Based on interviews, record review, review of the Job Description of the Administrator, the facility failed to ensure policies and procedures were developed and implemented for residents who vape, to address safe storage, safe charging, and where vaping was permitted. On 03/04/2024 staff found multiple vapes devices in RI #286's room. Upon investigation, it was revealed that the Director of Nursing (DON) had found a vape in RI #286's room on two separate occasions weeks prior to 03/04/2023. Further staff revealed that RI #286 was found with vapes in his/her rooms on multiple other occasion and no actions were taken. Multiple staff indicated RI #286 would sleep with a vape device on his/her chest and would charge the devices at bedside. The staff indicate RI #286 used his/her cell phone charger to charge the vape devices. It was determined the facility's noncompliance with one or more requirements of participation had cause, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.70 Administration. at a scope and severity of J. On 06/01/2024 at 10:08 PM, Administrator, the Director of Nursing, Director of the Care Services, and Corporate Registered Nurse, were provided the IJ templates and notified of the findings at the immediate jeopardy level in the area of Administration at F835-Administration. The IJ began on 03/04/2024 and continued until 06/02/2024 when the facility implemented corrective actions. On 06/03/2024, the immediate jeopardy was removed, F 835 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. These failures had the potential to affect residents had the desire to vape in the facility. This deficient practice was cited as a result of the investigation of a Facility Reported Incident, complaint/report number AL00047176. Findings Include: Cross Refernce F 689, F 867 and F 926. Review of the Administrator's, Job Description with a revised date of 02/10/2023 revealed the following: Administrator . POSITION SUMMARY: Provides leadership, direction and administration of all aspects of skilled nursing facility and other entities to ensure compliance with established objectives and realizations of quality .health care services, . ESSENTIAL DUTIES AND Responsibilities: Assures Resident safety . Establishes performance goals . Initiates organization wide polices and procedures to facilitate the kind and type of organization need to accomplish the nursing home's, objectives and programs . The DON was interviewed on 06/01/2024 at 9:10 AM and asked how and when did she become aware that RI #286's had vapes in his/her room. She stated the first time she saw the vapes in his/her room they were on a shelf and then several weeks later, she observed another vape lying in RI #286's bed with him/her, but did not remember the dates, but was prior to 03/04/2024. She further stated she retrieved the vapes and took them to the activities staff to store them. The DON stated that she removed vapes from RI #286's room two times and verbally warned him/her not to do it again, but did not document it. The DON stated the facility did not have a policy that addressed residents who vaped and vaping would be added to the smoking policy. The DON further stated the facility needed a policy to address vapes, just like cigarettes, because the staff needed to know about vapes too. The DON did not know how vapes should be charged. The DON said it was important to charge vaping devices according to the manufacture's guidelines. The DON said for safety and not charging a vaping device with a charger that did not come with the vaping device would be an electrical safety concern. The DON confirmed the facility did not have policy on vaping and how vapes should be charged and that she responsible for the overall safety of the residents. An interview was conducted on 06/01/2024 at 11:27AM with the Former Administrator (FADM). She was asked how did facility's smoking policy address residents who vaped. The FADM stated the facility's smoking policy did not address vapes, but they should be treated like cigarettes for safety. The FADM said without a policy, the staff would not know how to respond to residents with vapes in their rooms. She stated resident's vape devices should be stored like cigarettes and probably charged by the activities staff. The FADM was asked when was the staff trained on vaping. She said the facility had never trained the staff about vaping or how vapes should be charged. The FADM was asked why was it important to charge vapes according to the manufacture's guidelines. She stated so the person using the vape would be safe, and the facility did not want to risk a fire with the vape, so the manufactures guidelines needed to be followed. She stated the facility's administrator was responsible for the resident's overall safety. On 06/01/2024 at 06:51 PM an interview was conducted with ADM. The ADM said she was responsible for the day to operation of the facility and the overall safety of the residents. She further said, she was responsible to ensure policy and procedures were implemented. The ADM said since she was not the current administrator at the time, she did not know when the facility's policy and procedures were reviewed after the facility identified concerns with a resident of the