and record review, the facility failed to provide a safe environment for two (Residents #17 and #79) of 172 residents currently living in the facility, by failing to keep sharp, potentially dangerous items out of resident rooms. The findings include: 1.During a tour of the facility on 3/2/2026 at 12:26 PM, resident room [ROOM NUMBER] on the secured Memory Care Unit located on the bottom floor of the facility was observed. In the room was a wooden dresser located near a window at the foot of Bed B (Resident #97) and Bed C (Resident #17). An open drawer revealed a clear plastic bag containing several blue razors and large nail clippers. (Photographic evidence obtained) A follow-up tour was made on 3/4/2026 at 4:04 PM. The clear plastic bag containing the blue razors and large nail clippers remained in the top drawer. Resident #17 was seated in his wheelchair near the end of the bed near the wooden dresser. He confirmed the dresser was his. He also confirmed the bag of razors and clippers were his. On 3/4/2026 at 4:39 PM, Registered Nurse (RN) P was accompanied to room [ROOM NUMBER]. Resident #17 remained seated in his wheelchair near the wooden dresser. Upon seeing the contents of the open drawer, RN P immediately removed the clear plastic bag. Resident #17 asked her if there was a problem. She advised him that he should not have those items in his room. She explained to him that when he wanted to shave, he would have to notify the staff and they would assist him. He responded by shrugging his shoulders stating, Well, that's how they gave it to me. He did not identify who they were. RN P exited the resident's room with the clear plastic bag. She confirmed that Resident #17 should not have had those items in his possession. She stated none of the residents were permitted to have those kinds of items in their rooms. 2.Resident #79 was observed in his room at 1:28 PM on 3/2/2026 sitting in his wheelchair preparing to eat his lunch. A pair of adult comfort grip scissors with a pointed tip was observed on the resident's table. He was asked what he was using the scissors for. He replied, To stab you with them. On 3/4/2026 at 3:09 PM, a pair of adult comfort grip scissors with a pointed tip as well as a cigarette lighter were observed on Resident #79's table. The resident was not in his room at the time. On 3/5/2026 at 1:32 PM, a pair of adult comfort grip scissors with a pointed tip and a cigarette lighter were observed on Resident #79's table. The resident was not in his room at the time. On 3/5/2026 at 3:25 PM, an interview was conducted with the Director of Nursing. He confirmed that no resident should have sharps/scissors in their room or possession of same at any point in time. On 3/5/2026 at 4:05 PM, an interview was conducted with Certified Nursing Assistant J, who was accompanied to Resident #79's room. The scissors that had been observed on the resident's table since Monday were pointed out to the CNA. He was asked if the resident was permitted to have the cigarette lighter and scissors in his room. CNA J said No and picked up the items. He was asked what he did when he finds items like this in a resident's room. He replied that he would remove the items first, notify the nurse, and then document the incident. A review of the facility's policy and procedure titled Nursing Home Code of Conduct (Dated February 16, 2024 and updated February 10, 2025), revealed: 2. Prohibited Items: - No weapons, including guns, knives, or any items that could potentially harm others, are allowed within the facility.

Based on observation, interview and record review, the facility failed to ensure a call light or hand bell was within reach for three (Residents #13, #43 and #149) of 73 sampled residents. The findings include:1.On 03/02/26 at 2:12 PM, Resident #13 was observed lying in bed with his eyes closed. A hand bell was observed on top of the light above the head of the bed. It was not within the resident's reach and was approximately 3.5 feet above the resident's bed. (Photographic evidence obtained). The resident did not respond to questions related to the call light or hand bell. The resident's roommate stated Resident #13 could not talk and that the resident was provided with a hand bell because his call light was not working.On 03/02/26 at 3:30 PM, the Director of Nursing (DON) was interviewed and was accompanied to Resident #13's room. He was asked if the resident was physically capable of reaching the hand bell above the light. The DON reported that the hand bell was provided to the resident because the call light was not working. The DON stated the resident was bedbound and would not be capable of reaching above his bed to retrieve the hand bell. On 03/03/26 at 9:00 AM, Resident #13's hand bell was observed on the resident's bed adjacent to the resident's left arm. 2.On 03/03/26 at 1:50 PM, Resident #43 was observed resting in his room. The Resident's call light was observed on the floor under the bed frame at the head of the bed. (Photographic evidence obtained) The resident said that he did not know where the call light was. On 03/04/26 at 9:37 AM, another observation was made of Resident #43's call light on the floor under the bed frame at the head of the bed. (Photographic evidence obtained) 3.On 03/03/26 at 1:50 PM, Resident #149 was observed resting in his room. The Resident's call light was observed on the floor behind the head of the bed. (Photographic evidence obtained). The resident said he did not know where it was. On 03/04/26 at 9:37 AM, another observation was made of Resident #149's call light on the floor behind the head of the bed. (Photographic evidence obtained) A review of the facility's Call Light Policy (Dated April 2022), revealed: 5. When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident.

Based on observation, interview and record review, the facility failed to 1) Ensure privacy curtains were provided to five (Residents #192, #116, #5, #82 and #105) of 30 residents sampled for privacy curtains, and 2) Ensure privacy curtains were not stained for two (Rooms 9B and 9D) of 32 privacy curtains observed.The findings include:On 03/03/26 at 10:36 AM, Resident #82 was observed in his bedroom, which lacked a privacy curtain track and privacy curtain. (Photographic evidence obtained)On 03/03/26 at 2:19 PM, resident room [ROOM NUMBER], beds 9B and 9D's curtains were observed to be heavily stained. Bed 9D had black scratch marks covering the lower portion of the privacy curtain. Bed 9B had large dark spots covering the upper right portion of the privacy curtain. (Photographic evidence obtained) On 03/04/26 at 9:51 AM, another observation was made of bed 9D with black scratch marks covering the lower portion of the privacy curtain and bed 9B with large dark spots covering the upper right portion of the privacy curtain. (Photographic evidence obtained) On 03/04/26 at 11:54 AM, an interview was conducted with the Director of Housekeeping and Laundry, who reported she had been employed by the facility for three years. She explained in relation to privacy curtains, that rooms were deep cleaned once a month or more as needed. During the deep cleaning process, privacy curtains were removed and sent to the laundry where they were washed. If laundry services washed a privacy curtain and noticed permanent stains, they informed her, and she placed the room and bed placement in a queue to replace the privacy curtain. She explained that during daily cleaning, if a soiled or stained privacy curtain was discovered, housekeeping staff would retrieve and attach a clean privacy curtain before removing the soiled privacy curtain so that the resident maintained their privacy. She further explained that housekeeping staff should inform her if a resident room was missing a privacy curtain. On 03/04/26 at 12:01 PM, the Director of Housekeeping was accompanied to room [ROOM NUMBER] and she verified curtains for bed B and bed D were heavily stained. She reported that the Administrator provided five new curtains each month and he kept a log of stained curtains that needed replacement. On 03/05/26 at 10:00 AM, Resident #192 and Resident #5 were observed in their bedroom, which lacked a privacy curtain track and privacy curtain. (Photographic evidence obtained) On 03/05/26 at 10:30 AM, Resident #116 was observed in her bedroom, which lacked a privacy curtain track and privacy curtain. (Photographic evidence obtained) On 03/05/26 at 1:52 PM, Resident #105 was observed in his bedroom, which lacked a privacy curtain track and privacy curtain. (Photographic evidence obtained)Review of the facility's Resident Rights Policy (Dated 07/2025), revealed: Each resident has the right to be treated with dignity and respect . 8. Reasonable Accommodations of Needs/Preferences . 33. Safe/Clean/Comfortable/Homelike Environment .

Based on observations, interviews and record reviews, the facility failed to ensure residents requiring respiratory care received such care, consistent with professional standards of practice, by failing to ensure that two (Residents #54 and #49) of two residents reviewed for respiratory care, received oxygen at the flow rate prescribed by their physicians.The findings include: 1. On 3/3/2026 at 9:30 AM, Resident #54's oxygen concentrator flow rate was observed to be set at 2.5 l/min (liters per minute). On 3/4/2026 at 9:00 AM, Resident #54's oxygen concentrator flow rate was observed to be set at 2.5l/min. During an interview on 3/4/2026 at 9:05 AM, Registered Nurse (RN) D stated, I check my oxygen concentrators when I arrive to check the settings. When asked if a resident had orders for oxygen at 2 liters per minute via nasal cannula, how that oxygen should be delivered, RN D stated, It should be at 2 liters a minute via nasal cannula. RN D was asked if she knew what Resident #54's oxygen flow rate should be set at and she replied, It should be at 2 liters a minute. RN D was accompanied to the resident's room, and she checked his flow rate setting. It was set at 2.5 l/min. RN D adjusted the flow rate to 2.0 l/min. A review of the resident's electronic health record revealed an admission date of 5/5/2022. Resident #54's diagnoses included chronic obstructive pulmonary disease. A physician's order, dated 10/17/2025, was for oxygen at 2 l/min. to be delivered via nasal cannula. 2. On 03/03/26 at 9:39 AM, Resident #49 was observed wearing a nasal cannula attached to an oxygen concentrator, which was set at a flow rate of 5 l/min. (Photographic evidence obtained) The resident stated, I don't touch the oxygen flow rate settings. A review of the resident's medical record revealed a physician's order for an oxygen flow rate of 2.0 l/min. as needed (prn) with a start date of 05/14/24. On 03/04/26 at 1:50 PM, another observation was made of Resident #49 wearing a nasal cannula attached to an oxygen concentrator with a flow rate set at 5 l/min. (Photographic evidence obtained). On 03/04/26 at 1:58 PM, an interview was conducted with Licensed Practical Nurse (LPN) F, who stated she had been employed by the facility for eight months. She was accompanied to Resident #49's room and she checked Resident #49's oxygen flow rate. LPN F stated the resident's flow rate was set all the way to five. She reviewed Resident #49's medical record and said the resident had a physician's order for oxygen at 2 l/min. as needed. She explained that her process to ensure residents received oxygen at the correct flow rate began at the beginning of her shift. When she started her shift, she checked resident electronic records for her assigned residents to review their oxygen orders. While making her rounds, she checked oxygen flow rates to ensure they were set correctly per the physicians' orders. She also checked oxygen saturation levels and oxygen tubing. When she was asked whether or not she was aware of the ramifications of a resident receiving an excess of oxygen beyond the physician's order, she was unable to answer the question. 2.A review of Resident #49's medical record revealed an admission date of 7/7/23 with diagnoses including: wheezing, human immunodeficiency virus (HIV) disease, myocardial infarction, and chronic obstructive pulmonary disease (COPD) with (acute) exacerbation. A review of Resident #49's minimum data set (MDS) assessment dated [DATE], revealed that the resident's brief interview for mental status (BIMS) score of 14 out of 15 possible points, indicated intact cognition. The resident was documented as independent with activities of daily living (ADLs). A review of Resident #49's active care plan, revised 04/11/25, revealed the following focus area: The resident uses oxygen therapy PRN related to a diagnosis of COPD with a cough. The goal noted the resident would be free from signs and symptoms of respiratory distress through the next review date. The care plan interventions included administering medications (oxygen) as ordered. A review of the facility's policy and procedure titled Oxygen Administration, Respiratory Care (Dated April 2022), revealed: Page two: 12. Adjust the delivery device so that it is comfortable to the resident and the proper flow of oxygen is being administered. A review of the facility's policy and procedure titled Administration of Drugs, Nursing Policy Manual (Dated 01/2026), revealed: Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director. 2. Drugs must be administered in accordance with the written orders of the attending physician . 6. Medications must be administered in a manner that reduces the risk of medication errors and ensures patient safety using the 5 Rights of Medication Administration: c. Right Dose – ensure that the dose is correct by checking the dose against the order.

Based on observation, interview and record review, the facility failed to ensure that one (Resident #82) of 73 residents in the total survey sample was provided with adequate and comfortable lighting at his bedside. Inadequate lighting can result in an increased risk for falls/accidents as well as potential psychological distress (anxiety/depression). The findings include: On 03/03/26 at10:27 AM, Resident #82 was observed resting in bed. The resident, in room [ROOM NUMBER] Bed D, shared a room with three other residents. His area of the room was observed to be dark without a light source. (photographic evidence obtained) Resident #82 stated he did not know why he did not have a light in his area of the room and it bothered him that it was so dark. Resident #82's roommate in Bed C stated he used to be in Bed D but had asked to move to Bed C so that he would have a working light fixture over the bed. room [ROOM NUMBER] Beds A, B and C were equipped with light fixtures on the wall at the head of the bed. The light fixtures were approximately four feet long and six inches high. (photographic evidence obtained) On 03/04/26 at 11:54 AM, an interview was conducted with the Director of Housekeeping and Laundry, who stated she had been employed by the facility for three years. She explained that daily and deep cleaning processes included dusting the light fixtures on the wall above the residents' beds. She verified that Bedroom [ROOM NUMBER], Bed D had no light fixture, but she had not reported that to Maintenance. A review of Resident #82's medical record revealed an admission date of 01/22/26 and diagnoses including unsteadiness on feet, generalized muscle weakness, other reduced mobility, absence of left leg below the knee and absence of right leg above the knee. A review of the resident's minimum data set (MDS) assessment, dated 01/28/26, revealed that the resident had a brief interview for mental status (BIMS) score of 11 out of 15 possible points, indicating moderate cognitive impairment. The resident had no indicators of psychosis, no physical or verbal behavioral symptoms directed towards others, and no rejection of care or wandering behaviors. The resident's functional abilities were assessed as: dependent for bed to chair transfer, eating with supervision; dependent for lower body dressing; substantial assistance for lying to sitting on side of bed; partial assistance for personal hygiene and upper body dressing; and substantial assistance for sit to lying and sit to stand. A review of Resident #82's care plan, revised 02/05/26, revealed a focus area indicating the resident had an activity of daily living (ADL) performance deficit related to bilateral amputee, cognitive issues and need for assistance with daily care tasks. Interventions included personal hygiene required partial assistance. A review of the facility's Resident Rights Policy, dated 07/2025, revealed: .Each resident has the right to be treated with dignity and respect .8. Reasonable Accommodations of Needs/Preferences .33. Safe/Clean/Comfortable/Homelike Environment . A review of the facility's Dignity Policy, dated 08/22/22, page 1 of 1, revealed: The Center must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life .

