Every finding on record at Winter Park Care and Rehabilitation

Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the facility's QAPI Plan revealed the facility must take actions aimed at performance improvement and measure its success and track performance to ensure that improvements were realized and sustained. The facility would develop and implement policies addressing how the facility would monitor the effectiveness of its performance improvement activities to ensure that improvements were sustained. The facility had deficiency cited at F641 during the previous recertification survey conducted 2/12/24 to 2/17/24 for accuracy of assessments. During this survey, the facility was found to again be in noncompliance with F641 for accuracy of assessments regarding Minimum Data Set (MDS) assessments. As a result of the repeat deficiency, it was identified there was insufficient auditing and oversight to prevent the citation.On 7/10/25 at 11:53 AM, the Administrator stated that with the transition between new employees in management roles, as well as the MDS role, maintaining accuracy of documentation must have fallen thru the cracks.

Based on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for nutritional approaches for 1 of 3 residents reviewed for nutrition, of a total sample of 30 residents, (#84).Findings:Resident #84 was initially admitted to the facility on [DATE] for strengthening following a hospital stay and a new lymphoma diagnosis. Resident #84 was discharged home with family and hospice services on 6/02/25. On 6/12/25 the resident was readmitted to the facility with generalized weakness and edema. The resident's diagnoses included diffuse large B-cell lymphoma (cancer), muscle wasting and atrophy, urinary tract infection, and stage 2 chronic kidney disease. Review of the admission MDS assessment with Assessment Reference Date of 6/19/25 revealed resident #84's nutritional approaches included parenteral or intravenous (IV) feeding while a resident and a mechanically altered diet which required a change in texture of food or liquids on admission. Under the section listed percent intake by artificial route the resident's proportion of total calories received through parenteral, or tube feed was documented as 25% or less while a resident and during the entire seven day look back. The resident was also documented as having received an average fluid intake per day by IV or tube feeding documented as 500 cubic centimeters (cc) /day or less while a resident and during the entire seven days. Under the section special treatment procedures and programs, the resident was documented as having no IVs. Parenteral nutrition is defined as feeding intravenously or through a vein. Parenteral nutrition bypasses your entire digestive system, from mouth to anus. It may include different amounts of essential nutrients such as water, carbohydrates, proteins, fats, vitamins and minerals, (retrieved from https://my.clevelandclinic.org on 7/11/25).Review of the resident's current diet order revealed regular/no added salt (NAS) diet with regular texture and thin consistency. The order indicated the resident was on an 1800 milliliter (ml) fluid restriction and fortified food with all meals. Review of all diet orders since initial admission on [DATE] revealed at no time was the resident on a parenteral, IV feeding or mechanically altered diet. On 7/09/25 at 12:32 PM, the Dietitian confirmed the resident's diet was a regular diet with regular textures and thin liquids. After reviewing the resident's medical record, he confirmed that at no time were there physician orders for a mechanically altered diet during either of her stays at the facility. He stated she never received nutrition from an IV feeding or tube feed. On 7/09/25 at 1:58 PM, the Certified Dietary Manager (CDM) revealed she was responsible for parts of the swallowing and nutritional status section of the MDS assessment. She confirmed that on the resident's admission MDS dated [DATE] she incorrectly coded the resident as having a mechanically altered diet. The CDM acknowledged the resident requiring a mechanically altered diet was a miscoding of the assessment. She stated the resident wasn't on a mechanically altered diet and hadn't been since admission. On 7/09/25 at 12:40 PM, the MDS Coordinator indicated the resident's current diet order was a regular diet with regular consistency. She confirmed that at no point during the resident's stay at the facility was she on a mechanically altered diet. She confirmed the admission MDS dated [DATE] listed the resident as having a mechanically altered diet. The MDS Coordinator then confirmed the resident was coded on the same assessment as having received parenteral or IV feeding. She acknowledged the resident has had no parenteral or IV feeding upon admission nor while a resident at the facility. The MDS Coordinator was unable to explain how she determined the proportion of total calories the resident received thru parenteral or tube feeding as 25% or less and the resident's intake was 500cc/day or less. The facility's job description dated August 2021 for MDS Coordinator under the section Essential Duties and Responsibilities indicated the MDS Coordinator was responsible for reviewing MDS assessments prior to closing and transmitting to ensure all sections were complete and accurate according to Federal Regulations. The facility policy and procedure titled Resident Assessment - Resident Assessment Instrument (RAI) (n date) states that it's the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS)to ensure a comprehensive and accurate assessment of residents.

Based on observation, interview, and record review, the facility failed to ensure an appropriate wheelchair was provided to accommodate the needs and preference of 1 of 1 resident reviewed for resident rights, of a total sample of 30 residents, (#82). Findings:Resident #82 was admitted to the facility from an acute care hospital on 2/24/25 with diagnoses that included wedge compression fracture, history of falls, muscle wasting with atrophy, and need for assistance with personal care. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed resident #82 had a Brief Interview of Mental Status (BIMS) of 15/15 which indicated she was cognitively intact and able to make her needs known. She had no upper or lower limitations in range of motion and utilized a wheelchair for mobility.On 7/07/25 at 11:45 AM, resident #82 was observed in her room sitting up in a transport wheelchair watching television. She stated she was a private person and preferred to do activities in her room but sometimes wanted to move around the room or go out into the hallway. She continued that she was unable to do those things because she did not have an appropriate wheelchair. Resident #82 said she had asked staff for a different wheelchair but was told she could not have it, and she did not know why. According to the National Association of Senior Fitness, a standard wheelchair is a chair with oversized rear wheels and rotating handrails that were designed to help individuals with mobility issues to steer themselves unaided. In contrast, a transport chair was compact and required a second person to push the user from behind. Furthermore, a standard wheelchair had padded seats and hand/leg rests which allowed for all day use, but a transport chair was not recommended for all day use due to lack of comfort, (retrieved on 7/11/25 from www.seniorfitness.net).Review of resident #82's Physical Therapy (PT) progress report for dates of service 3/28/25-4/10/25, revealed she was weight bearing as tolerated, utilized a walker and wheelchair for mobility, and her mobility function score was 11 out of 12, with 12 being the highest function. On 7/09/25 at 10:24 AM, the Therapy Director said resident #82 was on the restorative program because she had reached a plateau for PT. She stated she was unaware that resident #82 had been provided with a transport wheelchair for daily use and not aware the resident wanted a standard wheelchair. She said resident #82 liked staying in her room and did not express a desire to leave the room. She believed it was not abnormal for a resident to receive a transfer wheelchair and explained the facility did not assign wheelchairs to residents unless they needed a specialized chair. She explained that all staff had the ability to obtain a wheelchair for a resident from where they were stored. The Therapy Director confirmed that resident #82 had not received a standard wheelchair until yesterday, almost five months since she was admitted . She acknowledged that residents were unable to independently maneuver a transport wheelchair, which limited their independence. On 7/09/25 at 2:22 PM, Licensed Practical Nurse (LPN) B explained that on admission the nurse would review the State Agency transfer form 3008, which included the resident's mobility status. The nurse said if the resident was weight bearing, the facility could provide a wheelchair for independent mobility but if the mobility status was not provided, the resident would need to be evaluated by PT before a wheelchair could be provided. She confirmed all staff had access to the storage room where wheelchairs were kept. Review of the State Agency transfer form 3008, dated 2/24/25, revealed that resident #82 required assistance with ambulation but was full weight-bearing. On 7/09/25 at 2:41 PM, resident #82 explained she had been at another long-term care facility prior to being hospitalized and while there had a wheelchair for independent mobility. She said when she was admitted to the current facility she was given the transport chair which limited her ability to independently move around the facility. Review of resident #82's care plan with revision date 3/27/25, revealed she had potential for pain related to compression fractures, and impaired mobility. The goal was to prevent decline in overall function and one intervention was to encourage mobility and physical activity as tolerated. There was no care plan to show the family wanted the resident in a transport chair. On 7/09/25 at 04:18 PM, the Director of Nursing (DON) stated she was aware of the difference between a transport wheelchair and a regular wheelchair. She said a transport wheelchair was inappropriate for a resident to use daily, especially if they were able to move around independently. She said she was unaware resident #82 was given a transport wheelchair because she was new to the facility and the resident had been admitted prior to her hire date. The DON explained she was informed that the resident did not receive the correct wheelchair until 7/08/25 after the resident had asked for it again, and the survey was in process. She agreed that providing an inappropriate wheelchair to a resident that could independently ambulate limited their right to independence and could potentially cause a decline in their ADL function.

Based on observation, interview, and record review, the facility failed to ensure the intravenous (IV) catheter dressing was changed every seven days per physician order for 1 of 1 resident reviewed for IV therapy, of a total sample of 30 residents, (#142).Findings:Resident #142 was admitted to the facility on [DATE] with diagnoses including fracture of neck, intraspinal abscess and spinal stenosis-cervical region. Review of resident #142's electronic medical record (EMR) revealed a Brief Interview for Mental Status (BIMS) assessment dated [DATE]. The assessment indicated he had a BIMs score of 15/15 which meant he was cognitively intact.A care plan initiated 7/07/25 indicated resident #142 received IV therapy related to antibiotic therapy administration. Interventions included, Observe dressing. Change dressing and record observations of site.Review of resident #142's EMR revealed physician orders were added on 7/07/25 for the care of the IV insertion site. The orders included directions to observe the site every shift, before/after medication administration and with dressing changes for redness, swelling, warmth and/or loosening or soiled dressing every shift and to change the site dressing as needed. An additional order dated 7/07/25 gave instructions to change the site dressing every week with transparent dressing on the night shift every Sunday and was scheduled to begin on 7/13/25. Review of the Medication Administration Record (MAR) for July 2025 revealed four nurses documented they had observed the IV site between 7/07/25 and 7/09/25. There was no documentation on the MAR or progress notes to indicate any licensed staff member had changed the dressing. On 7/07/25 at 10:58 AM, resident #142 was observed in bed with head of bed elevated watching television. An IV pole was observed next to the bed, but no medications were present. Resident #142 stated he received an antibiotic due to an infection from a recent surgery. The IV insertion site was not visible and resident #142 did not wish to show it at that time.On 7/08/25 at 8:55 AM, resident #142 was observed in bed. He allowed a Registered Nurse surveyor to observe the IV dressing which was located on his right upper arm. The IV dressing was dated 7/01/25. On 7/09/25 at 3:24 PM, Licensed Practical Nurse (LPN) B went to administer IV medications to resident #142. She observed the transparent IV dressing and verified it was dated 7/01/25, eight days prior. LPN B continued with her task of administering medication. LPN B did not express why the IV dressing was not changed for over a week, nor did she attempt to change the dressing.On 7/09/25 at 3:41 PM, LPN A reviewed the physician orders for resident #142. She verified she entered the orders for care of the IV site and dressing on 7/07/25. LPN A reviewed the IV dressing change order and confirmed the IV dressing was scheduled to be changed on Sunday, 7/13/25. She explained a transparent IV dressing should be changed every seven days. LPN A stated the dressing should have been changed when resident #142 was admitted and then every seven days thereafter. She was informed the date on the dressing was 7/01/25 which was verified by LPN B. LPN A acknowledged 7/13/25 would be almost two weeks since the dressing was changed. She stated she should have looked at the dressing prior to entering the order and scheduling the initial date for it to be changed. LPN A acknowledged the dressing change was missed and had not been done for over a week. On 7/09/25 at 4:16 PM, the Director of Nursing (DON) acknowledged the date on resident #142's IV dressing, that the dressing had not been changed and that it was not scheduled to be changed until 7/13/25. The DON stated the IV dressing should have been changed within seven days of the date on the dressing. She was not sure why it had not been changed or why the order was initiated for change on 7/13/25 instead of seven days from the date on the IV dressing. The DON acknowledged the order was wrong and that the dressing change was missed.The facility's policy and procedure for Guidelines for Preventing Intravenous Catheter-Related Infection revised August 20014 indicated the purpose was to reduce the risk of infection associated with indwelling intravenous catheters. The policy clarified that transparent semipermeable membrane dressings should be changed every five to seven days and as needed if damp, loosened or visibly soiled.

Based on interview, and record review, the facility failed to ensure 1 of 3 residents reviewed for administration had an accurate medical record, of a total sample of 3 residents, (#1). Findings: Review of the medical record revealed resident #1, an [AGE] year old female was admitted to the facility for respite care from home on 5/23/24, 6/07/24, 7/08/24, 8/23/24, and 9/16/24. The resident discharged home on 10/14/24, and most recently readmitted on [DATE]. The resident's diagnoses included: cerebral arteriosclerosis, encounter for palliative care, holiday relief care, Alzheimer's Disease, vascular dementia with behavioral disturbance, gastrostomy (feeding tube), type 2 diabetes mellitus, major depressive disorder, anxiety disorder, hypertension, hyperlipidemia, and insomnia. The most recent comprehensive Minimum Data Set admission assessment with assessment reference date 10/01/24 noted resident #1 was unable to complete the Brief Interview for Mental Status and assessed by staff with severely impaired cognitive skills for daily decision making. No behavioral symptoms or rejections of evaluation or care was noted. The Functional Abilities assessment showed the resident used a wheelchair and was dependent on staff for mobility and to complete activities of daily living. No ulcers, wounds, or skin problems were noted on the assessment. The Comprehensive Care Plan included focus areas for fall with injury risks, impaired mobility, impaired self-care abilities, need for staff assistance, and impaired cognition. Review of the Agency for Health Care Administration (AHCA) Form 5000-3008 dated 9/23/24 revealed the skin care and body map section noted resident #1 did not have any areas of skin impairment or bruises. The nursing Admit/Readmit Screener evaluation completed by Licensed Practical Nurse (LPN) B on 9/24/24 at 1:35 PM, documented a complete skin assessment was conducted and revealed resident #1's skin integrity was normal with no areas of breakdown. A nurse's Progress Note completed by LPN B on 9/24/24 noted the resident #1's skin condition and read, . does have some spotty discoloration to bilateral legs and G tube (feeding tube) present to upper abdomen . On 10/29/24 at 10:39 AM, LPN B explained she completed skin checks for residents who were newly admitted or readmitted to the facility. The LPN said nurses were required to document any bruises, injuries, wounds, or impairments on the electronic Admit/Readmit Screener form. The LPN recalled she was the only nurse who completed resident #1's re-admission evaluations on 9/24/24, and she did not remember any bruises. She stated, I would have put an old bruise if I saw one. In a telephone interview on 10/29/24 at 11:41 AM, resident #1's hospice Registered Nurse (RN) explained she completed head to toe skin assessments on residents, and any bruises or scratches were noted on the medical records. The RN said she knew resident #1 well, and checked the medical records for 9/23/24 and 9/30/24. She said there were no notations resident #1 had any bruises. The nurse recalled the resident fell on [DATE] and she completed reports after the incident. She checked the records and said on 10/01/24, after the fall the documentation showed bruising to her face was noted in the hospice nurses progress notes. Review of the hospice Plan of Care Review completed by the hospice RN dated 9/25/24, after resident #1 was readmitted to the facility nurses documented the resident's skin was intact with no wounds. A nurses Progress Note written by LPN C on 10/01/24 documented resident #1 fell to the floor in the dining room at 3:40 PM. The note read, . bruising to right forehead, right knee front small scrape/skin tear . On 10/29/24 at 10:17 AM, LPN C recalled resident #1 was included in her assignment the day she fell on [DATE]. The LPN explained the resident sustained a bruise to her forehead and a minor injury to her right knee. The nurse could not recall a bruise on resident #1's forehead prior to the fall. Review of a nurse's progress note written by the RN [NAME] Unit Manager on 10/02/24 at 9:35 AM read, . bruise to resident was from admission, not the fall . On 10/28/24 at 2:45 PM, the RN [NAME] Unit Manager said she knew resident #1 well as she frequently came to the facility for hospice respite services. The RN recalled on 9/16/24, the resident was readmitted to the facility and stated, I did her head to toe assessment from her admission. She already had a bruise on her head; it was green. Review of resident #1's medical record did not include a head to toe skin assessment completed by the RN [NAME] Unit Manager. The nurse's Weekly Skin Evaluation dated 9/30/24 completed by LPN D, after the resident was admitted and before she fell on [DATE] documented the resident's skin was intact, and she did not have any bruises. On 10/29/24 at 1:19 PM, LPN D said resident #1 was often included in her assignments, and she knew her well. The LPN explained nurses documented any areas of skin discoloration or bruises on the Weekly Skin Evaluation form. The nurse stated, If it's on the forehead I would see it. It wasn't there, (on 9/30/24) or I would have noted it on the record. On 10/29/24 at 12:53, resident #1's daughter explained she was upset after the [NAME] RN Unit Manager told her the resident's forehead bruise occurred during transportation for readmission to the facility on [DATE]. She recalled she was with her mother when she arrived to the facility that day, and she was certain her mother did not have a bruise on her forehead and stated, I would have noticed and I would have said something; my sister and brother saw her too and there was no bruise; she had nothing on her face before the 1st of October. On 10/29/24 at 10:44 AM, the Director of Nursing (DON) explained she expected nurses to make notations of any bruises on admission, progress notes, and/or weekly skin evaluations. She said the RN [NAME] Unit Manager was aware of the expectations for documentation and that it was imperative to document bruises to track any injuries of unknown origin. The DON explained, she expected nurses to document skin assessments completely and correctly. She said she was on leave between 9/16/24 and 10/02/24 and could not explain why the RN [NAME] Unit Manager's notes and recollections would conflict with other nurses. The facility's undated standards and guidelines titled Medical Records read, . The facility will maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible, . includes: Medical and general health status; . The facility's undated job description for RN Unit Manager read, . Ensures completion of assessments of residents at admission, discharge, as necessary and required.Ensures nursing policies and procedures are implemented and followed .

Based on interview, and record review, the facility failed to prevent a fall with major injury for a vulnerable, physically, impaired resident, and failed to ensure the correct procedure was followed when using a mechanical lift to transfer residents for 1 of 6 residents sampled for falls, out of a total sample of 45 residents, (#197). On 2/08/24 at approximately 6:00 PM, the facility failed to prevent a fall with major injury during a transfer with a mechanical lift. The facility failed to utilize the appropriate type of mechanical lift and failed to follow policy requiring two staff for mechanical lift transfers. While Certified Nursing Assistant (CNA) G transferred resident #197 by herself from chair to bed using the wrong mechanical lift, the resident became unstable and was manually lowered to the floor. The resident complained of pain and x-rays done at the facility identified a fractured left clavicle, (A clavicle fracture-collarbone, is diagnosed through physical examination and x-rays. Symptoms of a broken collarbone include severe pain and swelling at the site of the fracture with visible deformity in some cases. Because of the critical location of the clavicle, any severe force on the shoulder such as falling directly on the shoulder or falling on an outstretched arm transfers force to the clavicle . retrieved from www. hopkinsmedicine.org on 2/20/24). She was transferred to the hospital on 2/09/24 for further scans and returned the same day with confirmed fractured left clavicle. The facility's failure to provide safe and appropriate care when using mechanical lifts placed all 41 residents who required mechanical lift for transfers at risk for serious injury/impairment/death and resulted in Immediate Jeopardy starting on 2/08/24. The facility's Administrator and Director of Nursing, and Corporate Clinical Nurse were notified of the Immediate Jeopardy on 2/15/24 at 3:17 PM, and provided the IJ templates. The Immediate Jeopardy was determined to be removed on 2/16/24 after verification of the immediate actions implemented by the facility. The scope and severity of the deficiencies was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy. The census at the start of the survey was 93. Findings: Cross reference to F600 Resident #197, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, asthma, atrial fibrillation, chronic obstructive pulmonary disease, diabetes, obstructive sleep apnea, obesity, and muscle weakness. On 2/09/24, the diagnosis of fractured left clavicle was added. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 2/05/24 revealed the resident's cognition was intact, with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The assessment noted resident #197 had adequate hearing, clear speech, understands, was understood, and had adequate vision. The assessment indicated resident #197 was independent for eating, oral hygiene, and personal hygiene. She required partial/moderate assistance for showers and upper body dressing, substantial/maximal assistance with rolling left to right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair to bed/bed to chair, and was dependent for toileting hygiene and lower body dressing. The assessment also revealed resident #197 had no impairment to her upper or lower extremities and used a wheelchair for mobility. The assessment indicated the resident had no behaviors towards herself or others. On 2/12/24 at 5:17 PM, resident #197 stated CNA G had put her back to bed from her wheelchair using the sit to stand mechanical lift on 2/08/24. The resident explained CNA G was in the room getting ready to transfer her by herself and she told the CNA she needed another person to help. Resident #197 said CNA G's response was Don't tell me how to do my job. The resident recalled, When I was in the mechanical lift, I told CNA G something did not feel right but she walked around to the side of the lift and the next thing I remember was being on the floor looking up at my nurse. A sling was observed on the resident's overbed table. She stated she had pain in her left shoulder now and explained she had to stay in the facility longer as she was not able to do therapy because of the fracture. She stated the fractured shoulder had set her back in her progress with therapy and delayed her discharge to home. Review of the x-ray done at the facility on 2/08/24 at 7:00 PM, showed the results were reported to the facility at 8:14 PM, with findings of a new non-displaced clavicle fracture. Review of the medical record indicated resident #197 was sent to the hospital on 2/09/24 due to continued pain in her shoulder. The results of the x-ray taken at the hospital on 2/09/24 at 12:46 PM indicated resident#197 had an angulated, nondisplaced fracture of the distal left clavicle. On 2/13/23 at 10:47 AM, during a telephone interview, Registered Nurse (RN) E stated CNA G was providing care to resident #197 and called out to him for help. The RN stated when he went in the room, CNA G was in the room alone. He recalled the resident was in the sit to stand mechanical lift in what looked like an unsafe position. He described the resident's knees were going toward the floor like she was going to fall. He said he called CNA F to the room to assist and they held the resident and lowered her to the floor. He reiterated only one CNA, CNA G was in the room when he was called to the resident's room. On 2/13/24 at 11:13 AM, in a telephone interview, CNA G stated when she went in resident #197's room, she was seated in her wheelchair. In conflict with resident #197's and RN E's statements, CNA G stated she and CNA F used the sit to stand mechanical lift to put resident #197 back to bed. CNA G then described that resident #197 moved her hands from the hand bar, became unstable, so she called RN E for assistance. CNA G stated the three of them, herself, RN E and CNA F took resident #197 off the sit to stand mechanical lift and held her to put her on the floor. CNA G added, she went to get the full body mechanical lift after RN E came to the room and she and CNA F transferred the resident back into bed. On 2/14/24 at 9:30 AM, during an interview, CNA F stated she was in the room with CNA G to help transfer resident #197 back to bed. She explained she put the sit to stand lift sling behind resident #197's back and hooked the sling to the lift machine when the resident moved her arm. She reported the resident became unstable and started to slide down and the two of us put her on the floor. CNA F stated she was sure the resident was already down on the floor when we called RN E. CNA F stated it was herself and CNA G that put the resident on the floor after she started to slide from the lift. She repeated the nurse, RN E was called to the room after they had lowered her to the floor. On 2/15/24 at 12:15 PM, the Corporate Nurse explained a two-person transfer, required two staff to be involved in the process of the transfer. She stated this indicated the number of staff required to safely transfer a resident but did not describe what type of lift was to be used. The Corporate Nurse explained the care plan did not detail the type of lift needed to transfer resident #197 until 2/08/24. Review of the resident's care plan and Kardex revealed resident #197 was assessed to require two-person assist for transfers. There was no indication on either the care plan or the Kardex as to the type of device needed to transfer the resident until 02/08/24, when the care plan was revised to indicate the resident required use of a full body mechanical lift for transfers. On 2/14/24 at 1:53 PM, Physical Therapy Assistant (PTA) I stated resident #197 was motivated on the first week of therapy because she wanted to go home. He explained that due to the fracture, the resident had pain and could not use her left arm so her therapy had to be extended. PTA I said resident #197 previously required moderate assistance for bed mobility but now required maximum to total assistance due to pain. He stated resident #197 told him there was only one person using the lift with her and she knew it was supposed to be two people. PTA I said, I also heard that it was one person using the mechanical lift with resident #197. Review of the written statement provided by the Administrator noted only one CNA was in the room when RN E was called to assist. The statement from RN E dated 2/8/24 at 6:00 PM, read, At the time of the incident CNA called me for help since she was using stand hoyer lift and she resident was in a unstable position and was kneeling towards the floor. She never crash to the ground. We had to put her on the floor for her safety. On 2/14/24 at 1:33 PM, the facility Administrator stated he came to the facility on [DATE] to interview staff after he was made aware of resident #197's x-ray results. He said resident #197 had been interviewed by the [NAME] Wing Unit Manager (UM) prior. The Administrator stated after his interviews, it was determined the root cause of the incident was resident #197 had become weak and a little dizzy during the transfer. He explained the two CNAs lowered her to the ground, then went to get the nurse. The Administrator stated resident #197 said she blacked out and could not recall the details. When asked if he had interviewed the resident, he said he had not interviewed the resident, but the UM did. When informed of the inconsistent statements from the two CNAs indicating whether RN E was present when the resident was placed on the floor from the lift, the Administrator did not provide an answer. On 2/15/24 at 12:15 PM, an interview was conducted with the Regional Nurse Consultant, the Director of Nursing (DON) and the Administrator. The Nurse Consultant explained that two person assist with transfers meant that two staff should be present to do the transfer. She described it could be for a standing lift or full mechanical lift transfers. She stated two person assist only indicated the number of staff, not the type of mechanical lift to be used. She acknowledged the type of mechanical lift was not reflected on resident #197's care plan until 2/08/24. The DON reported that CNAs would know the type of lift to be used with the resident as, It would be on the care plan and on the task. We manually add directions to the task. The Administrator added, in the morning meeting, the Minimum Data Set Nurse inputs any changes to the care plans and Kardex. He explained after the meeting, any changes would be communicated to the CNAs verbally. He said the type of lift to be used for resident #197 should have been in the electronic system as a task but explained it did not get written in the Kardex until 2/8/24. He did not clarify if the specific lift was added prior to the incident or after the incident. The Administrator reported the wrong mechanical lift was used for the resident as she did not like the full body mechanical lift and the CNA said she had used the sit to stand mechanical lift previously with the resident. When asked if CNAs determined the type of lift to use to transfer residents, the Administrator did not provide an answer. They were asked to clarify the inconsistencies in statements from the both the resident and RN E who stated only one CNA transferred the resident and CNAs G and F's statements that it was 2 CNAs. The Administrator replied he was told two CNAs transferred the resident. Review of CNA G's completed training included CNA Transfer/Lifting Competency Test completed one year ago, on 2/09/23. The facility policy, Safe Resident Handling/Transfers implemented 11/03/2020 and revised 11/29/22 read: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident. Two staff members must be utilized when transferring residents with a mechanical lift. Review of the CNA job description included duties to ambulate and transfer residents utilizing appropriate assistive devices and body mechanics. The resident sample was expanded to include five additional residents who were identified as requiring a mechanical lift for transfers. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * On 2-09-24, staff members involved were given 1:1 education by the Staff Development Coordinator on the proper use of mechanical lifts. * On 2-09-24 through 2-15-24 current nursing staff and therapy staff were educated on the transfer of residents and the use of the mechanical lifts by the Director of Nursing, Staff Development Coordinator and Nurse managers. Twenty five nursing staff members were educated on 2-09-24, 8 nursing staff members were educated on 2-12-24, 5 nursing staff were educated on 2-13-24, 1 nursing staff was educated on 2-14-24, 50 staff members were educated on 2-15-24. Newly hired staff members and agency staff will be educated during the orientation process. Staff members that are on vacation will receive education prior to the start of their next shift. * On 2-12-24 through 2-15-24 current staff were educated on ANME (Abuse, Neglect, Misappropriation, Exploitation) by Staff Development Coordinator, Nurse Managers and Department Heads. On 2-12-24, 18 facility staff members were educated, on 2-13-24, 17 facility staff members were educated, and on 2-15-24, 89 staff were educated. Newly hired staff members and agency staff will be educated during the orientation process. Staff members that are on vacation or FMLA will receive education prior to the start of their next shift. * On 2/16/24, out of 88 Total nursing and therapy employees-77 nursing and therapy employees received education on the use of the mechanical lifts. * On 2/16/24, out of 124 Total facility employees, 103 Facility staff received education on ANME. * Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held on 2-16-24 with Medical Director, Administrator, DON, Staff Development Coordinator, Therapy Director, and Unit Manager to discuss transfer status, mechanical lift use and root cause analysis. Interviews conducted from 2/17/24 with 13 facility staff including licensed nurses and CNAs revealed they were knowledgeable about the facility's transfer policy, and the need to review the care plan and Kardex to identify number of persons and mode of transfer or which mechanical lift for resident transfers. They verified a return demonstration was completed after the education. They confirmed they received Abuse/Neglect education followed by a post test.