facility keeping vape devices in room, allegedly vaping in room, and CNAs voicing they vaped in facility to ensure those issues were addressed in the facility's policy and procedure. She said, the facility should have reviewed the policy and procedure to address those issues and further stated the facility did not currently have any policies and procedure specific to vaping. The ADM was asked what was the concern of not having policies and procedure specific for vaping. She said that policy and procedures made it clear on what to do for residents who vape and provided guidelines about vaping just like the smoking policy. She was asked when should smoking policies be reviewed or revised. The ADM said quarterly, annually, and when there is a significant change and she was responsible for ensuring the facility smoking policy was implement. ****************************************************************************** On 06/03/2024 at 6:27 PM ; the facility submitted an acceptable removal plan, which documented: To correct the lack of effective Administration, the new Nursing Home Administrator was educated on role, job description and available tools and resources to effectively administer nursing facility operation on 6/2/2024 by the Chief Operations Officer. The Director of Operations Officer will provide oversight of facility administration with weekly 1:1 interaction reviewing the Nursing Home Administrator ability to oversee operations and develop and implement policies and procedures, staffing and the administration of medications by staff to ensure residents are receiving the highest level of care possible. Meetings will include a review of any current or ongoing Quality Assurance and Performance Improvement minutes, to validate the Administrator's ability to effectively self-identify new issues and validate available tools are being used to administer the facility in the highest possible manner. The Chief Operations Officer and Administrator will have these encounters to ensure education is understood. The plan of correction will be reviewed weekly to ensure all the audits are completed and issues are identified for four weeks and/or until substantial compliance is achieved. Monthly QAPI meeting will be conducted and attended by the Chief Operations Officer and Clinical QA RN for a periods of three months to ensure compliance is sustained. E-cigs, vapes and other electronic nicotine distribution systems were reviewed with residents, no residents identified as using these devices as of 6/1/2024. Resident use of these devices will not be permitted in the facility. ***************************************************************************** After review of documentation supporting the above corrective actions, including the facility investigation file, in-service/education records, QAPI documentation, staff interviews, the survey team verified the facility implemented corrective actions including ongoing monitoring on 06/03/2024.

Based on interviews, record review and the job description of the Director of Operations (Care Center), the Governing Body failed to provide oversite to ensure policies and procedures were developed and implemented for residents who vape, to address safe storage and safe charging. On 03/04/2024 staff found multiple vapes devices in RI #286's room. Upon investigation, it was revealed that the Director of Nursing (DON) had found a vape in RI #286's room on two separate occasions weeks prior to 03/04/2023. Further staff revealed that RI #286 was found with vapes in his/her rooms on multiple other occasion and no actions were taken. Multiple staff indicated RI #286 would sleep with a vape device on his/her chest and would charge the devices at bedside. The staff indicate RI #286 used his/her cell phone charger to charge the vape devices. It was determined the facility's noncompliance with one or more requirements of participation had cause, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.70 Administration. at a scope and severity of J. On 06/01/2024 at 10:08 PM, the Administrator, the Director of Nursing, Director of the Care Services, and Corporate Registered Nurse were provided the IJ templates and notified of the findings at the immediate jeopardy level in the area of Administrator at F837-Governing Body. The IJ began on 03/04/2024 and continued until 06/02/2024 when the facility implemented corrective action. On 06/03/2024, the immediate jeopardy was removed, F 837 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. These failures had the potential to affect all residents had the desire to vape in the facility. This deficient practice was cited as a result of the investigation of a Facility Reported Incident, complaint/report number AL00047176. Finding Include: Cross Reference F 689, F 867 and F 926. A review of the job description of the Director of Operations (Care Centers), with a reviewed/revised date of 3/2024 revealed: POSITION SUMMARY: Provides leadership, direction, and administration of all aspects skilled nursing facility . to ensure compliance . ESSENTIAL DUTIES AND RESPONSIBILITY: Directs and provides leadership and day to day operational functions . Initiates organization wide policies and procedures . to accomplish the Care Center's