Based on a review of facility and resident records, staff interviews, and review of the Quality Assurance and Performance Improvement (QAPI) plan, the facility failed to have an effective QAPI process that used adverse event data to identify a Root Cause Analysis (RCA) and develop relevant performance improvement activities to prevent similar future events. Resident #1, with a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), who chewed and consumed briefs and disposable incontinence pads, was found unresponsive with feces and bits of blue plastic resembling incontinence pads in his mouth. As a result of the incident, Resident #1 died. Despite direct observation of the event by CNAs A, B, C, the unit manager (UM) and nurse practitioner (NP), the facility failed to thoroughly investigate in order to identify an RCA and develop measures needed to ensure the safety and protection of other residents at risk. This had the potential to affect 52 residents in the facility who were care planned for maladaptive behaviors. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 4:20 PM on July 1, 2025. On June 20, 2025 at 1:49 PM, Immediate Jeopardy (IJ) began. On July 2, 2025, at 6:30 PM, the Administrator was notified of the IJ determination, IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on July 2, 2025. The findings include:Cross Reference F600, F610 and F835A review of a facility report authored by the Director of Nursing (DON) on 6/27/25, revealed that on 6/20/25 at 1:49 PM, Resident #1 was observed unresponsive in bed by a certified nursing assistant (CNA). Upon entering the room, the Unit Manager (UM) observed brown stuff coming from Resident #1's mouth. Code Blue (a term used for a medical emergency involving respiratory or cardiac arrest) was paged and chest compressions were initiated. Emergency Medical Services (EMS) was also called. EMS arrived at the facility and took over cardiopulmonary resuscitation (CPR). Resident #1 was transported to the emergency room but did not survive. The report noted Resident #1's care plan indicated he had a behavior of eating his briefs/disposable incontinence pads. (Photographic evidence obtained)An interview was conducted with CNA B on 7/1/25 at 10:36 a.m. She reported finding (Resident#1) unresponsive with disposable incontinence pad pieces and feces in his mouth on 6/20/25. Resident #1 did not wear briefs or use disposable pads anymore. He had a brain injury and would chew on his socks, shirt and the incontinence pads or briefs. She stated she did not know how he got the incontinence pad.CNA C was interviewed on 7/1/25 at 11:13 AM. She worked on 6/20/25 and responded to a call for help in Resident #1's room. CNA B was trying to pull disposable incontinence pad pieces out of the resident's mouth. Strands of pads and feces were in his mouth, and feces was on his hand and leg.CNA A was interviewed on 7/1/25 at 1:40 PM. She was assigned to Resident #1 on 6/20/25 for the first time. At approximately 2:00 PM, she heard CNA B and someone else call for help. She responded to Resident #1's room and witnessed CNA B pulling stuff out his mouth with a hanger. A piece of a disposable pad this long (she used both hands to gesture the length of approximately 14 inches) came out. CNA B started chest compressions, and the Unit Manager (UM) arrived and took over. Pieces of the incontinence pad were on the floor. When paramedics arrived and took over compressions, another piece of a pad came out of his rectum. He pooped the pads out. She stated she heard Resident #1 passed away on the way to the hospital.The UM was interviewed on 7/1/25 at 2:38 PM. He stated Resident #1 had traumatic brain injury (TBI) with craniotomy (surgery to remove part of the skull to access the brain). On the day of the event, the UM was called to Resident #1's room. He entered the room and saw that Resident #1 was not exchanging air. The CNA said it looked like the resident was choking on feces, and there were some blue plastic particles mixed in that he later realized were pieces of the incontinence pad. CNA B started CPR. Resident #1 was in and out of consciousness and CPR continued until the paramedics arrived. Resident #1 expired, but the cause of death was not certain. The UM had seen him picking at his brief and trying to eat his socks in the past; he would eat anything.During a telephone interview with the Medical Examiner (ME) on 7/1/25 at 4:20 PM, he stated he performed the autopsy on Resident #1. When medics arrived at the facility, Resident #1's oral cavity was filled with feces mixed in with small pieces of disposable incontinence pad; feces and plastic stuff. He stated believed Resident #1 choked and that was how he died. When he opened the resident's cavity, it was full of the plastic material. The presence of feces in Resident #1's mouth indicated he was recycling it (defecating then eating the pad-tainted pieces).During an interview with Licensed Practical Nurse (LPN) A on 7/2/25 at 9:54 AM, she said Resident #1 was once reported trying to eat his incontinence brief. He would even tear his mattress and try to eat it. It was a new behavior every week.In an interview with the Director of Nursing (DON) on 7/2/25 at 10:30 AM, he said Resident #1 would try to eat everything around him, including his feces. The CNAs had to feed him so he could not get to the Styrofoam. Eating feces was kind of new but was not present on admission. Within a month or two, Resident #1 began pulling his briefs to shreds. Putting things in his mouth was also pretty new. He would try to eat his socks. That had been happening for a while. He would tear his mattress, and everything would go to his mouth so they removed everything they could.A review of Resident #1's record revealed he was admitted to the facility on [DATE], discharged [DATE] and readmitted [DATE]. The electronic medical record's (EMR's) landing page included a Special Instructions warning advising that Resident #1 should not be given, have within reach, or be left unattended if items were made from plastic, sponge, foam and paper. Disposable incontinence pads/bed padding/under padding, brief/ disposable incontinence briefs/diaper and pull-ups, except for mattresses, were barred. (Photographic evidence obtained) The resident's diagnoses included, but were not limited to, TBI (traumatic brain injury), hip fracture, unspecified protein-calorie malnutrition, muscle weakness, hemiplegia and hemiparesis (one sided weakness or paralysis) following cerebral infarction (stroke) affecting left non-dominant side, dysphagia oropharyngeal phase (difficulty initiating swallowing), cognitive communication deficit, need assistance with personal care, anxiety, depression, restlessness and agitation.The Quarterly Minimum Data Set (MDS) assessment, with a reference date 6/7/25, revealed that Resident #1 had severe cognitive impairment and was dependent on staff for activities of daily living including eating. He was frequently incontinent of bowel.A physician's order was obtained on 6/13/25 for no items made of plastic, sponge, foam and/or paper to be left within the resident's reach.A review of nursing progress notes revealed an entry dated 6/3/24 by the Psychiatric Nurse Practitioner (PNP) reporting that a CNA advised him Resident #1 was trying to eat his incontinence pads. (Photographic evidence obtained) A Nursing Alert progress note dated 6/17/24 advised that Resident #1 was found in bed eating a Styrofoam cup. He returned the remainder of the cup to the nurse but continued to chew and appeared to swallow the part of the cup that was in his mouth. The Nurse Practitioner (NP) was notified, and no new orders were given. (Photographic evidence obtained)Resident #1 was care planned on 6/2/24 for impaired or inappropriate behaviors related to his TBI. No specific description of inappropriate behavior was provided in the care plan after revisions were made on 6/10/24, 9/25/24, and 12/6/24. On 6/20/25, the care plan was revised to add, Resident removes his diapers, puts self on floor, slams leg against footrest/mattress, and eats briefs/[disposable pads]. (Photographic evidence obtained)The facility began an investigation on 6/20/25 and gathered written statements from multiple staff including the UM and CNAs A and B; all witnesses to the 6/20/25 event. CNA B's report, dated 6/25/25, noted the blue pieces of incontinence pads in the resident's mouth. (Photographic evidence obtained) No interviews were conducted as part of the investigation.On 7/2/25 at 12:40 PM, the Administrator was asked about the event and the results of her investigation. She said she was on leave but was advised of the incident. On 6/20/25, she instructed staff to conduct an Ad Hoc (impromptu) QAPI meeting, which she participated in via telephone. She presented the meeting minutes at this time and explained that the committee had not developed a performance improvement project (PIP) yet, because it would be a month or two before the medical examiner reports were released. The Administrator stated when she returned from leave, an investigation had already been completed. The Administrator was asked if she conducted any staff interviews as part of the investigation. She responded, no, only written statements were obtained.The Ad Hoc QAPI meeting minutes, dated 6/20/25, were reviewed. The reason for the meeting: The resident was stuffing noted non-eatable [sic] products, sent out 911 for vomiting feces/coded. Opportunity for Improvement: Resident stuffing non-eatable [sic] products in their mouth (i.e. adult briefs, [disposable incontinence pads], etc.). Data: Resident observed with [disposable pads] in mouth. Analysis: Resident is care planned for behavior of eating adult briefs and [disposable pads]. Plan: Not to have any briefs or [disposable pads] in patient's bed. Responsible Team: DON, Assistant DON, UMs and CNAs. A hand-written note on the form revealed that the Regional Nurse, CEO (Chief Executive Officer) and CNO (Chief Nursing Officer) had been notified on 6/20/25 by the DON and the Administrator. There was no root cause analysis completed (A structured process to identify the contributing factors or underlying cause of an adverse patient outcome. Analysis addresses what happened, why it happened, and what could be done to prevent future occurrences). The Administrator was asked if the QAPI committee had identified a root cause analysis. She replied, Like I said, I just got back and am still investigating, so no. (Photographic evidence obtained) A review of the facility's Quality Assurance Performance Improvement (QAPI) plan, dated 12/20/24, revealed that the purpose of the plan was to provide guidance for the overall quality improvement program. The guidelines drive the decision making as the Center always strives to exceed expectations and achieve quality outcomes. Decisions will be made to promote excellence and focus areas will include systems that affect quality of care and services. Each area of care and services should have a representative on the committee, and activities will cross service areas to address all concerns. Under the Responsibility and Accountability section the plan notes that the Administrator has responsibility and is accountable to the Risk Management, QAA (Quality Assessment and Assurance) Committee and Corporation to ensure QAPI is implemented throughout the Center. Under the Framework for QAPI section the policy states the committee will prioritize opportunities for improvement and determine which PIPs (Performance Improvement Plans) will be initiated. When an issue or problem is identified that is not systemic and does not require a PIP, the QAA committee will decide how to correct the issue or problem. These corrections may include an easy decision, corrective action plan, or rapid improvement cycle. The policy further stated factors that are considered high-risk will drive how potential PIPs will be identified. The final section, which described how the team would conduct the PIP, states the team will follow steps and processes needed for any quality improvement process. The team will use root cause analysis to ensure the root cause and contributing factors are identified. (Photographic evidence obtained)

Based on a review of facility and resident records, facility's policy and procedure titled Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI), and interviews with staff and outside medical professionals, the facility failed to conduct a thorough investigation to rule out abuse or neglect after one (Resident #1) of one resident with a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), who chewed and consumed incontinence briefs and disposable incontinence pads, was found unresponsive with feces and bits of blue plastic resembling incontinence pad pieces in his mouth. As a result of the incident, Resident #1 died. Despite direct observation of the event by CNAs A, B, C, the Unit Manager (UM) and Nurse Practitioner (NP), no interviews were obtained and there was no evidence verifying that a thorough record review was conducted. Only written statements, which omitted relevant information, were gathered for the investigation. Without a thorough analysis of adverse resident events, the facility was unable to identify causes and measures needed to ensure the safety and protection of other residents at risk. This failure had the potential to negatively impact all 52 residents in the facility who were care planned for behaviors. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 4:20 PM on July 1, 2025. On June 20, 2025 at 1:49 PM, Immediate Jeopardy (IJ) began. On July 2, 2025, at 6:30 PM, the Administrator was notified of the IJ determination, IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on July 2, 2025. The findings include:Cross Reference F600, F835, and F867An electronic medical record (EMR) review for Resident #1 revealed he was admitted to the facility on [DATE], discharged on 9/4/24, and readmitted on [DATE]. The EMR landing page included a Special Instructions warning on the dashboard advising that Resident #1 should not be given, have within reach, or be left unattended if items were made from plastic, sponge, foam and/or paper. As a result, all following items are barred from use [disposable incontinence pads]/bed padding/under padding, brief/ [adult disposable incontinence briefs]/diaper and pull-ups, except for mattresses. Items made from fabric are ideal . (Photographic evidence obtained) Diagnoses included, but were not limited to, traumatic brain injury (TBI), hip fracture, unspecified protein -calorie malnutrition, muscle weakness, hemiplegia and hemiparesis (one sided weakness or paralysis) following cerebral infarction (stroke) affecting left non-dominant side, dysphagia oropharyngeal phase (difficulty initiating swallowing), cognitive communication deficit, need for assistance with personal care, anxiety, depression, restlessness and agitation.The quarterly minimum data set (MDS) assessment, with a reference date of 6/7/25, revealed that Resident #1's brief interview for mental status score was 7 out of a possible 15 points, indicating severe cognitive impairment. He was frequently incontinent of bowel with no active toileting program. He was care planned on 6/2/24 for impaired or inappropriate behaviors related to his TBI (traumatic brain injury). On 6/20/25, the care plan was revised to add the following details: Resident removes his diapers, puts self on floor, slams leg against footrest/mattress, and eats briefs/[disposable pads]. Interventions did not address supervision or removal of such objects from his room. (Photographic evidence obtained)A review of the physician's order dated 6/13/25 prohibited exposure to plastic, sponge, foam and paper and barred disposable incontinence pads/bed padding/under padding, brief/disposable briefs/diaper and pull-ups, except for mattresses. There was no corresponding progress note to explain why this order was entered at this time.A progress note authored by the Unit Manager (UM) on 6/20/25 at 2:43 PM, revealed that at approximately 1:49 PM, a certified nursing assistant (CAN) called the UM to [Resident #1's] room. Resident #1 was found in bed, unresponsive, and in respiratory distress. Two CNAs were at bedside and a brown substance was coming from the resident's mouth. He had no pulse, was warm to the touch, and was difficult to arouse with a sternal rub. Fecal matter was scattered over the bed, the resident's body, hands and face. Chest compressions were initiated, Code Blue (term used for a medical emergency involving respiratory or cardiac arrest) was called, and Emergency Medical Services (EMS) was called for assistance. Rescue arrived at approximately 2:07 PM and the resident was transferred to the hospital at 2:25 p.m. (Photographic evidence obtained)A review of a facility report authored by the Director of Nursing (DON) on 6/27/25, revealed that on 6/20/25 at 1:45 PM, Resident #1 was observed unresponsive in bed by a certified nursing assistant (CNA). The CNA called the Unit Manager (UM) immediately and upon entering the room, the UM observed brown stuff coming from Resident #1's mouth. A Code Blue (term used for a medical emergency involving respiratory or cardiac arrest) was paged overhead and chest compressions were initiated. Emergency Medical Services (EMS) was also called. EMS arrived at the facility and took over cardiopulmonary resuscitation (CPR). Resident #1 was taken to the emergency room but did not survive. The facility's report noted that Resident #1's care plan indicated he had a behavior of eating his briefs/disposable incontinence pads. The report concluded that there was no diagnosis received from the emergency room (ER) and autopsy and toxicology reports were pending but normally took two months to receive. The report also noted that an Adult Protective Investigator (API) came to the facility to investigate following a call she received from the sheriff's office. (Photographic evidence obtained)A review of the Adult Protective Investigator's (API's) 6/21/25 investigative report revealed that on 6/20/25, Resident #1 was pronounced deceased while in the care of the facility. He required 24-hour supervision, and the facility knew he liked to put things in his mouth. Resident #1 was left around those things and should have been supervised. He was able to put things in his mouth which possibly led to his death, but it was unknown if that was the cause. On 6/21/25, the API visited the facility and obtained interviews with staff involved. Supervisor A stated she was not in the building when the incident occurred but was aware that Resident #1 was hospitalized two or three months ago for placing inappropriate items in his mouth, including plastic forks, [disposable incontinence] pads, and adult diapers (briefs). According to Supervisor A, Resident #1's care plan should have included instructions for keeping these items out of his room. She also noted that this resident was not on one-on-one (1:1) supervision at the time. The report noted that CNA A stated 6/20/25 was her first day assigned to Resident #1 but no one informed her that he was not supposed to have incontinence pads in his room. CNA A also stated it was CNA B and CNA C who discovered Resident #1 with a disposable pad in his mouth, which had feces wrapped in it. When CNA A arrived at Resident #1's room, CNA B was attempting to remove the pad from the resident's mouth while the supervisor retrieved the emergency cart. CNA A reported she was informed by the UM at 3:00 PM that Resident #1 was not supposed to have disposable incontinence pads or briefs in his room due to his tendency to ingest them. CNA A stated she believed that Resident #1 should have been on one-on-one (1:1) supervision due to his behavior. During the API's interview, CNA A became emotional, began to cry and stated she had previously told the UM this resident needed one-on-one supervision. The staff dismissed her concerns saying she was trying to act like a supervisor. In the API's interview with Resident #1's family member, he explained that the facility contacted him and reported that Resident #1 was found eating his feces and an incontinence pad; behavior Resident #1 exhibited while living with family, which was part of the reason he was placed in a facility. (Photographic evidence obtained)The facility's investigation file into the 6/20/25 incident was reviewed. The file consisted of written statements from multiple staff members who reported they had seen nothing unusual or nothing at all. The statement from the UM, dated 6/20/25, noted a brown substance in Resident #1's mouth, but said nothing about blue material. He wrote that EMS initially reported a possible homicide, thinking someone stuffed incontinence pads down the resident's mouth/throat. CNA B's report, dated 6/25/25, documented her observation of blue pads mixed with feces protruding from Resident #1's mouth during the event. (Photographic evidence