Based on record review, and interview, the facility neglected to provide appropriate care and services to prevent a fall with major injury for a vulnerable and physically impaired resident, during a transfer with a mechanical lift and failed to complete a thorough investigation after a fall with major injury for 1 of 6 residents sampled for falls, (#197). On 2/08/24 at approximately 6:00 PM, the facility failed to prevent a fall with major injury during a transfer with a mechanical lift. The facility failed to utilize the appropriate type of mechanical lift and failed to follow policy requiring two staff for mechanical lift transfers. While Certified Nursing Assistant (CNA) G transferred resident #197 by herself from chair to bed using the wrong mechanical lift, the resident became unstable and was manually lowered to the floor. The resident complained of pain and x-rays done at the facility identified a fractured left clavicle, (A clavicle fracture-collarbone, is diagnosed through physical examination and x-rays. Symptoms of a broken collarbone include severe pain and swelling at the site of the fracture with visible deformity in some cases. Because of the critical location of the clavicle, any severe force on the shoulder such as falling directly on the shoulder or falling on an outstretched arm transfers force to the clavicle . retrieved from www. hopkinsmedicine.org on 2/20/24). She was transferred to the hospital on 2/09/24 for further scans and returned the same day with confirmed fractured left clavicle. The facility's failure to provide safe and appropriate care when using mechanical lifts placed all 41 residents who required a mechanical lift for transfers at risk for serious injury/impairment/death and resulted in Immediate Jeopardy starting on 2/08/24. The facility's Administrator, Director of Nursing (DON), and Corporate Clinical Nurse were notified of the Immediate Jeopardy on 2/15/24 at 3:17 PM and provided the IJ templates. The Immediate Jeopardy was determined to be removed on 2/16/24 after verification of the immediate actions implemented by the facility. The scope and severity of the deficiencies was decreased to a D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy Findings: Cross reference to F689 Resident #197, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, asthma, atrial fibrillation, chronic obstructive pulmonary disease, diabetes, obstructive sleep apnea, obesity, and muscle weakness. On 2/09/24, unspecified left clavicle fracture was added to her diagnosis. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date 2/05/24 revealed the resident's cognition was intact, with a Brief Interview for Mental Status score of 15 out of 15. The assessment noted resident #197 had adequate hearing, clear speech, understood, was understood, and had adequate vision. The assessment indicated the resident was independent for eating, oral hygiene, and personal hygiene, but required partial/moderate assistance for showers and upper body dressing, substantial/maximal assistance with rolling left to right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair to bed/bed to chair, and dependent for toileting hygiene, and lower body dressing. The assessment also revealed the resident had no impairment to upper or lower extremity range of motion and used a wheelchair for mobility. The assessment indicated resident #197 had no behaviors toward herself or others. On 2/12/24 at 5:17 PM, resident #197 spoke about the incident that occurred on 2/8/24 at 6:00 PM. She stated Certified Nursing Assistant (CNA) G was putting her back to bed from her wheelchair using the sit to stand mechanical lift. The resident said CNA G was attempting the transfer alone and she told the CNA she needed two staff to transfer with the lift. The resident recalled CNA G told her, Don't tell me how to do my job. The resident explained she knew it had to be two staff to use the lift because the physical therapist had instructed another CNA on day shift with the sit to stand mechanical lift and told her it always had to be two staff. That is why I told the CNA it should be 2 people. Resident #197 continued, When I was in the lift, I told the CNA something did not feel right but she walked around to the side of the lift and the next thing I remember, I was on the floor looking up at my nurse. She stated she had pain in her left shoulder now and explained she had to stay in the facility longer as she was not able to do therapy because of the fracture. On 2/13/23 at 10:47 AM, in a telephone interview, Registered Nurse (RN) E stated CNA G was with resident #197 when she called out to him for help. He said when he went in the room, the resident was in the sit to stand mechanical lift sliding down and falling towards the floor. He recalled he tried to help CNA G but resident #197 was too heavy for two staff to lift. He said he called CNA F to come to the room to assist. RN E said the three of them managed to put her on the floor . He stated after the resident was on the floor, CNA F and G went to get the full body mechanical lift and the two CNA's transferred the resident back to her bed. RN E reiterated CNA G was in the room transferring the resident by herself when she called out to him for help. Review of nursing progress note dated 2/09/24 at 12:02 AM, by RN E read, At the time of the incident CNA would call me for help since she was using the stand lift, and the resident was in an unstable position and was kneeling towards the floor. I never crash to the ground. We had to put her on the floor for her safety. We lift her in the 'full body mechanical' lift and transfer her to the bed. On 2/13/24 at 11:13 AM, in a telephone interview, CNA G stated when she went in resident #197's room she was seated in her wheelchair. In conflict with resident #197's and RN E's statements, CNA G stated she and CNA F used the sit to stand mechanical lift to put resident #197 back to bed. CNA G then described resident #197 moved her hands from the hand bar so she called the nurse for assistance. CNA G stated the three staff (herself, RN E and CNA F) took resident #197 off the sit to stand mechanical lift and put her on the floor. CNA G added that she went to get the full body mechanical lift after the nurse, RN E came to the room and she and CNA F transferred the resident back into bed. On 2/14/24 at 9:30 AM, in contradiction to resident #197 and RN E's statements, CNA F stated she was in the room with CNA G to help transfer resident #197 back to bed. She explained, we went in to transfer her from the chair to the bed. CNA F stated she put the sling behind resident #197's back and was hooked the sling to the sit to stand mechanical lift when the resident moved her arm. CNA F stated the resident started to slide down and she and CNA G put her on the floor. CNA F said, The resident was already down on the floor when we called RN E. She stated the RN E came to the room and was told the resident was placed on the floor from the lift. She noted RN E checked the resident for injuries and then she and CNA G transferred the resident to bed using the full mechanical lift. Review of the x-ray done at the facility on 2/08/24 at 7:00 PM, showed the results were reported to the facility at 8:14 PM, with findings of a new non-displaced clavicle fracture. Review of the medical record indicated resident #197 was sent to the hospital on 2/09/24 due to continued pain in her shoulder. The results of the x-ray taken at the hospital on 2/09/24 at 12:46 PM indicated resident#197 had an angulated, nondisplaced fracture of the distal left clavicle. On 2/14/24 at 1:53 PM, Physical Therapy Assistant (PTA) I stated resident #197 was motivated on the first week of therapy because she wanted to go home. He explained that due to the fracture, the resident had pain and could not use her left arm so her therapy had to be extended. PTA I said resident #197 previously required moderate assistance for bed mobility but now required maximum to total assistance due to pain. He stated resident #197 told him there was only one person using the lift with her and she knew it was supposed to be two people. PTA I said, I also heard that it was one person using the mechanical lift with resident #197. Review of the care plan and Kardex revealed resident #197 was assessed to require two-person assist for transfers. There was no indication on either the care plan or the Kardex as to the type of device needed to transfer the resident until 02/08/24, when the care plan was revised to indicate the resident required use of a full body mechanical lift for transfers. On 2/15/24 at 12:15 PM, the Corporate Nurse explained a two-person transfer, required two staff to be involved in the process of the transfer. She stated this indicated the number of staff required to safely transfer a resident but did not describe what type of lift was to be used. The Corporate Nurse explained the care plan did not detail the type of lift needed to transfer resident #197 until 2/08/24. On 2/13/24 at 8:40 AM, resident #197 stated police officers came to see her last night. The resident stated she was not sure why they were there. She stated they said they were here to see how she was doing but didn't really say much more than that. On 2/13/24 at 10:00 AM, the Administrator stated he called the police and Department of Children and Family (DCF) because resident #197 alleged neglect concerning her fall on 2/8/24. He stated he had not reported the incident to the State Agency as he was still investigating. On 02/15/24 at 5:33 PM, resident #197 stated someone came to her room today and told me she had spoken to me before. The resident explained this person did not introduce themselves when they came to her room. She said this person recounted incorrect information about the incident on 2/08/24. The resident said, this person told me that I had said I had pulled myself up in bed, heard a pop, and that caused the fracture in my shoulder. The resident was visibly upset and noted, I told her I have never said that to you. I don't know where you got that from. On 2/16/24 at 1:50 PM, CNA M spoke about resident #197's transfer needs. I personally would not feel comfortable using a sit to stand with her because she is very dependent on help with any movement. When I took care of her before and after the incident, she was not able to pull herself up in bed. I went into the room at least two to three times during my shift to pull her up in bed and it always took two people. On 2/15/24 at 12:15 PM, an interview was conducted with the Regional Nurse Consultant, the Director of Nursing (DON) and the Administrator. The Nurse Consultant explained that two person assist with transfers meant that two staff should be present to do the transfer. She described it could be for a standing lift or full mechanical lift transfers. She stated two person assist only indicated the number of staff, not the type of mechanical lift to be used. She acknowledged the type of mechanical lift was not reflected on resident #197's care plan until 2/08/24. The Administrator added, in the morning meeting, the Minimum Data Set Nurse inputs any changes to the care plans and Kardex. He explained after the meeting, any changes would be communicated to the CNAs verbally. He said the type of lift to be used for resident #197 should have been in the electronic system as a task but explained it did not get written in the Kardex until 2/8/24. He did not clarify if the specific lift was added prior to the incident or after the incident. The Administrator reported the wrong mechanical lift was used for the resident as she did not like the full body mechanical lift and the CNA said she had used the sit to stand mechanical lift previously with the resident. When asked if CNAs determined the type of lift to use to transfer residents, the Administrator did not provide an answer. They were asked to clarify the inconsistencies in statements from the both the resident and RN E who stated only one CNA transferred the resident and CNAs G and F's statements that it was 2 CNAs. The Administrator replied he was told two CNAs transferred the resident. The Abuse, Neglect and Exploitation policy most recently revised 11/16/23 read, Neglect means failure of the facility, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility policy, Safe Resident Handling/Transfers implemented 11/03/2020 and revised 11/29/22 read, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident. Two staff members must be utilized when transferring residents with a mechanical lift. Review of the CNA job description included duties to ambulate and transfer residents utilizing appropriate assistive devices and body mechanics. The resident sample was expanded to include five additional residents who were identified as requiring a mechanical lift for transfers. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * On 2-09-24, staff members involved were given 1:1 education by the Staff Development Coordinator on the proper use of mechanical lifts. * On 2-09-24 through 2-15-24 current nursing staff and therapy staff were educated on the transfer of residents and the use of the mechanical lifts by the Director of Nursing, Staff Development Coordinator and Nurse managers. Twenty five nursing staff members were educated on 2-09-24, 8 nursing staff members were educated on 2-12-24, 5 nursing staff were educated on 2-13-24, 1 nursing staff was educated on 2-14-24, 50 staff members were educated on 2-15-24. Newly hired staff members and agency staff will be educated during the orientation process. Staff members that are on vacation will receive education prior to the start of their next shift. * On 2-12-24 through 2-15-24 current staff were educated on ANME (Abuse, Neglect, Misappropriation, Exploitation) by Staff Development Coordinator, Nurse Managers and Department Heads. On 2-12-24, 18 facility staff members were educated, on 2-13-24, 17 facility staff members were educated, and on 2-15-24, 89 staff were educated. Newly hired staff members and agency staff will be educated during the orientation process. Staff members that are on vacation or FMLA will receive education prior to the start of their next shift. * On 2/16/24, out of 88 Total nursing and therapy employees-77 nursing and therapy employees received education on the use of the mechanical lifts. * On 2/16/24, out of 124 Total facility employees, 103 Facility staff received education on ANME. * Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held on 2-16-24 with Medical Director, Administrator, DON, Staff Development Coordinator, Therapy Director, and Unit Manager to discuss transfer status, mechanical lift use and root cause analysis. Interviews conducted from 2/17/24 with 13 facility staff including licensed nurses and CNAs revealed they were knowledgeable about the facility's transfer policy, and the need to review the care plan and Kardex to identify number of persons and mode of transfer or which mechanical lift for resident transfers. They verified a return demonstration was completed after the education. They confirmed they received Abuse/Neglect education followed by a post test.

Based on interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee implemented effective Performance Improvement Plans (PIPs) to correct and monitor identified deficiencies, and ensure sustained improvements. Findings: In a joint interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 2/17/24 at 3:51 PM, the NHA stated the facility's QAPI committee implemented PIPs to address regulatory noncompliance identified during surveys, and as needed. The DON provided a document dated 6/09/23 that she identified as a PIP for falls. She explained the Regional Director of Operations had re-implemented the plan on 2/16/24. She noted they intended to identify opportunities for improvement related to fall occurrences that included investigations and identification of the root causes and stated, so we can put a true intervention in place. The NHA said regulatory compliance was discussed when any entity visited the facility whether it was a State Agency, Department, or the Ombudsman. He stated there was an Ad Hoc meeting held in December after a complaint survey for falls, and there were none in January 2024. He explained, any identified problems were discussed in morning meetings and regular QAPI meetings. He stated PIPs were discussed monthly for monitoring, improvement tracking, and revision. He said if the problems improved, they were tracked quarterly until they were removed. The NHA explained that in August 2024, the facility developed a Resident Engagement Program to provide increased supervision for residents with a high fall risk. He said he wasn't sure if the facility had monitored their PIPs with documentation and /or audits. The DON said she was not aware of any documentation. The NHA stated, I guess we don't have them; I don't know where they could be. The NHA provided copies of signature pages from QAPI meetings from the previous year. He provided an additional document dated 1/05/24 that he identified as a PIP for improvement in the timeliness of processed applications. He explained, the PIP included plans to have all documentation within 72 hours, and the former Business Office Manager was supposed to update him weekly on the status of all open applications. He said the Business Office Manager had not completed the interventions or met the standards and stated, it didn't work out that well, so we are going to be starting over. On 2/17/24 at 8:30 AM, the NHA said he investigated a resident's fall in the facility that occurred on 2/08/24 and resulted in a fracture. He explained he interviewed the staff involved over the telephone. He said he had not interviewed the resident, and his investigation had not included a staff return demonstration of the incident. He explained his investigation concluded a Facility Related Incident report was not required. He said he was not aware the staff involved provided inconsistent recollections to surveyors during their interviews. Review of the facility's regulatory compliance history revealed the nursing home had repeat deficiencies at F609 and F610 identified during the 2 prior complaint surveys on 11/15/23, and 5/9/23. The facility had a prior Immediate Jeopardy at F689 one year ago, on 2/17/23 and on 4/13/2021. The facility's policies and procedures titled Quality Assurance and Performance Improvement (QAPI) dated 8/08/22 read, .Adverse Event is an untoward, undesirable and usually unanticipated event that causes death or serious injury, or the risk thereof, including near misses. High Risk refers to care or service areas associated with significant risk for the health or safety of residents . Performance Improvement (PI) is the continuous study and improvement of processes with the intent to improve services or outcomes, and prevent or decrease the likelihood of problems, by identifying opportunities for improvement, and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement. Quality Assurance (QA) is the specification of (1) standards for quality of care, service and outcomes, and (2) systems throughout the facility for assuring that care is maintained at acceptable levels in relation to those standards. QAPI is the coordinated application of two mutually reinforcing aspects of a quality management system: (QA) and Performance Improvement (PI). 4. The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include . b. Systems and reports demonstrating systematic identification, reporting, investigation analysis, and prevention of adverse events. c. Documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. 5. The plan and supporting documentation will be presented to the State Agency or Federal surveyor at each annual recertification survey and upon request. 3. Program Feedback, Data Systems, and Monitoring -- a. The facility maintains procedures for feedback, data collection systems, and monitoring including adverse event monitoring. The Facility Assessment Executive Summary read, Date of Assessment/Update: 9/19/2023 . Date Assessment Reviewed with the Quality Committee: 9/20/2023 . 3.2b Staffing Plan . quality assurance . 3.4 Policies and Procedures for Provisions of Care . QAPI will evaluate what policies and procedures may be required in the provision of care, and how you ensure those meet current professional standards of practice, include, our process to determine if new or updated policies are needed, and how they are developed or updated. Examples of policies and procedures include . fall prevention . 3.5a Expectations . QAPI committee will meet quarterly to discuss standard, protocols and help develop the best quality of care for residents. This will include working medical professionals, MD [Medical Doctor], physician, ARNP [Advanced Registered Nurse Practitioner], etc. to develop, adjust or implement process and protocols .

Based on observation, interview, and record review the facility failed to provide an on-going individualized program of activities for 2 of 2 residents reviewed for activities of a total sample of 45 residents, (#2, #79). Findings: Record review revealed resident #2, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included diabetes type II, Chronic Obstructive Pulmonary Disease (COPD), heart disease, psychosis, dementia, blindness of her right and left eye, anxiety disorder, and cognitive communication deficit The annual Minimum Data Set (MDS) assessment, with assessment reference date of 2/24/23 revealed resident #2 had a Brief Interview of Mental Status score of 7 which indicated the resident had severe cognitive impairment. Section F- Preferences for customary routine and activities revealed code 1 was documented, indicating it was very important to the resident for the following activities: listen to music she liked, be around animals such as pets, do things with groups of people, do favorite activities, go outside to get fresh air when the weather is good, and participate in religious services or practices. The assessment indicated the resident was the primary respondent for the daily and activity preferences. The assessment noted resident #2 was totally dependent on staff for transfers and required extensive assistance with bed mobility. The resident's quarterly MDS assessment dated [DATE], revealed the resident's BIMS score was 3, indicating worsening cognitive impairment from the assessment done on 2/24/23. A care plan for activities initiated 6/23/23 and revised on 2/15/24, indicated resident #2's previous recreational interests/patterns included group activities, leisure time outside, and listening to music. The goal was for her to participate in activities of choice and participate in one-on-one visits at least 2 times per week. Interventions included activity staff to provide one-on-one visits, provide a program of activities that was of interest, and to provide room activities that included healthy hands, conversing, snack delivery, prayer, and visits with family and friends. A 30 day look back of the resident's POC (Point Of Care) Response History for the period 1/14/24 to 2/15/24 revealed no data for one-to-one activities, activity participation, self-directed/independent activities, or group activities. An Activity Participation Note dated 5/23/21 read, She spends most of her time in her room with little participation in limited group programs Friendly activities are offered 2-3 x week for social stimulation and support. Room activities include healthy hands, putting lotion on resident's hands, music (tablet), singing, prayer, daily word, conversing, snack facetime with volunteers and assisting with TV/headset operation. Leisure time is spent listening to music. On 2/12/24 at 10:02 AM, on 2/13/24 at 1:45 PM, resident #2 was observed lying in bed on her back, the television was not on, and the radio on her bedside table was not on. On 2/15/24 at 11:11 AM, Licensed Practical Nurse (LPN) B stated the resident was confused, and they tried to get the resident out of bed one to two times weekly, and one-on-one activities was done by the activities department. On 2/15/24 at 3:43 PM, resident #2 was observed lying in bed on her back. Her eyes were closed, but the resident responded when her name was called. The radio on her bedside table was off, and the television was not on. When asked if she liked music, the resident said yes ma'am I do. On 2/15/24 at 3:51 PM, the Activities Director stated residents were assessed for activities depending on their level of independence. She explained they had three levels of assessment, and level II was for residents with impaired cognition, and the assessment would be completed by conducting interviews with the resident's family, responsible party, or staff, and review of the admission nursing assessment. She stated bedside activities were provided, along with friendly visits. If the resident was bed ridden, room visits would be provided three times weekly, and documented in the facility's electronic medical record under the POC screen. Review of the resident's medical records with the Activities Director revealed no documentation regarding room visits, one-on-one visits, or any other activities provided for the resident. The Activities Director shared that she had not documented activities for the day and did not know how to review the history for documentation. She stated she would review the resident's activity progress notes that were documented when a care plan was initiated. Review of the resident's care plan for activities revealed it was initiated on 6/23/23, and the last documented Activity Note identified was dated 5/23/21. This was confirmed by the Activities Director. On 2/15/24 at 4:00 PM, observation with the Activities Director, showed resident #2 lying in bed on her back with no television or radio on. The Activities Director acknowledged neither the radio was playing nor the television was on. On 2/15/24 at 4:52 PM, and on 2/16/24 at 11:44 AM, the Activities Director, stated she called the Activity Assistant who documented room visits. The Activities Director identified there was not any documentation history for the resident from 2023. She verbalized the Activity Assistant did not visit with resident # 2, and the resident was not seen on 12/14/24 for activities. She confirmed that no documentation electronic or otherwise could be identified to indicate the resident was provided with activities as indicated in her care plan. 39943 2. Resident #79 was admitted to the facility on [DATE] with diagnoses to include stroke, gastrostomy status(feeding tube), encephalopathy, and difficulty swallowing. The resident's quarterly MDS assessment with Assessment Reference Date (ARD) of 12/02/23 revealed the resident's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) of rarely/never understood. Review of resident #79's activity care plan revealed an intervention to provide 1:1 visits three times weekly. Review of the Activities- Initial - Review dated 6/08/23 at 2:09 PM read: resident #79 enjoys spending time in room and in hallway for social interaction. She enjoys music socials and morning visits. Friendly and 1:1 visits offered daily. On 2/12/23 at 4:30 PM, resident #79 was observed lying in bed with her eyes open. On 2/13/24 at 9:15 AM, resident #79 was observed lying in bed with her eyes closed. The resident's daughter was at the bedside and stated her mother did not go out of the room and she had never seen anyone from activities in the room with her mother. On 2/13/24 at 5:14 PM, resident #79 was observed lying in bed on her left side, eyes closed and head of bed elevated. On 2/14/24 at 10:49 AM, resident #79 was observed lying in bed facing the window, with her eyes open. On 2/16/24 at 3:01 PM, the Activity Director stated resident #79 used to come out of her room every day for activities but she chose not to come out anymore. She stated someone from the activity team went to her room several times per week to visit and read to her. The Activity Director explained all visits with residents were documented in the medical record. She reviewed the resident's medical record and was unable to locate any documentation for room visits. She stated, I am not sure why the documentation is not showing up. We do visit resident #79 in her room. She noted she did not know how to pull up the notes and would try to ask someone how to retrieve the notes. The Activity Director did not provide any documentation for one to one room visits for resident #79. Review of the Activities- Initial - Review dated 6/08/23 at 2:09 PM read: resident #79 enjoys spending time in room and in hallway for social interaction. She enjoys music socials and morning visits. Friendly and 1:1 visits offered daily. The facility's policy Activities implemented on 11/2020, and reviewed/revised on 1/2024 read, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessments, care plan, and preferences . activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being . Special considerations will be made for developing meaningful activities for residents with dementia and /or special needs.

Based on observation, and interview, the facility failed to provide a homelike environment for all residents who ate their meals in the main dining room, by serving the resident's meals on serving trays at the table in an institutional manner. Findings: On 2/13/24 at 12:30 PM, during meal observation in the main dining room,13 residents were observed seated at the tables in the dining room. Each resident was noted to have a serving tray on the table in front of them which contained the lunch meal. The plates, cups, bowls and eating ware remained on the tray and were not removed from the trays at the table. On 2/13/24 at 4:46 PM, during meal observation, 12 residents were observed seated in the main dining room. Each resident had a serving tray in front of them with their meal, dinnerware and eating utensils on the tray. On 2/13/24 at 4:50 PM, Certified Nursing Assistant (CNA) P was in the dining room. She acknowledged she was the only staff person in the dining room and had served meals to all 12 residents. CNA P stated the meals were always served on trays in the dining room. On 2/13/24 at 4:56 PM, the Administrator, Director of Nursing (DON) and Regional Nurse Consultant observed the meal trays in front of residents in the dining room. The Administrator and DON acknowledged the dining room should be a home-like environment and resident meals should be removed from meal trays. On 2/16/24 at 10:23 AM, the Administrator explained it was his expectation that staff provide a home-like environment for residents eating in the main dining room. The Administrator explained he was not aware staff were leaving meals on serving trays. The facility's policy and procedure for Safe and Homelike Environment revised 4/11/23 listed under General Considerations, Eliminate the use of meal trays during dining service, unless otherwise requested by the resident.

Based on observation, interview, and record review, the facility failed to ensure 1 of 1 resident was assessed to be clinically appropriate to self-administer medication of a total sample of 45 residents, (#18). Findings: Resident #18, a [AGE] year-old female was admitted to the facility on [DATE], with diagnoses that included mechanical complication of internal fixation device of left femur, asthma, atrial fibrillation, and major depressive disorder. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 1/10/24, revealed the resident's cognition was intact, with a Brief Interview of Mental Status (BIMS) score of 13 out of 15. On 2/12/24 at 11:48 AM, resident #18 was lying in bed, awake, alert, and oriented. Observation showed a handheld inhaler of Albuterol on the resident's tray table. She stated she administered it herself approximately every eight hours. On 2/12/24 at 4:45 PM, resident #18 was sitting up in her bed, working on a cross word puzzle. The Albuterol inhaler was in her bag, which she took out and showed to the surveyor. The resident stated the Albuterol was prescribed by her Primary Care Physician (PCP) and said the facility was aware she had the Albuterol, because she told them about it when she was admitted to the facility. On 2/12/24 at 4:47 PM, observation of the Albuterol inhaler at the resident's bedside was conducted with Licensed Practical Nurse (LPN) A. The resident shared with the LPN, that she used the inhaler approximately every eight hours. Resident #18 said when she had a cold, she had a terrible time and used the Albuterol inhaler more often. Review of the resident's physician orders with the LPN revealed no physician order for the Albuterol inhaler, and no order for self-administration of medication for resident #18. A self-administration evaluation was also not identified. On 2/12/24 at 4:51 PM, the Director of Nursing (DON) said if a resident was to self-administer medications, an assessment for self-administration of medication had to be completed, a physician order for self-administration obtained, and a lock box provided for the resident to store the medication safely at bedside. However, observation, interview, and record review revealed that this was not done for resident #18. The facility's policy Resident Self-Administration of Medication implemented on 11/2020, read, A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely The results of the interdisciplinary team assessment are recorded on the Self-Administration of Medication Evaluation, which is located in the resident's medical record.

Based on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessment accurately reflected health conditions regarding bladder and bowel for 1 of 1 resident reviewed for urinary catheter, of a total sample of 45 residents, (#20). Findings: Record review revealed resident #20 was a 52- year-old-male admitted to the facility on [DATE], with his most recent readmission on 10/26/23. His diagnoses included hydronephrosis with ureteral stricture, spinal muscular atrophies, paranoid schizophrenia, malignant neoplasm of prostate, paraplegia, and anoxic brain damage. Review of the resident's Medical Certification For Medicaid Long-term Care Services And Patient Transfer Form (3008) dated 3/01/22 revealed the resident had a colostomy, and a right Urostomy/nephrostomy. A colostomy is surgery to create an opening called a stoma. The opening creates a passage from the large intestines to the outside of your body . so that solid stool and gas can leave the body through the stoma instead of passing through the rectum. (retrieved on 2/21/24 from cancer. net) A Urostomy is a surgically created opening in the abdominal wall through which urine passes. A urostomy may be performed when the bladder is either not functioning or has to be removed. (retrieved on 2/21/24 from ostomy.org) A nephrostomy is a procedure to drain urine from your kidney using a catheter (tube) (retrieved on 2/21/24 from healthdirect.gov.au). The resident's physician orders dated 9/02/22 read, colostomy and urostomy care every shift. Review of a Provider progress note dated 10/05/23, showed documentation that read, History of prostate cancer/obstructive uropathy-s/p (status/post) urostomy-s/p colostomy Review of the quarterly MDS assessment dated [DATE], revealed Section H: Bladder and Bowel question H0100 titled Appliances, indwelling catheter (including suprapubic catheter and nephrostomy tube) was checked, Ostomy (including urostomy, ileostomy, and colostomy) was not checked. Question H0300, urinary continence was coded with the number 3, indicating the resident was always incontinent. Question H0400 bowel continence was also coded with the number 3, indicating the resident was always incontinent of bowel. On 2/13/24 at 4:59 PM, and on 2/15/24 at 11:11 AM, the resident's primary nurses, Registered Nurse (RN) E, and Licensed Practical Nurse (LPN) B stated resident #20 had a colostomy, and a urostomy, that were monitored as per physician's orders. On 2/16/24 at 9:30 AM, the MDS Coordinator stated MDS assessments were completed doing a seven day look back, and included review of the resident's clinical records, a bedside assessment of the resident, interview of the resident if the resident's cognition was intact, and if not, an interview would be conducted with the family/responsible party, interview of the resident's primary nurse, rehab, and the resident's Certified Nursing Assistants (CNA) as needed. The MDS Coordinator stated a care plan would be initiated and implemented based on the resident's comorbidities, and diagnoses. Resident # 20's quarterly MDS assessment dated [DATE] was reviewed with the MDS Coordinator. He confirmed the resident had a colostomy, and urostomy, and explained he completed the assessment, and section H was not accurate. For H0100 ostomy should have been checked and for H0300, and H0400 the number 9 should have been coded, for not rated, since the resident had a urostomy, and a colostomy. The facility's policy MDS 3.0 Completion implemented on 11/03/20, and reviewed/revised on 9/19/22, read, According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity.

Based on observation and interview, the facility failed to ensure residents' dignity was maintained, by failing to knock on doors prior to entry during dining observation on 1 of 2 wings, (East Wing). Findings: On 2/12/24 at 12:08 PM, during dining observation on the East Wing, Certified Nursing Assistant (CNA) D was observed serving meal trays. CNA D entered rooms 101, 104, 105, 106, and room [ROOM NUMBER], and did not knock on the doors, or announced herself prior to entry. On 2/12/24 at 12:15 PM, CNA D donned appropriate Personal Protective Equipment (PPE), for Transmission Based Precaution (TBP) to deliver meal trays to residents in room [ROOM NUMBER]. The CNA did not knock on the door prior to entry and used her foot to push the door open. On 2/12/24 at 12:33 PM, CNA D acknowledged she did not knock on the residents' doors prior to entering rooms to serve meal trays. The CNA stated that normally she did not knock on the doors, but just went in and dropped off the trays. On 2/17/24 at 9:08 AM, resident #83 in room [ROOM NUMBER], stated her preference was for staff to knock on her door prior to entry. On 2/17/24 at 1:08 PM, the Director of Nursing (DON) stated that knocking on doors prior to entry was common practice, as the facility was the residents' home. She explained the practice showed respect for resident's dignity. She stated education regarding dignity was done when staff were hired and annually. The facility's policy Promoting/Maintaining Resident Dignity implemented on 11/03/2021, and revised/reviewed on 1/2024, read, The resident's .personal choices will be considered when providing care and services to meet the resident's needs and preferences.

Based on observation, interview, and record review, the facility failed to ensure enteral feeding was infused as prescribed by the physician for 1 of 2 residents reviewed for tube feeding, of a total sample of 45 residents, (#83). Enteral feeding refers to intake of food via the gastrointestinal (GI) tract. (Retrieved from https//www.healthline.com 2/27/24). Findings: Resident #83, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included diabetes type II, asthma, gastrostomy, heart failure, hyperlipidemia, hypertension, and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was intact with a Brief Interview for Mental status (BIMS) of 15 out of 15. The assessment revealed the resident had a feeding tube, and received a mechanically altered, and therapeutic diet. The resident's physician's order dated 9/16/23 noted Glucerna 1.5 continuous at 65 milliliters (ml) per hour for twenty (20) hours per day, off at 8:00 AM to 12:00 PM. The Nutrition Risk Screen dated 12/06/23 revealed the resident's tube feeding was Glucerna 1.5 at 65 ml/hour for 20 hours. On 2/13/24 at 1:33 PM, resident #83 was observed with enteral feed Glucerna 1.5 connected to a feeding pump and infusing at 75 ml/hour. The bottle was dated 2/13/24, no time was documented, and 750 ml of the formula remained in the bottle. On 2/14/24 at 11:59 AM, resident #83 was observed lying in bed on her back, with the head of the bed elevated at approximately 45 degrees. The resident's eyes were closed, and there was no response when spoken to. Glucerna 1.5 bottle dated 2/13/24 was noted at the feeding pump, and infused at 75 ml per hour. On 2/14/24 at 2:41 PM, observation showed enteral feed Glucerna via feeding pump infused at 75 ml per hour, with 200 milliliters remaining in the bottle. On 2/14/24 at 2:43 PM, Licensed Practical Nurse (LPN) B stated resident #83 was on enteral feed, Glucerna 1.5 at 75 ml per hour, off at 8 AM, and back on at 12 PM. Review of the resident's physician orders conducted with the LPN showed order for Glucerna 1.5 at 65 ml/hour. On 2/14/24 at 2:56 PM, observation of the resident's enteral feed was conducted with LPN B. Glucerna 1.5 bottle dated 2/13 9 PM, labeled with rate 75 ml, was hanging, and infusing via a feeding pump at 75 ml/hour. LPN B stated she usually checked, but when she received report at the beginning of her shift, she was told a bottle was already hanging, and running, and she did not check the rate. She verbalized the enteral feed should be infusing at 65 ml/ hour. On 2/14/24 at 3:01 PM, the Director of Nursing (DON) stated the expectation was that nurses would check physician orders, to ensure enteral feed was infusing as ordered. The resident's care plan At risk for Malnutrition related to diabetes . gastrostomy status .enteral feeding .was initiated on 8/31/23, with revision on 10/12/23. A goal was to maintain nutritional status, and interventions included, Provide enteral feeding as ordered. The facility's policy Care and Treatment of Feeding Tubes implemented on 11/03/20, and reviewed/revised on 1/2024 read, Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. The document directed staff to provide Periodic evaluation of the amount of feeding being administered for consistency with practitioner's orders.

Based on observation, interview, and record review, the facility failed to provide mouth care for 1 of 5 residents observed for Activities of Daily Living (ADL) care of a total sample of 45 residents, (#72). Findings: Resident #72 was admitted to the facility on [DATE] with diagnoses to include stroke, difficulty swallowing, aphasia, and need for assistance with personal care. The resident's 5-day Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 1/13/24 revealed the resident's cognition was severely impaired. The assessment noted his speech was unclear and he required maximum assistance for oral hygiene. The assessment noted the resident did not have any behaviors. On 2/13/24 at 3:14 PM, the resident was observed lying in bed with his eyes closed. He had his mouth open and his tongue and teeth were coated with a thick white substance. On 2/14/24 at 10:43 AM, the resident was observed lying in bed awake looking at the television. His tongue and teeth were coated with a thick white substance. On 2/14/24 at 3:10 PM, the resident was observed lying in bed and his tongue and teeth were covered with a thick white substance. At 3:15 PM, Licensed Practical Nurse (LPN) C observed the residents mouth and acknowledged the resident needed mouth care. The LPN explained mouth care should be done at least every shift and as needed. LPN C directed Certified Nursing Assistant (CNA) O to provide mouth care to the resident. The CNA stated she tried to clean resident #72's mouth earlier and he would not let her. She stated he kept closing his mouth. She proceeded to use the mouth care swabs and the resident remained still, with his mouth open to allow her to clean it. Review of resident #72's Order Summary Report revealed an active order that read, complete oral care every shift. Resident #72's Care Plan for enteral feeding had an intervention that read, mouth care every shift and prn (as needed), initiated 11/17/23. The Activities of Daily Living (ADL'S) policy implemented on 11/03/2020 and revised on 11/29/22 read: Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming, and oral care. 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 interview and record review, the facility failed to ensure 2 residents/representatives were provided the opportunity to participate in their care plan reviews, (#33, #58); and failed to ensure 2 residents/representatives were invited and participated in the development of care plans, (#80, #83), of a total sample of 45 residents. Findings: 1. Review of the medical record revealed resident #33, a [AGE] year old female was admitted to the facility on [DATE] and readmitted from an acute care hospital on 2/07/23. Her diagnoses included thoracic vertebra (mid-spine) fractures, heart failure, pulmonary (lung) hypertension, atrial fibrillation (heart rhythm dysfunction), Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, malnutrition and, type 2 diabetes mellitus with kidney disease. The most recent Minimum Data Set (MDS) Quarterly Assessment with Assessment Reference Date (ARD) of 2/01/24 noted the resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated the resident was cognitively intact. Functional Abilities and Goals noted the resident had functional range of motion limitations in both legs, required moderate to substantial assistance from staff for mobility in bed, to transfer, and to complete Activities of Daily Living (ADLs), was incontinent of bladder and bowel functions, was at risk for pressure ulcers, received pain medications as needed, and received routine high risk insulin, anti-anxiety, anti-coagulant (blood thinner), and diuretic (fluid removing) medications during the look back period. Participation in Assessment and Goal Setting indicated the resident was an active participant in setting her goals with a discharge plan to return to the community. The Comprehensive Care Plan initiated 9/07/22 and revised 3/07/23 included interventions and goals for diabetes, risk for falls/injury, adverse medication effects, impaired mobility, incontinence, pain, psychosocial well-being, preferred activities, behaviors, malnutrition, risk for skin impairment, ADL self-care performance deficits, and discharge plans to remain in the facility for long-term care services. The Order Summary Report revealed resident #33's active physician's ordered medications included Tylenol 650 milligrams (MG) as needed for pain, Alendronate Sodium 35 MG for osteoporosis, Apixaban (blood thinner) 5 MG for atrial fibrillation, Atorvastatin 40 MG for high cholesterol, Guaifenesin as needed for cough, Furosemide (water pill) 20 MG for heart failure, Jardiance 25 MG for heart failure and diabetes, Lactulose as needed for constipation, Lantus insulin injection for diabetes, Meclizine as needed for dizziness, Metoprolol Tartrate 50 MG for elevated heart rate, Novolog insulin injection for diabetes, Nystatin cream for rash, Ondansetron HCI 4 MG as needed for nausea/vomiting, Protonix 40 MG for Gastroesophageal Reflux Disease (GERD), Senna 17.2 MG for constipation, Sertraline 100 MG for depression, Trulicity 0.75 MG injection for diabetes and neuropathy (nerve pain), and Triamcinolone Acetonide Cream 0.5% for rash. On 2/13/24 at 10:20 AM, resident #33 said staff had not offered her the opportunity to participate in Interdisciplinary Team (IDT) discussions or meetings about her plan of care. Review of resident #33's Electronic Health Record (EHR) revealed the last Care Plan Meeting Invitation to the resident was dated almost one year ago on, 2/27/23 for a 3/09/23 scheduled meeting. The EHR did not include additional invitations or Care Plan Conference Summary documents to show the resident or resident representative participated in subsequent plan of care reviews. In an interview on 2/16/24 at 9:30 AM, the MDS Coordinator stated the former Business Office Manager was responsible for the completion of residents/representative care plan meeting invitations. He explained, he had taken over the duties for approximately two weeks and they had been, behind schedule. He said it was important for residents and their families to be involved in their care planning because, they do better. 2. Review of the medical record revealed resident #58, an [AGE] year old female was admitted to the facility on [DATE] and readmitted from an acute care hospital on 8/31/23 with diagnoses of Parkinson's Disease, stroke, neuro-cognitive disorder, diabetes, malnutrition, dementia, hypertension, depression, spondylosis (small crack between two spinal bones), lumbar (lower back) stenosis (narrowing of spinal canal), and history of falls. The most recent MDS Quarterly Assessment with an ARD of 11/24/23 noted the resident scored 2 out of 15 on the BIMS that indicated the resident was severely cognitively impaired. Functional Abilities and Goals noted the resident had functional range of motion limitations in both legs, required substantial/maximum assistance to dependence from staff for mobility in bed, to transfer, and to complete ADLs, was incontinent of bladder and bowel functions, had 1 fall, received pain medications as needed, and routine high risk insulin, anti-depressant, and anti-biotic medications during the look back period. Participation in Assessment and Goal Setting indicated the resident was an active participant in setting her goals and there were no discharge plans to return to the community. The Comprehensive Care Plan included interventions and goals for history of falls and risk for falls/injury, adverse medication effects, diabetes, impaired mobility, incontinence, risk for gastrointestinal complications, anemia, impaired cognition, dementia, depression, insomnia, pain, psychosocial well-being, preferred activities, refusals of care, nutrition and weight loss, risk for skin impairment, ADL self-care performance deficits, advanced directives, and discharge plans to remain in the facility for long-term care services. The Order Summary Report revealed resident #58's active physician's ordered medications included Tylenol 650 MG as needed for pain, Amlodipine 5 MG for high blood pressure, Bisacodyl EC 5 MG as needed for constipation, Escitalopram 10 MG for depression, Melatonin 3 MG for insomnia, Memantine HCI 5 MG for Alzheimer's, Novolin 70/30 insulin injection for diabetes, Rytary ER 36.5-145 MG for Parkinson's disease, and Trazodone HCL 50 MG for insomnia, On 2/16/24 at 9:30 AM, the MDS Coordinator explained residents' Comprehensive Care Plans were reviewed routinely by the IDT according to the MDS schedule, after admission, quarterly, annually, and for significant changes. Review of the EHR Care Plan Review History revealed quarterly reviews were completed 11/11/23 and 2/09/24. The Care Plan Conference Summary scanned in the record noted the last IDT review with the resident's representative was held 8/17/23. On 2/17/24 at 10:33 AM, the Social Services Director explained that she was part of the IDT and attended care plan meetings where she discussed advanced directives and ensured they were up to date to reflect the correct choice. She said a record of meetings was kept on Care Plan Conference Summary forms that were signed by participants. She said it was important for residents and their representatives to be informed of their care reviews and advanced directives on record. She stated the meetings and discussions were important, and the process affected overall health and treatment outcomes. She explained, the goal in social services was, to reduce anxiety and depression so they can make decisions in their care. Review of the facility's standards and guidelines titled Comprehensive Care Plans dated 7/27/22 read, . Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives., and . 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: . e. The resident and the resident's representative . 32131 3. Resident #80 was an 89- year-old female admitted to the facility on [DATE] with diagnoses which included displaced fracture of anterior wall left acetabulum, history of falls, generalized muscle weakness, and cognitive communication deficit. Review of the resident's quarterly MDS assessment dated [DATE], revealed the resident's cognition was severely impaired with a BIMS score of 03 out of 15. On 2/12/24 at 12:41 PM, resident #80's daughter stated she had not been invited or approached regarding any care plan meeting for the resident. On 2/14/24 at 11:28 AM, in an interview with the Registered Nurse (RN) MDS Coordinator, and the Licensed Practical Nurse (LPN) MDS, they stated that previously, invitation letters for care plan meetings were sent out by the prior receptionist, and two weeks ago MDS took over the task. The LPN MDS explained that a schedule of the monthly care plan meetings due were pulled, and invitation letters, were given and/or mailed to the resident and /or the resident's Power of Attorney (POA)/responsible party. She stated the POA/responsible party would also be called to inform them that the invitation letter was mailed out. A care plan meeting would be scheduled as confirmed by the resident/POA/responsible party, and the meeting could be held via telephone, in person, or in the resident's room. She stated a copy of the invitation letter was placed in a drive in the facility's electronic record. The RN MDS Coordinator stated resident #80's last care plan meeting was held on 1/12/24. He stated he tried to contact the resident's family, since no one was sending invitation letters out, but never received a response. However, there was no documentation to indicate an attempt was made to contact the resident's family. On 2/16/24 at 9:30 AM, the RN MDS Coordinator stated it was important to get the family involved in the resident's care plan meeting, because the family could participate, be updated about the resident's care, which would benefit the resident, and help to guide the residents' care. The resident's Care Plan Conference Summary dated 1/12/24, was reviewed with the RN MDS Coordinator. There was no documentation to indicate any involvement of the family /resident in the care plan meeting. The only signature for attendees documented on the form was the RN MDS Coordinator. This was confirmed by the RN MDS Coordinator. He stated no other Care Plan Conference Summary could be identified for the resident. He explained that if a summary was not in place, it indicated that a care plan meeting had not been conducted. 4. Resident # 83, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included diabetes type II, asthma, gastrostomy, heart failure, hyperlipidemia, hypertension, and major depressive disorder. Review of the resident's quarterly MDS dated [DATE], revealed the resident's cognition was intact with a BIMS of 15 out of 15. On 2/13/24 at 1:24 PM, resident #83 stated she had not attended any care plan meeting, did not know if the facility had care planning meetings, and would have attended the meeting if she was made aware. On 2/14/24 at 11:28 AM, the RN MDS Coordinator stated resident #83's last care plan meeting was held on 12/01/23, and the resident was not present. He stated an invitation letter was to be provided to the resident, however no documentation could be identified to indicate the resident was informed or invited to her care plan meeting. On 2/14/24 at 11:32 AM, the Regional MDS Coordinator said when a care plan meeting was held, a signature sheet/summary sheet would have documentation of all persons in attendance. Review of the resident's Care Plan Conference Summary dated 9/14/23, and 11/16/23 revealed no documentation to indicate the resident was invited or participated in her care plan meeting. On 2/16/24 at 9:30 AM, the RN MDS Coordinator stated at first he was not aware of all he had to do in his role. He said he could not identify any additional Care Plan Conference Summary for the resident, apart from the ones mentioned, and acknowledged the resident with intact cognition was not involved in her care plan meetings. The facility's policy Care Planning-Resident Participation implemented on 11/03/20, and reviewed/revised on 1/2024 read, This facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment . The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan.