aims, objectives and programs . Ensures compliance with all regulatory agencies governing health care delivery and the rules of accredited bodies by continually monitoring the authority's operations and it programs . and initiating changes where required . On 06/01/2024 at 8:01 PM an interview was conducted with the Director of Operations (Care Center) DCS. The DCS confirmed that he was responsible for the overall safety of the residents and to ensure policy and procedures are implemented. The DCS said the Administrator was also responsible making sure the policy and procedures were followed. The DCS was asked who was responsible and accountable for the Quality Assurance and Performance Improvement (QAPI) Program. He said the Administrator was ultimately responsible for the QAPI Program, but as a member of the governing body he gives feedback with guidelines. The DCS was asked what oversight the Governing Body provided to the Administrator. He said the Governing Body reviewed policies and procedures and participated in QAPI. During the interview with the DCS, he said the administrator was expected to communicate with him about any patient outcomes, major injuries, and any abuse or neglect incidents. The DCS was asked what was the Governing Body's role in RI #27's abuse incident and RI #286's incident with vapes being found in his/her room. He stated he was made aware of the abuse incident but was not made aware of the incidents with the vapes until recently. The DCS was asked if the facility had a policy and procedure to ensure residents safety for vaping including storage and charging of device and locations where vaping was prohibited. He said the facility did not have a policy or procedure specific to vaping only but had a policy for smoking and tobacco use. He said the Administrator, QAPI, and Governing Body were responsible to ensure a policy and procedures was developed to ensure resident safety for vaping. The DCS was asked did he attend the QAPI meeting that the FADM stated they discussed the incident regarding resident aping in his/room. He said no he was not in the meeting, and said he was not made aware of some QAPI meetings. When asked if the QAPI Committee identified that the facility did not have a policy and procedure to ensure resident's safety for vaping including storage and charging of the device. He said that to his knowledge that had not be a QAPI meeting specifically about vapes. ***************************************************************************** On 06/03/2024 at 4:55 PM, the facility submitted an acceptable removal plan, which documented: In-Service 1. On 06/01/2024, all patients and residents that use nicotine products to include electronic smoking devices and smokeless tobacco signed acknowledgment of update center policy and 30-day discharge issuance should policy be violated 2. All staff in-serviced on 6/02/2024 regarding the centers smoking policy and procedure to include transitioning to a smoke free campus effective 06/01/2024 for all new admissions, daily smoking schedule, safe smoking interventions to be utilized, and facility action plan should the centers smoking policy be violated. 3. E-cigs, vapes andother electronic nicotine distribution systems were reviewed with residents, no resident identified as using theses devices as of 06/01/2024. Resident use of these devices will not be permitted at the facility. 4. Resident council meeting facilitated by the Activities Director on 6/02/2024 informed all patients and residents of new smoke free campus effective 06/01/2024 for all new admissions. 5. Smoke detectors were installed in all patient and resident rooms that a current smokers resides in on 06/02/2024. *************************************************************************************************** After review of documentation supporting the above corrective actions, including the facility investigation file, in-service/education records, QAPI documentation, staff interviews, the survey team verified the facility implemented corrective actions including ongoing monitoring on 06/03/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, review of a facility policy titled, Abuse, Exploitation and Neglect Prevention, Investigation and Reporting, review of Facility Reported Incidents (FRIs) received by the Alabama State Survey Agency, review of the facility's investigative file, a review of the Incident/Offense Report, and the facility policy titled Medication Administration the facility failed to: 1) protect Resident Identifier (RI) #27 right to be free from sexual abuse perpetrator by a visitor. In late November or early December 2023 RI #27's daughter called the facility and informed them that a male visitor was upsetting RI #27 when he came to visit. RI #27's daughter said she did not want the male visitor visiting RI #27. The staff member advised the daughter she needed to come to the facility to complete paperwork. In early December 2023 the male visitor returned and visited with RI #27 at the nurses' desk. The facility notified RI #27's daughter and advised her to come to speak with the Director of Nursing. The daughter reported she did not have a ride to the facility. On 12/21/2023 a Certified Nursing Assistant (CNA) #20 went