obtained) CNA A's undated statement omitted all information of her direct witness to the blue material coming from the resident's mouth or rectum. There was no written statement by CNA C, who was in the room during the event. The investigation file was void of any staff interviews and was not reflective of a comprehensive record review in an effort to determine what happened or how blue foreign particles were discovered in Resident #1's feces.An interview was conducted with CNA B on 7/1/25 at 10:36 AM. She found Resident#1 unresponsive with several pieces of disposable incontinence pad pieces and feces in his mouth. She removed them with her fingers. Resident #1 had a brain injury and would chew on his socks, shirt and the incontinence pads or briefs. She did not know how he got the pad as he did not use disposable pads or briefs anymore because he would chew them. She was diligent in making sure Resident #1 was visible from the hall by making sure his window treatments and privacy curtains were pulled back, and the bed was placed so the resident's face could be seen from the hall. Resident #1 was not on one-on-one supervision. CNA B was not interviewed by any staff member after the event. She was only interviewed by the API.CNA C was interviewed on 7/1/25 at 11:13 AM. She stated she heard CNA B yelling for the nurse, so she ran to Resident #1's room. CNA B was trying to pull disposable pads out of the resident's mouth. There were strands of pads and feces in his mouth, and feces on his hand and leg. CNA B removed the pads, then she and CNA C laid him back down and started CPR (cardiopulmonary resuscitation). There was no plastic pad under the resident, and he was not wearing a brief, but he had been doing that, eating them. The CNAs reported it, and the UM was trying to figure out what to do and what to tell everyone to do. She thought the resident's physician knew about it. As far as she was aware, this behavior was new and had only been occurring for about four weeks. Resident #1 couldn't get up independently, so no one knew how he got an incontinence pad. No one from the facility interviewed her after the event, which she said she found strange since she was in the room at the time. CNA A was interviewed on 7/1/25 at 1:40 PM. She was assigned to Resident #1 for the first time on 6/20/25. She said she saw Resident #1 eating his brief about two weeks ago when she worked on the locked unit for the first time. She went to Resident #1's room around 2:00 PM after hearing calls for help. When she entered the room she saw CNA B was pulling stuff out of his mouth with a hanger, and a disposable pad this long (she used both hands to gesture the length of approximately 14 inches) came out. She stated the resident's jaw was locked, and his tongue was sticking out. CNA B was trying to use the hanger to get the material out his mouth, but she was unsuccessful. CNA B started chest compressions, and the UM showed up and took over. Pieces of the incontinence pad were on the ground. When paramedics arrived and took over compressions, another piece of a pad came out of his rectum. He pooped the pads out. The next day (6/21/25) adult protective services came to the facility. CNA A stated she told the UM two weeks prior to the incident that she saw Resident #1 eating his briefs. CNA A stated the UM said, We have it under control. and accused the CNAs of breaking protocol. CNA A stated, We told [Licensed Practical Nurse (LPN) A] too but were told the residents on that unit always did that. CNA A concluded by reporting that no one from the facility interviewed her as part of an investigation into the event.The UM was interviewed on 7/1/25 at 2:38 PM. He confirmed that he responded to calls for help on 6/20/25 and found Resident #1 was not exchanging air. The UM stated the CNA said it looked like the resident was choking on feces. Resident #1 ate his feces and there were some blue particles he later realized were particles of incontinence pads. Resident #1's mouth was open, and it looked like he was choking. CNA B started CPR, which continued until paramedics arrived. Resident #1 expired, but the cause of death was not certain. The UM had seen the resident picking at his brief and trying to eat his socks; he would eat anything. Resident #1 defecated on the incontinence pads a lot, so that was what he was eating, but there were no remnants of a pad anywhere in the room. The facility investigated and obtained written statements but nothing unusual was reported.A telephone interview was conducted with the Medical Examiner (ME) on 7/1/25 at 4:20 PM. He confirmed that he performed the autopsy on Resident #1. He reported the resident had a head injury, and there was a non-food items order on the resident's chart. When EMS arrived, Resident #1's oral cavity was filled with feces mixed in with small pieces of disposable incontinence pads; feces and plastic stuff. He stated he believed Resident #1 choked and that was how he died. When he opened the resident's cavity, it was full of the plastic material. The presence of feces in Resident #1's mouth indicated he was recycling it (defecating then eating the pad-tainted pieces). The ME stated at one point he just got tired of picking the material out piece-by-piece, as there was so much. He stated the body did not produce enzymes to break down plastic.A telephone interview was conducted with the Adult Protective Investigator (API) on 7/2/25 at 7:30 AM. She verified the accuracy of the interviews documented in her report dated 6/21/25. She said she had a phone conversation with a family member who reported that the facility was aware of Resident #1's behavior on admission; he was eating items and feces in the past while living at home. This was why he was admitted to the facility.On 7/2/25 at 12:40 PM, the Administrator was asked about the 6/20/25 event. She stated she was on leave but was advised of the incident. She was told that Resident #1 had feces in his mouth. She did not know if Resident #1 aspirated or choked. When police arrived to investigate, they said they were trying to rule out homicide due to the presence of what appeared to be incontinence pads in the resident's mouth. She stated she had been told of the small pieces of what appeared to be pads in his mouth, but the resident had not had access to those items for a long time. The Administrator acknowledged the physician's order prohibiting access to those items was not obtained until 6/13/25; one week before the incident. When advised the resident also defecated the blue material during the event, she said she had not been told that. She was asked if she investigated the incident. She said when she returned from leave, the investigation was already completed. The administrator was asked if she conducted any staff interviews as part of the investigation. She responded no and again insisted the investigation had been completed in her absence. She confirmed that only written statements were obtained. When asked if she realized how dangerous pica behavior/ingesting inedible objects was, she replied, I am not a nurse, so I don't know anything about pica. The Administrator acknowledged the presence of non-food items in Resident #1's mouth along with feces should have warranted a more thorough investigation and that interviews with staff involved would have likely revealed additional pertinent information. The Administrator was advised that the written statements failed to reflect details of what staff actually said they saw. She had no response. She returned to the conference room at 1:26 PM with scattered handwritten notes on a legal pad. She said she had been told by the UM that Resident #1 was picking at his plastic incontinence pads but would also pick at cloth ones. The UM had used a Yankauer device to suction the resident's mouth and noticed bits of feces and shreds of little blue plastic pieces in the feces. Pieces were coming from his mouth and rectum and were on his hands. She pointed to a handwritten note indicating that statements had been obtained but interviews were needed. There was also a question about the root cause. Another note was a reminder to identify other residents with behaviors. The Administrator said she heard Resident #1's jaws were locked so he could have had a seizure. She stated since he had never eaten feces prior to this, that was a question she also had. The Administrator had no awareness of pica behaviors observed during his initial admission in 2024; she was not here then. This writer advised her those notes were in the electronic medical record (EMR). She said she did not know why the CNAs weren't telling the nurses about the resident's behavior. She was advised that interviews were obtained to the contrary during the survey. Had she interviewed staff she may have had this information. A review of the facility's policy titled Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI) (undated), revealed:Intent: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences and protect its residents. Stated under section V. Investigation: The facility will investigate different types of violations, identify and interview all involved persons, including witnesses, and others who might have knowledge of the allegations. The investigation will focus on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and provide complete and thorough documentation of the investigation. (Photographic evidence obtained)

Based on a review of facility and resident records, the facility's policy and procedure titled Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI), and interviews with staff and outside medical professionals, the facility failed to protect Resident #1's right to be free from neglect, by failing to ensure adequate supervision and safeguards to prevent the resident, with a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), from consuming his incontinence pad, choking and dying. On June 20, 2025 at 1:49 PM, Resident #1 was found in his bed unresponsive with feces and bits of blue plastic resembling incontinence pad pieces in his mouth. Resuscitation efforts were initiated, and he was transported to the hospital by Emergency Medical Services (EMS), but resuscitation efforts failed. The Medical Examiner discovered during an autopsy that Resident #1 was full of foreign blue matter. The facility's failure to adequately supervise a resident with behavioral issues, resulting in his death, has the potential to negatively affect 52 other residents with behavioral care plans from a total of 173 residents residing in the facility. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 4:20 PM on July 1, 2025. On June 20, 2025 at 1:49 PM, Immediate Jeopardy (IJ) began. On July 2, 2025, at 6:30 PM, the Administrator was notified of the IJ determination, IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on July 2, 2025.The findings include:Cross reference F610, F835, and F867A review of a facility report authored by the Director of Nursing (DON) on 6/27/25, revealed that on 6/20/25 at 1:49 PM, Resident #1 was observed unresponsive in bed by a certified nursing assistant (CNA). The CNA called the Unit Manager (UM) immediately and upon entering the room, the UM observed brown stuff coming from Resident #1's mouth. A Code Blue (term used for a medical emergency involving respiratory or cardiac arrest) was paged overhead and chest compressions were initiated. Emergency Medical Services (EMS) was also called. EMS arrived at the facility and took over cardiopulmonary resuscitation (CPR). Resident #1 was taken to the emergency room but did not survive. An adult protective investigator (API) came to the facility, following a call she received from the sheriff's office, to investigate. The facility's report noted that Resident #1 was care planned for his behavior of eating his briefs/disposable incontinence pads. The report concluded that there was no diagnosis received from the emergency room (ER) and autopsy and toxicology reports were pending but normally took two months to receive. (Photographic evidence obtained)A review of the Adult Protective Investigator's (API's) 6/21/25 investigative report revealed that on 6/20/25, Resident #1 was pronounced deceased while in the care of the facility. He required 24-hour supervision, and the facility knew he liked to put things in his mouth. Resident #1 was left around those things and should have been supervised. He was able to put things in his mouth which possibly led to his death, but it was unknown if that was the cause. On 6/21/25, the API visited the facility and obtained interviews with staff involved. Supervisor A stated she was not in the building when the incident occurred but was aware that Resident #1 was hospitalized two or three months ago for placing inappropriate items in his mouth, including plastic forks, [disposable incontinence] pads, and adult diapers (briefs). According to Supervisor A, Resident #1's care plan should have included instructions for keeping these items out of his room. She also noted that this resident was not on one-on-one (1:1) supervision at the time. The report noted that CNA A stated 6/20/25 was her first day assigned to Resident #1 but no one informed her that he was not supposed to have incontinence pads in his room. CNA A also stated it was CNA B and CNA C who discovered Resident #1 with a disposable pad in his mouth, which had feces wrapped in it. When CNA A arrived at Resident #1's room, CNA B was attempting to remove the pad from the resident's mouth while the supervisor retrieved the emergency cart. CNA A reported she was informed by the UM at 3:00 PM that Resident #1 was not supposed to have disposable incontinence pads or briefs in his room due to his tendency to ingest them. CNA A stated she believed that Resident #1 should have been on one-on-one (1:1) supervision due to his behavior. During the API's interview, CNA A became emotional, began to cry and stated she had previously told the UM this resident needed one-on-one supervision. The staff dismissed her concerns saying she was trying to act like a supervisor. In the API's interview with Resident #1's family member, he explained that the facility contacted him and reported that Resident #1 was found eating his feces and an incontinence pad; behavior Resident #1 exhibited while living with family, which was part of the reason he was placed in a facility. (Photographic evidence obtained)An interview was conducted with CNA B on 7/1/25 at 10:36 AM. She reported recently finding Resident#1 unresponsive with several disposable incontinence pad pieces in his mouth. Feces were on the pad. She stated she could not say that was why he coded though. She picked up a hand full of leaves from the ground as an example of much material she found in his mouth (a small handful). She stated she removed pieces of the incontinence pad from the resident's mouth with her fingers, and when she did, he flinched. CNA B stated Resident #1 did not wear briefs or use disposable pads anymore. He had a brain injury and would chew on his socks, shirt, the pads and/or his briefs. She did not know how he got the pad she found in his mouth. The UM had recently advised the CNAs never to use the plastic pads, as the resident would chew on them. Resident #1's CNA that day was new to him and had only worked on the locked unit two or three times. CNA B did not know if the assigned CNA put the incontinence pad in the room, nor did she know where the rest of the pad (other than what she pulled from his mouth) was. She stated she felt terrible about the situation for three days. She was diligent in making sure Resident #1 was visible from the hall by making sure his window treatments and privacy curtains were pulled back, and he was placed so you could see his face from the hall. Resident #1 was not on one-on-one supervision.CNA C was interviewed on 7/1/25 at 11:13 AM. She stated she typically worked in the locked unit and usually had about 14 residents assigned to her, which kept her very busy. Residents were checked every two hours. On 6/20/25, she was across the hall and heard CNA B yelling for the nurse, so she ran into Resident #1's room. CNA B was trying to pull disposable incontinence pads out of the resident's mouth. There were strands of pads and feces in his mouth, and feces on his hand and leg. CNA B removed the pads, then she and CNA C laid him back down and started CPR (cardiopulmonary resuscitation). There was no plastic pad under Resident #1, and he was not wearing a brief, but he had been doing that, eating them. The CNAs reported it, and the UM was trying to figure out what to do and what to tell everyone to do. She thought the resident's physician knew about it. As far as she was aware, this behavior was new and had only been occurring for about four weeks. Resident #1 couldn't get up independently, so no one knew how he got an incontinence pad. He was taken to the hospital, and she found out that he didn't make it. He was gasping when she last saw him, so he was still breathing.CNA A was interviewed on 7/1/25 at 1:40 PM. She explained that she normally worked on another unit. The first time she worked in the locked unit, she saw Resident #1 eating his brief. This was about two weeks ago. She removed the brief and took it out of the room, but no one ever told her he could not have plastic briefs or pads. Later she saw him eating a cracker, and he was not supposed to have those because he could choke. She was assigned to Resident #1 on 6/20/25. When she first got to the locked unit, she was warned that Resident #1 would hit and kick, so CNA B volunteered to provide the resident's incontinence care that day. Since she had never worked with him before, CNA A agreed. She stated she was not used to those types of behaviors. She fed Resident #1 breakfast that morning and he sucked it down like a vacuum. He was not on one-on-one supervision, but she said he should have been. CNA A recalled that Resident #1 was not wearing brief, only shorts. There was no disposable pad. Later that day, CNA C said she had seen a pad on his bed but took it off. No one told her he couldn't be around briefs or pads. At about 2:00 PM, she was assisting a resident in another room, when she heard CNA B and someone else call out, [UM's name]! It's [Resident #1]! CNA A went to the room and when she went in, CNA B was pulling stuff out his mouth with a hanger, and a disposable pad this long (she used both hands to gesture the length of approximately 14 inches) came out. She stated the resident's jaw was locked and his tongue was sticking out. CNA B was trying to use the hanger to get the material out his mouth, but she was unsuccessful. CNA B started chest compressions, and the UM showed up and took over. Pieces of the incontinence pad were on the ground. CNA A stated she thought Resident #1's feces may have smelled like collard greens, which was what she fed him for lunch. He had asked for more greens after lunch. Maybe he ate the feces. There was no pad on the bed and Resident #1 could not move. When paramedics arrived and took over compressions, another piece of a pad came out of his rectum. He pooped the pads out. She stated she heard Resident #1 passed away on the way to the hospital. The next day (6/21/25) adult protective services came to the facility. Resident #1's entire chart was down/inaccessible, and when it became available again, a banner appeared on the chart. It was this whole huge warning about not providing incontinence pads or diapers. CNA A stated she told the UM two weeks prior to the incident that she saw Resident #1 eating his briefs. CNA A stated the UM said, We have it under control and accused the CNAs of breaking protocol. CNA A stated, We told [Licensed Practical Nurse (LPN) A] too but were told the residents on that unit always did that.The UM was interviewed on 7/1/25 at 2:38 PM. He stated there were a lot of resident behaviors on the locked dementia unit. No specific behavioral training was provided upon hire; they just used basic strategies. Any information related to medical history that came with a resident was put in the care plan on admission. When a behavior was reported or observed, it was documented and added to the care plan. CNAs could document on behaviors and a care warning could be placed on the electronic medical record (EMR) dashboard. The nurse would also notify the psychiatric nurse practitioner (PNP) or the physician. Resident #1 had a TBI (traumatic brain injury) with craniotomy (surgery to remove part of the skull to access the brain). He was combative with staff, cursed and bossed them around, kicked and punched at them. On the day of the event, the UM was at the nurses' station. The CNA called him to come to Resident #1's room. He went and could see Resident #1 was not exchanging air. The UM stated the CNA said it looked like the resident was choking on feces. He ate his feces and there were some blue particles he later realized were particles of an