Based on interview, and record review, the facility failed to accurately assess a resident's vision and failed to initiate a comprehensive care plan for impaired vision for 1 of 2 residents reviewed for vision/hearing of a total sample of 45 residents, (#197). Findings: Resident #197, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, atrial fibrillation, diabetes, and fracture of left clavicle. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 2/05/24 revealed the resident's cognition was intact, with a Brief Interview for Mental Status (BIMS) score of 15/15. The assessment noted resident #197 had adequate vision and was independent with eating. On 2/13/24 at 8:40 AM, Certified Nursing Assistant, (CNA) Q explained to resident #197 where the food was situated on her plate. The CNA stated the resident did not see very well so we always make sure she knows where the food and drinks are situated on her plate. The resident stated she was legally blind and could only see shadows. On 2/17/24 at 10:57 AM, the MDS Coordinator said he was not aware resident #197 was visually impaired. He acknowledged the resident did not have a care plan for impaired vision and added that while MDS did most of the care plans, other staff could add a care plan and stated it was an interdisciplinary responsibility. On 2/17/24 at 1:34 PM, the Director of Nursing (DON) stated care plans were reviewed at care plan meetings. She stated her expectation was that anyone who cared for the resident should contribute to their care plan to address the resident's needs. Review of the Comprehensive Care Plans policy implemented 11/2020 and revised 7/27/2022 read: The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences , will also be addressed. The comprehensive care plan will describe, at a minimum, the following: Resident specific interventions that reflect the resident's needs. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: A registered nurse with responsibility for the resident A nurse aide with responsibility for the resident

Based on interview and record review, the facility failed to develop a Baseline Care Plan timely for 2 of 2 residents of a total sample of 45 residents, (#25, #82). Findings: 1. Review of the medical record revealed resident #25, a [AGE] year old female was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included Alzheimer's Disease, malnutrition, diabetes, failure to thrive, and need for assistance with personal care. The Baseline Care Plan scanned to the Electronic Health Record (EHR) noted the nurse signed the plan of care was developed on 10/15/23. The document did not indicate any notations or signatures that indicated the resident or resident's representative was included. On 2/16/24 at 9:30 AM, the MDS Coordinator explained development of the Baseline Care Plan was included in the initial admissions process that staff nurses on the units completed. He said immediate treatment plans were important and the resident or resident representative needed to be involved as, it enhances their recovery and treatment. 2. Review of the medical record revealed resident #82, an [AGE] year old female was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included Addisonian crisis (low cortisol levels), dementia, and gastrostomy (feeding tube) status. The Baseline Care Plan scanned to the Electronic Health Record (EHR) noted the nurse signed the plan of care was developed on 12/21/23. The document showed the resident signed the form and dated the review on 12/28/39. There was an illegible handwritten line added and crossed over the number 28. On 2/16/24 at 1:47 PM, the Director of Nursing (DON) stated her expectation was for Baseline Care Plans to be completed by the nurse who admitted the resident within 24 to 72 hours. She said she was not aware of any problems that nurses had not completed them timely. Review of the facility's standards and guidelines titled Baseline Care Plan dated 9/18/23 read, . The facility will develop and implement a baseline care plan of reach resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of care. The baseline care plan will: a. be developed within 48 hours of a resident's admission. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed.

Based on interview, and record review, the facility failed to ensure a thorough investigation was conducted for a fall with fracture for 1 of 6 residents reviewed for falls of a total sample of 45 residents, (#197). Findings: Resident #197, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, asthma, atrial fibrillation, chronic obstructive pulmonary disease, diabetes, obstructive sleep apnea, obesity, and muscle weakness. On 2/09/24, the diagnosis, fracture of unspecified part of left clavicle was added. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 2/05/24 revealed the resident's cognition was intact, with a Brief Interview for Mental Status (BIMS) score of 15/15. The assessment noted resident #197 had adequate hearing, clear speech, was understood, and understands, and had adequate vision. The assessment indicated the resident was independent for eating, oral hygiene, and personal hygiene, required partial/moderate assistance for showering and upper body dressing, substantial/maximal assistance with rolling left to right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair to bed/bed to chair, and dependent for toileting hygiene, lower body dressing and putting on/taking off footwear. The assessment also revealed the resident had no impairment to upper extremity( shoulder, elbow, wrist, hand), lower extremity(hip, knee, ankle, foot), and used a wheelchair for mobile device. The assessment indicated the resident had no behaviors. On 2/12/24 at 5:17 PM, resident #197 explained Certified Nursing Assistant (CNA) G put her back to bed from her wheelchair using the sit to stand mechanical lift by herself on 2/8/24. She said she told the CNA there should be two staff when transferring her with the lift and the CNA responded, Don't tell me how to do my job. The resident said she told the CNA that something did not feel right but the CNA continued to move me in the lift. The resident said the next thing she remembered was being on the floor looking up at a nurse. 02/13/24 08:40 AM, the resident stated, the police came here last night to see me. She said she was not sure why they came but they said they were here to see how she was doing. They didn't really say much more and they left. On 2/13/24 at 10:00 AM, the Administrator stated he called the police as the resident alleged neglect with the mechanical lift incident. He explained he was still investigating the 2/8/24 incident. On 2/13/23 at 10:47 AM, during a telephone interview, Registered Nurse (RN) E recalled CNA G was with resident #197 and called out to him for help. The RN stated when he went in the room the resident was in the sit to stand mechanical lift in what looked like an unsafe position. When I entered the room, CNA G was with resident #197 by herself. I called CNA F to come and help us. On 2/13/24 at 11:13 AM, during a telephone interview, CNA G stated she was with CNA F when they transferred resident #197 back to bed. CNA G explained the resident took her hands off the lift, became unstable and she called for the nurse, RN E. She said the three of them lowered the resident to the floor. On 2/14/24 9:30 AM, during a telephone interview, CNA F stated she was in the room with CNA G to help with the transfer from the wheelchair to the bed. She said resident #197 took her hands off the sit to stand lift and started to slide down and the two CNAs lowered the resident to the floor. In a conflicting statement, CNA F stated resident #197 was on the floor when the nurse came into the room. Review of the care plan and Kardex revealed the resident was assessed to require assistance from two staff persons for transfers with a full body mechanical lift, not the sit to stand mechanical lift which was being used at the time of the incident. On 2/14/24 at 1:33 PM, the Administrator recalled he interviewed the 2 CNAs and the nurse by telephone. He said the Unit Manager interviewed the resident. He stated he was aware the resident had a fractured clavicle and he was told the CNA's had her on the ground before they called the nurse. The Administrator explained the root cause of the accident was the resident got weak and felt a little dizzy and that is when they lowered her to the ground. In response to the discrepancies in the interviews with the CNAs and the RN, he explained he was told there were two people doing the transfer and the resident was on the floor when the nurse went in the room. He did not provide any written documentation of his interviews. Review of the Unit Manager's written statement noted she spoke to the resident about her shoulder pain after the incident with the lift. She wrote the resident told her she had torn rotator cuffs in both shoulders and her left shoulder started hurting after she pulled herself up in bed. The statement also noted resident #197 stated the mechanical lift was used incorrectly when she was transferred. The statement documented the Unit Manager asked the resident about the placement of the mechanical lift sling and informed the resident it was applied appropriately. On 02/16/24 at 12:26 PM, resident #197 stated she was not physically capable of pulling herself up in bed and never told anyone that she hurt her shoulder by pulling herself up in bed. She explained she was told about 25-[AGE] years ago that she had a torn rotator cuff but she did not have pain. On 2/17/24 at 8:30 AM, the Administrator said he did not report the incident to the State agency as he there was nothing to report. He said the staff involved told him the transfer was completed with two staff in attendance. He did not explain the inconsistent statements from RN E and the resident who noted only one CNA transferred the resident. He did not provide an explanation as to why a sit to stand lift was used when the resident was assessed to require a full mechanical lift. He said he only interviewed the staff by telephone and did not request a demonstration of how the resident was transferred and how she sustained a fractured clavicle.

Based on interview, and record review, the facility failed to thoroughly investigate an incident involving neglect and failed to report the results of the investigation to the State Survey Agency related to an avoidable fall with major injury for 1 of 6 residents sampled for falls, of a total sample of 45 residents, (#197). Findings: Resident #197, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, asthma, atrial fibrillation, chronic obstructive pulmonary disease, diabetes, obstructive sleep apnea, obesity, muscle weakness. On 2/09/24, a diagnosis fracture of unspecified part of left clavicle was added. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 2/05/24 revealed the resident's cognition was intact, with a Brief Interview for Mental Status (BIMS) score of 15/15. The assessment noted resident #197 had adequate hearing, had clear speech, was understood, and understands, and had adequate vision. The assessment indicated the resident was independent for eating, oral hygiene, and personal hygiene, required partial/moderate assistance for showering and upper body dressing, substantial/maximal assistance with rolling left to right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair to bed/bed to chair, and dependent for toileting hygiene, lower body dressing and putting on/taking off footwear. The assessment also revealed the resident had no impairment to upper extremity( shoulder, elbow, wrist, hand), lower extremity (hip, knee, ankle, foot), and used a wheelchair for mobile device. The assessment indicated the resident had no behaviors. On 2/12/24 at 5:17 PM, resident #197 recalled she was being transferred from her wheelchair to the bed by one Certified Nursing Assistant (CNA) using a sit to stand mechanical lift. She explained CNA G picked her up with the sit to stand mechanical lift and she told CNA G there needed to be two people to use the mechanical lift. The resident said CNA G commented, Don't tell me how to do my job. Resident #197 noted CNA G put her feet in the lift and she told CNA G that something did not feel right. She stated CNA G proceeded to lift her up using the machine and then walked to the back of the machine. She said the next thing she knew, she was on the floor and Registered Nurse (RN) E was sitting next to her. On 2/13/24 at 8:40 AM, the resident stated the police came here last night to see me. On 2/13/24 at 9:44 AM, the Administrator explained on 2/8/23, CNA F and another CNA said while resident #197 was in the sit to stand lift, she moved her hands from the lift and they lowered her to the floor. CNA G said they called RN E to assist them. The Administrator stated he did not report the incident, because there was nothing to report. When asked why the police came to see resident #197 last night, he replied the resident alleged neglect with the mechanical lift incident. The Director of Nursing (DON) stated Department of Children and Families was called but did not accept the report. The Administrator stated he was still investigating and was still within the time frame for reporting the incident. On 2/14/24 at 1:33 PM, the Administrator explained the morning after the incident he interviewed CNA F, CNA G and RN E by telephone as it was priority. He stated he had them describe what happened when they transferred the resident with the sit to stand lift. The Administrator said he was aware of x-ray results when he did interviews. The Administrator was informed that interviews obtained yesterday with the three staff involved were different. Each CNA had a different story and the nurse reported there was only one CNA in the room when he was called to help. CNA G stated resident #197 was in the lift when she called the nurse and the three of them put the resident on the floor. CNA F stated resident #197 was already on the floor when the nurse was called to the room. The Administrator replied, they all told him there were two people doing the transfer. He did not provide any documentation of his telephone conversations with the staff. Review of the resident's record revealed an x-ray was completed at the facility post incident on 2/08/24 at 7:00 PM. The report showed the resident had nondisplaced distal clavicle fracture, new. (Clavicle fracture-collarbone, is diagnosed through physical examination and x-rays. Symptoms of a broken collarbone include severe pain and swelling at the site of the fracture and with visible deformity in some cases. Because of the critical location of the clavicle, any severe force on the shoulder such as falling directly on the shoulder or falling on an outstretched arm transfers force to the clavicle . retrieved from https: www. hopkinsmedicine.org on 2/20/24). The record revealed on 2/09/24, resident #197 was transported to the hospital for follow up x-rays which confirmed the left clavicle fracture. Review of the care plan and Kardex revealed the resident required two person assist for transfers, using a full body mechanical lift. Resident #197 was transferred by one person using a sit to stand mechanical lift and sustained a fracture during the intended transfer. Review of the facilities Compliance with Reporting Allegations of Abuse/Neglect/Exploitation implemented 11/2020 and revised 8/15/22 read: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment.are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Neglect: failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation . The Administrator or designee will: Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of a serious bodily injury, no later than 2 hours after discovery or forming the suspicion.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring for a physically and cognitively impaired vulnerable resident to prevent unsupervised exit from the facility through the front lobby doors for 1 of 6 residents reviewed for elopement, out of a total sample of 12 residents, (#1). This failure contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was likelihood he could have fallen, been accosted by unknown persons, become lost, drowned, or been hit by a car. On 2/09/23 at approximately 1:00 PM, resident #1 left his room and walked towards the facility's front lobby unnoticed by staff. When the receptionist opened the front doors for incoming transportation personnel, she did not maintain focus on the doors and resident #1 left the building simultaneously. Nursing staff did not conduct rounds at the change of shift, and resident #1's assigned nurse did not notice he was missing until approximately 4:00 PM. On 2/12/23 at approximately 4:00 AM, a concerned citizen contacted law enforcement regarding the well-being of a man loitering at a gas station over three miles away from the facility. Law enforcement responded, identified the man as resident #1, and arranged medical transport to the hospital. The facility was unaware of resident #1's whereabouts for three days until law enforcement notified the Administrator he was found. The facility's failure to accurately identify elopement risk factors, provide the appropriate level of supervision, and maintain a secure environment contributed to resident #1's elopement and placed all residents who wandered at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy which began on 2/09/23 and was removed on 2/17/23. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F600 and F835. Review of the medical record revealed resident #1, a [AGE] year-old male, was admitted to the facility from the hospital on 8/22/22. His diagnoses included stroke, adult failure to thrive, hypertension, major depressive disorder, homelessness, alcohol abuse with alcohol-induced mood disorder, altered mental status, and metabolic encephalopathy. Metabolic encephalopathy is defined as a syndrome of temporary or permanent disturbance of brain functions that occurs in different diseases. Resulting psychiatric and neurological symptoms range from mild mental disorders to coma and death (retrieved on 2/22/23 from https://pubmed.ncbi.nlm.nih.gov/28084256/). The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 8/22/22 revealed resident #1's primary diagnosis in the hospital was altered mental status. The document indicated he required a surrogate to make healthcare decisions and was alert and disoriented but could follow simple instructions. The form revealed he had risk alerts for falls, difficulty swallowing, and seizures. Resident #1 walked and transferred with assistance, was fully weight-bearing, and used a walker. Review of the admission nurse's Skilled Evaluation dated 8/22/22 revealed on page one that resident #1's clinical evaluation showed he was not alert and oriented, did not have clear speech, and he exhibited comprehension issues. However, in conflicting information on page two, the admission nurse noted the resident was alert and oriented to person, place, and time with no cognitive impairment. The evaluation did not reflect safety precautions for seizures as noted on the hospital transfer form. The resident's gait was documented as unsteady with poor balance, but he was able to reposition himself and move all extremities. The evaluation form indicated resident #1 did not wander at night, but the source of that information was not evident as there was no documentation of contact with his healthcare surrogate. Review of the admission Elopement Evaluation dated 8/22/23 revealed an elopement risk score of NA or not applicable. The document indicated scores of ten or above deemed a resident to be at risk for elopement. The evaluation incorrectly showed resident #1 was dependent for activities of daily living (ADLs) or could not move without assistance. Questions related to the resident's mental status, mobility, speech patterns, history of wandering, and contributing diagnoses including cognitive impairment were left blank. Review of resident #1's medical record revealed the facility did not initiate a care plan for elopement risk on admission. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 9/13/22 revealed resident #1 was hospitalized for treatment of left hand cellulitis and a healing fracture. The form indicated he was at risk for falls, independently ambulatory, did not require a mobility device, and remained alert and disoriented. Review of hospital Discharge Summary Case Management discharge planning documentation in the hospital record revealed the resident .would like to return to rehab but not the rehab he was previously at. However, the hospital transfer form indicated resident #1 returned to the facility. Review of the readmission Elopement Evaluation dated 9/13/22 revealed resident #1's elopement risk score was four, which deemed him not to be at risk for elopement. The evaluation incorrectly showed he had no diagnosis of dementia or cognitive impairment and noted no history of wandering. The Quarterly Minimum Data Set (MDS), Version 1.17.1 assessment with assessment reference date of 11/26/22 revealed resident #1 had a Brief Interview for Mental Status score of 10 out of 15 which indicated moderate cognitive impairment. The MDS assessment indicated the resident was independent for transfers, walking, and eating. He required limited assistance with bed mobility, extensive assistance for toilet use and personal hygiene, and physical help with bathing. The resident's balance was unsteady, but he was able to stabilize himself without staff assistance. The document revealed he was frequently incontinent of urine, and experienced shortness of breath when lying flat. Resident #1's family did not participate the assessment. Review of the readmission Elopement Evaluation dated 12/13/22 revealed resident #1's elopement risk score remained four, and still showed he had no diagnosis of dementia or cognitive impairment. A Late Entry nursing Narrative Note dated 2/09/23 at 4:10 PM revealed resident #1's nurse noted he was not in his room during rounds and a search was initiated. Staff were unable to find him, and notifications were made to the physician, family, State agency, and law enforcement. On 2/14/23 at 4:32 PM, resident #1 was in his room with Certified Nursing Assistant (CNA) G seated at the doorway. CNA G explained she was assigned to provide one-on-one supervision for resident #1 as he had recently eloped. Resident #1 was alert to self only and was not able to name his current city of residence. He verified he recently left the facility, and when asked why, the resident said, I was just looking for something better. Resident #1 explained he had memory issues and could not recall details of his time outside the facility but thought he slept somewhere like a [name of a large 24-hour gas station / convenience store]. On 2/14/23 at 5:02 PM, in a telephone interview, resident #1's sister stated her brother had lived a transient lifestyle on the streets and been homeless for approximately ten years. She explained he was an alcoholic and his condition had worsened in the last two years. The sister stated in the past, he would normally go to a relative's home or to a homeless shelter when he needed a place to sleep or needed food, but recently he rarely did this due to his mental decline. She stated he also began to have significant balance issues that resulted in several falls from his bicycle. The resident's sister stated he usually stayed in his room and was a loner who did not like confrontation. She recalled on the past Thursday, the facility called her at about 4:00 PM to ask if she or anyone else had taken her brother out of the building. She stated the facility called again at about 4:45 PM to inform her the security cameras showed her brother got out of the facility at about 1:00 PM, and they had notified law enforcement. Resident #1's sister stated her brother did not have a cell phone, credit cards, or cash, and the weather forecast indicated rain and cool temperatures. She explained law enforcement did not find her brother on Thursday or Friday, so after work on Friday and again during the day on Saturday she drove around searching for him unsuccessfully. She said, I would think there were dangers out there for him although he does have some street smarts. We thought we were going to get a call that he froze to death. Resident #1's sister recalled on Sunday morning at about 7:30 AM, the facility notified her that her brother had been found at a gas station in another city. On 2/15/23 at 10:41 AM, the receptionist stated her desk was located in the mail room on the right side of the lobby, and there was a frosted sliding glass window that faced the opposite wall. She explained the front lobby doors were to the left of her office, but she could not see them when seated at her desk. She stated there was a monitor on her desk that showed different views of the lobby area and she used buttons under the desk to remotely unlock and open front doors. The receptionist recalled on the day resident #1 eloped, she was standing in the doorway of her office shortly after 1:00 PM, when she saw resident #8's transportation personnel approaching the front doors. The receptionist said, I took my eyes off the door when I leaned in to push the button. She stated she neither saw resident #1 in the lobby area, nor noticed him leave through the doors. The receptionist stated she was not aware resident #1 was gone until someone called her at about 4:00 PM during her break. On 2/15/23 at 12:51 PM, videotape recording from the security camera system was reviewed with the Administrator. The footage showed the events occurred on 2/09/23. At 1:05 PM, resident #8 was seated in her wheelchair in the lobby facing the front doors, awaiting transportation personnel for an appointment. At 1:09 PM, the footage showed transportation personnel rang the doorbell as resident #1 was observed walking through the lobby. The resident was approximately eight feet from the front doors when the bell rang. At 1:09 PM, as the double doors swung open to allow the transportation personnel to enter, resident #1 simultaneously exited and left the building. The resident followed the walkway and was quickly out of camera range. Review of a law enforcement Event Report dated 2/12/23 at 4:09 AM, revealed officers were dispatched to a large gas station and convenience store in response to an employee's call about a man in dirty clothing who was seated on the sidewalk and appears to look like he hasn't eaten in days. The document indicated officers arrived at the location at 4:16 AM, and then notified the facility that resident #1 was found and would be transferred to the hospital to be evaluated for complaints of back and knee pain. On 2/15/23 at 7:32 PM, in a telephone interview, the responding police officer recalled on arrival at the gas station, resident #1 could not tell her where he was from, but he eventually provided his name. She stated the resident looked dirty and seemed very disoriented. She stated she was told resident #1 went into the convenience store to get food and someone might have given him a sandwich because she noticed a wrapper beside him. The police officer recalled it had been raining intermittently all night and the resident looked like he was cold. She said, He was definitely in an unsafe situation. The Fire Department transported him to [name of a hospital], but if they hadn't, we would have taken him. In that state, we would not have left him behind. She stated the area around the convenience store was not necessarily a high-crime area, but there were frequent motor vehicle accidents at that intersection, and the main thoroughfare was very busy. On 2/16/22 at 12:09 AM, in a telephone interview, the convenience store employee explained he called the police when he became concerned about a man who had been outside the location at night for two to three days. He said, Something was off about him. I did not see where he slept but I assume he slept at the tables. The facility is located on a moderately to heavily trafficked two-lane road, across from an elementary school. It is approximately 400 feet away from a large, heavily trafficked major intersection of two 7-lane divided highways. The area around the facility was densely populated with a mix of commercial and residential properties and a university. Resident #1 would likely have walked along the major thoroughfare and crossed multiple busy intersections, side streets, driveways, and parking lots before he arrived at the convenience store almost four miles away. It is unknown if resident #1 crossed the major road where there was a large lake (retrieved on 2/24/23 from www.googlemaps.com). The temperatures during the period resident #1 was away from the facility, 2/09/23 to 2/12/23, ranged from 60 to 84 degrees Fahrenheit. On 2/09/23 between 10:00 PM and 12:00 AM, there was rain and thunderstorms. On 2/10/23 at approximately 4:00 PM, and on 2/12/22 between 1:00 AM and 3:30 AM there was rain (retrieved on 2/16/23 from www.timeanddate.com). On 2/14/23 at 8:13 PM, resident #8 stated on the day resident #1 eloped, she was seated in the lobby waiting for transportation to an appointment. She explained she dozed off and was awakened when her driver arrived. Resident #8 recalled the driver pushed her wheelchair through the front doors and when they arrived at the gate that led to the parking lot they encountered a man who appeared to be having difficulty opening the latch and he seemed a little confused. She stated the driver opened the latch and the man held the gate open for them. Resident #8 stated the driver thanked him, and she did not see where the man went afterward. On 2/14/23 at 7:00 PM, CNA C stated she was assigned to resident #1 on the 3:00 PM to 11:00 PM shift on the day he eloped. She explained earlier that day, on the 7:00 AM to 3:00 PM shift, she was assigned to residents on the opposite side of the hallway from resident #1's room. CNA C stated her hall partner CNA B was assigned to resident #1's room for the day shift. She recalled she took over CNA B's side of the hallway as her new assignment at 3:00 PM but did not do change of shift walking rounds with CNA B. CNA C stated the last time she saw resident #1 was at lunchtime while she was distributing meal trays. She said, I had to get up another resident at family request. I did not take report from her that day because we were working together and I saw her residents through the day shift.When you get busy you don't always have the time. CNA C recalled she was in a room with a resident when the nurse asked if she had seen resident #1. After completing that task, she went to look for resident #1 and noted he was not in bed or the bathroom. She stated someone used the overhead paging system to announce a Code Green to alert all staff to a missing resident situation. On 2/15/22 at 12:08 PM, CNA A stated she was regularly assigned to care for resident #1 on the 7:00 AM to 3:00 PM shift. She explained he usually stayed in his room except for the days when he went to the shower room. She recalled on the day he eloped, he was dressed in red shorts, a black short-sleeved shirt, and socks when she went in to remove his lunch tray at about 12:45 PM. CNA A stated all residents were to be checked at least every 2 hours, and every 30 to 60 minutes if at risk for wandering or elopement. She acknowledged CNAs were expected to walking rounds during change of shift report, but she did not follow protocol and do this with CNA C that day. CNA A said, Some staff will do it and others won't. On 2/14/23 at 8:17 PM, Registered Nurse (RN) A stated he was assigned to resident #1 on the 3:00 PM to 11:00 PM shift on 2/09/23. He explained he arrived at 3:00 PM but did not get report until 3:45 PM as the day shift nurse, RN D was still busy with residents. RN A stated he noticed resident #1 was not in his room when he went to administer medication to the roommate. RN A stated the roommate informed him resident #1 was dressed in regular clothing as if he were going out with his family. RN A said, I went to check the appointment list and didn't see his name. Then I realized there was a problem. On 2/17/23 at 11:20 AM, RN D stated on 2/09/23 she was resident #1's assigned nurse for the 7:00 AM to 3:00 PM shift. She recalled the resident was in his room eating lunch at about 12:30 PM when she administered medications to the roommate. She explained there was no specified frequency for rounds, but she checked on resident as her heavy workload allowed. RN D stated at the end of her shift, she gave report to the oncoming nurse, RN A, and left the facility. She confirmed she did not conduct walking rounds with RN A to verify the status or location of their residents during change of shift report. Review of the facility's policy and procedure for Elopements revised on 7/13/22 read, This facility ensures that residents who are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to their elopement risk. Adequate supervision will be provided to help prevent accidents or elopements. The document indicated residents would be assessed for elopement risk on admission and regularly throughout their stay in the facility, and the interdisciplinary team would develop care plan approaches that addressed unique risk factors for each resident. On 2/14/23 at 5:44 PM, the Administrator, Director of Nursing (DON) and Regional Nurse Consultant (RNC) discussed the facility's elopement incident investigation. The facility determined the root causes of resident #1's elopement included visual observation of door was not done and his past lifestyle was not considered in determining his risk for elopement. However, the root cause analysis did not show nursing staff failed to offer the minimum level of supervision required by monitoring the resident's whereabouts at least every two hours. The Administrator explained the facility did not have an electronic system that alarmed when residents who wore wander monitoring devices approached exterior doors. He said, We rely on staff supervision and monitoring of residents. Alarms can lull you into a false sense of security. The DON verified assigned CNAs and nurses did not do change of shift walking rounds at 3:00 PM, and no staff noticed the resident was missing for three hours. The Administrator acknowledged by the time law enforcement was notified and a K-9 officer arrived with a dog, the resident had been missing for approximately four hours. He stated the K-9 officer retrieved the resident's pillowcase to obtain his scent but the dog only tracked the resident for a short distance headed south along the major thoroughfare before losing his scent. On 2/14/23 at 6:30 PM, the Staff Development Coordinator (SDC) stated she participated in the root cause analysis conducted by the Quality Assurance and Performance Improvement committee. The SDC stated she was aware there were issues with change of shift rounding not being completed as required. She said, Staff might be in a hurry or have to leave early. The SDC acknowledged education regarding nursing change of shift rounds to verify the location and status of residents and to ensure rooms were free of clutter and hazards, began only within the past 30 minutes. Review of the Facility assessment dated [DATE] revealed the facility could provide care for residents with psychiatric, mood and neurological conditions including anxiety, depression, and dementia. Available services included mental health and behavior management. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 2/09/23 at 4:09 PM, a complete head-count by nursing staff confirmed all residents of facility were present, except resident #1. *On 2/09/23, the nursing management team completed elopement risk evaluations on all residents and no new residents were identified as at risk. The elopement risk binders were reviewed by the DON to validate that each resident at risk for elopement had demographic information in the binder. *On 2/09/23, the Staff Development Coordinator (SDC) initiated all staff education the facility's policy for prevention of Abuse, Neglect and Exploitation, with an emphasis on Neglect, to include reporting requirements, elopement standard and guidelines, responding to door alarms and proper actions to take upon responding, and maintaining visual observation of all persons entering and exiting the facility. A post-test was used to validate comprehension of education received. The facility achieved 100% compliance on 2/16/23. *On 2/09/23, the DON reviewed clinical records of residents identified to be at risk for elopement to confirm elopement risk care plans were in place. Residents were confirmed to have orders in place for increased monitoring, behavior monitoring for exit seeking, interventions attempted for exit seeking and outcome of those interventions. *On 2/09/23, the button that allowed staff to open the front lobby doors remotely, without direct supervision of the doors, was removed by the Maintenance Director. The front desk staff were educated by the Administrator on only opening the front lobby doors at the keypad next to door. *On 2/09/23, the Maintenance Director relocated the receptionist's desk to an area that allows direct supervision of the door. *On 2/10/23, the Receptionist job description was revised by the Administrator to include maintaining visual observation of persons entering and exiting the front door. *On 2/10/23 at 5:30 AM, the Maintenance Director checked egress doors for alarms and function with no issues identified. *On 2/10/23, elopement drills were initiated on the 11:00 PM to 7:00 AM shift and conducted every shift until the 11:00 PM to 7:00 AM on 2/16/23. Elopement drills will be ongoing, conducted weekly on alternating shifts until it is determined by the QAPI committee that it is appropriate to decrease the frequency to monthly on alternating shifts. *On 2/10/23, the facility held an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting. Attendees included the Medical Director. The committee reviewed QAPI minutes and accepted the Performance Improvement Plan. *On 2/12//23, resident #1 was found by law enforcement, transported to the hospital for evaluation, and returned to the care of the facility at approximately 11:20 AM. The DON completed a head-to-toe assessment of resident #1 and noted blisters to both feet and scabbed areas to his right hand and right arm. *On 2/12/23, resident #1 was assessed for elopement risk and identified as high risk. His photo and demographic information were placed in the Elopement Risk Binder. The resident was placed on one-to-one supervision immediately, and will remain with that level of supervision until otherwise determined by the interdisciplinary team. *On 2/12/23, the RNC and members of the facility's management team reviewed and revised the facility's Elopement Evaluation form to include additional risk factors of history of homelessness and substance abuse. All current residents were re-evaluated for elopement risk by the nursing administrative team and one new resident was identified as at risk. *On 2/14/23, Elopement Binder Quality Monitoring (QM) reviews were completed. A Quality Review re: elopement process was completed. *On 2/16/23, the facility achieved 100% with education provided by the SDC for nursing staff on rounding during and between shifts. Agency staff and newly hired staff will be educated during the orientation process or prior to starting their next shift. *On 2/17/23, the QAPI committee reviewed results of elopement drills to determine any need for systematic change. Staff elopement education validation QM and staff rounding QM tool were completed. *On 2/17/23, the facility held an Ad Hoc QAPI committee meeting to review current QAPI Performance Improvement Plans to determine the need for further changes. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on topics listed above. On 2/17/23, interviews were conducted with 20 agency and facility staff representing all shifts. The Activities Director, one laundry staff, five RNs, four LPNs, and nine CNAs verbalized understanding of the education provided. The resident sample was expanded to include five additional residents who were at risk for elopement. Observations, interviews, and record reviews revealed no concerns for residents #2, #3, #4, #5, and #6 related to accuracy of elopement evaluations and appropriateness of person-centered care plan interventions.