into RI #27's room and witnessed a male visitor with his hand down RI #27's shirt. CNA #20 said the male visitor was foundling RI #27's breast. The facility did not have a policy or procedure for screening visitors or providing supervision during visits. The male visitor was later identified as a registered sex offender. It was determined the facility's noncompliance with one or more requirements of participation had cause, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect and Exploitation, at a scope and severity of K. On 06/01/2024 at 10:08 PM, the Administrator, the Director of Nursing/Director of Nursing Services, Corporate Registered Nurse (CRN), and the Director of Care Services (DCS) were provided the IJ templates and notified of the findings at the immediate jeopardy level and substandard quality of care in the area of Freedom From Abuse, Neglect, and Exploitation at F 600-Free from Abuse and Neglect. The IJ began on 12/21/2023 and continued until 06/03/2024 when the survey team verified that onsite corrective actions had been implemented. On 06/04/2024, the immediate jeopardy was removed, F 600, was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00046506. 2) Further the facility failed to protect RI #38's right to be free from physical abuse by RI #26. This deficient practice affected RI #38, but this did not rise to the Immediate Jeopardy Level. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00047570. 3) Further the facility failed to protect RI #286's right to be free from neglect by CNA #19. CNA #19 gave RI #286, a resident with a history of substance abuse, a medication, Klonopin, from her personal prescription. The facility had not provided training to staff on how to deescalate situtations involving residents with substance abuse. This deficient practice affected RI #286, but this did not rise to the Jeopardy Level. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00047176. These deficient practices affected three of four residents reviewed for abuse and neglect prevention. Findings Include: A review of the facility's policy titled, Abuse, Exploitation and Neglect Prevention, Investigation and Reporting, with a revised date of 11/2017, revealed: . PURPOSE: Provide a facility that protects residents from all forms of abuse, neglect and exploitation. POLICY . It is the policy of this facility that all residents be free from all forms of abuse, neglect . Furthermore, it is our policy that all allegations of abuse and neglect will be reported and thoroughly investigated . PROCEDURE . I. Our facility will not permit any resident to be subjected to abuse by anyone, including staff members, other residents, . and staff of other agencies .friends, or other individuals. II. To assist our facility in defining incidents of abuse, the following definitions are provided: A. ABUSE is the willful infliction of injury ., intimidation or punishment with resulting physical harm, pain or mental anguish . It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, . Willful, as used in this definition, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . D. SEXUAL ABUSE is non-consensual sexual contact of any type with a resident . E. PHYSICAL ABUSE includes hitting, slapping, pinching and kicking . H. 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 . In an effort to protect our residents from abuse, certain procedures are implemented, which include the following components: . 2. Training. All employees will be required to receive training . Training will be provided in the following areas: i. Appropriate interventions to deal with aggressive . reactions of residents, including how to deal with residents who have behavioral health challenges or mental health challenges . 3. Prevention . Analysis will include: . f. The Behavior Management Committee will monitor residents with behavior problems on a regular basis and will formulate behavior management plans . RI #27 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease with Late Onset. A review of RI #27's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/2024, indicated RI #27's Brief Interview Mental Status as 99, which indicated the resident was unable to complete the interview. A review of RI #27's Care plan with a Problem Onset Date of 11/07/2023 documented: . COGNITIVE LOSS Resident has impaired cognition due to Alzheimer's DX (diagnosis) . The Alabama Department of Public Health Online Incident Reporting System form, dated 12/21/2023 documented: .Narrative summary of incident: .