incontinence pad. Resident #1's mouth was open, and it looked like he was choking. The UM stated he ran, grabbed the crash cart, called Code Blue, and then called 911. CNA B started CPR. Resident #1 was in and out of consciousness and CPR continued until paramedics arrived. Resident #1 expired but the cause of death was not certain. The diagnosis of pica was not on his chart, but it was not a new behavior. The psychiatry service was aware. The UM stated he had seen Resident #1 picking at his brief and trying to eat his socks; he would eat anything. Resident #1 did not have one-on-one supervision, but the UM put documentation in his chart indicating no more briefs. This was on Friday the 13th (6/13/25). This was also put on the dashboard in the EMR. Resident #1 was care planned for no plastic, disposable pads, or anything like that. The facility investigated and got written statements from staff. Nothing unusual was reported and the CNAs who found the resident didn't say anything was different about him. They watched for disposable pads, but it may have been a brief too. He could not say where or when the resident obtained it. Resident #1 defecated a lot in the pads, so that was what he was eating, but there were no remnants of a pad anywhere in the room. The UM was asked if a KUB (abdominal x-ray) was ordered after discovering the resident was eating non-food items. He did not know. He stated Resident #1 had a history of this behavior according to CNA B, but that information was nowhere in the chart. The behavior resurfaced maybe a week before he put it in the resident's chart, and he advised CNA B to only use cloth pads. The UM stated he took the information to the Interdisciplinary Team and the Director of Nursing (DON) said, Ok, we will look into it. Eventually the environmental team provided the unit with cloth incontinence pads, but it took some time. Resident #1 had a fabric pad under him on 6/20/25. The UM stated he was unaware of the long strands of disposable incontinence pads on the floor. He said perhaps he didn't notice because they were covered with feces.The nurse practitioner (NP) was interviewed on 7/1/25 at 3:20 PM. She stated she came to the facility three times a week and Resident #1 was her resident. This was only the second time she had seen this resident, so she didn't know him that well. He had aggressive behaviors and would hit, kick, box, and once snarled at her. He was an eater. They called her to report he ate a sock one day, but she didn't know what to do about that. She was present on the day of the event (6/20/25) but had not been in the resident's room. When she got to him on 6/20/25, CPR had already been started. The UM had already suctioned out a lot of stuff but she did not know what it was. The UM used something like a Yankauer (a suction tip used for suctioning fluids and debris from a patient's airway) to get matter out. The NP used her hand to gesture a digging motion. It was really a Code [NAME] (a hospital code that generally refers to a hazardous spill that requires special handling). The NP stated Resident #1 would tear his sheets; he was an eater, like a toddler. His behavior was such that he was hard to work with. The disposable pad thing was addressed often. The UM made sure there were no plastic materials. The NP speculated that maybe it was an incontinence brief that they found in his mouth. She stated it was unfortunate but given the gravity of his issues, she did not know what more they could have done to prevent it. She asked herself if there was anything she could have done but felt that there was nothing more that could have done. When asked if additional supervision had been considered, she did not reply.A telephone interview was conducted with the Medical Examiner (ME) on 7/1/25 at 4:20 PM. He confirmed that he performed the autopsy on Resident #1. He reported the resident had a head injury, and there was a non-food items order on the resident's chart. When EMS arrived, Resident #1's oral cavity was filled with feces mixed in with small pieces of disposable incontinence pads; feces and plastic stuff. He stated he believed Resident #1 choked and that was how he died. When he opened the resident's cavity, it was full of the plastic material. The presence of feces in Resident #1's mouth indicated he was recycling it (defecating then eating the pad-tainted pieces). The ME found aspirated feces deep in the lungs and the resident's airway was stained with feces. Everything was contaminated. The ME stated he removed chunks of the material and digestive contents. He speculated it would take several days for the pad material to pass through the digestive system. The foreign matter extended past the resident's stomach; it was blue plastic with what looked like absorbent mesh. He stated he was surprised there was no obstruction or perforations, and he surgically removed a 6x6 centimeter square of white matter. At one point he just got tired of picking the material out piece-by-piece. The ME concluded by explaining that the material was not going to break down in the digestive tract, as the body did not produce enzymes to break down plastic.A telephone interview was conducted with the Adult Protective Investigator (API) on 7/2/25 at 7:30 AM. She verified the information in her report dated 6/21/25. She said she had a phone conversation with family who reported the facility was aware of Resident #1's behavior on admission. He was eating items and feces in the past while living at home. This was why he was admitted to the facility. She stated CNA B told her she had asked the nurses for one-on-one staffing but was told to stop acting like a supervisor; they already had it under control.During an interview with Licensed Practical Nurse (LPN) A on 7/2/25 at 9:54 AM, she said she worked on 6/20/25 but was not assigned to Resident #1. She was on break when he coded (cardiac/respiratory arrest). The UM advised her that the resident was in respiratory distress, had fecal matter all over him and coded. He said he had never seen anything like it. She gave Resident #1 his medications that morning. He was not on a disposable pad but was chewing his gown. She retrieved scissors and cut the tag off the gown. He would eat anything if you let him. Anything. The CNAs once reported he was trying to eat his brief. He would even tear his mattress and try to eat it. It was a new behavior every week. She did not know when the behavior started. The UM had written something, and the behavior was care planned, but he was not on one-on-one supervision. LPN A said she was familiar with pica behavior. All you must do is take items out of his reach. LPN A stated the new nurse practitioner (NP) came to the Code Blue. The psychiatric nurse practitioner (PNP) also worked with Resident #1, but medication did not always work. Resident #1 was polypharmacy (using multiple medications), but the PNP could not stop his aggressive behavior. LPN A stated psychotropic drugs (drugs that affect one's mental state) also make you eat a lot, so nothing worked in reducing Resident #1's desire to eat. She said, He was miserable and simply needed Jesus. At one point the PNP told her, I am maxed out (with meds); I don't know what more to do.An interview with the DON on 7/2/25 at 10:30 AM revealed that Resident #1 required total care and total assistance with transfers. He would try to eat everything around him, including his feces. The CNAs had to feed him so he could not get to the Styrofoam. Eating feces was kind of new but was not present on admission. Within a month or two, Resident #1 began pulling his briefs to shreds. Putting things in his mouth was also pretty new. The DON denied awareness of the 2024 incident when Resident #1 ingested a Styrofoam cup but reported that he would try to eat his socks. That had been happening for a while. He would tear his mattress, and everything would go to his mouth, so they removed everything they could. Staff kept Resident #1 in the TV room during the day to supervise him. These behaviors were discussed in our meetings. When asked what interventions were implemented to keep Resident #1 safe, The DON replied, Spoon-feeding and removing everything from his room. He said he thought Resident #1 had been care planned for his behavior from the start. He was followed by psychiatric services, was on medication, and the Medical Director (MD) knew of his behavior. The DON stated he was not present for the 6/20/25 event, but CNA A told him there were small pieces of blue incontinence pads in his mouth. The UM also reported this to him; that was why they did not use disposable pads for Resident #1. He was not sure how long the pads had been in his system, and speculated there were probably very long pieces present. He thought Resident #1 defecated and re-ingested them. There was a large amount of feces in the resident's mouth. The DON was unaware that during CPR, Resident #1 defecated pieces of blue plastic material.The MDS coordinator (MDSC) was interviewed on 7/2/25 at 11:45 AM. She explained that during morning meetings the team reviewed nursing and CNA notes about resident behaviors. They followed up with the psychiatric NP as needed. She knew Resident #1 but did not recall him chewing/eating incontinence pads or briefs. The MDSC reviewed Resident #1's care plan and confirmed it was not revised to include eating non-food items including briefs and incontinence pads until 6/20/25. She said she wished previous care plans had been more specific. The interdisciplinary team was responsible for developing care plan goals and interventions. She was not advised of Resident #1's behavior until the UM told her, and she was not sure what interventions were in place on the nursing unit. The MDSC knew about the dangers of pica behavior and took it very seriously.An electronic medical record (EMR) review for Resident #1 revealed he was admitted to the facility on [DATE], discharged on 9/4/24, and readmitted on [DATE]. The EMR landing page included a Special Instructions warning on the dashboard advising that Resident #1 should not be given, have within reach, or be left unattended if items were made from plastic, sponge, foam and/or paper. As a result, all following items are barred from use [disposable incontinence pads]/bed padding/under padding, brief/ [adult disposable incontinence briefs]/diaper and pull-ups, except for mattresses. Items made from fabric are ideal . (Photographic evidence obtained) Diagnoses included, but were not limited to, traumatic brain injury (TBI), hip fracture, unspecified protein -calorie malnutrition, muscle weakness, hemiplegia and hemiparesis (one sided weakness or paralysis) following cerebral infarction (stroke) affecting left non-dominant side, dysphagia oropharyngeal phase (difficulty initiating swallowing), cognitive communication deficit, need for assistance with personal care, anxiety, depression, restlessness and agitation.The quarterly minimum data set (MDS) assessment, with a reference date of 6/7/25, revealed that Resident #1's brief interview for mental status score was 7 out of a possible 15 points, indicating severe cognitive impairment. Inattention, disorganized thinking and altered level of consciousness fluctuated. Resident #1 used a wheelchair for mobility and was dependent on staff for activities of daily living including eating. He was frequently incontinent of bowel with no active toileting program. Resident #1 received routine antidepressant and anticonvulsant medications.Resident #1 was care planned on 6/2/24 for impaired or inappropriate behaviors related to his TBI. No specific description of inappropriate behavior was provided in the care plan. The goal was to be free from behavior through the next review. Interventions included medications as ordered, monitor for side effects and effectiveness; If reasonable, discuss resident's behavior. Explain why behavior is inappropriate or unacceptable to the resident. Provide a program of activities that accommodates the resident's status. Provide non-pharmacological interventions. Revisions were made on 6/10/24, 9/25/24, and 12/6/24; however, there were no changes to the interventions and no specific behaviors described until 6/20/25 to add, I.E. Resident removes his diapers, puts self on floor, slams leg against footrest/mattress, and eats briefs/[disposable pads]. (Photographic evidence obtained)A physician's order dated 6/13/25 instructed, [Resident #1] should not be given, have within reach or be left unattended if items are made from plastic, sponge, foam and paper. As a result, all following items are barred from use [disposable incontinence pads]/bed padding/under padding, brief/ [disposable incontinence briefs]/diaper and pull-ups, except for mattresses. Items made from fabric are ideal, therefore they are acceptable. There was no corresponding progress note to justify why this order was entered at this time.The physician's order for behavior monitoring, dated 1/22/25, instructed to monitor for: Itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, and refusal of care. There were no revisions or instructions to monitor Resident #1 for placing inedible objects and items into his mouth or eating them. (Photographic evidence obtained)A review of nursing progress notes revealed an entry dated 6/3/24 by the psychiatric nurse practitioner (PNP) reporting that a CNA advised him that Resident #1 was trying to eat his [incontinence pads]. (Photographic evidence obtained) A Nursing Alert progress note dated 6/17/24 advised that Resident #1 was found in bed eating a Styrofoam cup. He returned the remainder of the cup to the nurse but continued to chew and appeared to swallow the part of the cup that was in his mouth. The Nurse Practitioner (NP) was notified, and no new orders were given. (Photographic evidence obtained)Further review of the record found no orders for diagnostic tests or imaging after ingesting part of the Styrofoam cup.A review of additional progress notes found that contrary to staff interviews, no information about Resident #1 tearing and/or eating inedible items including briefs or incontinence pads was documented until 6/20/25 at 2:43 PM when the UM described the incident. The note said at approximately 1:49 PM, a CNA called the UM to [Resident #1's] room. Upon arrival, Resident #1 was found in bed, unresponsive and in respiratory distress. Both eyes were open, and two CNAs were at bedside. A brown substance was coming from the resident's mouth. He had no pulse, skin was warm to the touch, and he was very difficult to arouse with a sternal rub. Fecal matter was scattered over the bed, the resident's body, hands and face. His skin was pale and bilateral (both) lower extremities were bluish purple. Chest compressions were initiated, Code Blue was called, and Emergency Medical Services (EMS) was called for assistance. Resident #1 started responding as evidenced by chest rise, a weak carotid pulse, and slight improvement in skin color. Rescue arrived at approximately 2:07 PM. The resident was in and out of consciousness when EMS arrived and was transferred to the hospital at 2:25 PM. (Photographic evidence obtained)The NP's Discharge summary, dated [DATE], stated Resident #1 had a medical emergency, was transferred to the ER and was discharged . He had last been seen on 5/20/25 for a monthly visit. There was no mention of blue material or feces in Resident #1's mouth. (Photographic evidence obtained) Further review of the record found no notes by the NP, Psychiatric NP, Physician or Psychologist about Resident #1 ingesting inedible items.On 7/2/25 at 12:40 PM, the Administrator was asked about the 6/20/25 event. She stated she was on leave but was advised of the incident. She was told that Resident #1 had feces in his mouth. She did not know if Resident #1 aspirated or choked. When police arrived to investigate, they said they were trying to rule out homicide due to the presence of what appeared to be incontinence pads in the resident's mouth. She stated she had been told of the small pieces of what appeared to be pads in his mouth, but the resident had not had access to those items for a long time. The Administrator was advised, and acknowledged, the physician's order prohibiting access to those items was not obtained until 6/13/25; one week before the incident. When she was advised that the resident also defecated the blue material during CPR, she said she had not been told that.In a second interview with the Administrator on 7/2/25 at 1:26 PM, she explained that the UM told her Resident #1 had been picking at his plastic incontinence pads but also picked at cloth pads. On the day of the event, while suctioning Resident #1's mouth with a Yankauer suction device, the UM noticed feces and shreds of little blue pieces of plastic inside the resident's mouth. The matter was also coming from the resident's rectum, and he had feces in his hand. The psychiatric NP told the Administrator he had not noted any such behavior. He said with TBI, any type of behavior could occur. The Administrator stated she had not known of these behaviors as the only warning the nurses gave her was to watch out, he kicks. The Administrator said she did not understand why the CNAs were not telling the nurses about the resident's behavior. She was advised that the CNAs said they had notified nursing but were told to stand down. She confirmed that Resident #1 was never on increased supervision but said they would provide one-on-one staffing if needed. This was the first time she had ever been advised that Resident #1 was ingesting inedible items. Nothing had ever been in the 24-hour reports, which she reviewed daily.In an interview with the Medical Director (MD) on 7/2/25 at 1:19 PM, she said she had not been advised that Resident #1 was attempting to ingest inedible objects. She was in the building frequently and only knew of him kicking. She heard he was sent to the hospital but could not remember if staff told her about the plastic. The NP usually brought this type of information to her attention. Resident #1 was followed by the psychiatric NP. Had she been aware of the behavior, she would have referred to him so there were not two providers involved.A review of the facility's policy titled Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI) (undated), revealed the purpose was to assure that the facility was doing all that was within its control to prevent occurrences of ANEMMI and protect its residents. The policy stated an alleged violation was a situation or occurrence that was observed or reported by staff, a resident, relative, visitor, another health care provider, or others, but had not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to . neglect. The policy defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish or emotional distress . The policy vowed residents would be protected from neglect by having structures and processes to provide needed care and services including identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. It stated the facility would analyze the supervision of staff on all shifts to identify inappropriate behaviors, including residents with self-injurious behavior. (Photographic evidence obtained)