Based on observation, interview, and record review, the facility's administration failed to effectively utilize its resources to oversee the implementation of policies and procedures and interdisciplinary team (IDT) processes to meet the safety and care needs of 1 of 11 residents reviewed for braces and elopement, (#1); and failed to identify and mitigate vulnerabilities in security of the front lobby and all exterior exit doors to prohibit unauthorized egress of 1 of 6 residents reviewed for elopement, (#1), of a total sample of 12 residents. These failures contributed to preventable complications related to brace use, and the elopement of resident #1, and placed him at risk for serious infection/injury/impairment/death. While resident #1 was out of the facility unsupervised, there was a likelihood he could have fallen, been accosted by unknown persons, become lost, drowned, or been hit by a car. On 8/22/22, resident #1 was admitted to the facility with a brace in place for a left wrist fracture. Facility staff did not obtain orders for necessary care and services, the device was never removed for skin evaluation, and the resident's left hand and arm were not assessed regularly. Resident #1 developed a wound and a skin infection under the brace and was transferred to the hospital on 9/10/22 for treatment. He required wound care, intravenous antibiotics, and consultation with an orthopedic specialist during his hospitalization . On 9/13/22, the resident was readmitted to the facility with a new brace. Nursing staff did not follow hospital discharge orders for follow up with the orthopedic specialist within two weeks. Over the next five months, resident #1's plan of care was not updated to reflect the frequency and duration of use of the device, and therapy orders were not obtained and implemented to promote optimal functional status. On 2/09/23 at approximately 1:00 PM, resident #1 left his room and walked towards the facility's front lobby unnoticed by staff. When the receptionist opened the front doors for incoming transportation personnel, she did not maintain focus on the doors and resident #1 left the building simultaneously. Nursing staff did not conduct rounds at the change of shift, and resident #1's assigned nurse did not notice he was missing until approximately 4:00 PM. On 2/12/23 at approximately 4:00 AM, a concerned citizen contacted law enforcement regarding the well-being of a man loitering at a gas station over three miles away from the facility. Law enforcement responded, identified the man as resident #1, and arranged medical transport to the hospital. The facility was unaware of resident #1's whereabouts for three days until law enforcement notified the Administrator he was found. The facility's failure to implement policies and procedures to develop appropriate plans of care and prevent neglect; and failure to maintain a safe and secure environment placed all residents who had braces and/or wandered at risk. These failures resulted in Immediate Jeopardy starting on 8/22/22. The Immediate Jeopardy was removed on 2/17/23. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F600, F607, F684, and F689. On 2/17/23 at 4:06 PM, the Administrator stated he had been on staff for approximately six weeks, and the Director of Nursing (DON) stated was hired about 10 weeks ago. He explained the issue with resident #1's splint occurred prior to their tenure. The Administrator acknowledged the facility's nursing management and the IDT were expected to function effectively and smoothly to implement all policies and procedures despite changes in staff. He explained the facility's administrative and management teams had scheduled meetings with defined content, purposes, and formats. The Administrator stated the daily Morning Meeting lasted about 30 minutes and was attended by all department heads and support staff. He explained department managers were expected to focus on issues related to the primary responsibilities of each department. The DON stated the Morning Meeting was followed by the clinical team meeting, which was attended by the Minimum Data Set nurse, nursing management including herself, the Director of Rehab, and the Administrator. The Administrator and DON validated the factors that contributed to resident #1's wound, skin infection, hospitalization , lack of orthopedic follow up, and elopement were not identified during daily meetings from August 2022 to February 2023. On 2/17/23 at 9:29 AM, the Director of Maintenance was asked to clarify the log posted to the left of the front lobby doors that indicated the doors were not checked on the weekends. He stated he checked the function of locks and alarms on all exterior egress doors daily, Monday through Friday. He acknowledged if the task was not done on Saturdays and Sundays it was a weakness in the facility's security. The Director of Maintenance said, I don't think the Administrator is aware doors are not being checked on the weekend. I planned to tell him. I will speak with him. On 2/17/23 at 9:34 AM, during observation of the front lobby doors and review of the door log with the Director of Maintenance, the Administrator approached. He was shown the log with blank boxes in the columns designated for Saturday and Sunday. He stated he was not aware the facility's exterior exit doors were not being checked on the weekends. The Maintenance Director told the Administrator he had been planning to tell him. The Administrator confirmed the issue was never brought to his attention in daily meetings and he never noticed the blank spaces on the log which was prominently post beneath the keypad. Review of the Facility assessment dated [DATE] revealed the facility could care for residents with common diagnoses including depression, stroke, dementia, and fractures. Based on residents' needs, services and care included daily activities of daily living care, mental health and behavioral support for dementia and wandering. The document indicated the facility provided rehabilitation services such as Occupational Therapy to assist with recovery from illness or injury and maintain skills for daily life. The Facility Assessment revealed the Medical Director would oversee the quality of medical care, attending physicians were responsible for all aspects of residents' medical care, and Advanced Practice Nurse Practitioners would assess residents and develop treatment plans. The document showed the facility's training program included the topics of effective communication, resident rights and special needs, prevention of Abuse and Neglect, dementia management, and caring for the cognitively impaired. The job description for Director of Nursing dated August 2021 revealed she was responsible for management of the overall operations of the Nursing Department. The DON's responsibilities included participating in meetings and directing the delivery of nursing services. The job description for Administrator dated December 2018 revealed he would lead and direct the overall operations of the facility.with focus on maintaining excellent care for the residents. His essential duties and responsibilities included monitor each department's activities, communicate policies, evaluate performance. The Administrator was expected to consult with department managers to address concerns and/or improve services. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 2/10/23, the receptionist's desk was temporarily relocated to the entry way, so he/she has a direct line of vision and is better able to monitor the front door. The button to open up the door has been deactivated and a staff member now needs to manually put in code at door site. This is a temporary solution until a permanent alternative is put in place. *On 2/10/23, the RNC educated the DON related to morning Clinical Meetings and the identification of device orders for new admissions/re-admissions, and current residents. *On 2/16/23, the Regional Director of Operations (RDO) reviewed the Administrator's job description, including understanding of allocating staff appropriately and efficiently to safely care for all residents. The RDO educated the Administrator on eliciting additional support services through regional team members and how to use resources effectively. The Administrator verbalized understanding. *On 2/16/23, the Regional Nurse Consultant (RNC) reviewed the Director of Nursing's job description, including understanding of allocating staff appropriately and efficiently to safely care for all residents. The Director of Nursing verbalized understanding. *As of 2/16/23, staffing is being reviewed daily by the Administrator and DON/or designee to ensure appropriate levels. Staffing will be adjusted as needed. *On 2/16/23, the RNC educated the Administrator and DON on the Quality Assurance and Performance Improvement process, and how to perform data analysis from the audits conducted to evaluate if performance improvement plans are effective or need to be redefined. Interviews conducted with the Administrator and DON on 2/17/23 revealed they received education on the above topics.

Based on observation, interview and record review, the facility failed to obtain physician orders and implement nursing interventions to promote healing of a fracture and prevent skin injury related to use of a brace; and failed to arrange a required orthopedic consultation and update the plan of care with approaches for management of a brace for 1 of 6 residents reviewed for braces of a total sample of 12 residents, (#1). These failures contributed to resident #1's hospitalization and placed him at risk for decreased mobility and serious infection/injury/impairment/death. On 8/22/22, resident #1 was admitted to the facility with a brace in place for a left wrist fracture. Facility staff did not obtain orders for necessary care and services, the device was never removed for skin evaluation, and the resident's left hand and arm were not assessed regularly. Resident #1 developed a wound and a skin infection under the brace and was transferred to the hospital on 9/10/22 for treatment. He required wound care, intravenous antibiotics, and consultation with an orthopedic specialist during his hospitalization . On 9/13/22, the resident was readmitted to the facility with a new brace. Nursing staff did not follow hospital discharge orders for follow up with the orthopedic specialist within two weeks. Over the next five months, resident #1's plan of care was not updated to reflect the frequency and duration of use of the device, and therapy orders were not obtained and implemented to promote optimal functional status. The facility's failure to provide appropriate care and services for a resident with a brace, and failure to obtain a follow up orthopedic appointment placed all residents with fractures and/or braces at risk for alteration in healing, decreased mobility, development of preventable wounds and infections, and at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy which began on 8/22/22 and was removed on 2/17/23. Findings: Cross reference F600, F607, and F835. Review of the medical record revealed resident #1, a [AGE] year-old male, was admitted to the facility from the hospital on 8/22/22. His diagnoses included stroke, adult failure to thrive, alcohol abuse with alcohol-induced mood disorder, and altered mental status. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 8/22/22 revealed resident #1's primary diagnosis in the hospital was altered mental status. The document indicated he required a surrogate to make healthcare decisions and was alert and disoriented but could follow simple instructions. The form revealed resident #1's rehabilitation potential was fair, and he was to be evaluated and treated by Physical Therapy five times weekly. On 2/14/23 at 5:02 PM, in a telephone interview, resident #1's sister explained in August 2022 her brother was admitted to the facility from the hospital with a brace on his left arm for a wrist fracture. She said, When he was transferred to the facility there was a mix-up. They did not check the brace, change it, or take it off and he ended up with pressure sores under there. He needed antibiotics to treat that infection. They never took it off or cleaned it and he went back to the hospital for treatment. Review of the admission nurse's Skilled Evaluation dated 8/22/22 revealed resident #1's skin was warm and dry, and he was able to move all extremities. The evaluation showed he had no impairment of the upper extremity (shoulder, elbow, wrist, hand). The section of the document designated for details of notifications made to the provider and responsible party was left blank, and there was no narrative note regarding any additional findings such as a left hand brace or of attempts to obtain information from the hospital or representative. The Minimum Data Set (MDS) Version 1.17.1 Admission assessment with assessment reference date of 8/26/22 revealed resident #1 displayed no behavioral symptoms and did not reject evaluation or care .that is necessary to achieve the resident's goals for health and well-being. The document showed he had no impairment of his upper extremity, received Physical and Occupational Therapy services, and did not have restorative nursing services that included brace or brace assistance. The MDS assessment revealed staff were unable to determine if the resident had a fracture related to a fall in the previous six months. Resident #1's Occupational Therapy evaluation dated 8/23/22 revealed documentation of a left wrist brace in place for an unknown injury. Occupational Therapist (OT) E noted the hospital record did not provide information on the injury and resident #1 was unable to offer clarification. She was unable to test the strength of his left arm due to presence of the brace. The OT plan of treatment recommended light right arm exercises as tolerated. Review of Occupational Therapy Treatment Encounter Notes from 8/23/22 to 9/09/22 revealed no documentation of additional information or clarification regarding resident #1's unknown injury or plan of care related to his left arm. On 8/30/22, OT E noted resident #1 complained of left arm pain while applying slight pressure on the walker. She collaborated with physical therapy staff regarding trial of an alternate device but there was no evidence OT E communicated with the resident's assigned nurse about his left arm pain and the brace. An Occupational Therapy Discharge Summary dated 9/12/22 revealed resident #1 had progressed with rehab services but was discharged to the hospital for evaluation of his left wrist which remained in a device for an unknown purpose. Review of the medical record revealed there were no admission physician orders or care plans related to resident #1's fracture, brace, and no instructions to ensure nursing staff conducted thorough evaluations of his left arm to prevent complications from the device. The facility's policy and procedure Admission Orders revised on 1/06/23 revealed the facility would obtain written or verbal physician or practitioner orders for residents' immediate care needs. The document read, The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission. The orders should provide information to maintain or improve the resident's functional abilities. The facility's Pressure Injury Prevention Guidelines revised on 1/06/23, individualized preventative interventions in accordance with physician orders. In the absence of prevention orders, the licensed nurse will utilize nursing judgement in accordance with pressure injury prevention guidelines to provide care, and will notify physician to obtain orders. A Medical Professional Progress Note dated 8/24/22 revealed Advanced Practice Registered Nurse (APRN) F assessed resident #1 and wrote, Extremities normal, no edema. APRN F's note did not reflect the presence of a left arm brace or a request for additional information about the injury or the device, and her plan of care did not include orders for monitoring the resident's arm and brace to prevent complications. A Late Entry Medical Professional Progress Note dated 8/25/22 revealed the attending physician assessed resident #1 and wrote, It was found he had a left forearm fracture due to a trauma. The note read, Plan of care discussed with nursing staff. However, the document did not include findings or orders related to a treatment plan of the resident's fracture and use of the brace. Another Late Entry progress note by the attending physician was dated 9/01/22 and indicated resident #1 had color changes and pain to his left arm. The note read, X ray was ordered and a fracture was discovered. [Patient]will probably be sent to the hospital. However, review of the medical record revealed inconsistency with the date of the attending physician's note. A Radiology Report indicated the x-ray of resident #1's left forearm that showed a fracture was done on 9/10/22, nine days after the Late Entry note. On 2/16/23 at 11:08 AM, in a telephone interview, APRN F recalled resident #1 was admitted to the facility with the brace, and no record of orthopedic orders. She explained resident #1 was not a good historian and could not provide information. APRN F recalled on the day she conducted her initial assessment, nursing staff were checking for the orders related to the brace. APRN F acknowledged she did not document the device on her initial assessment note, nor give orders and recommendations for monitoring and treatment. APRN F said, I would think the nurse would have mentioned a device to the admitting physician, especially if there are no orders from the hospital. I would expect the nurse to follow up with the hospital and possibly request an [orthopedic] consult if no orders were found. Resident #1's medical record revealed a physician order dated 8/23/22 for weekly skin evaluations every Monday during the evening shift. Review of Progress Notes revealed resident #1 had a complete nursing skin assessment on 8/24/22 that showed Overall skin intact. The nurse's note did not indicate there was a brace on his left arm. A Weekly Skin Evaluation with an effective date of Monday 8/29/22 but signed a week later on 9/05/22 read, Resident refused skin evaluation. Areas that were seen included discoloration to bilateral upper extremities. There was a brace on left lower arm. In a Late Entry Narrative Note dated 9/08/22, the Assistant Director of Nursing (ADON) noted she spoke with resident #1 and his sister about the left arm brace and then updated the physician who ordered an x-ray based on her concerns. The ADON did not document the condition of the resident's brace or skin, or any alternative approaches used to conduct a thorough skin assessment. On 2/15/23 at 2:10 PM, the ADON stated she had never been assigned to care for resident #1, and she could not remember why she assessed his left hand. She said, I'm assuming it was because someone said something about a brace.I remember that he would not allow me to see it. I would assume a nurse or [Certified Nursing Assistant] CNA noticed something wrong. She acknowledged her nursing note was a Late Entry note and did not describe her assessment findings. Resident #1's medical record revealed a SBAR [Situation, Background, Appearance, Review and Notify] Communication Form dated 9/10/22. The form indicated the resident had swelling, pain and an abrasion to his left thumb and forearm. A SNF/NF [Skilled Nursing Facility / Nursing Facility] Transfer Form dated 9/10/22 at 10:45 PM, revealed resident #1 had a pressure ulcer or injury associated with a brace on his left forearm. The document indicated he was noncompliant with activities of daily living (ADL) care and his left forearm was not assessed. Review of the hospital record from 9/10/22 to 9/13/22 revealed resident #1 arrived in the Emergency Department on 9/10/22 at 11:35 PM, for treatment of a thumb wound caused by a Velcro wrist strap on an orthotic device that became embedded in his thumb after not being removed for over ten days. His left hand was extremely swollen, and he had limited range of motion of his fingers. The hospital record described the wound as a medical device related pressure injury that was painful, bleeding, draining, with a foul, pungent odor. Diagnostic testing done on 9/11/22 revealed resident #1 had a healing wrist fracture, a foul-smelling wound, and evidence of cellulitis or a skin infection. Resident #1 was assessed by an Infectious Disease specialist physician who ordered two intravenous (IV) antibiotics, Cefepime 2 grams and Vancomycin 1500 milligrams (mg) to treat his left hand tendon infection. The hospital Discharge Summary dated 9/13/22 revealed the orthopedic specialist physician .evaluated patient and placed Velcro wrist brace with padding underneath, follow-up in 1-2 weeks as an outpatient. Wound care recommended to be continued. The document included instructions to follow up with specialists as directed. Resident #1 was readmitted to the facility on [DATE] and his demographic sheet was updated to reflect new diagnoses of left forearm fracture, local skin infection, and cellulitis of the left finger and left arm. The Order Summary Report showed on readmission, resident #1 had a wound treatment order dated 9/14/22 to cleanse the wound at the base of his left thumb with normal saline and apply calcium alginate to absorb drainage daily and as needed. The resident also had medication orders dated 9/14/22 for oral antibiotic medications for cellulitis, Doxycycline Hyclate 100 mg twice daily for seven days and Levaquin 500 mg once daily until 9/19/22. The report reflected orders dated 9/14/22 for a Wound Care specialist physician consult and follow-up with an Orthopedic specialist physician in one to two weeks. An order dated 9/14/22 read, Monitor capillary refill for nail beds to left hand. May remove brace for skin assessment. A Wound Care Consult note dated 9/14/22 revealed resident #1 was seen post-hospitalization for left hand swelling, drainage, and abscess. The assessment described a wound at the base of the resident's left thumb with etiologies of abscess [and] surgical that measured 0.4 x 3.0 x 0.3 centimeters (cm). The Wound Care physician noted resident #1 wore the left forearm brace. On 2/15/23 at 12:41 PM, the Wound Care specialist physician confirmed he was consulted to assess and treat resident #1 after he was hospitalized for left arm cellulitis and a left thumb wound in September 2022. He reviewed his notes and stated the resident wore a left forearm brace during his initial evaluation on 9/14/22. He explained it was a professional standard of practice for clinical staff to conduct regular skin checks of all areas under any removable device regularly to ensure there was no skin breakdown caused by pressure or friction. The Wound Care physician stated nursing staff should check any extremity with a device for swelling, redness, skin condition, and evidence of compromised circulation every shift. He stated he would expect nurses to promptly report any issues observed on an extremity with a device. The medical record did not contain progress notes or orders related to an orthopedic consultant follow-up after readmission. In addition, there was no documentation regarding protocols for donning and doffing the brace, duration of use, and specific therapeutic exercises to promote healing of the fracture and improve the resident's mobility. Review of the policy and procedure Skin Assessment revised on 1/06/23 revealed performance of a full body assessment was an integral approach to preventing pressure injuries. The document indicated the assessment would be conducted on admission, readmission and then weekly. The procedure directed nurses to remove any devices if not ordered to remain in place. Review of resident #1's skin evaluations from September 2022 to February 2023 revealed his brace was in place from 9/14/22 to 10/20/22. From 10/27/22 to 2/08/23, Weekly Skin Evaluation forms did not reflect use of a brace. The skin checks were not done as ordered over this period, with six of eighteen evaluations missed. The medical record did not indicate when, if, why, or by whom resident #1's brace was discontinued. Although the Medication Administration Record for February 2023 showed nurses' initials to validate resident #1's left hand was checked every shift, there was no documentation to show whether or not he still wore the brace. On 2/14/23 at 4:32 PM, resident #1 was observed in bed with no brace on his left arm. On 2/15/23 at 10:26 AM, he still did not wear a brace and a blue device was noted on the bedside table, partially covered by a backpack. On 2/15/23 at 4:40 PM, the facility's Appointment Scheduler stated she had never been asked to make an outside physician appointment or arrange transport for resident #1. She provided her log and reviewed all residents' appointments made from August 2022 to February 2023. The log showed no documentation of an appointment for an outpatient orthopedic consultation. On 2/15/23 at 1:40 PM, 2/15/23 at 4:46 PM and 2/16/23 at 1:07 PM, the Regional Nurse Consultant (RNC) stated she reviewed resident #1's chart and saw no evidence that his follow-up orthopedic consult was ever arranged. She explained if resident #1 required brace application, he should either have been on the facility's Restorative Nursing Program or had the task added to the Treatment Administration Record. The RNC confirmed resident #1's medical record did not show adequate instructions and appropriate orders for care of his left arm fracture and brace. The RNC acknowledged staff did not evaluate and monitor resident #1's left hand according to facility protocols. She explained on admission and readmission, nurses were to conduct a full assessment and identify and document that a brace was in place. The RNC stated if there were no orders for follow up of a fracture and monitoring the extremity with a brace, her expectation was nurses would contact the hospital and mention the brace to the attending physician at the time other admission orders were obtained. The RNC verified clarification of resident #1's orders related to his fracture and brace was ultimately the responsibility of the nursing department. On 2/15/23 at 10:33 AM, and 2/16/23 at 3:41 PM, OT E stated on his initial admission assessment, resident #1 had a brace. She recalled the hospital record did not indicate he had a left wrist injury. OT E said, I probably discussed with his assigned nurse on that hall. It was my understanding that nursing would follow up. She stated resident #1 was hospitalized for issues related to his brace and readmitted with another device. She explained there were no therapy readmission orders such as passive range of motion for his left hand. OT E said, We were waiting for guidance. I do know about the follow-up being ordered. I read it in the hospital notes when he came back. OT E confirmed resident #1 was on therapy caseload from 9/15/22 to 10/12/22, and during the four week period no clarification was received regarding treatment for the resident's fracture and use of the brace. OT E explained she was directed to evaluate the resident today and found he had a pain level of eight on a zero to ten scale with movement of his left wrist. She stated the resident had limited range of motion of the left wrist which currently impacted him as it was his dominant hand. OT E stated resident #1 now compensated by using his right hand for eating and other ADLs. On 2/17/23 at 1:30 PM, the Director of Rehab stated the normal process for residents admitted with fractures involved a follow-up with the treating orthopedic physician. She explained most orthopedic specialists were very particular about their orders, such as range of motion exercises with specified measurements in degrees and maximum weight limits. The Director of Rehab stated those types of restrictions were necessary to promote the healing process. She acknowledged that if a resident did not receive appropriate rehab services, negative outcomes could include decreased range of motion, weakness, stiffness, pain, and difficulty with tasks that required fine motor movement. Review of the facility's policy and procedure for Restorative Nursing Programs revised on 1/06/23, revealed the facility would provide services to maintain or improve a resident's abilities, to include assistance with braces and passive or active range of motion exercises. Review of the Facility assessment dated [DATE] revealed the facility could provide care for residents with musculoskeletal conditions including fractures. Services included assistance with ADLs, wound care, and rehabilitation. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 10/05/22, resident #1's wound was noted to be healed by the Wound Care physician. *On 2/15/23, the physician's order to monitor capillary refill for the resident's nail beds to left hand was discontinued. *On 2/15/23, the Restorative Nurse received education related to care plans, tasks and management of splints. *On 2/16/23, resident #1 had an x-ray that showed a healed distal radial fracture. *On 2/16/23, the clinical management team completed skin assessments of 100% of current residents and no new skin alterations were identified. *On 2/16/23, the Restorative Nurse completed an audit of the facility's restorative splint programs. Any required corrections were made at that time. *On 2/16/23, the facility achieved 94% compliance with education provided to active nursing staff related to the completion of weekly skin observations, documentation, and notification. Any nurse who has not received the education will be educated prior to the next scheduled shift. *On 2/16/23, a splint binder was created, and residents who currently use splints have a task assigned in the plan of care that includes skin integrity check before and after placement. *On 2/16/23, current new admissions/re-admission charts were reviewed for appointments. Any concerns identified were corrected at this time. Follow up appointments for future appointments were reviewed with no concerns noted. *On 2/16/23, education was provided for Nurse Managers regarding reviewing new admissions/re-admissions and follow up appointments for new orders. Education included creation of a transportation binder that is communicated daily in morning clinical meetings and updated with transportation pick up time, location of appointment, escort, and then follow up information from the appointment. (i.e., new orders, future appointments, referrals etc.) *On 2/17/23, the facility held an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting with the Medical Director in attendance. All plans were agreed upon and accepted. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on topics listed above. On 2/17/23, interviews were conducted with four Registered Nurses, four Licensed Practical Nurses, and one Occupational Therapist. All verbalized understanding of the education provided. The resident sample was expanded to include five additional residents who wore braces. Observations, interviews, and record reviews revealed no concerns for residents #7, #9, #10, #11, and #12 related to obtaining and following physician orders, and developing and implementing appropriate nursing interventions for braces.