(Name of CNA #20) reports that she went inside residents room when she saw a man with his hand under the his/her blouse. She immediately informed the nurse with resident daughter notified and police notified immediately, Police came with male visitor (Name of Visitor) and was required to leave. (Name of Sergeant) and resident's daughter came to facility.Investigation began immediately into this report . The report further documented: .Resident was at the nurses station. The visitor pushed the resident down to (his/her) room. The resident went willingly with the visitor. The resident was inside (his/her) room in bed with (CNA #20) witnessed this incident . The facility's incident summary dated 12/21/203 documented: (Name of CNA #20) reports she went into resident room and saw a man with his hand down the resident's shirt . The investigation continues with the resident being interviewed . (He/She) shared the he did not touch (his/her) breast and if he had (he/she) would have slapped the shit out of him . The resident was interviewed also by (Name of Administrator). The resident is confused and did not recall anyone coming to her room . It took her several minutes to get a thought process going to communicate. (He/She) shares that (he/she) cannot remember any man coming into her room . The investigation continues with (Name of Administrator) reaching out to the daughter. The daughter shares that (Name of visitor) . had been inappropriate with . (RI #27) in the past. She also shares that she knew that . he is a registered sex offender . The investigation continues with our nurse (LPN #16) sharing that she instructed the daughter to go to administration and do paperwork if she only had certain visitors she wanted to visit with her (father/mother). (LPN #16) also reported that one day when (male visitor's name) came to the facility she contacted the daughter and told her that he was at the facility as a reminder to come and complete the request for him not to be allowed to visit the resident . The local police department's Incident/Offense Report dated 12/21/2023 documented: .DISPATCHED TO [NAME] HEALTH AND REHAB FOR A REPORT OF AN ELDERLY (MALE/FEMALE) WITH DEMENTIA (LATER IDENTIFIED AS (RI #27)) BEING TOUCHED IN A SEXUAL MANNER . THEN SPOKE WITH THE WITNESS (CNA #20), STATED SHE WALKED INTO (RI #27'S) ROOM TO FIND (the Male Visitor (MV)) WITH HIS HANDS IN (RI #27'S) SHIRT FONDLING (HIS/HER) BREAST. (CNA #20) FURTHERMORE STATED (RI #27) DID NOT APPEAR TO KNOW WHAT WAS GOING ON OR THAT (HE/SHE) WAS AWARE OF ANYTHING IN THAT MOMENT (DUE TO (HIS/HER) DEMENTIA) . WHILE I WAS SPEAKING WITH THE PARTIES INVOLVED A (RI #27'S daughter) ARRIVED ON SCENE (THE VICTIMS DAUGHTER AND PRIMARY CARE GIVER/PERSON WITH POWER OF ATTORNEY OVER THE VICTIM) . (RI #27'S daughter) ADVISED SHE RECEIVED A CALL FROM [NAME] BEFOREHAND ABOUT A SIMILAR EVENT INVOLVING (RI #27) AND (the MV), IN WHICH (RI #27'S daughter) WAS GOING TO FILL OUT SOME PAPERWORK SO (the MV) COULD NOT COME BACK SO SEE HER (MOTHER/FATHER). (RI #27's daughter) STATED SHE FEELS UNSAGE FOR . (RI #27) AND FEARS (the MV) WILL DO THIS TO SOMEONE ELES WHO'S MENTALLY UNABLE TO DEFEND THEMSELVES. LIST OF VIOLATIONS . Sexual Abuse-First Degree . On 05/29/24 at 09:43 AM RI #27 was observed in his/her room and an interview was attempted. RI #27 asked what was his/her name, and RI #27 responded by making noises. RI #27 was unable to engage in a meaningful conversation. During an interview on 05/30/2024 at 4:38 PM, CNA #20 stated that on 12/21/2023, she went into RI #27's room and saw a male visitor with his hand down RI #27's shirt fondling his/her breast. CNA #20 stated she startled the male visitor and he moved away from the resident and she immediately called for (Licensed Practical Nurse) LPN #16 to come to the room. CNA #20 said she thought a reasonable person in RI #27's position, would feel scared. CNA #20 said she thought he/she would not want him to touch his/her breast or anywhere inappropriately because she would not want a man to touch her inappropriately. An interview was conducted on 05/30/2024 at 3:14 PM with the DON. The DON stated RI #27 was not capable of giving consent for sexual contact because he/she had a diagnosis of Dementia. The DON stated it was sexual abuse when the male visitor put his hand down RI #'s 27 shirt. The DON was asked what actions were immediately taken to protect the resident from the MV. The DON said she first became aware that the MV was a sex offender on 12/21/2023. The DON said the facility put a picture of the MV at the nurses station to alert the staff that he was not allowed in the building and to call the police. The DON was asked how would RI #27 would feel about the male visitor touching her under her shirt, if she was not demented. The DON stated, she would have been very angry and felt violated. The DON was asked what was the result of this abuse investigation. She said it was substantiated as sexual abuse. An interview was conducted on 05/30/2024 at 6:52 PM with the resident's sponsor who was his/her daughter. The RI #27's daughter stated she was notified of the incident regarding his/her mother and male visitor on 12/21/2023 by a nurse. She stated she was told CNA #20 observed a male visitor with his hand down her mother's shirt. RI #27's daughter stated RI #27 was not capable of giving consent for sexual contact due to her diagnosis of Dementia. The surveyor asked the resident's daughter how would RI #27 feel about the male visitor putting his hand down RI #27's shirt, if she was not demented. The resident's daughter stated RI #27 would not have wanted him to touch him/her like that, he/she would be upset. RI #27's daughter said RI #27 did not like anyone touching her not even the resident's spouse at times. The sponsor also said the MV had been in prison and was a sex offender. An interview was conducted on 05/31/24 at 9:09 AM per phone with LPN #16. LPN #16 stated she was at the nurses' station when CNA #20 called to her