Based on a review of facility and resident records, facility job descriptions, policies and procedures, and interviews with staff and medical professionals, the facility's Administration failed to provide oversight of the facility in a manner that ensured necessary interventions, including supervision, were in place for Resident #1's safety when he had a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), and consistently chewed/consumed his briefs and disposable incontinence pads. On June 20, 2025 at 1:49 PM, Resident #1 was found in his bed unresponsive with feces and bits of blue plastic resembling incontinence pad pieces in his mouth. Resuscitation efforts were initiated, and he was transported to the hospital by Emergency Medical Services (EMS), but resuscitation efforts failed, and the resident expired. Despite numerous staff members' awareness of the resident's behaviors, neither the Administrator nor the Medical Director had knowledge of the behaviors or risk factors for this resident's safety. Administration failed to exact immediate action following an event resulting Resident #1's death, failed to implement measures for resident safety, and failed to thoroughly investigate the incident to identify system failures and facility needs. This affected one (Resident #1) of three residents reviewed for behavioral issues, from a total of 52 residents with behavioral care plans. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 4:20 PM on July 1, 2025. On June 20, 2025 at 1:49 PM, Immediate Jeopardy (IJ) began. On July 2, 2025, at 6:30 PM, the Administrator was notified of the IJ determination, IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on July 2, 2025. The findings include:Cross reference F600, F610, and F867 A review of a facility report authored by the Director of Nursing (DON) on 6/27/25, revealed that on 6/20/25 at 1:49 PM, Resident #1 was observed unresponsive in bed by a certified nursing assistant (CNA). The Unit Manager (UM) responded and observed brown stuff coming from Resident #1's mouth. Code Blue (a term used for a medical emergency involving respiratory or cardiac arrest) was paged overhead, chest compressions were initiated, and Emergency Medical Services (EMS) was called. Upon arrival, EMS took over cardiopulmonary resuscitation (CPR). Resident #1 was transported to the emergency room but did not survive. An Adult Protective Investigator (API) came to the facility following a call she received from the sheriff's office. The facility's report noted that Resident #1 was care planned for his behavior of chewing/eating his briefs/disposable incontinence pads. The report concluded that there was no diagnosis received from the emergency room (ER) and autopsy and toxicology reports were pending. (Photographic evidence obtained)A review of the Adult Protective Investigator's (API's) 6/21/25 investigative report revealed that on 6/20/25, Resident #1 was pronounced deceased while in the care of the facility. He required 24-hour supervision, and the facility knew he liked to put things in his mouth. Resident #1 was left around those things and should have been supervised. During her visit to the facility on 6/21/25, the API interviewed Supervisor A, who reported Resident #1 was hospitalized two or three months ago for placing inappropriate items in his mouth, including plastic forks, [disposable incontinence] pads, and adult diapers/briefs. According to Supervisor A, Resident #1's care plan should have included instructions for keeping these items out of his room. The report noted that Certified Nursing Assistant (CAN) A was assigned to Resident #1 on 6/20/25, but no one informed her that he was not supposed to have incontinence pads in his room. CNA B and CNA C discovered Resident #1 with a disposable incontinence pad in his mouth, which had feces wrapped in it. CNA A saw CNA B attempting to remove the pads from the resident's mouth. At 3:00 PM that day, the UM told the API that Resident #1 was not supposed to have disposable pads or diapers in his room due to his tendency to ingest them. The API concluded by saying she believed Resident #1 should be on one-on-one supervision due to his behavior. CNA A became emotional, began to cry and stated she had previously told the UM this resident needed one-on-one supervision. The staff dismissed her concerns, saying she was trying to act like a supervisor. In the API's interview with Resident #1's family member, the family member explained that the facility contacted him and reported that the resident was found eating his feces and an incontinence pad; behavior Resident #1 exhibited while living with family, which was part of the reason he was placed in a facility. (Photographic evidence obtained)An interview was conducted with CNA B on 7/1/25 at 10:36 a.m. She reported recently finding (Resident#1) unresponsive with disposable incontinence pad pieces in his mouth. Feces were on the pad. She stated she could not say that was why he coded though. She picked up a hand full of leaves from the ground as an example of much material she found in his mouth (a small handful). She stated she removed pieces of the incontinence pad from the resident's mouth with her fingers, and when she did, he flinched. CNA B stated Resident #1 did not wear briefs or use disposable pads anymore. He had a brain injury and would chew on his socks, shirt, the pads and/or his briefs. She did not know how he got the pad she found in his mouth. The UM had recently advised the CNAs never to use the plastic pads, as the resident would chew on them. Resident #1's CNA that day was new to him and had only worked on the locked unit two or three times. CNA B did not know if the assigned CNA put the incontinence pad in the room, nor did she know where the rest of the pad (other than what she pulled from his mouth) was. She stated she felt terrible about the situation for three days. She was diligent in making sure Resident #1 was visible from the hall by making sure his window treatments and privacy curtains were pulled back, and he was placed so you could see his face from the hall. Resident #1 was not on one-on-one supervision.CNA C was interviewed on 7/1/25 at 11:13 AM. She stated she typically worked in the locked unit and usually had about 14 residents assigned to her, which kept her very busy. Residents were checked every two hours. On 6/20/25, she was across the hall and heard CNA B yelling for the nurse, so she ran into Resident #1's room. CNA B was trying to pull disposable incontinence pads out of the resident's mouth. There were strands of pads and feces in his mouth, and feces on his hand and leg. CNA B removed the pads, then she and CNA C laid him back down and started CPR (cardiopulmonary resuscitation). There was no plastic pad under Resident #1, and he was not wearing a brief, but he had been doing that, eating them. The CNAs reported it, and the UM was trying to figure out what to do and what to tell everyone to do. She thought the resident's physician knew about it. As far as she was aware, this behavior was new and had only been occurring for about four weeks. Resident #1 couldn't get up independently, so no one knew how he got an incontinence pad. He was taken to the hospital, and she found out that he didn't make it. He was gasping when she last saw him, so he was still breathing.CNA A was interviewed on 7/1/25 at 1:40 PM. She explained that she normally worked on another unit. The first time she worked in the locked unit, she saw Resident #1 eating his brief. This was about two weeks ago. She removed the brief and took it out of the room, but no one ever told her he could not have plastic briefs or pads. Later she saw him eating a cracker, and he was not supposed to have those because he could choke. She was assigned to Resident #1 on 6/20/25. When she first got to the locked unit, she was warned that Resident #1 would hit and kick, so CNA B volunteered to provide the resident's incontinence care that day. Since she had never worked with him before, CNA A agreed. She stated she was not used to those types of behaviors. She fed Resident #1 breakfast that morning and he sucked it down like a vacuum. He was not on one-on-one supervision, but she said he should have been. CNA A recalled that Resident #1 was not wearing brief, only shorts. There was no disposable pad. Later that day, CNA C said she had seen a pad on his bed but took it off. No one told her he couldn't be around briefs or pads. At about 2:00 PM, she was assisting a resident in another room, when she heard CNA B and someone else call out, [UM's name]! It's [Resident #1]! CNA A went to the room and when she went in, CNA B was pulling stuff out his mouth with a hanger, and a disposable pad this long (she used both hands to gesture the length of approximately 14 inches) came out. She stated the resident's jaw was locked and his tongue was sticking out. CNA B was trying to use the hanger to get the material out his mouth, but she was unsuccessful. CNA B started chest compressions, and the UM showed up and took over. Pieces of the incontinence pad were on the ground. CNA A stated she thought Resident #1's feces may have smelled like collard greens, which was what she fed him for lunch. He had asked for more greens after lunch. Maybe he ate the feces. There was no pad on the bed and Resident #1 could not move. When paramedics arrived and took over compressions, another piece of a pad came out of his rectum. He pooped the pads out. She stated she heard Resident #1 passed away on the way to the hospital. The next day (6/21/25) adult protective services came to the facility. Resident #1's entire chart was down/inaccessible, and when it became available again, a banner appeared on the chart. It was this whole huge warning about not providing incontinence pads or diapers. CNA A stated she told the UM two weeks prior to the incident that she saw Resident #1 eating his briefs. CNA A stated the UM said, We have it under control and accused the CNAs of breaking protocol. CNA A stated, We told [Licensed Practical Nurse (LPN) A] too but were told the residents on that unit always did that.The UM was interviewed on 7/1/25 at 2:38 PM. He stated there were a lot of resident behaviors on the locked dementia unit. No specific behavioral training was provided upon hire; they just used basic strategies. Any information related to medical history that came with a resident was put in the care plan on admission. When a behavior was reported or observed, it was documented and added to the care plan. CNAs could document on behaviors and a care warning could be placed on the electronic medical record (EMR) dashboard. The nurse would also notify the psychiatric nurse practitioner (PNP) or the physician. Resident #1 had a TBI (traumatic brain injury) with craniotomy (surgery to remove part of the skull to access the brain). He was combative with staff, cursed and bossed them around, kicked and punched at them. On the day of the event, the UM was at the nurses' station. The CNA called him to come to Resident #1's room. He went and could see Resident #1 was not exchanging air. The UM stated the CNA said it looked like the resident was choking on feces. He ate his feces and there were some blue particles he later realized were particles of an incontinence pad. Resident #1's mouth was open, and it looked like he was choking. The UM stated he ran, grabbed the crash cart, called Code Blue, and then called 911. CNA B started CPR. Resident #1 was in and out of consciousness and CPR continued until paramedics arrived. Resident #1 expired but the cause of death was not certain. The diagnosis of pica was not on his chart, but it was not a new behavior. The psychiatry service was aware. The UM stated he had seen Resident #1 picking at his brief and trying to eat his socks; he would eat anything. Resident #1 did not have one-on-one supervision, but the UM put documentation in his chart indicating no more briefs. This was on Friday the 13th (6/13/25). This was also put on the dashboard in the EMR. Resident #1 was care planned for no plastic, disposable pads, or anything like that. The facility investigated and got written statements from staff. Nothing unusual was reported and the CNAs who found the resident didn't say anything was different about him. They watched for disposable pads, but it may have been a brief too. He could not say where or when the resident obtained it. Resident #1 defecated a lot in the pads, so that was what he was eating, but there were no remnants of a pad anywhere in the room. The UM was asked if a KUB (abdominal x-ray) was ordered after discovering the resident was eating non-food items. He did not know. He stated Resident #1 had a history of this behavior according to CNA B, but that information was nowhere in the chart. The behavior resurfaced maybe a week before he put it in the resident's chart, and he advised CNA B to only use cloth pads. The UM stated he took the information to the Interdisciplinary Team and the Director of Nursing (DON) said, Ok, we will look into it. Eventually the environmental team provided the unit with cloth incontinence pads, but it took some time. Resident #1 had a fabric pad under him on 6/20/25. The UM stated he was unaware of the long strands of disposable incontinence pads on the floor. He said perhaps he didn't notice because they were covered with feces.The nurse practitioner (NP) was interviewed on 7/1/25 at 3:20 PM. She stated she came to the facility three times a week and Resident #1 was her resident. This was only the second time she had seen this resident, so she didn't know him that well. He had aggressive behaviors and would hit, kick, box, and once snarled at her. He was an eater. They called her to report he ate a sock one day, but she didn't know what to do about that. She was present on the day of the event (6/20/25) but had not been in the resident's room. When she got to him on 6/20/25, CPR had already started. The UM had already suctioned out a lot of stuff but she did not know what it was. The UM used something like a Yankauer (a suction tip used for suctioning fluids and debris from a patient's airway) to get matter out. The NP used her hand to gesture a digging motion. It was really a Code [NAME] (a hospital code that generally refers to a hazardous spill that requires special handling). The NP stated Resident #1 would tear his sheets; he was an eater, like a toddler. His behavior was such that he was hard to work with. The disposable pad thing was addressed often. The UM made sure there were no plastic materials. The NP speculated that maybe it was an incontinence brief that they found in his mouth. She stated it was unfortunate but given the gravity of his issues, she did not know what more they could have done to prevent it. She asked herself if there was anything she could have done but felt that there was nothing more that could have done. When asked if additional supervision had been considered, she did not reply.A telephone interview was conducted with the Medical Examiner (ME) on 7/1/25 at 4:20 PM. He confirmed that he performed the autopsy on Resident #1. He reported the resident had a head injury, and there was a non-food items order on the resident's chart. When EMS arrived, Resident #1's oral cavity was filled with feces mixed in with small pieces of disposable incontinence pads; feces and plastic stuff. He stated he believed Resident #1 choked and that was how he died. When he opened the resident's cavity, it was full of the plastic material. The presence of feces in Resident #1's mouth indicated he was recycling it (defecating then eating the pad-tainted pieces). The ME found aspirated feces deep in the lungs and the resident's airway was stained with feces. Everything was contaminated. The ME stated he removed chunks of the material and digestive contents. He speculated it would take several days for the pad material to pass through the digestive system. The foreign matter extended past the resident's stomach; it was blue plastic with what looked like absorbent mesh. He stated he was surprised there was no obstruction or perforations, and he surgically removed a 6x6 centimeter square of white matter. At one point he just got tired of picking the material out piece-by-piece. The ME concluded by explaining that the material was not going to break down in the digestive tract, as the body did not produce enzymes to break down plastic.A telephone interview was conducted with the Adult Protective Investigator (API) on 7/2/25 at 7:30 AM. She verified the information in her report dated 6/21/25. She said she had a phone conversation with family who reported the facility was aware of Resident #1's behavior on admission. He was eating items and feces in the past while living at home. This was why he was admitted to the facility. She stated CNA B told her she had asked the nurses for one-on-one staffing but was told to stop acting like a supervisor; they already had it under control.During an interview with Licensed Practical Nurse (LPN) A on 7/2/25 at 9:54 AM, she said she worked on 6/20/25 but was not assigned to Resident #1. She was on break when he coded (cardiac/respiratory arrest). The UM advised her that the resident was in respiratory distress, had fecal matter all over him and coded. He said he had never seen anything like it. She gave Resident #1 his medications that morning. He was not on a disposable pad but was chewing his gown. She retrieved scissors and cut the tag off the gown. He would eat anything if you let him. Anything. The CNAs once reported he was trying to eat his brief. He would even tear his mattress and try to eat it. It was a new behavior every week. She did not know when the behavior started. The UM had written something, and the behavior was care planned, but he was not on one-on-one supervision. LPN A said she was familiar with pica behavior. All you must do is take items out of his reach. LPN A stated the new nurse practitioner (NP) came to the Code Blue. The psychiatric nurse practitioner (PNP) also worked with Resident #1, but medication did not always work. Resident #1 was polypharmacy (using multiple medications), but the PNP could not stop his aggressive behavior. LPN A stated psychotropic drugs (drugs that affect one's mental state) also make you eat a lot, so nothing worked in reducing Resident #1's desire to eat. She said, He was miserable and simply needed Jesus. At one point the PNP told her, I am maxed out (with meds); I don't know what more to do.An interview with the DON on 7/2/25 at 10:30 AM revealed that Resident #1 required total care and total assistance with transfers. He would try to eat everything around him, including his feces. The CNAs had to feed him so he could not get to the Styrofoam. Eating feces was kind of new but was not present on admission. Within a month or two, Resident #1 began pulling his briefs to shreds. Putting things in his mouth was also pretty new. The DON denied awareness of the 2024 incident when Resident #1 ingested a Styrofoam cup but reported that he would try to eat his socks. That had been happening for a while. He would tear his mattress, and everything would go to his mouth, so they removed everything they could. Staff kept Resident #1 in the TV room during the day to supervise him. These behaviors were discussed in our meetings. When asked what interventions were implemented to keep Resident #1 safe, The DON replied, Spoon-feeding and removing everything from his room. He said he thought Resident #1 had been care planned for his behavior from the start. He was followed by psychiatric services, was on medication, and the Medical Director (MD) knew of his behavior. The DON stated he was not present for the 6/20/25 event, but CNA A told him there were small pieces of blue incontinence pads in his mouth. The UM also reported this to him; that was why they did not use disposable pads for Resident #1. He was not sure how long the pads had been in his system, and speculated there were probably very long pieces present. He thought Resident #1 defecated and re-ingested them. There was a large amount of feces in the resident's mouth. The DON was unaware that during CPR, Resident #1 defecated pieces of blue plastic material.The MDS coordinator (MDSC) was interviewed on 7/2/25 at 11:45 AM. She explained that during morning meetings the team reviewed nursing and CNA notes about resident behaviors. They followed up with the psychiatric NP as needed. She knew Resident #1 but did not recall him chewing/eating incontinence pads or briefs. The MDSC reviewed Resident #1's care plan and confirmed it was not revised to include eating non-food items including briefs and incontinence pads until 6/20/25. She said she wished previous care plans had been more specific. The interdisciplinary team was responsible for developing care plan goals and interventions. She was not advised of Resident #1's behavior until the UM told her, and she was not sure what interventions were in place on the nursing unit. The MDSC knew about the dangers of pica behavior and took it very seriously.An electronic medical record (EMR) review for Resident #1 revealed he was admitted to the facility on [DATE], discharged on 9/4/24, and readmitted on [DATE]. The EMR landing page included a Special Instructions warning on the dashboard advising that Resident #1 should not be given, have within reach, or be left unattended if items were made from plastic, sponge, foam and/or paper. As a result, all following items are barred from use [disposable incontinence pads]/bed padding/under padding, brief/ [adult disposable incontinence briefs]/diaper and pull-ups, except for mattresses. Items made from fabric are ideal . (Photographic evidence obtained) Diagnoses included, but were not limited to, traumatic brain injury (TBI), hip fracture, unspecified protein -calorie malnutrition, muscle weakness, hemiplegia and hemiparesis (one sided weakness or paralysis) following cerebral infarction (stroke) affecting left non-dominant side, dysphagia oropharyngeal phase (difficulty initiating swallowing), cognitive communication deficit, need for assistance with personal care, anxiety, depression, restlessness and agitation.The quarterly minimum data set (MDS) assessment, with a reference date of 6/7/25, revealed that Resident #1's brief interview for mental status score was 7 out of a possible 15 points, indicating severe cognitive impairment. Inattention, disorganized thinking and altered level of consciousness fluctuated. Resident #1 used a wheelchair for mobility and was dependent on staff for activities of daily living including eating. He was frequently incontinent of bowel with no active toileting program. Resident #1 received routine antidepressant and