Based on observation, interview and record review, the facility neglected to implement policies and procedures and follow standards of practice related to care of a fracture with a brace for 1 of 6 residents reviewed for braces, (#1); and failed to provide the care and services to ensure the safety of a resident who was at risk for elopement for 1 of 6 residents reviewed for elopement, (#1), out of a total sample of 12 residents. These failures contributed to resident #1's hospitalization and elopement and placed him at risk for serious infection/injury/impairment/death. While resident #1 was out of the facility unsupervised, there was likelihood he could have fallen, been accosted by unknown persons, become lost, drowned, or been hit by a car. On 8/22/22, resident #1 was admitted to the facility with a brace in place for a left wrist fracture. Facility staff did not obtain orders for necessary care and services, the device was never removed for skin evaluation, and the resident's left hand and arm were not assessed regularly. Resident #1 developed a wound and a skin infection under the brace and was transferred to the hospital on 9/10/22 for treatment. He required wound care, intravenous antibiotics, and consultation with an orthopedic specialist during his hospitalization . On 9/13/22, the resident was readmitted to the facility with a new splint. Nursing staff did not follow hospital discharge orders for follow up with the orthopedic specialist within two weeks. Over the next five months, resident #1's plan of care was not updated to reflect the frequency and duration of use of the device, and therapy orders were not obtained and implemented to promote optimal functional status. On 2/09/23 at approximately 1:00 PM, resident #1 left his room and walked towards the facility's front lobby unnoticed by staff. When the receptionist opened the front doors for incoming transportation personnel, she did not maintain focus on the doors and resident #1 left the building simultaneously. Nursing staff did not conduct rounds at the change of shift, and resident #1's assigned nurse did not notice he was missing until approximately 4:00 PM. On 2/12/23 at approximately 4:00 AM, a concerned citizen contacted law enforcement regarding the well-being of a man loitering at a gas station over three miles away from the facility. Law enforcement responded, identified the man as resident #1, and arranged medical transport to the hospital. The facility was unaware of resident #1's whereabouts for three days until law enforcement notified the Administrator he was found. The facility's failure to implement policies and procedures to prevent neglect and implement a plan of care that reflected necessary care and services placed all residents who had braces and/or were at risk for elopement at risk for serious infection/injury/impairment/death. This failure resulted in Immediate Jeopardy starting on 8/22/22. The Immediate Jeopardy was removed on 2/17/23. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F607, F684, F689, and F835. Review of the medical record revealed resident #1, a [AGE] year-old male, was admitted to the facility from the hospital on 8/22/22. His diagnoses included stroke, adult failure to thrive, alcohol abuse with alcohol-induced mood disorder, and altered mental status. The resident was readmitted to the facility on [DATE] and his demographic sheet was updated to reflect new diagnoses of left forearm fracture, local skin infection, and cellulitis of the left finger and left arm. On 2/14/23 at 5:02 PM, and 2/15/23 at 2:38 PM, in telephone interviews, resident #1's sister explained in August 2022 her brother was admitted to the facility from the hospital with a brace on his left arm for a wrist fracture. She said, When he was transferred to the facility there was a mix-up. They did not check the brace, change it, or take it off and he ended up with pressure sores under there. He needed antibiotics to treat that infection. They never took it off or cleaned it and he went back to the hospital for treatment. The resident's sister stated the facility notified her on the past Thursday, 2/09/23, that security cameras showed her brother left the facility unaccompanied at about 1:00 PM. She explained she was concerned about her brother's safety due to his impaired cognitive and physical status, and she was relieved when law enforcement found him. Resident #1's sister verified she was legally his healthcare surrogate. She explained her brother was an alcoholic who lived a transient lifestyle on the streets and been homeless for approximately ten years. The sister stated facility staff did not contact her when her brother was admitted or readmitted to obtain information about him. She said, Nobody asked me about previous behaviors or wandering. I think he would be at risk to leave the building because when he gets bothered about something, that's what he would do, get up and leave. Review of the medical record revealed there were no admission physician orders or care plans related to resident #1's fracture, brace, and no instructions to ensure nursing staff conducted thorough evaluations of his left arm to prevent complications from the device. On 2/15/23 at 11:07 AM, the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) were informed resident #1's medical record showed no admission orders in August 2022 related to his left wrist fracture or monitoring of his brace, and no evidence that a follow-up appointment was scheduled after re-admission from the hospital in September 2022. The DON stated she started work at the facility on 11/28/22 and was not aware resident #1 had a splint and suffered an injury as a result of appropriate care not being provided. She stated since the resident's elopement, she still had not reviewed his chart thoroughly. On 2/15/23 at 1:40 PM, the RNC stated she spoke with the Assistant DON and the previous DON who informed her resident #1 refused to have the brace removed for skin checks. The RNC acknowledged the resident's refusals should have been addressed with appropriate interventions. She confirmed the medical record contained no evidence alternate approaches were used to conduct skin evaluations and no instructions to nursing staff for monitoring his left hand. The RNC explained the admission nurse did not identify that resident #1 had a brace. She acknowledged the admission nurse, assigned nurses, and nursing management staff did not contact the hospital to clarify orders for the fracture and brace and/or notify the attending physician. The RNC confirmed the orthopedic consult was never arranged in the five months since readmission and resident #1's plan of care did not reflect instructions for use of the brace. She stated these issues were ultimately the responsibility of the nursing department. On 2/14/23 at 5:25, and 2/16/23 at 3:30 PM, the Director of Rehab confirmed resident #1 was admitted to the facility in August 2022 for therapy services. She recalled he was admitted with a left wrist fracture and ended up returning to the hospital three weeks later due to increased pain of the left arm and was readmitted on [DATE] and resumed therapy. She reviewed his chart and noted on initial admission and readmission, the resident was on Occupational Therapy caseload to work on tasks including dressing and activities of daily living. The Director of Rehab stated the therapist who did his initial evaluation in August 2022, Occupational Therapist (OT) E, noted the resident had a left wrist brace in place. The Director of Rehab stated the Nursing department would normally follow up to obtain orders for orthopedic consults and instructions for the brace. She acknowledged there was a lapse in communication and said, Therapists could have pushed a little more as they saw him five times weekly. The Director of Rehab stated she attended multiple interdisciplinary team (IDT) meetings including daily clinical meetings and did not recall any discussion regarding clarification of orders or revision of the plan of care for resident #1's fracture and brace. She validated every meeting over the past six months was a missed opportunity to exchange and discuss information and concerns about care and services for resident #1's left wrist fracture and brace. On 2/16/23 at 3:41 PM, OT E recalled resident #1 had a brace on admission and was readmitted from the hospital with a different type of removable device. She confirmed there were never any specific physician orders for therapy interventions such as passive range of motion exercises, but on readmission there was an order for follow up with an orthopedic specialist in one to two weeks. OT E reviewed resident #1's chart and confirmed he was last discharged from Occupational Therapy services on 10/12/22, approximately four weeks after readmission. When asked how she selected appropriate treatments for resident #1 despite no orders for either admission, OT E said, I kept doing what was done in the hospital. During the time he was on caseload, I recall asking nursing staff at least once a week at a minimum regarding [orthopedic] follow up. I spoke directly to the DON, possibly twice, and she stated she would follow up. OT E explained she received a physician's order today and evaluated resident #1's left wrist for the first time. She stated his pain level with left wrist movement was eight on a zero to ten scale. OT E confirmed the resident was left-hand dominant and now compensated by doing activities of daily living (ADLs) including eating with right non-dominant hand. Review of the admission Elopement Evaluation dated 8/22/23 revealed an elopement risk score of NA or not applicable. The document indicated scores of ten or above deemed a resident to be at risk for elopement. The evaluation incorrectly showed resident #1 was dependent for ADLs or could not move without assistance. Questions related to the resident's mental status, mobility, speech patterns, history of wandering, and contributing diagnoses including cognitive impairment were left blank. There was no associated nursing documentation to show the admission nurse or any member of nursing management contacted the resident's sister, his healthcare surrogate, to obtain accurate information regarding his medical and social history. On 2/16/23 at 10:49 AM, the RNC explained the score of NA on admission elopement evaluation resulted from the admission nurse's selection that inaccurately deemed resident #1 dependent for ADLs or not able to move independently. She acknowledged that response conflicted with information on the hospital transfer form. The RNC validated there was no evidence in the medical record that resident #1's healthcare surrogate was contacted to ensure admission evaluation form were completed correctly. On 2/14/23 at 5:44 PM, the Administrator, DON and RNC discussed the facility's elopement incident investigation. The Administrator explained resident #1 walked through the front lobby doors unnoticed by staff when the receptionist unlocked and opened the doors for transportation personnel who arrived to pick up another resident. He confirmed the receptionist was not able to see the door from her desk, and she did not look at the security camera monitors to ensure there was no unauthorized egress from the facility. The DON explained nursing staff did not notice the resident was missing until after 4:00 PM as none of the assigned staff conducted walking rounds at change of shift. The DON stated the investigation showed Certified Nursing Assistant (CNA) B who was assigned to the resident during the 7:00 AM to 3:00 PM shift was on break after the residents' lunch meals were completed. The DON discovered at change of shift, CNA C, who was assigned to the resident on the 3:00 PM to 11:00 PM felt rounding was unnecessary as she had worked on the opposite hallway and saw CNA B's residents periodically throughout the day shift. The Administrator stated on Sunday 2/12/23 at 4:32 AM, three days after the resident walked out of the facility, a police officer called to notify him resident #1 was at a gas station in another city. The Administrator recalled the police officer described resident #1 as looking cold and hungry when he was found. The Administrator stated resident #1 had no injuries but complained of mild back pain so he was transported from that location to the hospital for evaluation. On 2/16/22 at 12:09 AM, in a telephone interview, the convenience store employee explained he called the police when he became concerned about a man who had been outside the location at night for two to three days. He said, Something was off about him. I did not see where he slept but I assume he slept at the tables. The employee stated one of the regular homeless people who spent the nights outside the convenience store brought concerns about the man's condition to his attention. The regular homeless person told the convenience store employee the man seemed to be defecating on the benches and said, This new guy has been all over my corner. He made a mess of it. The convenience store employee stated the regular homeless person told him customers had bought food for him but he barely touched it. The convenience store employee said, He seemed like a wounded animal, just laying there in his own filth and refusing to eat anything. On 2/15/23 at 11:07 AM, the DON stated when resident #1 returned to the facility, she assessed him and noted his feet were macerated and he had blisters on both feet. She recalled it had been raining for several days and confirmed it was probable the resident's feet had been wet for an extended period of time. The DON stated resident #1 was currently being seen by a Wound Care specialist physician. On 2/15/23 at 12:41 PM, the Wound Care physician reviewed his notes and stated he assessed and treated resident #1 after he was hospitalized for a left hand wound and cellulitis. He explained it was a professional standard of practice for nursing staff to conduct regular checks of all areas under any device to ensure no skin breakdown such as pressure or friction occurred. He stated complications could be avoided if nursing staff monitored an extremity with a brace for signs of swelling, redness, and compromised circulation every shift. The Wound Care physician emphasized it was essential to promptly report any issues to the attending physician. He stated he was in the facility today to evaluate and treat blisters on resident #1's feet. The Wound Care physician was aware the resident was missing for three days, and the total distance he walked was unknown. He explained the blisters were probably a result of friction from his shoes. Review of a Wound Care Consult note dated 2/15/23 revealed resident #1 had lesions to both feet. The document indicated blisters on the right foot measured 2.0 centimeters (cm) x 2.0 cm, and 3.0 cm x 3.0 cm. The blisters on the left foot measured 2.5 cm x 1.5 cm, and 0.6 cm x 0.7 cm. The Wound Care physician noted the etiology of all lesions was trauma and friction. On 2/17/23 at 9:43 AM, CNA G stated she was assigned to care for resident #1 when he was returned to the facility. She recalled he wore the same clothing he was last seen in three days before and said, He was very dirty. His hair was long and all over the place. He had a full beard, and it was dirty. He smelled like urine. It was strong.He had blisters on both feet, bubbled skin. CNA G stated resident #1 was unsteady and weak when she transferred him to a wheelchair. On 2/17/23 at 4:06 PM, the DON explained professional nursing standards would guide nurses to note the resident's brace, identify potential issues, contact the attending physician for orders, and if no records were included in admission paperwork, contact the hospital. The DON stated her expectation was nurses would communicate with authorized representatives if residents were unable to provide reliable information. She acknowledged the IDT was responsible for reviewing the medical records of newly admitted , readmitted , and current residents to ensure the completion and accuracy of documentation including admission assessments and elopement evaluations. The DON validated although there was interdepartmental communication and IDT meetings, somehow resident #1's splint went unnoticed and untreated, and his risk for elopement was never identified. She confirmed information regarding necessary care and services to meet his needs was not entered into his plan of care. Review of the job description for Registered Nurse dated April 2020 revealed essential duties included consult with the resident's physician in providing the resident's care, treatment [and] rehabilitation. Registered Nurses were expected to review residents' care plans daily to verify they received appropriate care and services. Review of the job description for Licensed Practical Nurse dated July 2021 revealed essential duties included working with physicians to review treatment plans and making rounds to ensure that care and services were being provided appropriately, and also to evaluate resident status. The facility's policy and procedure for Abuse, Neglect and Exploitation revised 7/13/22, defined Neglect as .failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 10/05/22, resident #1's wound was noted to be healed by the Wound Care physician. *On 2/09/23 at 4:09 PM, a complete headcount by nursing staff confirmed all residents of facility were present, except resident #1. *On 2/09/23, the nursing management team completed elopement risk evaluations on all residents and no new residents were identified as at risk. The elopement risk binders were reviewed by the DON to validate that each resident at risk for elopement had demographic information in the binder. *On 2/09/23, the DON reviewed clinical records of residents identified to be at risk for elopement to confirm elopement risk care plans were in place. Residents were confirmed to have orders in place for increased monitoring, behavior monitoring for exit seeking, interventions attempted for exit seeking and outcome of those interventions. *On 2/09/23, the Staff Development Coordinator (SDC) initiated all staff education on the facility's policy for prevention of Abuse, Neglect and Exploitation, with an emphasis on Neglect, to include reporting requirements, elopement standard and guidelines, responding to door alarms and proper actions to take upon responding, and maintaining visual observation of all persons entering and exiting the facility. A post-test was used to validate comprehension of education received. The facility achieved 100% compliance on 2/16/23. *On 2/09/23, the button that allowed staff to open the front lobby doors remotely, without direct supervision of the doors, was removed by the Maintenance Director. The front desk staff were educated by the Administrator on only opening the front lobby doors at the keypad next to door. *On 2/09/23, the Maintenance Director relocated the receptionist's desk to an area that allows direct supervision of the door. *On 2/10/23, the facility held an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting. Attendees included the Medical Director. The committee reviewed QAPI minutes and accepted the Performance Improvement Plan. *On 2/10/23 at 5:30 AM, the Maintenance Director checked egress doors for alarms and function with no issues identified. *On 2/10/23, the Receptionist job description was revised by the Administrator to include maintaining visual observation of persons entering and exiting the front door. *On 2/10/23, elopement drills were initiated on the 11:00 PM to 7:00 AM shift and conducted every shift until the 11:00 PM to 7:00 AM on 2/16/23. Elopement drills will be ongoing, conducted weekly on alternating shifts until it is determined by the QAPI committee that it is appropriate to decrease the frequency to monthly on alternating shifts. *On 2/12/23, resident #1 was found by law enforcement, transported to the hospital for evaluation, and returned to the care of the facility at approximately 11:20 AM. The DON completed a head-to-toe assessment of resident #1 and noted blisters to both feet and scabbed areas to his right hand and right arm. *On 2/12/23, resident #1 was assessed for elopement risk and identified as high risk. His photo and demographic information were placed in the Elopement Risk Binder. The resident was placed on one-to-one supervision immediately and will remain with that level of supervision until otherwise determined by the interdisciplinary team. *On 2/12/23, the RNC and members of the facility's management team reviewed and revised the facility's Elopement Evaluation form to include additional risk factors of history of homelessness and substance abuse. All current residents were re-evaluated for elopement risk by the nursing administrative team and one new resident was identified as at risk. *On 2/14/23, Elopement Binder Quality Monitoring (QM) reviews were completed. A Quality Review re: elopement process was completed. * On 2/15/2023, the Restorative nurse was educated on care plans, tasks, and management of splints to ensure the provision of care. *On 2/16/23, resident #1 had an x-ray that showed a healed distal radial fracture. *On 2/16/23, the clinical management team completed skin assessments of 100% of current residents and no new skin alterations were identified. *On 2/16/23, active nursing staff were educated on completion of weekly skin observations, documentation, and notification. The facility achieved 94% compliance. The facility utilized a scenario of Neglect related to not providing appropriate clinical care and identification of Neglect. Any nurse that has not received the education will be educated prior to next scheduled shift. *On 2/16/23, a Splint binder was created. Current splints have a task assigned in the plan of care that includes skin integrity check before and after placement. *On 2/16/23, current new admissions/re-admission charts were reviewed for appointments. Any concerns identified were corrected at this time. A review of follow up appointments for future appointments revealed no concerns. *On 2/16/23, Nurse Managers were educated on reviewing new admissions/re-admissions and follow up appointments for new orders. They were educated on the creation of a transportation binder that is communicated daily in morning clinical meetings and updated with transportation pick up time, location of appointment, escort, and then follow up information from the appointment. (i.e., new orders, future appointments, referrals etc.) *On 2/16/23, the facility achieved 100% with education provided by the SDC for nursing staff on rounding during and between shifts. Agency staff and newly hired staff will be educated during the orientation process or prior to starting their next shift. *On 2/17/23, an Ad Hoc QAPI committee meeting was completed with the Medical Director to review current QAPI Performance Improvement Plans to determine the need for further changes. Results of elopement drills were reviewed by the QAPI committee to determine any need for systematic change. All plans were agreed upon and accepted. Review of in-service attendance records revealed staff signatures to reflect participation in education on topics listed above. On 2/17/23, interviews were conducted with five Registered Nurses, four Licensed Practical Nurses, nine CNAs, one Occupational Therapist, the Activity Director, and one laundry staff. All verbalized understanding of the education provided. The resident sample was expanded to include five additional residents who wore braces and five additional residents who were at risk for elopement. Observations, interviews, and record reviews revealed no concerns for residents, #2, #3, #4, #5, #6, #7, #9, #10, #11, and #12 related to the provision of necessary care and services to prevent Neglect.

Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure vulnerable residents did not exit the facility unsupervised and failed to secure and monitor doors to maintain a safe and secure environment for 1 of 4 residents reviewed for elopement risk, (#1). These failures contributed to resident #1 exiting the facility and placed him at risk for serious injury/impairment/death. While the resident was out of the facility unsupervised, there was high likelihood he could have fallen, been hit by a car or become lost. On 03/29/21 at 6:23 AM, a cognitively impaired resident, #1 exited the facility through the front entrance door in the dark, unsupervised. He propelled his wheelchair along the covered side walk to the latched fence at the front of the facility. He stood up from his wheelchair, unlatched the fence and walked while he pushed his wheelchair to the middle of the facility's parking lot. The facility was located on a 3 lane street and near a busy 4 way intersection. Resident #1 was spotted in the parking lot by staff arriving for work. The resident's whereabouts were unknown to the facility until the staff notified the facility approximately 15 minutes after he exited the facility. The facility failed to ensure resident #1 was adequately supervised and failed to secure and monitor the exit door to ensure vulnerable residents did not exit the facility without supervision. The facility's failure to provide adequate supervision and a secure environment resulted in Immediate Jeopardy. The Immediate Jeopardy began on 3/29/2021 and was removed on 4/13/2021. The scope and severity of the deficiency was decreased to a D, no actual harm with potential for minimal harm that is not Immediate Jeopardy. Findings: Resident #1, an [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, repeated falls, and difficulty walking. Review of resident #1's most recent quarterly comprehensive Minimum Data Set (MDS) assessment dated [DATE], documented he had hearing difficulty and severely impaired cognitive skills for daily decision-making. He required supervision with transfers, walking in the hallways, and used a wheelchair for mobility. He had 1 fall since the prior assessment. Review of resident #1's plan of care dated 03/04/21 showed he was at risk for elopement, wandering and exit seeking behaviors. The goal included that resident #1 will not elope from the facility and staff will monitor his whereabouts on an ongoing basis. Interventions included to monitor for tailgating and diversional activities when exit-seeking behavior occurred (i.e. offer food, activity, and one-on-one company when allowed). A care plan for impaired cognitive skill for decision making, short-term and long-term memory problems and problems understanding others due to dementia was initiated on 04/13/20. A care plan for impaired communication related to his being hard of hearing was initiated on 04/13/20. A care plan for falls was initiated on 04/13/20 and documented resident #1 sustained falls on 06/07/20, 10/28/20 and most recently on 03/04/21. Review of resident #1's Elopement Evaluations dated 04/03/20, 06/29/20, 09/16/20, 10/20/20, 01/15/21, and 03/29/21 assessed him at being at risk to wander to high risk to wander. Review of resident #1's Nursing Progress Note dated 03/29/21, read that resident #1 was observed in the parking lot at 6:25 AM by oncoming staff. The progress note revealed resident #1 was interviewed by the Administrator and Director of Nursing (DON) and he stated he pushed the handicap button, then pushed the front entrance door open and left the facility unattended. Resident #1 had stated, I made it to the parking lot. That's when several nurses caught me and tried to bring me back into the building. I was trying to get to the store. The resident was seen by a psychologist on 03/29/21 and the consult note read, resident was seen today because he is exit seeking, experiencing a significant amount of anxiety and was placed on 1:1 supervision. The resident stated that he was exit seeking because he wanted go to the grocery store to pick up a few items such as orange juice and brownies. He admitted to experiencing some sadness and nervousness when he is unable to get items he wants. The resident is on [CONDITION(S)] medications to maintain functional status and a gradual dose reduction (GDR) is not recommended at this time. On 04/12/21 at 6:15 AM, resident #1 was observed sitting on the side of his bed. He was alert and well dressed. The resident had a bag of candy and a bag of popcorn on the bed and his jacket was laying at the head of his bed. He was very hard of hearing, confused and laughing. He said he liked sweets. He then went back to bed and closed his eyes. On 04/12/21 at 6:15 AM, Certified Nursing Assistant, (CNA) C stated she was assigned to resident #1 on 03/29/21 on the 11 PM-7 AM shift. She said the resident had been up all night walking in the hallways. She said she provided care to resident #1's roommate early in the morning and when she came out of the bathroom, resident #1 was not in the room. I heard that a nurse found him in the parking lot. Beats me how he got out of the facility because you need a code to get out of the front entrance door. CNA C said she did not hear an alarm sound during her shift. On 04/12/21 at 6:25 AM, Licensed Practical Nurse (LPN) D stated she worked the 11 PM-7 AM shift (East Wing) on 03/29/21. She said she did not hear any alarms sound that night. She noted the lab technician was in the facility early morning of 03/29/20 and thought perhaps the resident may have followed them out the front door when they left the facility. I believe they have the code to the front door. LPN D added that resident #1 was often seen at the nurses station but he always returned to his room. On 04/12 at 6:27 AM, Registered Nurse (RN) E stated she worked the 11 PM-7 AM shift (West Wing) on 03/29/21 when resident #1 exited the facility unsupervised. RN E said the resident #1 wandered in the facility and used his wheelchair like a walker. I would see him watching the front entrance door. He was watching who was coming in and going out like he was making a plan. On 04/12/21 at 6:30 AM, RN B said she was assigned to resident #1 on 03/29/21 on the 11 PM-7 AM shift. She stated she had a split assignment and worked on both East Wing and West Wing that night. RN B said she saw resident #1 on the East Wing and she had stopped to speak with him for 5 minutes during her shift. She said she then went to the West Wing to administer medications to residents. RN B said she received a phone call from the day nurse at 6:45 AM, informing her that resident #1 was in the parking lot. At first he refused to come back in the facility but the CNA and I were able to bring him back. He was out in the parking lot for about 15 minutes. She stated she did not hear an alarm sound that night. On 04/12/21 at 7:30 AM, LPN A said she was the nurse who found resident #1 in the facility parking lot on the morning of 03/29/21. LPN A said she arrived at the facility at 6:25 AM. She said she drove into the facility's front parking lot and saw the resident in the middle of the parking lot standing behind his wheelchair. I recognized the resident because he used to be on the West Wing. As I approached him he became verbally and physically aggressive and he was hitting and kicking the staff .Before the incident I would see him in the front lobby. On 04/12/21 at 10 AM, an interview was conducted with the Administrator and DON. The Administrator revealed on 03/29/21 at 6:25 AM, resident #1 left the facility unattended. She said the last time resident #1 was seen by staff was at 6:20 AM by RN B. She said RN B saw resident #1 sitting outside the Administrator's office adjacent to the front lobby. The DON revealed the facility did not have a wander monitoring system and the only intervention for residents at risk for wandering/elopement was staff supervision. The DON acknowledged that resident #1 was assessed and identified at risk for wandering/elopement. She added it was unsafe for him to be out of the facility unsupervised. The DON said all residents were required to be monitored every 2 hours regardless of whether they were at low risk or high risk for elopement. The DON did not explain how residents assessed at high risk for wandering/elopement were monitored at same time intervals as residents who were not at risk for wander/elopement. The Administrator revealed the facility's investigation determined the root cause for resident #1's elopement was the result of the handicap door system that bypassed the front door lock security system. The Administrator did not address the lack of knowledge regarding the facility's front door security system. The DON did not address the level of supervision and individualized plan of care for resident #1's identified wandering/elopement behaviors which led to him exiting the facility unattended. On 04/12/21 at 11:35 AM, the Maintenance Director explained that resident #1 was able to bypass the facility's front entrance door security system on 03/29/21. He demonstrated that when the handicap wall switch was pressed, it disengaged the magnetic lock system on the front door but the alarm stayed on. He said resident #1 pushed the handicap wall switch, waited 15 seconds, pushed the door open, went out the door and closed the door to stop the alarm. The Maintenance Director stated he was not aware of how the handicap door system functioned until the door company came in to check the front door function on 03/30/21. The Maintenance Director then revealed, we have a video of the night resident #1 exited the facility by himself. On 04/12/21 at 11:50 AM, the facility's video camera recording of the resident's elopement on 03/29/21 was viewed with the Maintenance Director. The Maintenance Director said the facility only had cameras at the front lobby and the front entrance way. The video camera recording showed resident #1 in the front lobby on 03/29/21 at 6:20 AM. At 6:22 AM, resident #1 pushed on the front door and the door did not open. He then backed up in his wheelchair to the handicap wall switch and pushed the button quickly with his hand. At 6:26 AM, he moved to the front door, waited 15 seconds and then pushed on the door 3 times. The front door opened and the resident wheeled himself out. He then looked back and closed the front door. The resident then wheeled himself toward the front of the facility. At 6:26 AM, RN B was seen in the front lobby. At 6:32 AM, RN B exited the front entrance door and walked toward the front of the facility. At 6:38 AM, resident #1 was seen on the camera recording being escorted via wheelchair back into the facility by RN C. On 04/12/21 at 11:35 AM, LPN A pointed out the exact location where she found resident #1 in the facility's parking lot on 03/29/21. On 04/12/21 at 4:30 PM, the resident's elopement route was retraced from his room to the parking lot where he was found. He wheeled himself 151 feet (ft) from his room to the facility's front entrance door. He exited through the door and wheeled 95 ft to the front latched gate. He unlatched the front gate and walked 65 ft to where he was found in the parking lot. The total distance from the resident's room to where he was found measured 311 feet. The resident was 65 ft from a 3 lane street located in front of the facility. He was 547 ft from a busy 4-way intersection with moderately trafficked 6-lane highway. According to Timeanddate.com, on 03/29/21 at 6 AM, it was 61 degrees and sunrise was at 7:20 AM. On 04/12/21 at 3:25 PM, CNA G stated that several of his residents were at risk for wandering/elopement. I have to check the residents every 2 hours. On 04/12/21 at 3:29 PM, CNA I could not explain how often wandering/elopement residents needed to be checked. She then stated, Every 2 hours. On 04/12/21 at 3:35 PM, LPN J could not provide the time interval or define the level of monitoring that was required for wander/elopement risk residents. To me it is knowing where your residents are. On 04/13/21 at 5:44 PM, the Medical Director stated he was aware resident #1 had exited the facility unsupervised on 03/29/21. He said he was aware residents at risk for wandering/elopement were placed on frequent checks, every 2 hours. It is most important that staff work together on providing supervision to all residents. Review of the facility's Elopements and Wandering Residents Policy, revised 02/29/21, read Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner . 4. d. Adequate supervision will be provided to help prevent accidents or elopements Review of the Facility Assessment, reviewed 03/09/21, revealed the facility was competent to provide care and services for residents with Mental Health and Behavior needs: memory impaired, understanding impaired, decision impaired, Dementia, Alzheimer's and Wandering. The facility's failure to secure their front entrance door and closely supervise a resident with severe cognitive impairment and active wandering/elopement behaviors resulted in resident #1 exiting the facility unsupervised and placed 7 others residents identified at risk for wandering/elopement at risk for serious injury, harm and death. Review of the corrective measures implemented by the facility revealed the following which were verified by the survey team: *Resident #1 was assessed on return to the facility on [DATE] and had no injuries. He was placed on 1:1 supervision. A head count was conducted to verify the safety of all residents. The required notifications were made to the physician and family. *An audit documented residents within the facility were reassessed for wandering and elopement on 3/29/21. *Facility front door code was changed on 3/29/21. *A contracted door company checked all the facility doors on 03/29/21 and the handicap door system was disengaged. *A door watch system was initiated 03/29/21-04/07/21 to ensure security of all facility doors. *Documentation of elopement drills with 100% of staff completed on 4/7/21. Drills will be continued on a regular basis. *Documentation of education regarding abuse, neglect, elopement started 3/29/21, completed with 100% of all current staff related to wandering/elopement. *Documentation of education initiated on 04/13/21 for all staff regarding monitoring of residents with wandering/elopement behaviors every hour. Education will continue until 100% of all staff is achieved. All agency staff will be educated prior to working their shift. *Green bracelets have been placed on all wandering/elopement risk residents on 4/13/21. *Physician orders obtained for all 9 current wander/elopement risk residents with whereabouts to be monitored every hour on 4/13/21. *Elopement risk was added to the CNA task on 4/13/21 for 9 the current wander/elopement risk resident and documented, Check every hour for wandering tendencies. *An Ad Hoc Quality Assurance meeting was held on 03/29/21 to discuss the elopement and a decision was made to relocate the handicap wall switch to the reception desk which was completed on 04/13/21. Screamer door alarms were installed on the kitchen door, employee break room door and electrical room door on 03/29/21. *The facility's 3 elopement risk alert binders were audited for accuracy on 3/29/21. *Enunciator door alarm panels were installed on 4/7/21 on both nursing units and will now alarm and announce the location of the facility door that has been breached. *The facility root cause analysis for resident #1's elopement was changed on 4/12/21 to lack of supervision and staff not responding to door alarms. *The sample was expanded to include residents #2, #3 and #4 who were ambulatory and at risk for wandering/elopement. Observations, interviews and record reviews revealed no concerns related to elopement risk evaluations and care plans. Interviews verified training regarding wandering/elopement, resident supervision and door security.