anticonvulsant medications.Resident #1 was care planned on 6/2/24 for impaired or inappropriate behaviors related to his TBI. No specific description of inappropriate behavior was provided in the care plan. The goal was to be free from behavior through the next review. Interventions included medications as ordered, monitor for side effects and effectiveness; If reasonable, discuss resident's behavior. Explain why behavior is inappropriate or unacceptable to the resident. Provide a program of activities that accommodates the resident's status. Provide non-pharmacological interventions. Revisions were made on 6/10/24, 9/25/24, and 12/6/24; however, there were no changes to the interventions and no specific behaviors described until 6/20/25 to add, I.E. Resident removes his diapers, puts self on floor, slams leg against footrest/mattress, and eats briefs/[disposable pads]. (Photographic evidence obtained)A physician's order dated 6/13/25 instructed, [Resident #1] should not be given, have within reach or be left unattended if items are made from plastic, sponge, foam and paper. As a result, all following items are barred from use [disposable incontinence pads]/bed padding/under padding, brief/ [disposable incontinence briefs]/diaper and pull-ups, except for mattresses. Items made from fabric are ideal, therefore they are acceptable. There was no corresponding progress note to justify why this order was entered at this time.The physician's order for behavior monitoring, dated 1/22/25, instructed to monitor for: Itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, and refusal of care. There were no revisions or instructions to monitor Resident #1 for placing inedible objects and items into his mouth or eating them. (Photographic evidence obtained)A review of nursing progress notes revealed an entry dated 6/3/24 by the psychiatric nurse practitioner (PNP) reporting that a CNA advised him that Resident #1 was trying to eat his [incontinence pads]. (Photographic evidence obtained) A Nursing Alert progress note dated 6/17/24 advised that Resident #1 was found in bed eating a Styrofoam cup. He returned the remainder of the cup to the nurse but continued to chew and appeared to swallow the part of the cup that was in his mouth. The Nurse Practitioner (NP) was notified, and no new orders were given. (Photographic evidence obtained)Further review of the record found no orders for diagnostic tests or imaging after ingesting part of the Styrofoam cup.A review of additional progress notes found that contrary to staff interviews, no information about Resident #1 tearing and/or eating inedible items including briefs or incontinence pads was documented until 6/20/25 at 2:43 PM when the UM described the incident. The note said at approximately 1:49 PM, a CNA called the UM to [Resident #1's] room. Upon arrival, Resident #1 was found in bed, unresponsive and in respiratory distress. Both eyes were open, and two CNAs were at bedside. A brown substance was coming from the resident's mouth. He had no pulse, skin was warm to the touch, and he was very difficult to arouse with a sternal rub. Fecal matter was scattered over the bed, the resident's body, hands and face. His skin was pale and bilateral (both) lower extremities were bluish purple. Chest compressions were initiated, Code Blue was called, and Emergency Medical Services (EMS) was called for assistance. Resident #1 started responding as evidenced by chest rise, a weak carotid pulse, and slight improvement in skin color. Rescue arrived at approximately 2:07 PM. The resident was in and out of consciousness when EMS arrived and was transferred to the hospital at 2:25 PM. (Photographic evidence obtained)The NP's Discharge summary, dated [DATE], stated Resident #1 had a medical emergency, was transferred to the ER and was discharged . He had last been seen on 5/20/25 for a monthly visit. There was no mention of blue material or feces in Resident #1's mouth. (Photographic evidence obtained) Further review of the record found no notes by the NP, Psychiatric NP, Physician or Psychologist about Resident #1 ingesting inedible items.On 7/2/25 at 12:40 p.m., the Administrator was asked about the 6/20/25 event and the results of her investigation. She stated she was on leave but was advised of the incident. She was told that Resident #1 had feces in his mouth. She did not know if Resident #1 aspirated or choked. When police arrived to investigate, they said they were trying to rule out homicide due to the presence of what appeared to be incontinence pads in the resident's mouth. The Administrator had been told of the small pieces of what appeared to be pads in his mouth, but he had not had access to those items for a long time. The Administrator was advised, and acknowledged, the physician's order prohibiting access to those items was not obtained until 6/13/25; one week before the incident. When she was advised that the resident also defecated the blue plastic material, she said she had not been told that. On 6/20/25, while not present in the facility, she instructed staff to conduct an Ad Hoc (impromptu) Quality Assessment and Performance Improvement (QAPI) meeting, which she participated in via telephone. She presented the meeting minutes at this time and explained the committee had not developed a Performance Improvement Plan (PIP) yet, because it would be a month or two before the medical examiner's reports were released. She was asked if she investigated the incident. She said when she returned from leave, the investigation was already completed. She was asked if she conducted any staff interviews as part of her investigation. She responded no, and again insisted the investigation was completed in her absence. Only written statements were obtained. When asked if she realized how dangerous pica behavior/ingesting inedible objects was, she replied, I am not a nurse, so don't know anything about pica. She acknowledged that the presence of non-food items in Resident #1's mouth along with feces should have warranted a more thorough investigation and that interviews with staff involved would likely have revealed additional information. The Administrator was advised that the written statements collected from staff failed to reflect details of what they said they actually saw. She had no response.The 6/20/25 Ad Hoc QAPI meeting minutes were reviewed. The meeting was chaired by the Director of Nursing (DON). The reason for the meeting: The resident was stuffing noted non-eatable [sic] products, sent out 911 for vomiting feces/coded. Opportunity for Improvement: Resident stuffing non-eatable [sic] products in their mouth (i.e. adult briefs, [disposable incontinence pads], etc. Data: Resident observed with [disposable pads] in mouth. Analysis: Resident is care planned for behavior of eating adult briefs and [disposable pads]. Plan: Not to have any briefs or [disposable pads] in patient's bed. Responsible Team: DON, Assistant DON, UMs and CNAs. A hand-written note on the form said the Regional Nurse, CEO (Chief Executive Officer) and CNO (Chief Nursing Officer) had been notified on 6/20/25 by the DON and the Administrator. There was no root cause analysis completed (A structured process to identify the contributing factors or underlying cause of an adverse patient outcome. Analysis addresses what happened, why it happened, and what could be done to prevent future occurrences). The Administrator was asked if the QAPI committee had identified a root cause analysis. She replied, Like I said, I just got back and am still investigating, so no. (Photographic evidence obtained)In an interview with the Medical Director (MD) on 7/2/25 at 1:19 PM, she said she had not been advised that Resident #1 was attempting to ingest inedible objects. She was in the building frequently and only knew of him kicking. She heard he was sent to the hospital but could not remember if staff told her about the plastic. She said the NP usually brought this type of information to her attention. Resident #1 was followed by the psychiatric nurse practitioner (PNP). Had she been aware of the resident's behavior, she would have referred to him so there were not two providers involved.In a second interview with the Administrator on 7/2/25 at 1:26 PM, she explained that the UM told her Resident #1 had been picking at his plastic incontinence pads but also picked at cloth pads. On the day of the event, while suctioning Resident #1's mouth with a Yankauer device, the UM noticed feces and shreds of little blue pieces inside the resident's mouth. The matter was also coming from the resident's rectum, and he had feces in his hand. The PNP told her he had not noted any such behaviors, and he said with a TBI (traumatic brain injury), any type of behavior could occur. She had not known of these behaviors, as the only warning the nurses gave her was to watch out, he kicks. The Administrator said she did not understand why the CNAs were not telling the nurses about the resident's behavior. She was advised that they said they had reported to nursing but were told to stand down. She confirmed that Resident #1 was never on increased supervision but said they would provide one-on-one staffing if [NAME][TRUNCATED]

Based on a review of facility and resident records, the facility's policy titled Charting and Documentation, and interviews with staff, the facility failed to maintain medical records for each resident that were accurately documented and reflective of one (Resident #1) of three residents reviewed for behavioral issues, from a total of 52 residents with behavioral care plans.The findings include:A review of a facility report authored by the Director of Nursing (DON) on [DATE], revealed that on [DATE] at 1:49 PM, Resident #1 was observed unresponsive in bed by a certified nursing assistant (CNA). The CNA called the Unit Manager (UM) immediately and upon entering the room, the UM observed brown stuff coming from Resident #1's mouth. A Code Blue (term used for a medical emergency involving respiratory or cardiac arrest) was paged overhead and chest compressions were initiated. Emergency Medical Services (EMS) was also called. EMS arrived at the facility and took over cardiopulmonary resuscitation (CPR). Resident #1 was transported to the emergency room but did not survive. There was no mention of disposable incontinence pads at the scene other than Resident #1's care plan, which indicated that he had a behavior of eating them. (Photographic evidence obtained)A review of the Adult Protective Investigator's (API's) [DATE] investigative report revealed that she visited the facility and obtained interviews with staff involved in the [DATE] event. Supervisor A (no longer employed) stated Resident #1 was hospitalized two or three months ago for placing inappropriate items in his mouth, including plastic forks, [disposable incontinence] pads, and adult briefs. Certified Nursing Assistant (CNA) A, CNA B and CNA C discovered Resident #1 with a disposable incontinence pad in his mouth, which had feces wrapped in it. Resident #1 was not supposed to have disposable pads or briefs in his room due to his tendency to ingest them. (Photographic evidence obtained)In an interview with CNA B on [DATE] at 10:36 AM, she said she found Resident#1 unresponsive with feces and disposable incontinence pad pieces in his mouth. Resident #1 would chew on his socks, shirt and the pads or briefs. She stated she did not know how he got the incontinence pad.CNA C was interviewed on [DATE] at 11:13 AM. She stated she worked on [DATE] and when she ran into Resident #1's room during the event, CNA B was trying to pull disposable pads out of his mouth. There were strands of pads and feces in his mouth. There was no plastic pad under Resident #1, and he was not wearing a brief, but he had been doing that, eating them. She said this behavior had been occurring for about four weeks.CNA A stated in an interview on [DATE] at 1:40 PM that the first time she worked in the locked unit was about two weeks ago, and at that time she saw Resident #1 eating his brief. She said she told the Unit Manager (UM) and he replied, We have it under control. He then accused the CNAs of breaking protocol. The CNAs also told Licensed Practical Nurse (LPN) A but were told the residents on that unit always did that. On [DATE], CNA A responded to the call to Resident #1's room and witnessed CNA B pulling stuff out his mouth with a hanger. A piece of a disposable pad this long (she used both hands to gesture the length of approximately 14 inches) came out. When paramedics arrived and took over compressions, another piece of a pad came out of his rectum. He pooped the pads out. The next day ([DATE]) adult protective services came to the facility. Resident #1's entire chart was down/inaccessible, and when it became available again, a banner appeared on the chart. It was this whole huge warning about not providing incontinence pads or diapers.The UM was interviewed on [DATE] at 2:38 PM. He stated when a behavior was reported or observed, it was documented and added to the care plan. CNAs could document on behaviors and a care warning could be placed on the electronic medical record's (EMR's) dashboard. The nurse would also notify the psychiatric nurse practitioner (PNP) or the physician. Resident #1 had a TBI (traumatic brain injury) with craniotomy (surgery to remove part of the skull to access the brain). On the day of the event, the UM responded to the call for help. The UM stated the CNA said it looked like the resident was choking on feces. There were some blue particles he later realized were particles of an incontinence pad. The UM stated he had seen Resident #1 picking at his brief and trying to eat his socks; he would eat anything. The UM stated he wrote orders and added them on the chart on [DATE] for no more briefs. This was also put on the EMR dashboard. Resident #1 had a history of this behavior according to CNA B, but that information was nowhere in the chart. The UM stated the behavior resurfaced maybe a week before he put it into the chart.During an interview with Licensed Practical Nurse (LPN) A on [DATE] at 9:54 AM, she said Resident #1 He would eat anything if you let him, anything. The CNAs once reported he was trying to eat his brief. He would even tear his mattress and try to eat it. It was a new behavior every week.In an interview with the Director of Nursing (DON) on [DATE] at 10:30 AM, he said Resident #1 would try to eat everything around him, including his feces. The CNAs had to feed him so he could not get to the Styrofoam. Eating feces was kind of new but was not present on admission. Within a month or two, the resident began pulling his diapers to shreds. Putting things in his mouth was also pretty new. He would try to eat his socks. That had been happening for a while. He would tear his mattress, and everything would go to his mouth so they removed everything they could. The DON was asked why the facility's report, that he authored, omitted any information regarding finding what appeared to be disposable pads in Resident #1's mouth. He said he thought he included that information in the report.A review of Resident #1's medical record revealed that he was admitted to the facility on [DATE], discharged [DATE] and readmitted [DATE]. His diagnoses included, but were not limited to, traumatic brain injury (TBI), hip fracture, unspecified protein -calorie malnutrition, muscle weakness, hemiplegia and hemiparesis (one sided weakness or paralysis) following cerebral infarction (stroke) affecting left non-dominant side, dysphagia oropharyngeal phase (difficulty initiating swallowing), cognitive communication deficit, need assistance with personal care, anxiety, depression, restlessness and agitation.The Quarterly Minimum Data Set (MDS) assessment with a reference date [DATE], revealed Resident #1 had severe cognitive impairment and was dependent on staff for activities of daily living, including eating.A physician's order was obtained on [DATE] revealing that Resident #1 should not be given, have within reach or be left unattended if items were made from plastic, sponge, foam and/or paper. As a result, all following items are barred from use: [disposable incontinence pads]/bed padding/under padding, brief/ [disposable incontinence briefs]/diaper and pull-ups, except for mattresses. Items made from fabric are ideal, therefore they are acceptable. There was no corresponding progress note or explanation for why the order was obtained.A nursing progress note by the Psychiatric Nurse Practitioner (PNP), dated [DATE], reported that a CNA told him Resident #1 was trying to eat his incontinence pads. A Nursing Alert progress note dated [DATE] advised that Resident #1 was found in bed eating a Styrofoam cup. He returned the remainder of the cup to the nurse but continued to chew and appeared to swallow the part of the cup that was in his mouth. The Nurse Practitioner (NP) was notified. (Photographic evidence obtained) Despite knowledge of the behaviors, neither the Nurse Practitioner (NP) nor the PNP entered that information into their assessments as an alert or a behavior. A review of nursing progress notes since the [DATE] entry, found no documentation verifying that Resident #1 was eating inedible objects as witnessed in the past by CNAs A, B, C, LPN A and the UM.Resident #1 was care planned on [DATE] for impaired or inappropriate behaviors related to his TBI. No specific description of inappropriate behavior was provided in the care plan, even after revisions were made on [DATE], [DATE], and [DATE]. The goal was to be free from behavior through the next review. Interventions were generic and failed to include information about inedible objects. On [DATE], the day Resident #1 died, the care plan was revised to add, Resident removes his diapers, puts self on floor, slams leg against footrest/mattress, and eats brief/[disposable pads]. (Photographic evidence obtained)The facility began an investigation of the event on [DATE] and gathered written statements from multiple staff members including the UM and CNAs A and B; all direct witnesses to the [DATE] event. The only person to note Resident #1 had blue pieces of incontinence pad in his mouth was CNA B on [DATE]. (Photographic evidence obtained) CNA A's and the UM's statements omitted any information of their direct witness to the blue material in the resident's mouth or rectum. There was no written statement by CNA C or the NP, both present during the event and who also witnessed the foreign matter in Resident #1's mouth.On [DATE] at 12:40 PM, the Administrator was asked about her investigation. She advised that the investigation was complete and had been done while she was on leave. She was advised that not only the facility's report, but all except one written statement obtained during the investigation failed to reflect any information about pieces of blue incontinence pad coming from Resident #1's mouth or rectum. The Administrator had no response or explanation for why that information was left out of the investigation.On [DATE] at 1:26 PM, during a second interview with the Administrator, she said this was the first time she had ever been advised that Resident #1 was ingesting inedible items. Nothing had ever been documented in the 24-hour reports, which she reviewed daily.A review of the facility's policy titled Charting and Documentation (revised [DATE]), revealed that any changes in the resident's medical, physical, functional or psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. This is to include objective observations and changes in the residents' condition. Documentation in the medical record will be complete and accurate, in accordance with state law and facility policy. (Photographic evidence obtained)

Based on a review of facility and resident records, a review of the facility's policy and procedure titled Care Plan-Comprehensive, and interviews with staff and medical professionals, the facility failed to develop and implement a comprehensive person-centered care plan detailing a focused problem area and specific interventions needed to protect one (Resident #1) of one resident with a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), from consuming incontinence pads. This affected one (Resident #1) of three residents reviewed for behavioral issues, from a total of 52 residents with behavioral care plans.The findings include:A review of a facility report authored by the Director of Nursing (DON) on 6/27/25, revealed that on 6/20/25 at 1:49 PM, Resident #1 was observed unresponsive in bed by a certified nursing assistant (CNA). The CNA called the Unit Manager (UM) immediately and upon entering the room, the UM observed brown stuff coming from Resident #1's mouth. A Code Blue (term used for a medical emergency involving respiratory or cardiac arrest) was paged overhead and chest compressions were initiated. Emergency Medical Services (EMS) was also called. EMS arrived at the facility and took over cardiopulmonary resuscitation (CPR). Resident #1 was taken to the emergency room but did not survive. The facility's report noted that Resident #1 was care planned for his behavior of eating his briefs/disposable incontinence pads. (Photographic evidence obtained)A review of the Adult Protective Investigator's (API's) 6/21/25 investigative report revealed that she visited the facility and obtained interviews with staff involved about the 6/20/25 event. Supervisor A (no longer employed) stated she was not in the building when the incident occurred but was aware that Resident #1 was hospitalized two or three months ago for placing inappropriate items in his mouth, including plastic forks, [disposable incontinence] pads, and adult briefs. According to Supervisor A, Resident #1's care plan should have included instructions for keeping these items out of his room. She also noted this resident was not on one-on-one (1:1) supervision at the time. Certified Nursing Assistant (CNA) A stated 6/20/25 was her first day assigned to Resident #1 but no one informed her that he was not supposed to have incontinence pads in his room. CNA A further stated it was CNA B and CNA C who discovered Resident #1 with a disposable incontinence pad in his mouth, which had feces wrapped in it. CNA A reported she was informed by the Unit Manager (UM) at 3:00 PM on the day of the event that Resident #1 was not supposed to have disposable pads or diapers in his room due to his tendency to ingest them. She concluded by saying she believed Resident #1 should have been on one-on-one supervision due to his behaviors. During the API's interview with Resident #1's family member, the family member explained that Resident #1 exhibited these behaviors while living with family, which was part of the reason he was placed in a facility. (Photographic evidence obtained)An interview was conducted with CNA B on 7/1/25 at 10:36 AM. She reported finding (Resident#1) unresponsive with pieces of disposable incontinence pad in his mouth. Feces were on the pad and several pieces were in his mouth. She removed them with her fingers. Resident #1 did not wear briefs or use disposable incontinence pads anymore. He had a brain injury and would chew on his socks, shirt and the pads or briefs. She did not know how he got the incontinence pad. The UM had recently advised the CNAs never to use the plastic pads, as he would chew on them. Resident #1's CNA that day was new to him and had only worked in the locked unit two or three times. CNA B did not know if that CNA put the pad in the room, nor did she know where the rest of the pad was.CNA C was interviewed on 7/1/25 at 11:13 AM. She worked on 6/20/25 and was across the hall when she heard CNA B yelling for the nurse. She ran into Resident #1's room and CNA B was trying to pull disposable incontinence pads out of Resident #1's mouth. There were strands of pads and feces in his mouth, and feces on his hand and leg. There was no plastic pad under Resident #1, and he was not wearing a brief, but he had been doing that, eating them. The CNAs reported it, and the UM was trying to figure out what to do and what to tell everyone to do. She thought the resident's physician knew about it. As far as she was aware, this behavior was new and had only been occurring for about four weeks.CNA A was interviewed on 7/1/25 at 1:40 PM. She explained that the first time she worked in the locked unit was about two weeks ago. She saw Resident #1 eating his brief and told the UM. He told her, We have it under control. and accused the CNAs of breaking protocol. The CNAs also told Licensed Practical Nurse (LPN) A but were told the residents on that unit always did that. CNA A was assigned to Resident #1 on 6/20/25 for the first time and was warned that he would hit and kick. She stated no one told her he couldn't have plastic incontinence pads or briefs. She checked on him periodically. He was not on one-on-one supervision, but she said he should have been. CNA A recalled that Resident #1 was not wearing a brief and there was no disposable incontinence pad under him that day. CNA C stated later that day, she saw a disposable pad on his bed but took it off. No one told her he couldn't be around briefs or pads. At approximately 2:00 PM, she heard CNA B and someone else call out for the UM to Resident #1's room. She responded and witnessed CNA B pulling stuff out his mouth with a hanger. A piece of a disposable pad this long (she used both hands to gesture the length of approximately 14 inches) came out. She stated the resident's jaw was locked and his tongue was sticking out. CNA B started chest compressions, and then the UM arrived and took over. Pieces of the pad were on the floor. When paramedics arrived and took over compressions, another piece of a pad came out of his rectum. He pooped the pads out. She heard that Resident #1 passed away on the way to the hospital. The next day (6/21/25), adult protective services came to the facility. Resident #1's entire chart was down/inaccessible, and when it became available again, a banner appeared on the chart. It was this whole huge warning about not providing incontinence pads or diapers. The UM was interviewed on 7/1/25 at 2:38 PM. He stated any information related to a resident's medical history was put in the care plan on admission. When a behavior was reported or observed, it was documented and added to the care plan. CNAs could document on behaviors and a care warning could be placed on the dashboard in the electronic medical record (EMR). The nurse would also notify the Psychiatric Nurse Practitioner (PNP) or the physician. Resident #1 had a TBI (traumatic brain injury) with craniotomy (surgery to remove part of the skull to access the brain). He was combative with staff, cursed and bossed them around, and kicked and punched at them. On the day of the event, the UM was at the nurses' station. The CNA called him to come to Resident #1's room. He went and could see Resident #1 was not exchanging air. The UM stated the CNA said it looked like the resident was choking on feces. Resident #1 ate his feces and there were some blue particles the UM later realized were particles of an incontinence pad. Resident #1's mouth was open, and it looked like he was choking. The UM stated he ran, grabbed the crash cart, called Code Blue, and then called 911. CNA B started CPR. Resident #1 was in and out of consciousness and CPR continued until paramedics arrived. Resident #1 expired but the cause of death was not certain. The UM had seen him picking at his brief and trying to eat his socks: he would eat anything. The UM put documentation in his chart on 6/13/25 for no more briefs. This was also put on the EMR dashboard. The resident was care planned for no plastic, disposable pads, or anything similar. Resident #1 had a history of this behavior according to CNA B, but that information was nowhere in the chart. The behavior resurfaced about one week before the UM added the documentation for no more briefs to be used in Resident #1's record. The UM took the information to the Interdisciplinary Team and the DON said, Ok, we will look into it.During a telephone interview with the Medical Examiner (ME) on 7/1/25 at 4:20 PM, he stated he performed the autopsy on Resident #1 When EMS arrived, Resident #1's oral cavity was filled with feces mixed in with small pieces of disposable incontinence pads; feces and plastic stuff. He stated he believed Resident #1 choked and that was how he died. When he opened the resident's cavity, it was full of the plastic material. The presence of feces in Resident #1's mouth indicated he was recycling it (defecating then eating the pad-tainted pieces). The ME speculated that it would take several days for the pad material to pass through the digestive system.A telephone interview was conducted with the API on 7/2/25 at 7:30 AM. She verified the information in her report dated 6/21/25. She stated she had a phone conversation with a family member who reported that the facility was aware of Resident #1's behavior on admission; he was eating items and feces in the past while living at home. This was why he was admitted to the facility.During an interview with Licensed Practical Nurse (LPN) A on 7/2/25 at 9:54 AM, she said she gave Resident #1 his medications the morning of 6/20/25. He was not on a disposable pad but was chewing his gown. She retrieved scissors and cut the tag off the gown. He would eat anything if you let him. Anything. The CNAs once reported he was trying to eat his brief. He would even tear his mattress and try to eat it. It was a new behavior every week. She stated she did not know when the behavior started. The UM had written something, and the behavior was care planned, but the resident was not on one-on-one supervision.In an interview with the DON on 7/2/25 at 10:30 AM, he said Resident #1 would try to eat everything around him, including his feces. The CNAs had to feed him so he could not get to the Styrofoam. Eating feces was kind of new but was not present on admission. Within a month or two, Resident #1 began pulling his briefs to shreds. Putting things in his mouth was also pretty new. He would try to eat his socks. That had been happening for a while. Resident #1 would tear his mattress, and everything would go to his mouth so they removed everything they could. These behaviors were discussed in meetings with the Interdisciplinary Team. When asked what interventions were implemented to keep resident #1 safe, he said, spoon-feeding and removing everything from his room. The DON thought Resident #1 had been care planned for his behavior from the start of the behaviors.A review of Resident #1's record revealed that he was admitted to the facility on [DATE], discharged [DATE] and readmitted [DATE]. The electronic medical record's (EMR's) landing page included a Special Instructions warning advising that Resident #1 should not be given, have within reach, or be left unattended if items were made from plastic, sponge, foam and/or paper. Disposable incontinence pads/bed padding/under padding, brief/ disposable incontinence briefs/diaper and pull-ups, except for mattresses, were barred. (Photographic evidence obtained) The resident's diagnoses included, but were not limited to, traumatic brain injury (TBI), hip fracture, unspecified protein -calorie malnutrition, muscle weakness, hemiplegia and hemiparesis (one sided weakness or paralysis) following cerebral infarction (stroke) affecting left non-dominant side, dysphagia oropharyngeal phase (difficulty initiating swallowing), cognitive communication deficit, need assistance with personal care, anxiety, depression, restlessness and agitation.The Quarterly Minimum Data Set (MDS) assessment with a reference date 6/7/25 revealed that Resident #1 had severe cognitive impairment. He exhibited fluctuating inattention, disorganized thinking and an altered level of consciousness. Resident #1 used a wheelchair for mobility and was dependent on staff for activities of daily living including eating. He was frequently incontinent of bowel.A physician's order was obtained on 6/13/25: [Resident #1] should not be given, have within reach or left unattended if items are made from plastic, sponge, foam and paper. As a result, all following items are barred from use: [disposable incontinence pads]/bed padding/under padding, brief/ [disposable incontinence briefs]/diaper and pull-ups, except for mattresses. Items made from fabric are ideal, therefore they are acceptable. There was no corresponding progress note to justify why this order was entered at this time. Behavior monitoring was ordered on 1/22/25 for itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, and refusal of care. There were no revisions or instructions to monitor Resident #1 for placing inedible objects and items into his mouth or eating them. (Photographic evidence obtained)A review of nursing progress notes revealed an entry dated 6/3/24 by the Psychiatric Nurse Practitioner (PNP) reporting that a CNA advised him that Resident #1 was trying to eat his [incontinence pads]. (Photographic evidence obtained) A Nursing Alert progress note dated 6/17/24 advised that Resident #1 was found in bed eating a Styrofoam cup. He returned the remainder of the cup to the nurse but continued to chew and appeared to swallow the part of the cup that was in his mouth. The Nurse Practitioner (NP) was notified, and no new orders were given. (Photographic evidence obtained)Resident #1 was care planned on 6/2/24 for impaired or inappropriate behaviors related to his TBI. No specific description of inappropriate behavior was provided in the care plan after revisions were made on 6/10/24, 9/25/24, and 12/6/24. The goal was to be free from behaviors through the next review. Interventions included medications as ordered, monitor for side effects and effectiveness; If reasonable, discuss resident's behavior. Explain why behavior is inappropriate or unacceptable to the resident. Provide a program of activities that accommodates the resident's status. Provide non-pharmacological interventions. On 6/20/25, the day Resident #1 died, the care plan was revised to add, Resident removes his diapers, puts self on floor, slams leg against footrest/mattress, and eats briefs/[disposable pads]. (Photographic evidence obtained)The MDS coordinator (MDSC) was interviewed on 7/2/25 at 11:45 AM. She explained that during morning meetings the team reviewed nursing and CNA notes about resident behaviors. They followed up with psychiatry as needed. She knew Resident #1 but did not recall him eating pads or briefs. The MDSC reviewed Resident #1's care plan and confirmed that it was not revised to include eating non-food items including briefs and pads until 6/20/25. She said she wished prior care plans had been more specific. The interdisciplinary team was responsible for developing care plan goals and interventions. She was not advised of Resident #1's behavior until the UM told her, and she was not sure what interventions were in place on the nursing unit. The MDSC knew about the dangers of pica behavior and said she took it very seriously.Review of the facility's policy titled Care Plan-Comprehensive (dated January 2023), revealed: Policy: A Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident.Policy Interpretation and Implementation:1. An Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a Comprehensive Care Plan for each resident.2. The Comprehensive Care Plan has been designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect treatment goals and objectives in measurable outcomes; Identify the professional services that are responsible for each element of care; e. Prevent declines in the resident's functional status/functional levels; f. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; g. Ensure the care plan is individualized and person-centered and reflects the resident's goals for h. admission and desired outcomes; i. Ensure culturally-competent and trauma-informed care.The resident's Comprehensive Care Plan is developed within seven (7) days of the completion of the 3. resident assessment (MDS) or within twenty-one (21) days after the resident's admission, whichever occurs first. Care plans are revised as changes in the resident's condition dictate.A Baseline Care Plan is developed upon the resident's admission. The Baseline Care Plan is used only until the Comprehensive Care Plan has been developed. Determine the history of trauma and/or Post-Traumatic Stress Disorder (PTSD), and care plan interventions to meet resident needs. (Photographic evidence obtained)

Based on observations, interviews and document review, the facility failed to store and prepare food in accordance with professional standards for food service safety, by failing to ensure kitchen equipment was clean and opened food was labeled, dated and sealed for 162 residents who received food from the facility's kitchen. The findings include: On 04/14/24 between 11:28 AM and 11:39 AM, the following items were observed in the kitchen's dry storage area: An open, undated and unsealed bag of potato chips, opened, undated penne pasta noodles, and opened, undated, unsealed Classic [NAME] Quick Grits mix. (Photographic evidence obtained) On 04/14/24 at 11:15 AM, two bags of opened, undated wheat bread were observed in the kitchen prep area. (Photographic evidence obtained) On 04/14/24 at 11:42 AM, the cook top and three sides of the kitchen's stove were observed covered with food debris, grease and grime. The interior of two ovens under the stove were also covered with food debris, grease and grime. (Photographic evidence obtained) On 04/14/24 at 11:46 AM, a cleaning schedule dated 04/12/24, was observed taped to a wall in the kitchen and noted an employee was assigned to deep clean the oven and stoves in the cook area that day. (Photographic evidence obtained) On 04/14/24 between 11:49 AM and 11:54 AM, the following items were observed in the kitchen's walk-in refrigerator: An unsealed, dated (4/12/24 prep date) canister of battered fish; a canister of opened, canned pineapple without a label or date; an open and undated bag of shredded lettuce; an unsealed, undated opened bag of iceberg lettuce heads; an undated, opened bag of chopped green peppers, and an opened and unsealed bag of chicken thighs. (Photographic evidence obtained) On 04/14/24 at 12:08 PM, an opened, unsealed bag of frozen biscuits was observed in a reach-in freezer in the kitchen. (Photographic evidence obtained) On 04/15/24 at 9:06 AM, a second observation was made of the kitchen's cooktop and three sides of the stove, which were covered with food debris, grease and grime, as well as the interior of two ovens under the stove that were covered with food debris, grease and grime. (Photographic evidence obtained) On 04/15/24 at 9:53 AM, a second observation was made in the kitchen of an unsealed bag of chicken thighs and an unsealed, undated opened bag of iceberg lettuce heads in the walk- in refrigerator. A second observation was made of an open, undated bag of penne pasta in the dry storage area. (Photographic evidence obtained) On 04/15/24 at 9:59 AM, a second observation was made of an open, unsealed bag of frozen biscuits in the kitchen's reach-in freezer. (Photographic evidence obtained) On 04/15/24 at 10:02 AM, an open, unsealed bag of tortillas was observed in the kitchen's walk-in refrigerator. (Photographic evidence obtained) On 04/18/24 at 10:40 AM, an interview was conducted with the Certified Dietary Manager (CDM). She stated she had been employed with the facility for eleven months. She explained the process to ensure that kitchen area cleanliness was maintained included both she and the kitchen supervisor checking the daily cleaning schedule. The CDM created a bi-weekly cleaning schedule, and the supervisor created a daily cleaning schedule. The CDM and kitchen supervisor made daily sweeps of the kitchen to determine what needed to be cleaned. A cleaning schedule was created and hung on the window in the main area of the kitchen. Staff were trained to check the cleaning schedule at the beginning of each shift. The CDM and supervisor checked daily to ensure kitchen staff had completed and signed off on their assigned cleaning tasks. She further explained that the dietician made a thorough assessment of the kitchen area and created a monthly sanitization report for items needing cleaning. The CDM reported that opened, perishable food was only good for three days in the walk in refrigerator. Employees should place opened food in a closed container or wrapped in plastic, labeled and dated. The same process should be used for opened, non-perishable food stored in the dry storage area. On 04/18/24 at 10:52 AM, the CDM verified the condition of the stove and ovens layered with food, grease and grime. She explained they had a floor technician who pressure washed once a month, which included cleaning the inside and outside of the stove and ovens. She further explained that the stove and ovens should be cleaned on a regular basis outside of the monthly pressure washing. A review of the facility's protocol (Undated) related to opened food, revealed the requirement to label food not stored in original containers, mark dates after opening or preparation. The facility's policy titled Leftovers (Dated April 2022), revealed: It is the dietary department's goal to maximize food usage in order to avoid waste. To this end, certain leftover foods are reused with restrictions. 5. Cover, label and date all containers with the date that the food was first prepared or thawed. A review of the facility's policy titled Cleaning and Sanitation of Food Service Area (Undated), revealed: The food service staff will maintain the sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. 5. Staff will be held accountable for cleaning assignments. A review of the facility's cleaning protocol (Undated), documented how to clean the inside of an oven. .