Based on observation, interview, and record review, the facility failed to supervise 4 of 8 residents who smoke and needed supervision, by requiring them to sign out Leave of Absence (LOA) to smoke unsupervised off the facility property (#142, 126, 95 & 88). This failure resulted in residents #142, #126, #95, and #88 smoking in an unsupervised and potentially unsafe area during the day and night. Two locations were identified where residents went to smoke off property. The first location was on an uneven public road sidewalk in the front of the facility. The second location was in the parking lot of a neighboring fitness gym business. The public road sidewalk was within 20 feet of a bus stop. This location was located within one block of the intersection of a 6 lane state road and a 4 lane boulevard. To get to the public sidewalk, residents had to maneuver down the facility's paved driveway which was on incline. The driveway had cracks and uneven paving from the oak trees growing by the road. To get to the business parking lot, a residents had to maneuver through a bed of mulch under a low hanging tree, then cross over the facility's service road. This parking lot was in direct sunlight. This facility practice has been in existence for at least two years according to staff and resident interviews. These potentially unsafe areas for which the facility requires these residents to smoke unsupervised, could potentially lead to falls, injuries, other harm, or death for these medically and physically compromised residents. This deficiency resulted in Substandard Quality of Care and Immediate Jeopardy. The immediacy was removed on 8/12/17 and the severity was lowered to D, no actual harm with potential for more than minimal harm. Also, based on observation, interview, and record review, the facility failed to provide an environment free from potential accident hazards by not securing closet doors to prevent potential access to hazards such as cleaning chemicals for 2 of 3 closets containing hazards on 1 of 2 wings (East). Findings: Cross reference F223, F242, F279, F353, F490 and F520. 1. On 8/08/17 at approximately 9:50 AM, resident #142 sat alone in a motorized wheelchair in a fitness gym's parking lot next to the facility with two lit cigarettes, one in each hand. He was smoking. He was not wearing any protective smoking gear. He sat in direct sunlight wearing shorts, a t-shirt, and non-skid socks. At this time, resident #142 stated that he lived at the facility and had signed out LOA to smoke off-property. Resident #142's medical record revealed he was originally admitted to the facility on [DATE] and readmitted on [DATE] for long-term care. He had [DIAGNOSES REDACTED]. The resident was receiving hospice services. His medications included Morphine Sulfate 20 milligrams (mg.) by mouth every 4 hours around the clock (ATC) for pain, Oxycontin 30 mg. every 12 hours for pain, and Methadone 10 mg. every 12 hours ATC. Resident #142 was assessed as an unsafe smoker on his readmission 8/03/17 and according to the Safe Smoking Evaluation, the resident was determined to be an unsafe smoker, but it indicated the resident did not require any supervision while smoking. The evaluation indicated that he had impaired decision making skills, inadequate vision, was not balanced while sitting or standing, had limited range of motion with no fine motor skills to securely hold a cigarette, was not able to communicate the risks associated with smoking, was not able to light a cigarette safely with a lighter, was not able to smoke safely, was not able to utilize an ashtray appropriately, and was not able to extinguish a cigarette safely and completely when finished smoking. On 8/08/17 at 11:17 AM, resident #142 said he had been smoking for about [AGE] years. He stated that he followed the facility rules for smoking which were: the nurse gives him 2 cigarettes, hands him a lighter, and then has him sign out LOA to leave facility property to smoke. He said that his left arm was weaker than his right, so he used his right hand to light and smoke cigarettes. On 8/08/17 at 4:10 PM, resident #142 said he had been verbally instructed by the administrator that if he wanted to smoke at times other than the facility's designated smoking times, he needed to sign out LOA and leave the property. Otherwise, he could smoke in the facility's supervised smoking area during the designated smoking times which were at 8:30 AM, 10:30 AM, 1 PM, 3:30 PM and 6:30 PM. On 8/09/17 at 9:35 AM, he said that since coming to live at the facility, on 4/12/17, he had been instructed by a previous administrator to go off-property to smoke. Resident #142's Minimum Data Set (MDS) Admission Assessment on 7/18/17 indicated he was a tobacco user. His Brief Interview for Mental Status (BIMS) was 13 out of a possible 15, meaning he had some impaired memory skills to time and required cueing for recall after five minutes. His hearing was adequate, speech was clear, but his vision was impaired due to a left prosthetic eye and his need for corrective glasses. His preferences and routines revealed it was very important to him to go outside and for fresh air when the weather is good. He was independent in mobility off the unit with his motorized scooter. Upon his readmission on 8/03/17, resident #142's Interim Care Plan indicated the resident smokes and (is) at risk for safety concerns related to desire to smoke and is designated as an impaired smoker. The goal read, Resident will smoke safely in designated areas at scheduled times. The approaches read, Resident will be supervised while smoking at all times .will demonstrate ability to physically hold the smoking device while smoking, resident and responsible party will be oriented to the smoking policy and smoking areas. Provide resident with protective gear while smoking. The interim care plan did not include that the resident was required to sign out LOA to smoke off premises and would be unsupervised if off-premises. Based on the above initial observation of resident #142 on 8/08/17 at about 9:50 AM, the facility did not require him to wear protective gear such as a smoking apron while smoking off premises even though the care plan indicated he needed protective gear. Resident #142's August 2017 monthly physician order sheet (POS) did not have an order for [REDACTED]. On 8/08/17 at 6:30 PM, the administrator validated there were no physician orders for LOA for resident #142. Resident #142's medical record revealed a Release of Responsibility for Leave of Absence (LOA) log. It read, I the undersigned, hereby accept complete responsibility for (name of resident) while away from (name of facility) and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition or accident that may happen while the resident is away. He had signed himself out on 6/04/17 at 11 AM and back in at 2 PM (3 hours), 6/10/17 at 10 AM with no return to facility time, and 8/08/17 at 9 AM and returned at 9:50 AM. On these days, his LOA times ranged from 50 minutes to 3 hours. Review of facility paperwork revealed that designated supervised smoking times for residents were 7 days week from 8:30 am-9 am, 10:30 am-11 am, 1 pm-1:30 pm, 3:30 pm-4 pm, and 6:30 pm-7 pm. The designated smoking area was located in an outside courtyard off the East wing's activity room on facility property. The staff responsible to supervise the residents in this area at those times were: East and West wing certified nursing assistants (CNAs), staff from plant operations, the receptionist, staff from dietary, and staff from the activities department. On 8/08/17 at 11:42 AM, registered nurse (RN) O said the smoking policy is as follows: nurses keep cigarettes and give them to residents so they can sign out LOA to go off premises to smoke if they wanted to off hours. On 8/08/17 at 12:17 PM, licensed practical nurse (LPN) B described the smoking process and policy, and said all residents outside in the designated fenced in smoking area under the gazebo must be assisted by staff at 8:30 AM, 10 AM, 1:30 PM, 3:30 PM and 6:30 PM. She said the nurses keep 1 smoking box at the 100 hall nurses' station with all the lighters and cigarettes. Residents can have 2 cigarettes at a time, but they are not allowed to light their own cigarettes. Staff assigned to supervise the residents in the designated smoking area light their cigarettes for them. She said resident #142 usually doesn't ask for more than 2 cigarettes, and never goes outside alone to smoke because he is a supervised smoker. She said residents aren't allowed to smoke alone. All residents who smoke have to be supervised including resident #142. This was contrary to what was observed on 8/08/17 at 9:50 AM for resident #142. On 8/09/17 at 5:06 PM, LPN E said that before 8/08/17, residents were allowed to sign out LOA to go off-premises to smoke outside of designated smoking times. Residents were allowed to go outside whenever they wanted, after or before smoking times. On 8/09/17 at 5:20 PM, CNA G stated that he has worked at the facility for 2 years on all 3 shifts and weekends. He stated whenever he is scheduled to supervise residents' smoke breaks, he takes residents outside to the designated smoking area during the designated smoking times. He is not aware of any residents going out at any other time. On 8/12/17 at 5:04 PM, LPN U said prior to 8/07/17, resident #142 was going off-property alone and unsupervised to smoke. On 8/11/17 at 10:36 AM, interview with the Resident Council President stated some residents were upset because their 6:30 PM smoking times were repeatedly being cancelled by the staff. She stated that a CNA, name unknown, was entering the code to the exit door so residents could go outside to the designated supervised smoking area, and then left them unsupervised. She said residents have been allowed to smoke off-property alone and unsupervised. On 8/09/17 at 10:49 AM, the administrator, who was new to the facility, said they had been making the residents sign the smoking policy beginning 8/02/17. The administrator said residents can't smoke on the facility property unless they are supervised. She said if they want to smoke outside of the designated smoking times, residents can sign themselves out LOA to go off-property to smoke. She said she doesn't think there is a written policy/directive, but said it was a verbal practice. She didn't know how staff tells the resident to sign out LOA to smoke, how the staff knows it's the practice of the facility, or how staff knows to tell residents that if they want to smoke to sign LOA to go off property to smoke. The administrator stated all residents have to be supervised to smoke on property. There is no other alternative for smoking during a non-designated smoking break time than to sign out LOA to go off-property to smoke unsupervised. 2. Review of resident #126's medical record revealed that he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Guillain-Barré syndrome is a rare but serious [DIAGNOSES REDACTED] disorder in which the immune system attacks healthy nerve cells in your peripheral nervous system. This leads to weakness, numbness, and tingling. It can eventually cause paralysis. (healthline.com). Quadriplegia is defined as paralysis caused by illness or injury results in the partial or total loss of use of all their limbs and torso The loss is usually sensory and motor, which means that both sensation and control are lost (disabled-world.com). On 8/11/17 at 8:34 AM, resident #126 said he goes outside off the property to smoke every day. He started going off the property signing out LOA with his dad to smoke about six months ago. At 4:34 PM, resident #126 said that when he smoked off property, he went out by the street in front of the facility. He validated that the facility makes him sign out LOA to do that. He stated that his dad has to hold the cigarette for him to smoke. The resident was not able to hold the cigarette for himself due to being a quadriplegic with Guillian-Barre syndrome. At this time, he demonstrated that he could only move one hand, his right hand an inch off the bed. Both hands were in splints. He said that he did not want to wear the smoking apron, so when he goes off-property with his dad, he does not use it. He said that about 6 months ago, the facility told him that he was no longer allowed to smoke during the designated smoking times in the facility's supervised smoking area. He said he was told that the staff were no longer allowed to hold his cigarette for him. He stated that he was told that he had to be able to hold his own cigarette and flick his ashes by himself. He said that he would like to go out to smoke in the facility's designated smoking area with everyone else at the designated smoke breaks. He said that he needs total assistance to get out of bed, cannot wheel his own wheelchair independently, cannot move his own arms or hands, and cannot take himself out to the supervised smoking area. This resident was totally dependent on staff for all his activities of daily living. On 8/09/17 at 1:50 PM, the director of nursing (DON) said resident #126 was not a safe smoker unassisted and that his father takes him off-property to smoke unsupervised. The DON said the resident is a quadriplegic and she feels it is not safe for him to smoke. She was not aware he was smoking at this current time when the survey began on 8/07/17. Review of the Release of Responsibility for Leave of Absence form, indicated resident #126's father signed him out on 8/05/17 at 12:40 PM and returned at 12:45 PM, on 8/08/17 at 2:20 PM with no return time written, on 8/09/17 at 10:30 AM and returned at 1 AM, and on 8/09/17 at 12:15 PM and no return time. Facility staff was not aware of the time the resident returned to the building as evidenced by not signing the resident back into the facility. On 8/09/17 at 4:35 PM, CNA A said resident #126 only smokes with his family. Since resident #126 can't use his hands, his family has to do everything for him. Resident #126 used to go out to the designated smoking area and staff would put a cigarette in his mouth, but it has been approximately a year since he went out to designated smoking area with staff. Administration does not want staff to assist any residents who want to smoke outside the scheduled times. Approximately 1 to 1.5 years ago, the residents did not sign themselves out LOA. The nurse gave out the cigarettes and lighter for those that wanted to go LOA to smoke unsupervised. On 8/12/17 at 5:04 PM, LPN U said prior to this week, resident #126 was going LOA off-property to smoke with his dad but he was not supervised by staff. The hospital History and Physical, dated 3/15/17, revealed that resident #126 was a tobacco smoker greater than 10 cigarettes per day. Resident #126's Quarterly Nursing Evaluation, dated 2/11/17, for the Safe Smoking Evaluation was incomplete on 7 out of 21 questions with no answers for the following questions: alert and oriented and can consistently perform safe smoking techniques, has fine motor skills needed to hold cigarette, resident smokes safely, utilizes ashtray safely and properly, extinguish cigarette safely and completely when finished smoking, candidate for e-cigarettes, and determination to be a safe smoker or not. He had no August 2017 physicians LOA order to go off-property. The last Admission MDS that included information about smoking for resident #126 was completed on 11/12/16 and was marked that he did not smoke. However, his Care Plan initiated on 11/16/16 indicated the resident wishes to use tobacco products. The care plan goal was updated on 2/14/17 and read resident #126 will smoke safely in designated area(s) at scheduled times through next review date. Approaches included resident will be supervised while smoking at all times. Review and discuss smoking/smokeless tobacco cessation alternatives with resident or responsible party. Smoking Assessment/Tobacco use assessment to be completed on admission and quarterly. Staff will assist resident with handling and storage of smokeless tobacco and/or smoking equipment. On 8/09/17 at 4:34 PM, the physician for residents #142 and #126 said in her professional opinion, If a resident is alert and oriented, I would not stop (the resident) from going out LOA to smoke. LOA is more of an institutional thing. I can't say residents can't smoke. I can't stop them from smoking. I don't sign LOA orders. Most of my patients can smoke at a designated time. I don't know how the facility enforces it if they were alert and oriented to leave. I think it would be prudent to know, once assessed, if the resident is safe. The doctor would like to know and be informed. I don't believe I can stop them and (resident #142) is smoking down the street with a cardiac history. If the resident has medical conditions they need to have someone to supervise them smoking. I don't know if the facility can enforce it. She said safety wise, it would be best if the physician knows the residents are going off property to smoke. It should be documented, with a discussion with the resident so they understand they are at risk, with discussed smoking cessation and other things documented. At least let the residents know they have a medical condition and their brief mental interview mental status (BIMS) with a score, make a medical decision and document it, to actually have the testing in the medical record to demonstrate it. She stated, I didn't know the residents were going off premises to smoke. We should institute a mental component, a leave of absence and the resident has to document they accept the risk. The functional ability is a big deal. She stated that medical conditions needed to be considered including cardiac and respiratory status to ensure that residents are safe to smoke unsupervised off property. The physician said, I have never seen the facility's 'Safe Smoking Evaluation'. At this same time, while looking at the facility's Safe Smoking Evaluation form, she said that it needed more information to protect the resident (and) more documentation to indicate that the facility had actually observed the resident for safe smoking. 3. Resident #95's medical record revealed that she was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was a long-term care resident. [DIAGNOSES REDACTED]. Review of resident #95's quarterly MDS assessment dated [DATE] revealed that she was a tobacco user. Her preferences regarding daily routines and activities indicated that it was very important for her to do her favorite activities and go outside to get fresh air. Her balance during transitions and walking was not steady, but she was able to stabilize herself without staff assistance. She was independent with walking in her room and corridor. She was independent with locomotion on and off the nursing unit with the assistance of wheelchair or walker as mobility devices. She had impaired vision requiring corrective lenses for reading. Her BIMS score was 14 out of 15 and had declined since her annual MDS score of 15 out of 15 dated 11/14/16. On 8/08/17 at 12:10 PM, resident #95 sat in her wheelchair in front of the East wing nurses' station. She was overheard requesting cigarettes and a lighter from the facility's education/talent manager nurse. The nurse opened a large yellow tackle box sitting at the nurses' station. It contained packs of cigarettes and lighters. The nurse handed cigarettes and a lighter to resident #95. The nurse then handed the resident her medical record, she signed the LOA log, and self-propelled off the unit. On 8/08/17 at about 5:45 PM, resident #95 stated that she was told by administration that she had to sign out LOA and go off-property if she wanted to smoke outside of the designated supervised smoking hours. She said that there was no staff supervision when she smoked off-property, and that most of the time she smoked alone when off-property. She stated that staff did not usually have time to take her out to smoke in between designated smoking times. She stated she was a long time smoker of [AGE] years. The resident stated that when she wanted to smoke outside of the designated smoking times, the nurses would give her the cigarettes and a lighter and have her sign out LOA. She would then self-propel off property to smoke. She indicated that this had been going on for a couple years, since she had been at the facility. The resident said that she had to be careful alone off-property. She stated that her lower legs were swollen from [DIAGNOSES REDACTED], making it too difficult for her to walk with her walker, so she was presently using her wheelchair to get around. Resident #95 stated that when she smoked off property, she would go to the other side of the facility's hedge in the fitness gym's parking lot or would go down the facility's driveway to the public sidewalk under the big tree beyond the facility's front entrance. She said that since the new administrator had come to the facility, (on 7/31/17), she was no longer allowed to stay on property in the designated smoking area with just her family to smoke. She said that the administrator told the smokers that it was against facility policy to smoke on property without staff present. The resident stated that if her family came and she wanted to smoke in between the designated smoking times, she was required to sign out LOA, and go off-property. Resident #95 stated she felt that the facility should allow her to smoke in the facility's designated smoking area with her family. She stated that the West wing CNAs did not always show up on time for the 6:30 PM scheduled designated smoking time. The resident stated that she recently just had cataract surgery, had fallen off the side of her bed a few days ago, and now wore the observed [DIAGNOSES REDACTED] wraps on both lower legs for excessive leg edema and fluid seepage. Resident #95's Safe Smoking Evaluation, dated 7/26/17, revealed that she had limited range of motion of both arms and hands, but was still considered a safe smoker who did not need supervision. Review of the facility's Smoking/Non-Smoking policy, revised on 8/01/17, revealed that all residents who smoked required staff supervision and must smoke in the designated smoking area. The facility's practice of giving cigarettes and a lighter to residents to smoke unsupervised contradicted the smoking policy. According to the smoking policy, residents were not be allowed to have access for self-use lighters, and the facility was responsible for lighting resident smoking material. Residents being required to go off-property were not supervised, were lighting their own cigarettes, and the facility had no way of knowing how residents were disposing of their cigarette debris. Resident #95's smoking care plan, dated 12/01/15 through 8/17/17, revealed the resident did need supervision while smoking. It read, Resident wishes to use tobacco products Resident will smoke safely in designated area(s) Resident will be supervised with smoking at all times Staff will assist resident with handling and storage of smokeless tobacco and/or smoking equipment. There was no documentation in the written care plan to indicate the resident went off facility property unsupervised to smoke. There was no documentation in the written care plan to reflect that the facility had made her physician aware that the resident smoked between the designated supervised smoking times, that the resident was required to smoke off-property in between designated supervised smoking times, and that the physician had advised either against it or for it. The care plan was not individualized to the resident for safe smoking preferences or medical needs. The care plan indicated that the resident needed to be supervised with smoking at all times, but the resident was not being supervised with smoking at all times as evidenced by the facility practice of requiring the resident to go off-property, unsupervised, to smoke in between designated smoking times. Review of a facility log revealed that resident #95 had 11 falls since October 2016. Review of her falls care plan, dated 5/17/17-8/17/17, revealed that her medical conditions required monitoring by staff and that she needed reminders by staff for safety. Approaches included Observe for side effects of any drugs that can cause gait disturbance, orthostatic hypotension, weakness, sedation, light headedness and/or dizziness Educate/remind resident to request assistance prior to ambulation and/or transfers Encourage resident to ask for assist, praise her when she does. Remind her to lock wheelchair brakes when transferring. This could not be done if the facility required her to smoke off-property without staff supervision. Her activities of daily living (ADLs) care plan dated 5/17/17-8/17/17 read, Resident will not develop any complications related to decreased ADL self-care performance Approaches included Encourage resident to ask for assistance when propelling wheelchair. The resident's falls and ADL care plans directed staff to monitor for weakness, dizziness, light headedness, remind her to lock brakes, encourage to ask for assistance when propelling her wheelchair, etc. This could not be done if the facility required her to smoke off-property without staff supervision. Her medications included Oxycontin 10 mg. three times a day for pain ATC, Klonopin 0.5 mg. as needed (PRN) twice a day for anxiety, and Tramadol 50 mg. every 6 hours for pain PRN. She received Klonopin twice on 8/01/17 and once on 8/06/17. She received Tramadol on 8/03/17, 8/04/17, 8/05/17, 8/06/17 and 8/07/17. Oxycontin may cause slow heartbeat, seizures, confusion, severe weakness or dizziness and a feeling 'like you want to pass out' (rxlist.com). Klonopin may cause drowsiness, dizziness, confusion and loss of balance or coordination. (rxlist.com) Resident #95's Release of Responsibility for Leave of Absence, LOA log revealed she had signed out LOA from 7/1/17 - 8/8/17 on 15 occasions. Her LOA sign out times ranged from 25 minutes to one hour. On 7 of those 15 times, she signed out on the 3 PM -11PM shift. On 8/3/17, she stayed out 20 minutes in the late evening, from 9:40 PM to 10 PM. On 8/4/17, she stayed out for 30 minutes in the middle of the night, from 1:50 AM to 2:20 AM, the 11 AM-7AM shift. The LOA log included a statement that would absolve the facility for their lack of supervision while on LOA as follows: I, the undersigned, hereby accept complete responsibility for (name of resident) while away from (name of nursing home) and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition or accident that may happen while the resident is away Review of the facility's Signing Resident Out (LOA) policy, with a review date of 6/1/15, did not include any information about the facility's practice requiring smokers to sign out LOA and/or requiring residents to smoke unsupervised off property. There was also not any guideline or information in the policy that would include a physician's assessment, recommendation, or order for a resident's LOA status. Review of the August 2017 physician order sheet (POS) for resident #95 included the following medical conditions: memory loss, smoker, coronary artery disease, hypertension, peripheral vascular disease, diabetes, and anxiety. The resident's former physician had written an order, dated 4/4/17 as follows: May go LOA with family. May not take narcotics on LOA. This POS had been signed by resident #95's current physician on 8/2/17. The facility not been following the physician's LOA orders, to go LOA with her family rather than alone. The nursing staff had allowed resident #95 to go off property alone, without family, at all times of the day and night to smoke unsupervised. There was no evidence of a LOA order for resident #95 to be able to go off-property, alone and/or unsupervised to smoke. On 8/09/17 at 4:34 PM, resident #95's physician stated that she had only been at the facility about two months and did not yet know all of her patients well. She stated that she did know which of her patients were smokers, but stated that she had not been informed by the facility that some of her patients were being required to sign out LOA to smoke off the property, without staff supervision. She stated that she thought it would be prudent for physicians to be informed of this practice, so that they could participate in the interdisciplinary planning and have input into the decision for or against unsupervised smoking. She stated, for example, if a resident had a medical condition such as a cardiac diagnosis, it might not be safe for the patient to be outside smoking, particularly in the sun unattended. She also stated that she felt it would be prudent to have a physician's order for a resident to go off property unsupervised to smoke. On 8/13/17 at 3:30 PM, resident #95 revealed that she had not felt safe smoking off the property unsupervised, compared to smoking on the property supervised by staff. She stated that the path to the off property smoking areas were a bit hazardous in her wheelchair. She confirmed that she had been allowed to go outside alone unsupervised by staff on 2-3 occasions during the midnight shifts to smoke off property. She stated there were crazy people walking through the parking lot and off property smoking areas. She said she had gotten to know them while outside smoking and they had become her friends. The resident stated that it got really dark out there. At this time, the resident also stated when smoking off property, she would not throw her cigarette butts on the ground. Instead, she would extinguish the cigarette butts, wrap them in a napkin or tissue, put the tissue inside her wheelchair cup holder, and then throw the tissue and butts into a trashcan inside the facility. 4. Review of resident #88's medical record revealed that she was initially admitted on [DATE] and readmitted on [DATE]. She was a long-term care resident. [DIAGNOSES REDACTED]., and anxiety. Review of resident #88's quarterly MDS, dated [DATE], revealed that she was a tobacco user. Her BIMS score was 14 out of 15, and had declined since her significant change MDS score of 15 out of 15 dated 9/19/16, in which she fell and broke her left hip. Her preferences regarding daily routines and activities indicated that it was very important for her to do her favorite activities and go outside to get fresh air. She used a walker and a wheelchair for mobility devices. Her balance during transitions and walking was not steady, but she was able to stabilize herself without staff assistance. She required extensive assistance of one person for locomotion off the unit and required set-up help only for locomotion on the unit. She required supervision and set-up help only for transfers. She required extensive assistance of one person for dressing, toileting, and person hygiene. She wore corrective eye glasses. Resident #88's medi

Based on observation, record review and interview the facility failed to maintain sufficient staff to meet the needs of the residents in regards to adequate supervision and assistance for 4 of 8 sampled smoking residents. These residents were required to smoke-off property without staff supervision in potentially unsafe area. The path taken by the residents to go off property to smoke had uneven pavement, low hanging tree branches and is located 1 block from major city highway (#142, 126, 95 & 88). The failure to provide sufficient staffing for smoking supervision resulted in Immediate Jeopardy. The immediacy was removed on 8/12/17 and the severity was lowered to D, no actual harm with potential for more than minimal harm. Findings: Cross reference F 223, F 242, F 279, F 323, F 490 & F 520. On 8/08/17 at approximately 9:50 AM, resident #142 was observed smoking independently off property in the parking lot next door to the facility. Interviews and record reviews validated residents #88, #95, and #126 had to go on leave of absence (LOA) to go off property to smoke. Resident #88 and 95 said the reason for signing out LOA and going off property to smoke was because staff were too busy to accommodate smoking outside of designated smoking times. Resident #142 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. His minimum data set (MDS) assessment dated [DATE] indicated preferences very important for him to go outside and get fresh air. He was cognitively intact, used a wheelchair and walker for mobility, was unsteady with transfers and walking. He needed staff supervision for dressing and extensive assistance from staff with toilet use. On 8/08/17 at 11:17 PM, resident #142, said he was told by the administrator that if he wanted to smoke outside of the designated smoking times that he would need to sign himself out LOA and go off the property and staff will not accompany him. On 8/09/17 at 10:49 AM the Administrator said, residents cannot smoke on the property unless they are supervised. If residents are alert and oriented and want to smoke outside of the designated smoking times, they can sign out LOA and go off the property. The administrator then stated there is no other alternative for smoking during a non-designated smoking break time than to sign out LOA to go off the premises unsupervised. On 8/09/17 at 4:35 PM interview with Certified Nursing Assistant (CNA) A confirmed that resident #126 goes out with his family to smoke. She said he is not able to use his hands and the family has to do everything for him. The staff used to take him out to the designated smoking area approximately 1 to 1 ½ years ago and facility staff would assist by holding the cigarette to his mouth. CNA A stated the administrator does not want staff to assist any residents who want to smoke outside of the scheduled times. Resident #126 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] indicated he was cognitively intact, totally dependent on 1-2 staff for his activities of daily living (ADL), and is wheelchair dependent. On 8/11/17 at 4:34 PM, resident #126 verified that he is a smoker and his father takes him off premises every other day to smoke. He stated the DON told him about 6 months ago that he could not go to the designated smoking area to smoke because he could not hold his own cigarette. Resident #126 said he would like to go where everyone else goes to smoke, but he needs total assistance to get out of bed, he can't wheel himself and is not able to move his arms and hands to smoke. Resident #95 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] indicate it was very important for her to do her favorite activity was to go outside to get fresh air. Her brief interview for mental status score (BIMS) was a 14 out of 15 which meant she was cognitively intact, she used a wheelchair or walker for mobility and her balance was not steady during transfers and walking. On 8/08/17 at 12:10 PM, resident #95 was observed sitting in her wheelchair in front of the east wing nurses station. She was overheard requesting cigarettes and a lighter from the facility's education/talent manager nurse. The nurse opened a large yellow tackle box that was located at the nurses' station. It contained packs of cigarettes and lighters. The nurse handed cigarettes and a lighter to resident #95, had her sign a leave of absence (LOA) form, and then the resident self-propelled herself off the unit. Later that same day, on 8/08/17 at 5:45 PM, an interview was conducted with resident #95. She said she was told by administration that if she wanted to smoke outside of the designated smoking hours that she would have to sign out LOA and go off property to smoke. She stated staff do not have time to take her out to smoke in between designated smoking times, no staff persons were present when she went off property to smoke, and most of the time she smoked alone. The resident was asked as to how she obtained cigarettes and lighter to smoke off property. Resident #95 indicated the nurse would give her the cigarettes, a lighter, then have her sign the LOA form, and she would self-propel in her wheelchair off property to smoke in the parking lot next to facility property. She said, she had to be careful due to weeping [MEDICAL CONDITION], swelling caused by fluid retention, in her legs, and the sidewalk leading to the parking lot next to facility had a big tree that she had to maneuver around with her electric wheelchair. Resident #95 said that she would like to be able to smoke in the designated smoking area at the facility when her family comes to visit, but the certified nursing assistants (CNA) do not always report at the designated smoking times to supervise residents. According to the facility's smoking times' list, the designated hours for supervised smoking were 8:30 AM, 10:30 AM, 1:00 PM, 3:30 PM and 6:30 PM. On 8/09/17 at 9:30 AM, 8/10/17 at 4:00 PM, and 8/12/17 at 7:30 PM an observation of the parking lot adjacent to the facility where the residents were going to smoke revealed sidewalk was cracked in multiple places, there were unshaded areas where cars were parked. On 8/09/17 the temperature was 94 degrees Fahrenheit (F) and the heat index was in the 100's F. On 8/09/17 at 11:27 AM and 4:18 PM, the director of nursing (DON) said that the facility's smoking policy stated, residents who have been assessed to be safe smokers could sign themselves out LOA and go off property to smoke unsupervised and that they did not need to have a physician's orders [REDACTED]. The DON validated that the nurses on the units were giving the residents cigarettes and lighter to go off property to smoke, and residents have been encouraged not to go out late at night to smoke, but are allowed to do so if they choose. The DON said, this has been the practice at the facility since she has been working here for the past 2 years as the DON. Review of the LOA sheets for resident #95 revealed that she had went out 15 times between 7/01/17 and 8/08/17, the sign out times were 25 minutes to 1 hour, and 7 of the sign out times were on the 3 PM to 11 PM shift. On 8/03/17 she signed out 9:40 PM to 10 PM. On 8/13/17 at 3:30 PM interview conducted again with resident #95 revealed that she did not feel safe smoking off the property unsupervised compared to smoking on the property with staff supervision. She confirmed that the path leading off the property is a bit hazardous in her wheelchair, and she had been allowed to go off property 2-3 times on the midnight shift to smoke off property. Resident #88's medical record revealed that she was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] indicated that she used tobacco, her BIMS score of 14 which meant she was cognitively intact. Her preferences indicated that it was very important for her to go outside to get fresh air, she used a walker and wheelchair for mobility, her walking was not steady, and she required extensive assistance from the staff for locomotion off the unit. On 8/08/17 at 11:45 AM, resident #88 was observed standing with her rolling walker at the east wing nurses' station requesting cigarettes and lighter from the talent manager nurse. The nurse had resident #88 sign LOA, handed her 2 cigarettes, a lighter, and then the resident walked off the unit using her walker. On 8/09/17 at 5:15 PM, resident #88 said if she wants to smoke outside of the designated smoking times she can sign out LOA anytime she wants. The nurse will give her cigarettes and lighter to go off property to smoke. She then stated, It has always been this way since being here, because the staff do not have time to take me out and they have work to do. Review of resident #88's LOA sheets from May 2017 to August 2017 indicate that she signed out 25 times for 10-30 minutes and at least 7 times was between the 3 PM to 11 PM shifts. The latest time she signed out was 7:30 PM to 8:20 PM. On 8/11/17 at 10:36 AM interview conducted with the Resident Council President revealed that the residents were upset because they could not smoke after 6:30 PM and the staff kept canceling the last scheduled smoking time. On 8/11/17 at 11:29 AM, LPN W was asked about staffing at the facility. She said, I usually have 23-25 residents on my assignment and I work very hard. She said she did not get to spend as much time as she would like with the residents and voiced her concerns to the management and was told that there was no ratio limits at the facility. On 8/12/17 at 5:04 PM LPN U was asked about staffing at the facility. She said, she worked the 7 PM to 7 AM shift and has also worked the 3 PM to 11 PM shift. She said she usually had 25 residents on hers assignment and frequently stay later than scheduled to finish the documentation. She is familiar with residents #95, 126, and 142. She said prior to that week, they were going off the property to smoke and resident #95 was going out nightly to smoke. The DON's job description read, Essential Duties & Responsibilities; Direct the nursing services department .schedule daily rounds to observe residents and determine if nursing needs are being met in accordance with the resident's request .monitor nursing service personnel to verify they are following established safety regulations in the use of equipment and supplies .assure residents a comfortable, clean, orderly and safe environment. On 8/13/17 at 9:12 AM, the DON stated that staffing coordinator at the facility is a Certified Nursing Assistant (CNA), however she and the talent manager assist with staffing. The scheduling of staff is done per state regulation and acuity. The DON indicated that she looks at the staffing if residents have increased needs such as wound care, intravenous therapy, gastric tubes and other special procedures when determining staffing numbers. Prior to this week none, of the CNAs were assigned to accompany residents who wanted to smoke after 6:30 PM and resident smoking needs was not considered in staffing calculations at facility. The DON was asked since they do not have Unit Managers at the facility, who oversees the 2 units. The DON said that she and the Assistant Director of Nursing (ADON) oversee the East and West Wings. They used to have 2 ADONs and the 2nd ADON position was eliminated. The DON was asked what other responsibilities she has at the facility. She said she is the Infection Control Nurse, Restorative Nurse and was doing Risk Manager duties up until the new Administrator started 1 week prior to survey. Since the facility was without a Social Services Director from end of January this year until May 1, 2017, the DON verified that she was also the acting Grievance Officer during that time. The DON confirmed that the facility census on start of survey was 91 residents, she frequently uses PRN (as needed) staff to work at the facility and she has a lot of responsibility at this time. The DON did not provide any facility policy regarding staffing. The facility conducted an Emergency Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting on 8/11/17 with the medical director and 5 additional members. The team discussed the current concerns of signing LOA to smoke off-property. On 8/08/17, the DON and ADON were re-educated on how to complete the safe smoking assessment by the regional nurse consultant. Eight residents were identified as smokers. Their care plans and CNA care cards were reviewed and revised for accuracy. There will be 3 full time employees (FTE) to fill the smoking aide position. The smoking area will be covered 16 hours per day. Until FTE staff are hired, existing facility staff will be trained, scheduled and responsible for assuming the position of a smoking aide. The administrator, DON, social services director (SSD), ADON, and talent manager were educated on the education plan by the regional nurse consultant. Education of all licensed staff and CNAs was initiated by the Administrator and designees on 8/10/17. The education included: Smoking policy and procedures, including where to find resident levels of assistance in writing Residents will no longer feel obligated to sign LOA to go to smoke Facility placed a 16 hour 7 day a week smoking aide General resident safety while outdoors (heat, cold, what to do in case of an emergency) Resident rights related to resident preferences Revisions to facility signing Resident out policy and facility practice How to complete the safe smoking evaluation, and all new hires to be educated in orientation. The administrator conducted a meeting with all the residents identified as smokers, a total of 8, on 8/11/17 regarding the Immediate Jeopardy, and potential harm to residents while smoking unsupervised, off-property. Residents were provided with the facility's smoking policy, and procedures and advised that the facility now had a smoking aide on site 16 hours a day 7 days a week, so residents no longer had to sign LOA to go to smoke off-property. As of the exit on 8/13/17, 78 out of 109 staff were in-serviced with ongoing in-service until all staff are educated prior to the start of their shift. On 8/13/17, observations of the designated smoking area showed area was covered with a canopy, ashtrays, fire blankets, fire extinguisher, and a cart with cold water in a cooler was observed. The designated smoking aide was aware of her role, and adequately verbalized the new process and procedures that were implemented. Interviews conducted with staff on 2 of 2 Wings of the facility from 11 AM to 2:05 PM indicated staff were aware of the new smoking times and procedures, and could verbalized what to do in case of an emergency, and interventions initiated to accommodate residents who wanted to smoke outside of the previous designated smoking times. Record reviews of the Facility smoking/Non Smoking Policy, Safe Smoking Evaluation, smoking log, smoking aide schedule, smoking monitor forms verified the sufficient implementation of the allegation to remove immediacy. The immediacy was removed on 8/12/17 and the severity was lowered to D, no actual harm with potential for more than minimal harm due to the need to fully implement and monitor effectiveness of the facility action plans to prevent reoccurrence.