Based on observation, record review and staff interview, the facility neglected to ensure each staff person who moved residents, using a mechanical lift, did so in a safe manner in order to prevent actual harm to 1 (#1) of 4 sampled residents. Furthermore the facility neglected to instruct staff on the number of people necessary to safely operate the mechanical lift for Resident #4. The findings include: An observation on 7/12/11 at 9:45 AM revealed Resident #1 in her bed sleeping. Quarter siderails were observed to be in the up position and the call bell was in reach of the resident. A review of the facility's Incident log provided by the facility indicated Resident #1 fell on [DATE]. A review of Resident #1's clinical record revealed a Transfer form dated 7/3/11 indicating the resident was transferred to the hospital emergency room by ambulance for a left femur fracture. Additional pertinent information on the transfer form stated indicated the resident was injured by a restorative aide had weighed the resident and accidentally hit the resident left leg on the bedrails. The information also revealed the residents left thigh was noted to be swollen. Continued review of Resident #1's clinical record revealed a radiology report dated 7/3/11 that revealed the resident had a displaced fracture mid-femur; no dislocation or foreign body was seen. Resident #1's clinical record revealed the resident's annual Minimum Data Set (MDS) assessment, dated 9/15/10, coded the resident as never understanding others, was severely impaired for decision making and was totally dependent on staff for all care. A review of Resident #1's Care Plan revealed a care plan, last reviewed 6/27/11, for Activities of Daily living (ADL) that noted the resident had self-care deficits which required assistance with transfers and staff were to assist with transfers as needed and use a mechanical lift. The care plan did not state how many people were necessary to safely operate the mechanical lift. Further review of the clinical record revealed a Restorative Interventions document, last reviewed 6/9/11, that revealed the resident has difficulty with transfers and required an assist of 2 people with a mechanical lift. An interview with the Director of Nursing (DON) on 7/12/11 at 10:45 AM, revealed the resident did not fall but was hurt when after being weighed on the weight lift, and while being returned to the bed the resident accidentally hit the bed rail. An observation of the weight lift revealed the weight lift had a swivel bar from which a sling was suspended. A review of the manufactures owners manual, provided by the facility, revealed "Special care MUST be taken with people with disabilities who cannot cooperate while being lifted." The manual further stated "Although (name of lift manufacture) recommends that two assistants be used for lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the healthcare professional for each individual case." An interview on 7/3/11 at 11:05 AM with the certified nursing assistant (CNA) who was involved in the incident on 7/3/11 with Resident #1, revealed was a restorative CNA and weighed residents monthly. She stated on 7/3/11 she had used the mechanical lift to lift the resident from her bed and get the resident's weight. She further stated when she went to lower the resident back on her bed the resident jerked, then went into a fetal position in the sling of the lift and the resident bumped her knee on her siderail. The CNA also stated that 2 people were supposed to do the lift but her co-worker who also did the weights, would not come in to work until 10:00 AM. She further stated she had been doing weights by herself on weekends for a long time, and 9 out of 10 times used the hoyer lift or weight lift by herself and the facility knew it. An interview with another restorative CNA on 7/12/11 at 11:53 AM revealed that they are supposed to have 2 people when doing weight lifts, but that she may weigh smaller people that she knows by herself. She further stated the facility was aware she sometimes used the mechanical lift by herself. An interview with DON and the Restorative nurse on 7/22/11 at 10:58 AM revealed 2 people should use the mechanical lift to weigh the residents. They further stated on the day of the incident the CNA could not get any one to help her, so she did it by herself . The DON further stated that the facility does not have a Protocol, Policy or Procedure for using the mechanical lifts other than the Owner's Operator Manual. An interview with the Risk Manager on 7/12/11 at 12:28 PM, revealed the restorative CNA who was involved in the incident on 7/3/11 had been counseled for using only one person to perform the mechanical lift. A review of the CNA's Counseling form, provided by the facility and dated 7/5/11, revealed the CNA was counseled for "employee weighing resident with the lift without assistance and hit residents leg on siderail." It further stated "While weighing residents with lift should have 2 people assist to prevent injury and maintain safety." The facility further provided a document dated 7/5/11 entitled "Taking weights with a total lift." The document stated, "1. Need two people when attempting to do weights with the total lift. 2. Ask for help always when doing weights using total lift. 3. Check equipment before use for good working condition" and was signed by 4 restorative CNA's on 7/5/11. A review of a document entitled " Proper Lift Procedures for Weighing and Transfer" dated 7/12/11 and provided to the surveyor at 3:28 PM, was information the staff were inserviced on for the first shift, revealed "CNAs were instructed while using the lift to weigh a resident they should use 2 people." It further stated "CNAs were instructed while using the lift to transfer a resident they should use 1-2 people, (to be determined by the lift assessment done upon admission). If unsure of number of people to use for the transfer they can refer to the CNA care plan which is located in the ADL book at each nurse station." However, when asked to provide the lift assessment for Resident #1, a document was provided entitled "Lift/Movement Assessment for Patients" dated 6/18/11, which did not include any direction as to how many people were needed to safely operate the mechanical lift for Resident #1. A review of the CNA care plan for Resident #1, located in the ADL book at the nurses station, revealed no direction if 1 or 2 people should be used to safely operate the mechanical lift for Resident #1. When asked to provide the "Lift/Movement Assessment for Patients" for another resident (#4) who is totally dependent and staff use the mechanical lift for weights and transfers, staff presented the document, dated 6/10/11, which also did not include any direction as to how many people were needed to safely operate the mechanical lift with Resident #4. A review of Resident #4's CNA care plan, located in the ADL book at the nurses station, revealed no direction if 1 or 2 people should be used to safely operate the mechanical lift for Resident #4. At 3:36 PM on 7/12/11, the facility provided a document that the DON stated would be posted. The documented stated, "Use of Transfer Lift. It stated "Effective immediately, all residents using a mechanical lift for transfer must be a 2 person assist until further instructions. If you have any questions, please refer to unit managers/supervisors. Thank you very much for all for cooperation regarding this matter." .

Based on observation, record review and staff interview, the facility failed to ensure adequate supervision and assistance to prevent accidents for 2 (#1, and #2) of 4 sampled residents. The facility failed to ensure a mechanical lift was manned by enough staff to safely operate the lift for which resulted in a fracture for Resident #1. Furthermore, the facility failed to ensure the safety of a resident at risk for falls for Resident #2. The findings include: 1. An observation on 7/12/11 at 9:45 AM revealed Resident #1 in her bed sleeping. Quarter siderails were observed to be in the up position and the call bell was in reach of the resident. A review of the facility's Incident log provided by the facility indicated Resident #1 fell on [DATE]. A review of Resident #1's clinical record revealed a Transfer form dated 7/3/11 indicating the resident was transferred to the hospital emergency room by ambulance for a left femur fracture. Additional pertinent information on the transfer form stated indicated the resident was injured by a restorative aide had weighed the resident and accidentally hit the resident left leg on the bedrails. The information also revealed the residents left thigh was noted to be swollen. Continued review of Resident #1's clinical record revealed a radiology report dated 7/3/11 that revealed the resident had a displaced fracture mid-femur; no dislocation or foreign body was seen. Resident #1's clinical record revealed the resident's annual Minimum Data Set (MDS) assessment, dated 9/15/10, coded the resident as never understanding others, was severely impaired for decision making and was totally dependent on staff for all care. A review of Resident #1's Care Plan revealed a care plan, last reviewed 6/27/11, for Activities of Daily living (ADL) that noted the resident had self-care deficits which required assistance with transfers and staff were to assist with transfers as needed and use a mechanical lift. The care plan did not state how many people were necessary to safely operate the mechanical lift. Further review of the clinical record revealed a Restorative Interventions document, last reviewed 6/9/11, that revealed the resident has difficulty with transfers and required an assist of 2 people with a mechanical lift. An interview with the Director of Nursing (DON) on 7/12/11 at 10:45 AM, revealed the resident did not fall but was hurt when after being weighed on the weight lift, and while being returned to the bed the resident accidentally hit the bed rail. An observation of the weight lift revealed the weight lift had a swivel bar from which a sling was suspended. A review of the manufactures owners manual, provided by the facility, revealed "Special care MUST be taken with people with disabilities who cannot cooperate while being lifted." The manual further stated "Although (name of lift manufacture) recommends that two assistants be used for lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the healthcare professional for each individual case." An interview on 7/3/11 at 11:05 AM with the certified nursing assistant (CNA) who was involved in the incident on 7/3/11 with Resident #1, revealed was a restorative CNA and weighed residents monthly. She stated on 7/3/11 she had used the mechanical lift to lift the resident from her bed and get the resident's weight. She further stated when she went to lower the resident back on her bed the resident jerked, then went into a fetal position in the sling of the lift and the resident bumped her knee on her siderail. The CNA also stated that 2 people were supposed to do the lift but her co-worker who also did the weights, would not come in to work until 10:00 AM. She further stated she had been doing weights by herself on weekends for a long time, and 9 out of 10 times used the Hoyer lift or weight lift by herself and the facility knew it. An interview with another restorative CNA on 7/12/11 at 11:53 AM revealed that they are supposed to have 2 people when doing weight lifts, but that she may weigh smaller people that she knows by herself. She further stated the facility was aware she sometimes used the mechanical lift by herself. An interview with DON and the Restorative nurse on 7/22/11 at 10:58 AM revealed 2 people should use the mechanical lift to weigh the residents. They further stated on the day of the incident the CNA could not get any one to help her, so she did it by herself . The DON further stated that the facility does not have a Protocol, Policy or Procedure for using the mechanical lifts other than the Owner's Operator Manual. An interview with the Risk Manager on 7/12/11 at 12:28 PM, revealed the restorative CNA who was involved in the incident on 7/3/11 had been counseled for using only one person to perform the mechanical lift. A review of the CNA's Counseling form, provided by the facility and dated 7/5/11, revealed the CNA was counseled for "employee weighing resident with the lift without assistance and hit residents leg on siderail." It further stated "While weighing residents with lift should have 2 people assist to prevent injury and maintain safety." The facility further provided a document dated 7/5/11 entitled "Taking weights with a total lift." The document stated, "1. Need two people when attempting to do weights with the total lift. 2. Ask for help always when doing weights using total lift. 3. Check equipment before use for good working condition" and was signed by 4 restorative CNA's on 7/5/11. A review of a document entitled " Proper Lift Procedures for Weighing and Transfer" dated 7/12/11 and provided to the surveyor at 3:28 PM, was information the staff were in-serviced on for the first shift, revealed "CNAs were instructed while using the lift to weigh a resident they should use 2 people." It further stated "CNAs were instructed while using the lift to transfer a resident they should use 1-2 people, (to be determined by the lift assessment done upon admission). If unsure of number of people to use for the transfer they can refer to the CNA care plan which is located in the ADL book at each nurse station." However, when asked to provide the lift assessment for Resident #1, a document was provided entitled "Lift/Movement Assessment for Patients" dated 6/18/11, which did not include any direction as to how many people were needed to safely operate the mechanical lift for Resident #1. A review of the CNA care plan for Resident #1, located in the ADL book at the nurses station, revealed no direction if 1 or 2 people should be used to safely operate the mechanical lift for Resident #1. 2. A review of the facility's Incident Log revealed Resident #2 had fallen on 4/16/11, 4/22/11, 5/26/11, and 7/2/11. A review of the clinical record of Resident #2 revealed the quarterly minimum data set ((MDS) dated [DATE] revealed the resident had disorganized thinking, inattention and falls. Further review of Resident #2's clinical record revealed a Care Plan for falls dated 1/26/11. The care plan approach included: 1. Use fall risk screen to identify risk factors on admission and quarterly. 2. Report falls to physician and responsible party. 3. Observe for side effects of any drugs. 4. Report to physician any side effects associated with the residents medication use. 5. Provide environmental adaptions; call light within reach; adequate glare free lighting. 6. Provide/monitor use of adaptive device; wheelchair, chair and bed alarm. 7. Remind resident and reinforce safety awareness to lock brakes on bed, chair etc before transferring, when rising from a lying position, sit on side of bed for a few minutes before transferring/standing. Educate/remind resident to request assistance prior to ambulation and appropriate footwear. However, there was no evidence of revision to the care plan, although the resident had fallen 4 times since the care plan was implemented on 1/26/11. An interview with a nurse familiar with Resident #2 on 7/12/11 at 1:30 PM revealed Resident #2's cognitive impairment did not allow him to remember safety awareness or to use the call light system. A review of the facility document entitled Fall/Change in Functional Status form dated 4/16/11 revealed the "resident observed on floor on knees." It further stated "resident had climbed out of bed - siderails still up." A review of the facility document entitled Fall/Change in Functional Status form dated 5/26/11 revealed the resident was found lying on his side next to the closet. It further stated the "chair alarm was intact on chair not going off. The part that was attached to res clothes was hanging over the side." An observation of Resident #2 at 3:04 PM on 7/12/11 revealed the resident in his bed with no bed alarm. An interview with the nurse on 7/12/11 at 3:07 PM revealed she thought there was only supposed to be a chair alarm and not a bed alarm. At 3:30 PM the nurse stated she had found out that the bed alarm was removed from the bed in order to clean it. .