Based on observation, interview, and record review, the facility failed to provide supervision necessary to prevent the potential for physical harm. They required residents to sign out to go off-premises to smoke unsupervised to absolve the facility of their responsibility for 4 of 8 medically compromised residents who required assistance and supervision (#142, 126, 88 & 95). The failure to prevent neglect for residents #142, #126, #88, and #95 resulted in Substandard Quality of Care and Immediate Jeopardy. Immediate Jeopardy is a situation in which immediate corrective action is necessary because the facility's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death to a resident receiving care in the facility. The immediacy was removed on 8/12/17 and the severity was lowered to D, no actual harm with potential for more than minimal harm. Findings: Cross reference F242, F279, F323, F353, F490, and F520. On 8/08/17 at approximately 9:50 AM, resident #142 sat alone in a motorized wheelchair in a fitness gym's parking lot next to the facility with two lit cigarettes, one in each hand, smoking. He did not wear any protective smoking gear. He was in direct sunlight, and wore shorts, a t-shirt, and non-skid socks. At that time, resident #142 stated he lived at the facility, and had signed out LOA to smoke off-property. Resident #142 was originally admitted to the facility on [DATE] and was last readmitted on [DATE] with a [DIAGNOSES REDACTED]. He was receiving hospice care. The facility staff assessed resident #142 as an unsafe smoker on his readmission 8/03/17. According to the Safe Smoking Evaluation, the resident was determined to be an unsafe smoker, but it indicated that he did not require any supervision while smoking. That is contradictory information. The Safe Smoking Evaluation indicated that he had impaired decision making skills, inadequate vision, not balanced while sitting or standing, had total or limited range of motion with no fine motor skills to securely hold a cigarette, was not able to communicate the risks associated with smoking, was not able to light a cigarette safely with a lighter, was not able to smoke safely, was not able to utilize an ashtray appropriately, and was not able to extinguish a cigarette safely and completely when finished smoking. On 8/08/17 at 11:17 AM, resident #142 said he followed the rules for smoking which were: the nurse gives him 2 cigarettes and a lighter, and he signs out LOA to go off the property to smoke unsupervised. At 4:10 PM, resident #142 said he was verbally instructed by the administrator that if he wanted to smoke at 8:30 AM, 10:30 AM, 1 PM, 3:30 PM and 6:30 PM, he could smoke supervised in the designated smoking area on the facility property. He said the administrator told him if he wanted to smoke outside of designated smoking hours, he had to sign out LOA to go off the facility property to smoke unsupervised. On 8/09/17 at 9:35 AM, resident #142 said he has always had to go gone off-property to smoke since his original admission on 4/12/17. Resident #142's Minimum Data Set (MDS) Admission Assessment on 7/18/17 indicated his mental status score was 13 out of a possible 15, meaning he had some impaired memory skills with disorientation to time. His vision was impaired due to a left prosthetic eye, and he needed corrective glasses. It was very important to him to go outside and get fresh air when the weather was nice. He was independent in mobility off the unit only with his motorized scooter. Upon his readmission, resident #142's 8/03/17 Interim Care Plan indicated he desires to smoke and is designated as an impaired smoker. The goal was he will smoke safely in designated areas at scheduled times. Approaches included, resident will be supervised while smoking at all times, resident will demonstrate ability to physically hold the smoking device while smoking, resident and responsible party will be oriented to the smoking policy and smoking areas, and provide resident with protective gear while smoking. The care plan did not mention supervised LOA for smoking off the facility's property. Observation on 8/08/17 at about 4 PM, of the known off-premises unsupervised smoking locations revealed that one of the locations was behind the facility's south hedge line in the parking lot of a neighboring fitness gym business. To get to the business parking lot, the residents self-propelled or were transported by family in wheelchairs across the facility's front entrance side walk, then drop off of the sidewalk into a bed of mulch under a low hanging tree, cross over the facility's side entrance service road onto a walkway through the facility's east hedge, and into the neighboring business parking lot. The other way required them to self-propel down the facility's front ramp and travel through the facility parking lot behind parked cars to access the walkway through the facility's east line of hedges to the business parking lot. There was minimal shade for residents who smoked in this area. Multiple cars were also parked in this area. The second area was located on a public road sidewalk under a large oak tree between the facility's driveway entrance and the neighboring fitness gym's public road entrance. The facility's driveway and the gym's driveways were on an incline. There were cracks in the pavement and the sidewalks. This off-property sidewalk was located within about 30 feet of a bus stop. Both off-property smoking areas are located within one block of a 6 lane road, at the intersection of Semoran Boulevard/State Road 436 and University Drive. The heat index high for 8/08/17 was in the 100's, and the high temperature was 93.9 degrees Fahrenheit. The heat index high for 8/09/17 was in the 100's, the high temperature was 94 degrees Fahrenheit. (Source: weatherunderground.com). According to the facility's Abuse, Neglect, Exploitation and Misappropriation of Property Policy, neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility staff did not assess residents for safety during LOA for smoking in potentially unsafe areas. The facility's smoking policy indicated all residents who smoke require supervision. The policy did not address smoking off-premises. The path to and from the parking lot off-premises where residents go on LOA to smoke is uneven and can pose a hazard for tripping or tipping a wheelchair. The LOA policy did not address smoking specifically, but included a statement that the facility is absolved of all responsibility for the resident while he or she is on LOA. The facility did not have a process to determine how long residents are off-property smoking and when they return unless they are signed out and back in by facility staff. There was no facility responsibility for a resident's whereabouts or their condition while off-premises in their LOA policy. Supervised smoking times for the residents were 8:30 AM, 10:30 AM, 1:30 PM, 3:30 PM and 6:30 PM. Even if residents were assessed as unsafe to smoke unsupervised and wanted to smoke outside of those times, the unwritten verbal policy was that residents were instructed to sign out of the facility LOA and leave the premises to smoke without supervision. Residents #142 and #126 were originally assessed as needing supervision to smoke to prevent potential accidents. On 8/08/17 at 11:42 AM, registered nurse (RN) O said the smoking policy is that nurses keep cigarettes and give them to residents so they can sign out LOA to go off-premises to smoke if they wanted to smoke at times other than the facility's smoking hours. At 12:17 PM, licensed practical nurse (LPN) B described the smoking process and policy, and said all residents must be assisted by staff outside in the designated smoking area in the fenced in area under the gazebo by a staff member at 8:30 AM, 10 AM, 1:30 PM, 3:30 PM and 6:30 PM. Nurses keep 1 smoking box at the 100 hall nurse's station with all the lighters and cigarettes. Residents can have 2 cigarettes at a time but they are not allowed to light their own cigarettes. She said resident #142 usually doesn't ask for more than 2 cigarettes and never goes outside alone to smoke because he is a supervised smoker. Residents aren't allowed to smoke alone. She said all residents who smoke have to be supervised, including resident #142. This was contrary to what was originally observed for resident #142 on 8/08/17. Resident #142's signed a Release of Responsibility for LOA on 8/08/17, left the facility at 9 AM, and returned at 9:50 AM. On 8/09/17 at 5:06 PM, LPN E said before 8/08/17, residents were allowed to sign out LOA to go off-premises to smoke outside of the facility's designated smoking times. Residents were allowed to go outside any time before and after smoking times. At 5:20 PM, certified nursing assistant (CNA) G , who has worked at the facility for 2 years on all 3 shifts and weekends, said whenever he is scheduled to supervise smoking breaks, he takes residents outside to the designated supervised smoking area at designated smoking times. He was not aware of any residents going out at any other time. On 8/12/17 at 5:04 PM, LPN U said resident #142 went off-property to smoke before 8/08/17. 2. Resident #126's medical record indicated he was originally admitted on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per his hospital history and physical, he had a history of [REDACTED]. (ninds.nih.gov). [MEDICAL CONDITION] is damage or disease affecting peripheral nerves. (wikipedia.org). On 8/09/17 at 1:50 PM, the director of nursing (DON) said he is not a safe smoker unsupervised, but his father takes him off premises to smoke unsupervised. The DON said resident #126 is a quadriplegic and she feels it is not safe for him to smoke and the DON was not aware he was smoking on 8/7/17 and his name was not provided on the original smoker list for the facility. The facility did not provide any evidence of safe smoking to the family. On 8/09/17 at 4:35 PM, interview with CNA A said resident #126 only smokes with his family. Since resident #126 can't use his hands, his family has to do everything for him. Resident #126 used to go out to the designated smoking area and staff would put a cigarette in his mouth, but that was approximately a year ago. Administration does not want staff to assist any residents who want to smoke outside the scheduled times. CNA A said approximately 1 to 1.5 years ago, the residents did not sign themselves out LOA, the nurse gives out the cigarettes and lighter for those that want to go LOA to smoke. On 8/11/17 at 8:34 AM, resident #126 said he goes outside to smoke every day. He started going off the premises signing out LOA to smoke a couple of days ago with his Dad. At 4:41 PM, resident #126 said he went to the first smoking meeting with his dad on 8/02/17 that discussed the smoking procedures. He said supervised smoking information was all new to him because he wasn't going to the designated smoke breaks. At 4:34 PM, he said he has been going out LOA with his dad to smoke off-property by the street. He said his dad holds the cigarette for him. The facility makes him sign out LOA to do that. He said he doesn't want to wear the smoking apron, and when he goes out with his dad he doesn't use it. About 6 months ago, the facility said he couldn't go out to the supervised smoking because he couldn't hold his own cigarette and flick the ashes, and the staff person told him he had to wear a smoking apron. He said his dad comes every other day and takes him out to smoke off-premises. He said he wants to go out to smoke when everyone else goes at the designated smoke breaks, but he needs total assistance to get out of bed, can't wheel his own wheelchair independently because he can't move his own arms or hands, and can't hold the cigarette by himself. On 8/12/17 at 5:04 PM, LPN U said prior to 8/07/17, resident #126 went on LOA off-premises to smoke. The hospital History and Physical, dated 3/15/17, indicated resident #126 was a tobacco smoker greater than 10 cigarettes per day. The facility's Quarterly Nursing Evaluation for resident #126, dated 2/11/17, was not completed for safe smoking evaluation on 7 out of 21 questions, with no answers for the following questions: alert and oriented and can consistently perform safe smoking techniques, has fine motor skills needed to hold cigarette, resident smokes safely, utilizes ashtray safely and properly, extinguish cigarette safely and completely when finished smoking, candidate for e-cigarettes, and determination to be a safe smoker or not. He had no August 2017 Physicians order for LOA order to go off- premises. Resident #126's 11/16/16 care plan read, Resident wishes to use tobacco products. The care plan goal was updated on 2/14/17, and read that resident #126 will smoke safely in designated area(s) at scheduled times through next review date. Approaches included, Resident will be supervised while smoking at all times, review and discuss smoking/smokeless tobacco cessation alternatives with resident or responsible party, smoking Assessment/Tobacco use assessment to be completed on admission and quarterly and staff will assist resident with handling and storage of smokeless tobacco and/or smoking equipment. Resident #126 LOA form revealed he went on LOA on 8/05/17 and left at 12:40 PM, and returned at 12:45 PM. On 8/08/17, he left at 2:20 PM with no return date/time. On 8/09/17, he left at 10:30 AM and returned at 11 AM. On 8/09/17, he left at 12:15 PM with no return time/no facility representative signature. On 8/10/17, he left at 2 PM with no return time. Facility staff was not aware of the time the resident returned to the building as evidenced by not signing residents back into the facility after a LOA. The facility has a verbal policy that if a resident wants to smoke outside of the designated supervised smoking times, they can sign out LOA to smoke unsupervised off-property, without protective gear or assistance with lighting the cigarette. Resident #126 cannot hold his own cigarette independently, and flick his ashes because he cannot use his own hands or arms to do that independently. 3. Resident #95's medical record revealed she was initially admitted to the facility on [DATE] and readmitted after on 8/09/16. She was a long-term care resident. [DIAGNOSES REDACTED]. Resident #95's quarterly MDS assessment, dated 5/11/17, revealed she was a tobacco user. Her preferences regarding daily routines and activities indicated that it was very important for her to go outside to get fresh air. Her balance during transitions and walking was not steady, but she was able to stabilize herself without staff assistance. She was independent with walking in her room and corridor. She was independent with locomotion on and off the nursing unit with the assistance of wheelchair or walker as mobility devices. She had impaired vision requiring corrective lenses. Her brief interview for mental status (BIMS) score was 14 out of 15 and had declined since her annual MDS score of 15 out of 15 dated 11/14/16. On 8/08/17 at 12:10 PM, resident #95 sat in her wheelchair in front of the East wing nurses station. She was overheard requesting cigarettes and a lighter from the facility's education/talent manager nurse. The nurse opened a large yellow tackle box sitting at the nurses' station. It contained packs of cigarettes and lighters. The nurse handed cigarettes and a lighter to resident #95. The nurse then handed the resident her medical record. The resident signed a LOA log in her medical record, and then self-propelled off the unit. On 8/08/17 at about 5:45 PM, resident #95 stated she was told by administration that she had to sign out LOA and go off-property if she wanted to smoke outside of the designated supervised smoking times. She stated that staff did not usually have time to take her out to smoke in between designated smoking times. She stated she was a long time smoker. She said there was no staff supervision when she smoked off-property. She stated that most of the time she smoked alone when she went off-property. The resident stated the nurses would give her the cigarettes and a lighter, have her sign out LOA, and she would then self-propel off-property to smoke. She indicated that this had been going since she has been at the facility. The resident said she had to be careful outside in the off-property areas. She stated that her lower legs were swollen, making it too difficult for her to walk with her walker, so she was presently using her wheelchair to get around. Resident #95 stated that when she smoked off property, she sat on the other side of the facility's hedge in a fitness gym's parking lot or would self-propel down the facility's driveway to the public sidewalk under the big tree beyond the facility's front entrance. Resident #95 said that since the new administrator had come to the facility, on 7/31/17, she was no longer allowed to stay on property in the designated smoking area with her family to smoke in between facility designated smoking times. She said that the administrator told the smokers that it was against facility policy to smoke on property without staff present. The resident stated that if her family came and she wanted to smoke in between the facility's designated smoking times, she was required to sign out LOA and go off-property. Resident #95 stated she felt that the facility should allow her to smoke in the facility's designated smoking area with her family. She stated that the West wing CNAs did not always show up or did not show up on time for their designated smoking supervision at 6:30 PM. The resident stated that she recently had cataract surgery, had fallen off the side of her bed a few days ago, and now required [MEDICAL CONDITION] wraps on both lower legs for excessive leg [MEDICAL CONDITION] and fluid seepage. These wraps were seen at the time of the interview. Review of a Safe Smoking Evaluation for resident #95, dated 7/26/17, revealed that she had limited range of motion of both arms and hands, but was still considered a safe smoker who did not need supervision. Resident #95's smoking care plan, dated 12/01/15 through 8/17/17, revealed the opposite, that the resident did need supervision while smoking. It read, Resident wishes to use tobacco products will smoke safely in designated area(s) will be supervised with smoking at all times Staff will assist resident with handling and storage of smokeless tobacco and/or smoking equipment. The care plan did not indicate that the resident went off facility property unsupervised to smoke, and did not reflect that the facility informed her physician that the resident smoked between the designated supervised smoking times, that the resident was required to smoke off-property in between designated supervised smoking times, and did not contain information that the physician had advised against for or against this LOA to smoke unsupervised. The care plan was not individualized to the resident for safe smoking preferences or medical needs. The care plan indicated that the resident needed to be supervised with smoking at all times, but the resident was not supervised with smoking at all times as evidenced by the facility practice of requiring the resident to go off-property, unsupervised, to smoke in between designated smoking times. Review of a facility log revealed that resident #95 had 11 falls since October 2016. Her most recent falls risk evaluation was conducted on 5/14/17 and had a score of 12. A resident who scores a 10 or higher was considered to be at risk for falls. Review of her falls care plan dated 5/17/17-8/17/17 revealed approaches that included Observe for side effects of any drugs that can cause gait disturbance, orthostatic [MEDICAL CONDITION], weakness, sedation, light headedness and/or dizziness Educate/remind resident to request assistance prior to ambulation and/or transfers Encourage resident to ask for assist, praise her when she does. Remind her to lock wheelchair brakes when transferring. Her activities of daily living (ADL) care plan dated 5/17/17-8/17/17 read, Resident will not develop any complications related to decreased ADL self-care performance Approaches included to Encourage resident to ask for assistance when propelling wheelchair. The resident's falls and ADL care plans for monitoring the resident for weakness, dizziness, and light headedness, and for reminding her to lock brakes, and encouraging her to ask for assistance when propelling her wheelchair could not be done when the facility required her to smoke off-property without staff supervision. Resident #95's Release of Responsibility for Leave of Absence log revealed she had signed out LOA from 7/01/17-8/08/17 on 15 occasions. Her LOA sign out times ranged from 25 minutes to one hour. On 7 of those 15 times, she signed out on the 3-11PM shift. On 8/03/17, she stayed out 20 minutes in the late evening, from 9:40-10 PM. On 8/04/17, she stayed out for 30 minutes in the middle of the night, from 1:50-2:20 AM, the 11 AM-7 AM shift. The LOA log included a statement that would absolve the facility for their lack of supervision while on LOA: I, the undersigned, hereby accept complete responsibility for (name of resident) while away from (name of nursing home) and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition or accident that may happen while the resident is away The facility's Signing Resident Out (LOA) policy, with a review date of 6/01/15, did not include any information about the facility's practice requiring smokers to sign out LOA and/or requiring residents to smoke unsupervised off property. There was no guideline or information in the policy that would include a physician's assessment, recommendation, or order for a resident's LOA status. The facility's Smoking/Non-Smoking Policy, revision date 8/01/17, contradicted the facility's safe smoking evaluation for resident #95 which indicated that she was a safe smoker who did not need supervision. The policy indicated that all residents who smoke must be supervised by designated facility staff. The facility's practice of giving cigarettes and a lighter for residents to smoke unsupervised contradicted the smoking policy. The facility neglected to supervise all smoking residents. According to the smoking policy, residents would not be allowed to have access for self-use lighters, and that the facility would be responsible for lighting resident smoking material. Residents being required to go off property unsupervised, were lighting their own cigarettes, and the facility had no way of knowing how residents were disposing of their cigarette butts. Resident #95's August 2017 physician order [REDACTED]. The resident's former physician's orders [REDACTED]. May not take narcotics on LOA. This POS was signed by resident #95's current physician on 8/02/17. The facility not been following the physician's LOA orders, to go LOA with her family rather than alone. The nursing staff had allowed resident #95 to go off property alone, without family, at all times of the day and night to smoke unsupervised. There was no evidence of a LOA order for resident #95 to be able to go off-property, alone and/or unsupervised to smoke. On 8/09/17 at 4:34 PM, resident #95's physician stated that she had only been at the facility about two months stated she knew which of her patients were smokers, but said she had not been informed by the facility that some of her patients were being required to sign out LOA to smoke off the property without staff supervision. She stated that she thought it would be prudent for physicians to be informed of this practice, so that they could participate in the interdisciplinary planning and have input into the decision for or against unsupervised smoking. She stated, for example, if a resident had a medical condition such as a cardiac diagnosis, it might not be safe for the patient to be outside smoking, particularly unattended in the sun. She also stated that she felt it would be prudent to have a physician's orders [REDACTED]. On 8/13/17 at 3:30 PM, resident #95 revealed that she had not felt safe smoking off the property unsupervised, compared to smoking on the property supervised by staff. She stated that the path to the off-property smoking areas were a bit hazardous in her wheelchair. She confirmed that she had been allowed to go outside alone unsupervised by staff on 2-3 occasions during the midnight shifts to smoke off-property. She stated that there were people walking through the parking lot and off-property smoking areas. The resident stated that it got really dark out there. The resident also stated when smoking off-property, she would not throw her cigarette butts on the ground. Instead, she would extinguish the cigarette butts, wrap them in a napkin or tissue, put the tissue inside her wheelchair cup holder, and then throw the tissue and butts into a trash can inside the facility. 4. Review of resident #88's medical record revealed that she was initially admission date of [DATE] and readmitted on [DATE]. She was a long-term care resident. [DIAGNOSES REDACTED]. ([MEDICAL CONDITION]), and you have fluctuating hearing loss (mayoclinic.org). Resident #88's quarterly MDS, dated [DATE], revealed that she was a tobacco user. Her brief interview for mental status (BIMS) score was 14 out of 15 and had declined since her significant change MDS score of 15 out of 15, dated 9/19/16, in which she fell and broken her left hip. Her preferences regarding daily routines and activities indicated that it was very important for her to do her favorite activities and go outside to get fresh air. She used a walker and a wheelchair for mobility devices. Her balance during transitions and walking was not steady, but she was able to stabilize herself without staff assistance. She required extensive assistance of one person for locomotion off the unit and required set-up help only for locomotion on the unit. She required supervision and set-up help only for transfers. She wore corrective eye glasses. On 8/08/17 at 11:45 AM, resident #88 stood with her rolling walker at the East wing nurses' station. She requested cigarettes and a lighter from the talent manager nurse. The nurse obtained a yellow tackle box containing packs of cigarettes and lighters. She handed the resident 2 cigarettes and a lighter. The nurse then brought the resident's medical record to her. The resident signed a LOA log in her medical record and left the unit. On 8/09/17 at 5:15 PM, resident #88 stated she went off-property to smoke in between designated smoking times. She stated the nurses make her sign out LOA and then give her a lighter and cigarettes to smoke off-property without staff supervision. She stated that she could go out anytime day or night but usually did not got out any later than 9 PM because it is dark out there and there are people walking around out there at that time of night. She stated that it had been this way since she came to the facility. The resident stated, Like right now, I would love a smoke in the designated smoking area with staff supervision, but staff don't want to take me out because they have work to do. She stated that when she smokes off-property, she goes either to the parking lot behind the hedge across the facility's property line or down by the road on the sidewalk, under the big tree. At 5:25 PM, resident #88 walked on the unit with her rolling walker. She had slight turn of right foot and slight limp in her right leg. When asked about it, she stated she broke her left hip in September 2016. She stated her leg and hip get tired. Resident #88's Safe Smoking Evaluation, dated 7/26/17, revealed that she had limited range of motion of both arms and hands, but indicated she was considered a safe smoker who did not need supervision. The Facility Smoking/Non-Smoking Policy, revised 8/01/17, contradicted the smoking evaluation that resident #88 was a safe smoker who did not need supervision. Resident #88's care plans for smoking, dated 4/06/16-9/12/17, revealed that the resident required staff supervision with the handling of the smoking equipment: resident will safely use tobacco product Staff will assist resident with handling and storage of smokeless tobacco and/or smoking equipment. The care plan did not indicate that the resident went off of facility property to smoke unsupervised. The care plan did not reflect that the facility had made her physician aware that the resident smoked between the designated supervised smoking times. There was no evidence to indicate that the physician had advised for or against the resident going off-property to smoke unsupervised. The care plan was not individualized to the resident for safe smoking practices, preferences, and medical needs while being required to smoke off property. Review of a facility log revealed that resident #88 had fallen 6 times while at the facility. The fall in September 2016 resulted in a broken hip. Review of resident #88's falls care plan dated 6/12/17-9/12/17 revealed that she was at risk for falls and included, At risk for fall related injury related to left [MEDICAL CONDITION], status [REDACTED]. The goal for falls was, Resident will reduce the risk of a fall related injury by utilizing fall precautions Approaches included, Observe for side effects of any drugs that can cause gait disturbance, orthostatic [MEDICAL CONDITION], weakness, sedation, light headedness, and/or dizziness Educate/remind resident to request assistance prior to ambulation and/or transfers Observe for any unsafe actions and intervene as needed for her safety. Resident #88's [MEDICAL CONDITION] care plan, dated 6/12/17-9/12/17, read, Resident is at risk for [MEDICAL CONDITION] related to her [DIAGNOSES REDACTED].#88 is required to smoke outside, off-property and unsupervised by staff, the resident was not observed for medication side effects that could potentially cause her to fall, was not being reminded to request assistance prior to ambulation and/or transfers, and was not observed for [MEDICAL CONDITION] per her care plan. The Facility Smok

Based on record review and interview, the facility failed to maintain an effective Quality Assessment and Assurance Committee (QAA) program to ensure a safe smoking environment to protect residents from accident and hazards. The QAA committee failed to identify the potential for serious injury, impairment and death when they required residents to take a leave of absence (LOA) and smoke off-property without supervision if they wanted to smoke at a time other than the designated smoking time established by the administration. This affected 4 of 8 residents who smoked (#142, 126, 95 & 88). This deficiency resulted in Immediate Jeopardy. The immediacy was removed on 8/12/17 and the severity was lowered to D, no actual harm with potential for more than minimal harm. Findings: Cross Reference F223, F246, F 279, F323, F353, & F490. On 8/08/17 at approximately 9:50 AM, resident #142 was observed smoking independently off property in the parking lot next door to the facility. Resident #88, 95, & 126 were not observed smoking off property, but interviews and record reviews validated that all 3 residents have signed leave of absence (LOA) to go off-property to smoke up to 10 PM. Resident #88 and 95 said the reason for signing out LOA and going off-property to smoke was because staff were too busy to accommodate smoking outside of designated smoking times. The administrator's job description read, Essential Duties & Responsibilities; Oversee regular rounds to monitor delivery of nursing care ensure resident needs are being addressed, Responsible for the QA (Quality Assurance) program, maintain a working knowledge of and confirm compliance with all governmental regulations consult with department managers concerning the operation of their departments to assist with eliminating/correcting problems areas, and/or improvement of services On 8/09/17 at 10:49 AM, the administrator said there was no written directive on signing LOA to smoke outside the designated smoking times off-property. She said it had been a practice of the facility before she assumed her role at the facility and she has not done anything to change it. The medical director's job description read, The medical director will coordinate medical care and coverage needs at the facility and provide clinical guidance and oversight regarding the implementation of resident care policies shall help the facility identify, evaluate and address/resolve medical and clinical concerns affecting resident care, medical care and quality of life general clinical guidance for facility staff regarding when to contact a practitioner to help residents attain and maintain their highest practicable level of functioning On 8/09/17 at 12:26 PM, the medical director indicated that resident smoking policies were discussed at last month QAA meeting. The medical director said it was up to the nurses' critical judgment to allow residents to go off-property to smoke and and they were working on physician awareness of the issue. He recommended that the primary physicians be notified regardless of the resident's cognition if they go off-property to smoke, and a LOA order is written that specifies the purpose as smoking. The medical director then stated, It would be good to have it in writing so that the patients are being taken care of properly. On 8/09/17 at 4:34 PM, the primary care physician for residents #95, #126 and #42 said she had not been informed by the facility that her residents were required to sign LOA to smoke off the property without supervision. She stated, It would be prudent for physicians to be informed of this so that we can participate and have input into the resident assessment and care plan for unsupervised smoking. She then said for example, if a resident has a medical condition such as cardiac diagnosis, it might not be safe for them to be outside smoking in the hot sun unattended. She confirmed that she thought it would be prudent for the resident to have a LOA order to smoke off-property unsupervised. On 8/13/17 at 4:30 PM, the administrator and director of nursing (DON) verified that the QAA committee meets monthly on the third Friday of the month and as needed with the DON, administrator, medical director, department heads, and any other staff members who wish to participate. The administrator said they discuss weight loss, infections, grievances, pain, labs, hospitalization s, survey prep, employee engagement and performance audits at our monthly QAA Meetings. The DON and administrator said that they did revise their smoking policy this month, August, and were scheduled to address it at their next QAA meeting. The administrator indicated no mention in her notes that she could find that would indicate that smoking was ever addressed at the QAA committee meetings. The administrator was asked if the staff were aware that residents were going off-property to smoke in the adjacent parking lot and she said, Yes. The DON verified that the facility had not brought up any concerns regarding smoking at the safety meetings, the residents care plans made no mention of them going LOA to smoke off-property and their care plans indicated all residents are to be supervised to smoke. The administrator and DON were asked how they ensured the resident's safety, providing them care and services, and making sure they are safe by allowing the staff to give residents cigarettes and lighter to go off the property to smoke unsupervised. The DON and administrator could not provide an answer when questioned about how they would ensure safety of residents when they left the premises to smoke. The facility's Smoking/Non-Smoking Policy read, All residents who smoke will be supervised by designated facility staff. The policy did not address smoking off-property. The facility conducted an Emergency Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting on 8/11/17 with the medical director and 5 additional members. The team discussed the current concerns of signing LOA to smoke off-property. The facility's Resident Signing Out policy was reviewed and revised, and residents identified as smokers were provided with a copy of the LOA guidelines and procedure. On 8/08/17, the DON and ADON were re-educated on how to complete the safe smoking assessment by the regional nurse consultant. Eight residents were identified as smokers. Their care plans and CNA care cards were reviewed and revised for accuracy. There will be 3 full time employees (FTE) to fill the smoking aide position. The smoking area will be covered 16 hours per day. Until FTE staff are hired, existing facility staff will be trained, scheduled and responsible for assuming the position of a smoking aide. The administrator, DON, social services director (SSD), ADON, and talent manager were educated on the education plan by the regional nurse consultant. Education of all licensed staff and CNAs was initiated by the Administrator and designees on 8/10/17. The education included: Smoking policy and procedures, including where to find resident levels of assistance in writing Residents will no longer feel obligated to sign LOA to go to smoke Facility placed a 16 hour 7 day a week smoking aide General resident safety while outdoors (heat, cold, what to do in case of an emergency) Resident rights related to resident preferences Revisions to facility signing Resident out policy and facility practice How to complete the safe smoking evaluation, and all new hires to be educated in orientation. The administrator conducted a meeting with all the residents identified as smokers, a total of 8, on 8/11/17 regarding the Immediate Jeopardy, and potential harm to residents while smoking unsupervised, off-property. Residents were provided with the facility's smoking policy, and procedures and advised that the facility now had a smoking aide on site 16 hours a day 7 days a week, so residents no longer had to sign LOA to go to smoke off-property. As of the exit on 8/13/17, 78 out of 109 staff were in-serviced with ongoing in-service until all staff are educated prior to the start of their shift. On 8/13/17, observations of the designated smoking area showed area was covered with a canopy, ashtrays, fire blankets, fire extinguisher, and a cart with cold water in a cooler was observed. The designated smoking aide was aware of her role, and adequately verbalized the new process and procedures that were implemented. Interviews conducted with staff on 2 of 2 Wings of the facility from 11 AM to 2:05 PM indicated staff were aware of the new smoking times and procedures, and could verbalized what to do in case of an emergency, and interventions initiated to accommodate residents who wanted to smoke outside of the previous designated smoking times. In interviews conducted with resident #95 and #88 on 8/13/17 at 3:30 PM, they said they felt safer smoking on property, they were happy with the extended smoking time, that a smoking aide was hired, and staff would be available to supervise them while smoking. Record reviews of the Facility smoking/Non Smoking Policy, Safe Smoking Evaluation, smoking log, smoking aide schedule, smoking monitor forms verified the sufficient implementation of the allegation to remove immediacy. The immediacy was removed on 8/12/17 and the severity was lowered to D, no actual harm with potential for more than minimal harm due to the need to fully implement and monitor effectiveness of the facility action plans to prevent reoccurrence.

Based on observation, interview, record review and facility policy review, the facility failed to administer its resources effectively to ensure a safe smoking environment, to protect residents from potential accidents and hazards. The facility failed to have an effective system in place to accommodate residents who wanted to smoke at a time other than the designated smoking time established by the administration. Residents were required to take a leave of absence (LOA) and smoke off-property without supervision. This affected 4 of 8 residents who smoked (#142, 126, 95 & 88). This deficiency resulted in Immediate Jeopardy. The immediacy was removed on 8/12/17 and the severity was lowered to D, no actual harm with potential for more than minimal harm. Findings: Cross reference F223, F242, F279, F323, F353, and F520. On 8/08/17 at approximately 9:50 AM, resident #142 was observed smoking off-property in the parking lot next door to the facility. Interviews conducted with resident #88, #95 #126 on 8/09/17 at 5:15 PM, 8/09/17 at 4:15 PM, and 8/11/17 at 4:34 PM respectively, indicated that all these residents had to sign a leave of absence (LOA) and go off-property to smoke outside of the facility's designated smoking times. Review of the LOA forms signed by the residents/responsible party showed that residents were on LOA outside of the facility's designated smoking times. This practice left the residents without supervision, and the potential for residents getting burned from the cigarettes or lighter, the possibility for setting themselves on fire, falling, injury while traveling off-property, and the potential for death, dehydration while off-property while exposed to the sun and heat, or the possibility of sunburn. Resident #88 and #95 said the reason for signing out LOA and going off-property to smoke was because staff were too busy to accommodate smoking outside of designated smoking times. On 8/09/17 at 10:49 AM, the administrator said residents cannot smoke on the facility property unless they are supervised. The administrator said if residents are alert and oriented and wanted to smoke outside of the designated smoking times, they can sign out LOA and go off-property, but they will not be supervised. There was no written directive on LOA for smoking. The administrator said signing LOA to smoke outside of the designated smoking times off-property has been a practice of the facility since before she assumed her role at the facility, and she has not done anything to change it. The administrator said the facility was not a prison, and the facility did not consider this to be a problem. Review of the facility's schedule for smoking, showed designated smoking times were 8:30 AM, 10:30 AM, 1 PM, 3:30 PM, and 6:30 PM. There was no evidence of any communication or effort by the facility to accommodate any other times outside of the scheduled times. Residents were not assessed for safety during LOA for smoking. The facility's policy Facility Smoking/Non- Smoking Policy indicated that All residents who smoke will be supervised by designated facility staff Residents will not be allowed to have access for self-use of lighters, matches or other devices used to ignite smoking materials. The facility will be responsible for lighting resident smoking material. The supervising staff member will: a) Hand out and light the residents' cigarettes and supervise and maintain the safety of the residents during smoking The policy did not not address smoking off-property. The facility did not have a process in place to determine how long residents are off the property smoking or when they return unless they sign out and sign back in. They did not have a time limit as to the length of time the residents could be off the property to smoke, and the facility did not have a process in place for supervision or monitoring of the residents while they were on LOA off-property smoking, to ensure their safety. The facility's smoking policy was not followed. Residents were given lighters along with their cigarettes when they sign out LOA. On 8/09/17 at 11:27 AM, the director of nursing (DON) said the directive for residents to sign LOA to smoke off- property outside of the facility's designated smoking times would have be given by the administrator, and that information would be relayed to the staff by the administrator. On 8/09/17 at 12:26 PM via telephone, the Medical Director said discussion regarding smokers was done in the Quality Assurance (QA) meeting, but LOA off-property for smoking was not addressed. He said the physicians should know where their residents are, and what the residents are doing. On 8/09/17 at 4:34 PM, the physician for resident #95, and #142 said she was not informed that the residents were smoking off-property. She said it would be prudent and in the best interest of the residents for the physician to be included in the smoking assessment process. The administrator's job description read, Essential Duties & Responsibilities; Oversee regular rounds to monitor delivery of nursing care ensure resident needs are being addressed maintain a working knowledge of and confirm compliance with all governmental regulations consult with department managers concerning the operation of their departments to assist with eliminating/correcting problems areas, and/or improvement of services Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents Identify and participate in process improvement initiatives that improve the customer experience Oversee regular rounds to monitor delivery of nursing care and ensure resident needs are being addressed. The DON's job description read, Essential Duties & Responsibilities; Direct the nursing services department .schedule daily rounds to observe residents and determine if nursing needs are being met in accordance with the resident's request .monitor nursing service personnel to verify they are following established safety regulations in the use of equipment and supplies .assure residents a comfortable, clean, orderly and safe environment. The facility conducted an Emergency Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting on 8/11/17 with the medical director and 5 additional members. The team discussed the current concerns of signing LOA to smoke off-property. The facility's Resident Signing Out policy was reviewed and revised, and residents identified as smokers were provided with a copy of the LOA guidelines and procedure. On 8/08/17, the DON and ADON were re-educated on how to complete the safe smoking assessment by the regional nurse consultant. Eight residents were identified as smokers. Their care plans and CNA care cards were reviewed and revised for accuracy. There will be 3 full time employees (FTE) to fill the smoking aide position. The smoking area will be covered 16 hours per day. Until FTE staff are hired, existing facility staff will be trained, scheduled and responsible for assuming the position of a smoking aide. The administrator, DON, social services director (SSD), ADON, and talent manager were educated on the education plan by the regional nurse consultant. Education of all licensed staff and CNAs was initiated by the Administrator and designees on 8/10/17. The education included: Smoking policy and procedures, including where to find resident levels of assistance in writing Residents will no longer feel obligated to sign LOA to go to smoke Facility placed a 16 hour 7 day a week smoking aide General resident safety while outdoors (heat, cold, what to do in case of an emergency) Resident rights related to resident preferences Revisions to facility signing Resident out policy and facility practice How to complete the safe smoking evaluation, and all new hires to be educated in orientation. The administrator conducted a meeting with all the residents identified as smokers, a total of 8, on 8/11/17 regarding the Immediate Jeopardy, and potential harm to residents while smoking unsupervised, off-property. Residents were provided with the facility's smoking policy, and procedures and advised that the facility now had a smoking aide on site 16 hours a day 7 days a week, so residents no longer had to sign LOA to go to smoke off-property. As of the exit on 8/13/17, 78 out of 109 staff were in-serviced with ongoing in-service until all staff are educated prior to the start of their shift. On 8/13/17, observations of the designated smoking area showed area was covered with a canopy, ashtrays, fire blankets, fire extinguisher, and a cart with cold water in a cooler was observed. The designated smoking aide was aware of her role, and adequately verbalized the new process and procedures that were implemented. Interviews conducted with staff on 2 of 2 Wings of the facility from 11 AM to 2:05 PM indicated staff were aware of the new smoking times and procedures, and could verbalized what to do in case of an emergency, and interventions initiated to accommodate residents who wanted to smoke outside of the previous designated smoking times. In interviews conducted with resident #95 and #88 on 8/13/17 at 3:30 PM, they said they felt safer smoking on property, they were happy with the extended smoking time, that a smoking aide was hired, and staff would be available to supervise them while smoking. Record reviews of the Facility smoking/Non Smoking Policy, Safe Smoking Evaluation, smoking log, smoking aide schedule, smoking monitor forms verified the sufficient implementation of the allegation to remove immediacy. The immediacy was removed on 8/12/17 and the severity was lowered to D, no actual harm with potential for more than minimal harm due to the need to fully implement and monitor effectiveness of the facility action plans to prevent reoccurrence.

Based on observation, interview and record review, the facility failed to individualize care plans related to smoking for 4 of 4 residents of a sample of 8 residents reviewed for smoking (#142, 126, 88 & 95). The failure to individualize care plans for residents #142, #126, #88 and #98 related to smoking resulted in Immediate Jeopardy. The immediacy was removed on 8/12/17 and the severity was lowered to D, no actual harm with potential for more than minimal harm. Findings: Cross reference F 223, F242, F323, F353, F490 and F520. 1. Resident #142 was originally admitted to the facility on [DATE] and was last readmitted on [DATE] with a [DIAGNOSES REDACTED]. He uses a motorized wheelchair to get around and his left arm is weaker, so he can use only his right hand to smoke. On 8/08/17 at approximately 9:50 AM, resident #142 sat alone outside in the sun wearing shorts and blue non-skid socks smoking in the gym parking lot. He was facing the facility in a motorized wheelchair with 2 lit cigarettes in his hand. He was not wearing protective gear for smoking, like a smoking apron. There was no staff supervising his smoking. Resident #142 verified that he lived at the facility and had signed out leave of absence (LOA) to smoke off-property. On 8/08/17 at 11:17 AM, resident #142 said he followed the rules for smoking- the nurse gave him 2 cigarettes and a lighter and he signed out LOA to go off the property to smoke. On 8/08/17 at 4:10 PM, he relayed that he was verbally instructed by the administrator that if he wanted to smoke he could smoke at 8:30 AM, 10:30 AM, 1 PM, 3:30 PM and 6:30 PM. He said the administrator told him that if he wanted to smoke outside of designated smoking times, he had to sign out LOA to go off the facility property. On 8/09/17 at 9:35 AM, he said he has always gone off-property to smoke. Resident #142's interim care plan, dated 8/03/17, indicated he desires to smoke and is designated as an impaired smoker. The goal was that the resident will smoke safely in designated areas at scheduled times. Approaches included: Resident will be supervised while smoking at all times, resident will demonstrate ability to physically hold the smoking device while smoking, resident & responsible party will be oriented to the smoking policy and smoking areas, provide resident with protective gear while smoking. There were no handwritten individualized approaches added to interim care plan and this care plan did not accurately reflect what resident #142 was currently doing while smoking. On 8/13/17 at 3:35 PM, the Minimum Data Set (MDS) Coordinator validated that the care plan for resident #142 was not individualized. 2. Resident #126 was originally admitted on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Guillain-Barre .syndrome is a rare disorder in which your body's immune system attacks your nerves. Weakness and tingling in your extremities are usually the first symptoms (mayoclinic.org). [MEDICAL CONDITION] .is damage or disease affecting peripheral nerves ([MEDICAL CONDITION]) in roughly the same areas on both sides of the body (wikipedia.org). On 8/11/17 at 8:34 AM, resident #126 said he goes outside to smoke every day. He started going off the property, signing out Leave of Absence (LOA) to smoke unsupervised with his Dad, and he has been smoking for the last 6 months. His Quarterly Nursing Evaluation, dated 2/11/17, was not completed for the Safe Smoking Evaluation on 7 out of 21 with no answers for the following questions: alert and oriented and can consistently perform safe smoking techniques, has fine motor skills needed to hold cigarette, resident smokes safely, utilizes ashtray safely and properly, extinguish cigarette safely and completely when finished smoking, candidate for e-cigarettes, and determination to be a safe smoker or not. His care plan, initiated on 11/16/16, reflected that he wishes to use tobacco products. The goal that was updated on 2/14/17 and read that resident #126 will smoke safely in designated area(s) at scheduled times through next review date. Care plan approaches included: resident will be supervised while smoking at all times, review and discuss smoking/smokeless tobacco cessation alternatives with resident or responsible party, Smoking Assessment/Tobacco use assessment to be completed on admission and quarterly and staff will assist resident with handling and storage of smokeless tobacco and/or smoking equipment. This care plan was not individualized and did not accurately reflect the way resident #126 was currently smoking. On 8/13/17 at 3:40 PM, the MDS Coordinator validated that the care plan for resident #126 was not individualized. 3. Resident #95's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was a long-term care resident. [DIAGNOSES REDACTED]. Resident #95's quarterly MDS assessment, dated 5/11/17, revealed that she was a tobacco user. Her preferences regarding daily routines and activities indicated that it was very important for her to do her favorite activities and go outside to get fresh air. Her brief interview for mental status (BIMS) score was 14 out of 15 and had declined since her annual MDS score of 15 out of 15 dated 11/14/16. 13-15 points: the person is intact cognitively. (verywell.com). On 8/08/17 at 12:10 PM, resident #95 sat in her wheelchair in front of the East wing nurses' station. She was overheard requesting cigarettes and a lighter from the facility's education/talent manager nurse. The nurse opened a large yellow tackle box sitting at the nurses' station. It contained packs of cigarettes and lighters. The nurse handed cigarettes and a lighter to resident #95. The nurse then handed the resident her medical record. The resident signed a leave of absence (LOA) log in her medical record and self-propelled off the unit On 8/08/17 at about 5:45 PM, resident #95 stated that she was told by administration that she had to sign out LOA and go off-property if she wanted to smoke outside of the designated supervised smoking times. She stated that staff did not usually have time to take her out to smoke in between designated smoking times. She stated that she been a long time smoker. She said that there was no staff supervision when she smoked off-property. She stated that most of the time she smoked alone when she went off-property. The resident stated that the nurses would give her the cigarettes and a lighter, have her sign out LOA, and she would then self-propel off-property to smoke. She indicated that this had been going on for a couple years, since she had been at the facility. The resident said that she had to be careful out in the off-property areas. She stated that her lower legs were swollen, making it too difficult for her to walk with her walker, so she was presently using her wheelchair to get around. Resident #95 stated that when she smoked off-property, she sat on the other side of the facility's hedge in a fitness gym's parking lot and/or would self-propel down the facility's driveway to the public sidewalk under the big tree beyond the facility's front entrance. Resident #95 also said that since the new administrator had come to the facility, on 7/31/17, she was no longer allowed to stay on property in the designated smoking area with her family to smoke in between facility designated smoking times. She said that the administrator told the smokers that it was against facility policy to smoke on property without staff present. The resident stated that if her family came and she wanted to smoke in between the facility's designated smoking times, she was required to sign out LOA and go off-property. Resident #95's Release of Responsibility for Leave of Absence, LOA log revealed she had signed out LOA from 7/01/17-8/08/17 on 15 occasions. Her LOA sign out times ranged from 25 minutes to one hour. On 7 of those 15 times, she signed out on the 3-11 PM shift. On 8/03/17, she stayed out 20 minutes in the late evening, from 9:40-10 PM. On 8/04/17, she stayed out for 30 minutes in the middle of the night, from 1:50-2:20 AM. The LOA log included a statement that would absolve the facility for their lack of supervision while on LOA: I, the undersigned, hereby accept complete responsibility for (name of resident) while away from (name of nursing home) and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition or accident that may happen while the resident is away Review of resident #95's smoking care plan dated 12/01/15 through 8/17/17 revealed that the resident needed supervision with smoking. It included, Resident wishes to use tobacco products will smoke safely in designated area(S) will be supervised with smoking at all times Staff will assist resident with handling and storage of smokeless tobacco and/or smoking equipment. There was no documentation in the written care plan to indicate the resident went off facility property unsupervised to smoke. There was no documentation in the written care plan to reflect that the facility had made her physician aware that the resident smoked between the designated supervised smoking times, that the resident was required to smoke off property in between designated supervised smoking times, and/or that the physician had advised against it/for it. The care plan was not individualized to the resident for safe smoking preferences or medical needs. The care plan indicated that the resident needed to be supervised with smoking at all times, but the resident was not being supervised with smoking at all times as evidenced by the facility practice of requiring the resident to go off-property, unsupervised, to smoke in between designated smoking times. On 8/11/17 at 4:34 PM, resident #95's physician stated that she had only been at the facility about two months and stated that the facility had not informed her that some of her patients were being required to sign out LOA to smoke off the property, without staff supervision. She stated that she thought it would be prudent for physicians to be informed of this practice, so that they could participate in the interdisciplinary planning and have input. The director of nursing (DON) and MDS coordinator validated on 8/12/17 at about 1:30 PM that the smoking care plans for residents #95 and #88 were not individualized to reflect the the facility's practice of the residents going off-property to smoke without supervision, LOA verbal policy requirements for smoking, and/or that the physician was aware of the practice. 4. Resident #88's medical record revealed that she was initially admission date of [DATE] and readmitted on [DATE]. She was a long-term care resident. [DIAGNOSES REDACTED]. Meniere's disease is a disorder of the inner ear that causes episodes in which you feel as if you're spinning ([MEDICAL CONDITION]) (mayoclinic.org). Resident #88's quarterly MDS, dated [DATE], revealed that she was a tobacco user. Her BIMS score was 14 out of 15 and had declined since her significant change MDS score of 15 out of 15 dated 9/19/16 in which she had also fallen and broken her left hip. Her preferences regarding daily routines and activities indicated that it was very important for her to go outside to get fresh air. She used a walker and a wheelchair for mobility devices. Her balance during transitions and walking was not steady, but she was able to stabilize herself without staff assistance. On 8/08/17 at 11:45 PM, resident #88 stood with her rolling walker at the East wing nurses' station. She requested cigarettes and a lighter from the talent manager nurse. The nurse obtained a yellow tackle box containing packs of cigarettes and lighters. She handed the resident 2 cigarettes and a lighter. The nurse then brought the resident's medical record to her. The resident signed a LOA log in her medical record and left the unit. On 8/09/17 at 5:15 PM, resident #88 stated she went off-property to smoke in between designated smoking times . She stated the nurses make her sign out LOA and then give her a light and cigarettes to smoke off-property without staff supervision. She stated that she could go out any time, day or night, but usually did not got out any later than 9 PM because it is dark out there and there are people walking around out there at that time of night. She stated that it had been this way since she came to the facility. The resident stated, Like right now, I would love a smoke in the designated smoking area with staff supervision, but staff don't want to take me out because they have work to do. She stated that when she smokes off-property, she goes either to the parking lot behind the hedge across the facility's property line or down by the road on the sidewalk under the big tree. At this time, resident #88 walked on the unit with her rolling walker. She had a slight turn of the right foot and slight limp in her right leg. When asked about it, she stated she broke her left hip in September 2016. She stated her leg and hip get tired. Resident #88's Release of Responsibility for Leave of Absence forms, dated May 2017-August 2017, revealed that she had signed out 25 times. Nineteen of those times, the nurse did not have the resident sign back in. For the days where there were times and the resident had signed in and out, the resident had been on LOA from 10-30 minutes. On at least 7 of those times, she had signed out on the 3-11 PM shift. The latest time signed out 7:30-8:20 PM. This LOA form included a statement that when signed by the resident would absolve the facility for their lack of supervision as follows: I, the undersigned, hereby accept complete responsibility for (name of resident) while away from (name of nursing home) and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition or accident that may happen while the resident is away Resident #88's care plans for smoking, dated 4/06/16-9/12/17, also revealed that the resident required staff supervision with the handling of the smoking equipment: Resident will safely use tobacco product Staff will assist resident with handling and storage of smokeless tobacco and/or smoking equipment. There was no documentation in the written care plan to indicate that the resident went off of facility property to smoke unsupervised. There was no documentation in the care plan to reflect that the facility had made her physician aware that the resident smoked between the designated supervised smoking times. There was no evidence to indicate that the physician had advised against it or for the resident going off-property to smoke unsupervised. The care plan was not individualized to the resident for safe smoking practices, preferences, and medical needs while being required to smoke off-property. On 8/10/17 at about 11:05 AM, resident #88's physician stated that she knew the resident smoked but was not aware that the resident was going off-premises to smoke without supervision. She said that she would like to be part of that determination of that decision for resident safety considerations, but that the facility had not informed her of it. On 8/12/17 at about 1:30 PM, the DON and MDS coordinator validated that the smoking care plans for residents #95 and #88 were not individualized to reflect the the facility's practice of the residents going off-property to smoke without supervision, LOA verbal policy requirements for smoking, and/or that the physician was aware of the practice. On 8/09/17 at about 10:49 AM, the administrator validated that it was the practice of the facility for a smoking resident to sign out LOA and go off-property to smoke at times other than the facility's designated smoking hours. On 8/09/17 at 11:27 AM and 4:18 PM, the DON stated if residents want to go out after 10 PM, they have been allowed to sign out anytime. She stated that per the facility's smoking policy, residents could not smoke on facility property unsupervised by staff, but they could smoke unsupervised off-property. She indicated that staff could not always be available at any time day or night to do supervised smoking. She validated that nurses give cigarettes and a lighter to the smokers who go off-property to smoke. She stated that residents have been encouraged to not go out late at night to smoke, but are allowed to do so. She stated that this had been the practice for at least two years, since she came back to the facility as DON. The facility conducted an Emergency Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting on 8/11/17 with the medical director and 5 additional members. The team discussed the current concerns of signing LOA to smoke off-property. The facility's Resident Signing Out policy was reviewed and revised, and residents identified as smokers were provided with a copy of the LOA guidelines and procedure. On 8/08/17, the DON and ADON were re-educated on how to complete the safe smoking assessment by the regional nurse consultant. Eight residents were identified as smokers. Their care plans and CNA care cards were reviewed and revised for accuracy. There will be 3 full time employees (FTE) to fill the smoking aide position. The smoking area will be covered 16 hours per day. Until FTE staff are hired, existing facility staff will be trained, scheduled and responsible for assuming the position of a smoking aide. The administrator, DON, social services director (SSD), ADON, and talent manager were educated on the education plan by the regional nurse consultant. Education of all licensed staff and CNAs was initiated by the Administrator and designees on 8/10/17. The education included: Smoking policy and procedures, including where to find resident levels of assistance in writing Residents will no longer feel obligated to sign LOA to go to smoke Facility placed a 16 hour 7 day a week smoking aide General resident safety while outdoors (heat, cold, what to do in case of an emergency) Resident rights related to resident preferences Revisions to facility signing Resident out policy and facility practice How to complete the safe smoking evaluation, and all new hires to be educated in orientation. The administrator conducted a meeting with all the residents identified as smokers, a total of 8, on 8/11/17 regarding the Immediate Jeopardy, and potential harm to residents while smoking unsupervised, off-property. Residents were provided with the facility's smoking policy, and procedures and advised that the facility now had a smoking aide on site 16 hours a day 7 days a week, so residents no longer had to sign LOA to go to smoke off-property. As of the exit on 8/13/17, 78 out of 109 staff were in-serviced with ongoing in-service until all staff are educated prior to the start of their shift. On 8/13/17, observations of the designated smoking area showed area was covered with a canopy, ashtrays, fire blankets, fire extinguisher, and a cart with cold water in a cooler was observed. The designated smoking aide was aware of her role, and adequately verbalized the new process and procedures that were implemented. Interviews conducted with staff on 2 of 2 Wings of the facility from 11 AM to 2:05 PM indicated staff were aware of the new smoking times and procedures, and could verbalized what to do in case of an emergency, and interventions initiated to accommodate residents who wanted to smoke outside of the previous designated smoking times. In interviews conducted with resident #95 and #88 on 8/13/17 at 3:30 PM, they said they felt safer smoking on property, they were happy with the extended smoking time, that a smoking aide was hired, and staff would be available to supervise them while smoking. Record reviews of the Facility smoking/Non Smoking Policy, Safe Smoking Evaluation, smoking log, smoking aide schedule, smoking monitor forms verified the sufficient implementation of the allegation to remove immediacy. The immediacy was removed on 8/12/17 and the severity was lowered to D, no actual harm with potential for more than minimal harm due to the need to fully implement and monitor effectiveness of the facility action plans to prevent reoccurrence.

Based on observation, interview and record review, the facility failed to honor choices related to smoking for 5 of 5 residents who smoked, out of 8 residents who smoke. The facility did not accommodate the residents' preference, and the facility did not have any other alternative for supervised smoking times for residents (#142, 126, 88, 95 & 112). This resulted in Substandard Quality of Care. The Immediacy was removed on 8/12/17, and the severity was lowered to D, no actual harm with potential for more than minimal harm. Findings: Cross reference F223, F279, F323, F353, F490, and F520. Review of the Resident Council Meeting minutes on 6/26/17 revealed that resident rights were reviewed including the right to choose their own activities and make their own schedules. Review of facility information revealed that they had 8 total residents who smoked in a census of 91 on 8/07/17. Review of facility's designated supervised smoking times for residents were from 8:30-9 AM, 10:30-11 AM, 11:30 PM, 3:30-4 PM, and 6:30-7 PM. There was no evidence of resident input regarding the smoking times. The designated smoking area was located in an outside courtyard off the East wing's activity room, on facility property. The staff responsible to supervise the residents in this area at these times were: certified nursing assistants (CNAs) West wing, CNAs East wing, staff of plant operations, the receptionist, dietary staff, and activities staff. 1. On 8/08/17 at approximately 9:50 AM, resident #142 sat alone in a motorized wheelchair with two lit cigarettes, one in each hand, smoking in a fitness gym's parking lot next to the facility. He was not wearing any protective smoking gear. He sat in direct sunlight wearing shorts, a t-shirt, and non-skid socks. At that time, resident #142 stated that he lived at the facility and had signed out leave of absence (LOA) to smoke off-property. On 8/08/17 at 11:17 AM, resident #142 said, I did what the rules said: I signed out LOA, went off-property, and smoked. The nurse gave him 2 cigarettes and a lighter, and he gave the lighter back. He was observed to use a motorized wheelchair to get around and said his left arm is weaker, so I can use only my right hand to smoke. He demonstrated how he lit the cigarette using only his right hand. He said he has been smoking for about [AGE] years. On 8/08/17 at 4:10 PM, resident #142 said he was told by the administrator that if he wanted to smoke, he could smoke at 8:30 AM, 10 AM, 1 PM, 3:30 PM and 6:30 PM. If he wanted to smoke outside of designated smoke times, he was verbally instructed that he had to sign out LOA and go off the property. On 8/11/17 at 9:47 AM, resident #142 said he likes to go to bed around 10 PM and would like to smoke before he goes to bed. His last opportunity to smoke supervised was at 3:30 PM. On 8/11/17 at 10:36 AM, the Resident Council President said the residents were upset because 6:30 PM was the last supervised smoking time, and staff kept cancelling it. Resident #142's Minimum Data Set (MDS) Admission Assessment on 7/18/17 indicated his preferred daily routines and activities included that it was very important to him to go outside and get fresh air when the weather is nice. He was independent in mobility off unit only with his motorized scooter. His Interim Admission Care Plan, dated 8/03/17, designated resident #142 as an impaired smoker. His comprehensive Care Plan, dated 8/08/17, indicated resident #142 will be supervised while smoking at all times and he will smoke in designated area. Resident #142's Admission Assessment, dated 7/18/17, reflected that it was very important to him to go outside and get fresh air when the weather is nice. On 8/08/17 at 11:42 AM, registered nurse (RN) O said the smoking policy is that nurses keep cigarettes and give them to residents so they can sign out LOA to go off-premises to smoke unsupervised if they wanted to smoke during the times other than the facility's designated smoking times. On 8/08/17 at 12:17 PM, licensed practical nurse (LPN) B said all residents must be assisted by staff, and residents go outside to the designated smoking area in the fenced in area under the gazebo by a staff member at 8:30 AM, 10 AM, 1:30 PM, 3:30 PM and 6:30 PM. Nurses keep 1 smoking box at the 100 hall nurses' station with all the lighters and cigarettes. Residents can have 2 cigarettes at a time but they are not allowed to light their own cigarettes. She said resident #142 usually doesn't ask for more than 2 cigarettes and never goes outside alone to smoke because he is a supervised smoker. This was contrary to the observation of resident #142 on 8/08/17 at approximately 9:50 AM. On 8/09/17 at 4:34 PM, resident #142's physician said she was unaware he was smoking across the street with a cardiac history. On 8/09/17 at 5:06 PM, LPN E said before 8/08/17, residents were allowed to sign out LOA to go off-premises to smoke unsupervised outside of designated smoking time. Residents were allowed to go outside after or before smoking times to smoke unsupervised. On 8/12/17 at 5:04 PM, LPN U said prior to 8/07/17, resident #142 went off-property to smoke. 2. On 8/11/17 at 4:34 PM, resident #126 said he has been going out with his dad the last few days to smoke out by the street and the facility makes him sign out LOA to do that. He said he doesn't want to wear the smoking apron when he goes out with his dad and doesn't use it. He said his dad comes every other day and takes him out to smoke off the property. On 8/11/17 at 4:41 PM, resident #126 said he went to the first smokers meeting with his dad on 8/02/17 that discussed the procedures and the information, which was new to him because he wasn't going to designated smoking breaks before, but rather he was signing out LOA and going with his dad off-property to smoke. Resident #126 said the rules don't matter to him because about 6 months ago, the director of nursing said he couldn't go to the designated supervised smoke breaks because he couldn't hold his own cigarette, and the facility staff were no longer allowed to hold his cigarette for him. Since then, he has been going out to smoke with his dad holding his cigarette. He wants to go out to smoke when everyone else goes, but he needs total assistance to get out of bed, and he can't wheel his own wheelchair independently because he can't move his own arms or hands. On 8/09/17 at 4:35 PM, CNA A said resident #126 only smokes with his family. Since he can't use his hands, the family has to do everything for him. She said resident #126 used to go out to the designated smoking area, and staff would put a cigarette in his mouth. It has been approximately a year since he went out to designated smoking area with staff. Administration does not want staff to assist any residents who want to smoke outside the scheduled times. She said in the past, approximately 1 to 1.5 years ago, the residents did not sign themselves out. The nurse gives out the cigarettes and lighter for those that want to go LOA to smoke. On 8/12/17 at 5:04 PM, LPN U said prior to this week, resident #126 was going LOA off-property to smoke. Resident #126's hospital History and Physical, dated 3/14/17, indicated he had a history of [REDACTED]. His 11/12/16 Admission Minimum Data Set (MDS) assessment included information about his daily preferences and reflected that it was very important for him to go outside to get fresh air when the weather is nice. His care plan, dated 11/16/16 and updated 5/16/17, included a care plan for smoking which read, Resident wishes to use tobacco products and the goal is that resident will smoke safely in designated area(s) at scheduled times through next review. Approach included staff will assist resident with handling and storage of smokeless tobacco and/or smoking equipment, resident will be supervised while smoking at all times, smoking apron as resident permits, and constant supervision. 3. Resident #95's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was a long-term care resident. Her quarterly MDS assessment, dated 5/11/17, revealed she was a tobacco user. Her preferences regarding daily routines and activities included that it was very important for her to go outside to get fresh air. Resident #95's care plan, dated 5/17/17, revealed that the resident would participate with care and activities of choice Approaches included, Attend activities of choice. On 8/08/17 at 12:10 PM, resident #95 sat in her wheelchair at the East wing nurses' station. She was overheard requesting cigarettes and a lighter from the facility's education/talent manager nurse. The nurse opened a large yellow tackle box which was at the nurses' station. The box contained packs of cigarettes and lighters. The nurse handed cigarettes and a lighter to resident #95. The nurse then handed the resident her medical record. The resident signed a leave of absence (LOA) log in her medical record and self-propelled off the unit. On 8/08/17 at about 5:45 PM, resident #95 stated she was a long time smoker. She stated that she smokes with her friends at the designated smoking times, but was recently told by the new administrator, who was hired on 7/31/17, that she had to sign out LOA and go off-property if she wanted to smoke outside of the designated supervised smoking times. She stated that she had previously been allowed to smoke on property in the designated smoking area with her family. She said that the administrator told the residents who smoke that it was against facility policy to smoke on property without staff present. The resident stated that if her family came and she wanted to smoke in between the smoking times designated by the facility, she was required to sign out LOA and go off-property. Resident #95 stated she felt that the facility should allow her to smoke in the facility's designated smoking area with her family. On 8/13/17 at 3:30 PM, while smoking with a resident friend during a supervised smoking time, resident #95 stated she enjoyed smoking with her friends on the property with supervision rather than off the property alone. 4. Resident #88's medical record revealed she was initially admitted to the facility on [DATE], and readmitted on [DATE]. She was a long-term care resident. Her quarterly MDS, dated [DATE], revealed that she was a tobacco user. Her preferences regarding daily routines and activities indicated that it was very important for her to go outside to get fresh air. On 8/08/17 at 11:45 PM, resident #88 stood with her rolling walker at the East wing nurses' station, and requested cigarettes and a lighter from the talent manager nurse. The nurse obtained a yellow tackle box containing packs of cigarettes and lighters. She handed the resident 2 cigarettes and a lighter. The nurse then brought the resident's medical record to her. The resident signed the LOA log in her medical record and left the unit. On 8/09/17 at 5:15 PM, resident #88 stated she went off-property to smoke in between designated smoking times. She stated that the nurses make her sign out LOA and then give her a light and cigarettes to smoke off-property without staff supervision. She stated that she could go out any time, day or night, but usually did not got out any later than 9 PM because it is dark out there and there are people walking around out there at that time of night. She stated that it had been this way since she came to the facility. She stated that she usually goes out alone, but prefers to be with her friends. The resident stated, Like right now, I would love a smoke in the designated smoking area with staff supervision, but staff don't want to take me out because they have work to do. She stated that when she smokes off- property, she goes either to the parking lot behind the hedge across the facility's property line or down by the road on the sidewalk under the big tree. Resident #88 expressed that since the 8/02/17, residents who smoke met with the administrator. She felt that the smoking residents were a problem to the facility and they did not want to provide any more assistance with their smoking needs other than the designated times. On 8/10/17 at about 1 PM, resident #88 smoked at the facility's supervised designated time and place with other residents. She talked, smiled, and laughed with the other smokers. Resident #88's care plan for recreational interests/patterns, dated 6/20/17-9/20/17, revealed that she has interests and activities which includes smoking. One of the goals was for the resident to express satisfaction with the type of activities and level of activity involvement. On 8/13/17 at 3:30 PM, resident #88 stated she preferred smoking in the designated smoking area with friends and with staff supervision instead of being alone smoking off-property unsupervised. On 8/09/17 at 4:35 PM, with CNA A said she has worked both 7-3 and 3-11 shifts. She stated that she heard that residents #95 and #88 go outside at night to smoke. She stated that the administration does not want us to assist residents who want to smoke outside the scheduled times. On 8/09/17 at 10:49 AM, the administrator stated that residents cannot smoke on property per their policy unless supervised by staff. She indicated that it was the practice of the facility for a smoking resident to sign out LOA and go off-property to smoke at times other than the facility's designated smoking hours. The administrator stated that there was a meeting with the residents who smoke on 8/02/17 to review the facility's smoking policy. She validated that the facility's written smoking policy did not include the facility practice of requiring smokers to sign out LOA and smoke off-property. She stated that it was a verbal policy/practice. On 8/09/17 at 11:27 AM and 4:18 PM, the director of nursing (DON) stated residents are allowed to sign out LOA at any time to smoke off-property, even if they want to go out after 10 PM. She stated that residents do ask and are allowed to go outside LOA to smoke at night unsupervised if they have been assessed to be safe smokers. She stated that there did not have to be an LOA physician's orders [REDACTED]. She stated that per the facility's smoking policy, residents could not smoke on facility property unsupervised by staff, but they could smoke unsupervised off-property. She indicated that staff could not always be available at any time day or night to do supervised smoking. She validated that nurses give cigarettes and a lighter to the smokers who go off-property to smoke. She stated that residents have been encouraged to not go out late at night to smoke, but are allowed to do so. When asked if there was enough staff to provide extra smoking supervision, she did not have an answer. She stated that this had been the practice for at least two years, since she came back to the facility as the DON. She stated that when residents smoked on the facility's property, they had to be supervised by staff per the facility's smoking policy. On 8/09/17 at 12:26 PM, the Medical Director said he knows residents cannot smoke in the building but was not aware of any policy to allow smokers to go off the property to smoke unsupervised. He said nurses use their critical judgement to determine if a resident should be allowed to go off the property to smoke. The medical director stated that in his professional opinion, it is the attending physician who should know where his/her residents are. He said there needs to be physician awareness in order to be thorough with patient care and safety. He said the doctors know that certain residents are smokers, but may not know that they are going off the property to smoke, We don't have any measures formally in place to let the physicians know about residents going LOA to smoke. 5. Resident #112 was admitted to the facility from an acute care hospital on [DATE] with [DIAGNOSES REDACTED]. The resident's history and physical, dated 10/04/15, showed resident #112 was a smoker. The plan and suggestions read, Smoking cessation counseling provided for this patient. He does not want pharmacological intervention at this time. The annual MDS 10/05/16 showed resident #112 was currently using tobacco. The quarterly MDS of 7/01/17 showed the resident required extensive assistance for bed mobility, dressing, toilet use and personal hygiene, limited assistance for transfer, and was independent for locomotion on/off the unit. Review of the Safe Smoking Evaluation completed on 7/26/17 showed he was determined to be a safe smoker, and did not require supervision. Resident #112's care plan goal for wishes to use Tobacco products, dated 10/08/15, was that Resident will smoke safely in designated area(s) at scheduled times through next review date, will safely use tobacco product. The care plan was last reviewed on 7/04/17. Approaches included resident and responsible party will be oriented to the smoking policy and smoking areas. On 8/09/17 at 2 PM, the DON said resident #112 came to her, and was upset. He said he was told at the meeting held with smokers on 8/02/17 that if his sister came to the facility and it was not a designated smoking time, she could not take him out to the designated smoking area to smoke. On 8/09/17 at 5:25 PM, resident #112 said he was at the meeting for smokers on 8/02/17. The administrator said residents could smoke at the regular smoking times if a CNA was present, otherwise they could not smoke. Resident #112 said he was upset, because his sister comes to visit him on Sundays, and they go out to the smoking area, talk and smoke. He was told by the administrator that he could not do that anymore. The resident said he obeys the rule all week, and just that one day when his sister comes, they said he was not allowed to smoke with her. On 8/11/17 at 2:19 PM, the assistant director of nursing (ADON) said the facility's, policy states that residents have to be supervised at all times while smoking. The ADON said a CNA/staff have to be present for the resident's safety. The ADON said resident #112 was told he could not smoke in the designated smoking area, unless a staff member was present, even if his sister was there. The facility's policy Facility Smoking/Non- Smoking Policy, signed by resident #112 and dated 8/02/17 read, On admission to the facility in which smoking is permitted, the admission coordinator, the charge nurse, social services, administrator, director of nursing, assistant director of nursing, MDS coordinator, or nursing supervisor will: Ascertain the resident's wishes about smoking, and respect the resident's decision. The facility conducted an Emergency Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting on 8/11/17 with the medical director and 5 additional members. The team discussed the current concerns of signing LOA to smoke off-property. The facility's Resident Signing Out policy was reviewed and revised, and residents identified as smokers were provided with a copy of the LOA guidelines and procedure. On 8/08/17, the DON and ADON were re-educated on how to complete the safe smoking assessment by the regional nurse consultant. Eight residents were identified as smokers. Their care plans and CNA care cards were reviewed and revised for accuracy. There will be 3 full time employees (FTE) to fill the smoking aide position. The smoking area will be covered 16 hours per day. Until FTE staff are hired, existing facility staff will be trained, scheduled and responsible for assuming the position of a smoking aide. The administrator, DON, social services director (SSD), ADON, and talent manager were educated on the education plan by the regional nurse consultant. Education of all licensed staff and CNAs was initiated by the Administrator and designees on 8/10/17. The education included: Smoking policy and procedures, including where to find resident levels of assistance in writing Residents will no longer feel obligated to sign LOA to go to smoke Facility placed a 16 hour 7 day a week smoking aide General resident safety while outdoors (heat, cold, what to do in case of an emergency) Resident rights related to resident preferences Revisions to facility signing Resident out policy and facility practice How to complete the safe smoking evaluation, and all new hires to be educated in orientation. The administrator conducted a meeting with all the residents identified as smokers, a total of 8, on 8/11/17 regarding the Immediate Jeopardy, and potential harm to residents while smoking unsupervised, off-property. Residents were provided with the facility's smoking policy, and procedures and advised that the facility now had a smoking aide on site 16 hours a day 7 days a week, so residents no longer had to sign LOA to go to smoke off-property. As of the exit on 8/13/17, 78 out of 109 staff were in-serviced with ongoing in-service until all staff are educated prior to the start of their shift. On 8/13/17, observations of the designated smoking area showed area was covered with a canopy, ashtrays, fire blankets, fire extinguisher, and a cart with cold water in a cooler was observed. The designated smoking aide was aware of her role, and adequately verbalized the new process and procedures that were implemented. Interviews conducted with staff on 2 of 2 Wings of the facility from 11 AM to 2:05 PM indicated staff were aware of the new smoking times and procedures, and could verbalized what to do in case of an emergency, and interventions initiated to accommodate residents who wanted to smoke outside of the previous designated smoking times. In interviews conducted with resident #95 and #88 on 8/13/17 at 3:30 PM, they said they felt safer smoking on property, they were happy with the extended smoking time, that a smoking aide was hired, and staff would be available to supervise them while smoking. Record reviews of the Facility smoking/Non Smoking Policy, Safe Smoking Evaluation, smoking log, smoking aide schedule, smoking monitor forms verified the sufficient implementation of the allegation to remove immediacy. The immediacy was removed on 8/12/17 and the severity was lowered to D, no actual harm with potential for more than minimal harm due to the need to fully implement and monitor effectiveness of the facility action plans to prevent reoccurrence.

Based on observation, interview and record review, the facility failed to ensure pain medication was given for 2 of 2 sampled residents reviewed for pain (#82 & 119). The failure to accurately assess and provide pain medication caused actual harm after resident #82 grimaced and moaned during an observation of wound care. Findings: 1. An observation was conducted with resident #82 on 6/23/15 at 2:30 p.m. during a wound care procedure performed by nurse B in his room. The resident had 2 wounds, one on the right heel and one on the side of the right big toe. The wounds had cream colored slough. The surrounding area was pinkish/reddish and slightly swollen. Slough is a layer or mass of dead tissue separated from surrounding living tissue, as in a wound. (www.medical-dictionary.com). During the procedure on 6/23/15 at 2:30 p.m., when the nurse moved the foot and touched the wound, the resident grimaced, moaned and groaned. The nurse was asked to stop and was then asked if the resident was medicated for pain prior to wound care. She stated, He always does that every time we change his dressing or if he gets moved. The nurse did not stop the treatment to assess the severity of the pain. She continued to provide the wound care. Another observation was conducted with resident #82 on 6/25/15 at 1:10 p.m. when certified nursing assistant (CNA) C transferred him back to bed. The resident moaned and groaned when he was moved and turned. When the resident was asked if he had pain, all he said was No, no, no. During this observation , the resident grimaced and pulled up his left leg. The CNA indicated that the resident always moans and groans when he is turned, transferred and moved. An interview with the resident was attempted on 6/23/15 at approximately 1:30 p.m. He was in his room in bed, did not respond to verbal communication, and just had a blank stare. On 6/23/15 at 3 p.m., the unit manager verified that the resident had vascular disease with several wounds but did not have any orders for pain medication. On 6/25/15 at 1:20 p.m., nurse B was asked how she would assess the resident for pain. She stated she would observe for grimacing, listen to moaning/crying and see if he pulls up his body. A review of the ultrasound for bilateral lower extremities arterial study conducted on 10/29/14 read that the clinical indication was diminished peripheral pulses. Impression: Probable moderate to significant [MEDICAL CONDITION] narrowing in the right posterior tibial and the right dorsalis pedis arteries (arteries in the foot). A review of the facility policy and procedure for Distinguishing Among Arterial, Diabetic, and Venous Ulcers revealed arterial ulcers have wound characteristics including but not limited to: even wound margins, gangrene or necrosis, deep and/or pale wound bed, severe pain, [MEDICAL CONDITION] (skin infection), and minimal exudate (fluid from wound). Review of the facility policy and procedure on Pain Management, effective date 12/2010 indicated Each resident identified with pain will have ongoing assessment, a monitoring system, and a specific plan of care to address these issues. A pain evaluation shall be completed upon admission for each resident located in the nursing admission information packet. Use a pain scale when a resident describes his/her pain and amount of pain relief: Pain scale of 0-10 can be used with residents who understand this concept. For residents who cannot understand a numerical scale, a visual analog scale using faces indicating degrees of happy and unhappy can be tried. Review of the nurses progress notes, dated 4/27/15 during risk committee meeting, indicated the resident had arterial wounds. His cognitive skills for daily decision making were impaired. Insight, judgment, concentration were poor. Review of the pain assessment conducted on 3/12/15 indicated the resident did not have any pain. Another assessment done on 6/10/15 also indicated zero for pain. The staff did not include observations of non-verbal signs and symptoms of pain when they moved and turned the resident or when he moaned and grimaced. The staff said the resident always moans and grimaces when he is moved but did not acknowledge that he exhibited signs of pain. There was no documentation that the physician was notified to obtain an order for [REDACTED]. The wound care consultant's progress notes were written on 5/01/15. On 6/12/15, the notes listed arterial/vascular wounds on the right great toe, right bunion, right 5th toe medial, right heel, and left great toe medial. The last wound measurements obtained by the wound care physician dated 6/12/15 were: Right heel was 4 centimeters (cm.) by 7.0 cm. by 0.1 cm. deep, macerated periwound. Right great toe was 2 cm. by 1.5 cm. with 100% eschar. Eschar is dead tissue that falls off (sheds) from healthy skin. (www.nlm.nih.gov). A review of the treatment administration record (TAR) for the month of June from 6/01/15 to 6/24/15 for pain management revealed that everyday was documented as 0 for pain, indicating no pain. This was initialed by the nurses. On the day of the wound care observation, 6/23/15 on the 7-3 shift, the nurse documented 0 pain, even with the observation at 2:30 p.m. that the resident grimaced and moaned in pain during wound care. 2. On 6/22/15 at 12:27 p.m. resident #119's direct care nurse stated that the resident had a fracture to the right upper arm in the past thirty days. review of the resident's medical record revealed [REDACTED]. to be given to the resident every 6 hours as needed for pain. A nurse's note dated 6/18/15 at 4:10 p.m. revealed that the therapist had informed the nurse to look at the resident's right upper arm. The arm was noted to be quite [MEDICAL CONDITION], warm to touch and resident cries out with pain upon manipulation. The resident's physician was notified at that time and an order was given for an X-ray for pain and swelling. The hospital report noted that the resident had a [MEDICAL CONDITION] humeral neck and greater tuberosity. Review of the Medication Administration Record [REDACTED]. The resident's medical record was reviewed with the assistant director of nursing (ADON). The ADON acknowledged that staff had noted that the resident was experiencing pain. The ADON also confirmed there was neither evidence that staff gave the resident [MEDICATION NAME] nor that the resident's pain was relieved.