from RI #27's doorway. LPN #16 said CNA #20 told her she observed a male visitor with his hand down RI #27's shirt. LPN #16 stated when she entered the room, RI #27 was sitting on the bed and the male visitor was sitting in a chair showing her pictures on the phone. LPN #16 told the male visitor that she would have to call her supervisor and the police. LPN #16 said, RI #27 was not able to give consent because she had a diagnosis of Dementia, because she did not remember anything. LPN #16 further stated that the male visitor putting his hand down RI #27's shirt was considered sexual abuse and it made her feel uncomfortable. LPN #16 said prior to the incident, she spoke to RI #27's daughter on the phone. LPN #16 said during the call RI #27's daughter said RI #27 was upset after the MV had visited. LPN #16 said she told her to come to the facility to talk with the Social Services staff or the DON about who she did not want to visit RI #27. LPN #16 said she was not aware of RI #27's daughter coming to the facility to discuss visitation prior to the incident on 12/21/2023. An interview was conducted on 05/31/24 at 2:36 PM with the DON. The DON stated the facility had visitors 24 hours a day seven days a week. The DON said there was no sign in and out policy/procedure in place. The DON stated the doors were unlocked during the day until 7:00 PM and no one monitored visitors who went in and out. 2) RI #38 was admitted to the facility on [DATE] and had diagnoses that included Paranoid Schizophrenia and Panic Disorder. RI #38's Quarterly MDS with an ARD of 04/15/2024 revealed RI #38 had a BIMS score of 15 of 15 which indicated the resident was cognitively intact. RI #26 was admitted on [DATE] and had diagnoses that included Anxiety and Presence of Artificial Knee Joint Bilateral. RI #26's Annual MDS with an ARD of 05/23/2024 revealed RI #26 had a BIMS score of 15 of 15 which indicated the resident was cognitively intact. The Alabama Department of Public Health Online Incident Reporting System form, dated 04/14/2024 documented: . RI #26 accused RI #38 of stealing her TV remote so she hit her on left knee . A review of the facility's summary the incident dated 04/14/2024 documented: (RN #12) night shift nurse .reports that resident (RI #26) shared that (RI #38) had stolen (his/her) remote control to (his/her) TV . (RI #26) swung (his/her) arm and hit the inside of (RI #38's) left knee area. (RI #38) was assessed immediately with no harm noted, and it was reported that RI #38 did not hit this resident back . Conclusion: The investigation did reveal that physical abuse occurred since RI #26 swung her arm and hit the inside of RI #38's left knee . TV remote control found . On 06/01/24 at 10:34 AM an interview was conducted with RI #38. RI #38 said on 04/14/2024, he/she was in the hall and RI #26 came out of his/her room, and said he/she had stolen his/her remote. RI #38 said as they were talking in the hallway, RI #26 hit him/her knee, but he/she did not have any injuries. RI #38 said he/she was surprised and shocked when he/she was hit in the knee by RI #26. On 05/31/2024 at 11:50 AM and interview was conducted with RN #12 who said RI #26 was coming out of RI #38's room and they were in the hall taking. RN #12 said she heard their voice's raise and she got up from behind the desk and saw RI #26 swing her hand at RI #38. She said she could not see where RI #26 hit RI #38 because it was a low swing. RN #12 said RI #38 said he/she was hit in the knee. RN #12 said RI #38 did not have any injuries. RN #12 said it was physical abuse when RI #26 hit RI #38 on the left knee. 3) The facility's policy titled Medication Administration with an implemented date of 01/21/2022 and a revised date of 02/20/2024 documented: . Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, . RI #286 was admitted to the facility on [DATE]. RI #286 had diagnoses that included Adjustment Disorder with Depressed Mood and Other Stimulant Dependence. RI #286 was discharged on 04/20/2024. RI #286's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/02/2023 revealed that RI #286 had a Brief Interview for Mental Status (BIMS) score 15 of 15 which indicated he/she did not have impaired cognition. On 03/06/2024 the State Survey Agency received a Facility Reported Incident which alleged CNA #18 was aware and did not report that CNA #19 administered a Klonopin 0.5mg to RI #286. The facility timeline documented on 03/06/2024 CNA #18 reported to the DON and FADM #1 that in December RI #286 disclosed to her that he/she had taken a Klonopin that CNA #19 had given him/her. CNA #18 did not report the information that RI #286 had revealed to her in December. The Facility timeline documented on: 03/06/2024 CNA #19 was interviewed by the Former Administrator (FADM) and the DON. CNA #19 acknowledged that she had given RI #286 Klonopin one time. 05/30/2024 at 2:53 PM CNA #18 was interviewed. CNA #18 reported that RI #286 had told CNA #18 that CNA #19 had given him/her one of her personal prescriptions, one pill of Klonopin while at the facility. CNA #18 did not report the information to anyone at the facility. On 05/30/2024 at 04:01 PM a phone interview was conducted with CNA #19. She stated that she had given RI #286 the Klonopin. Although CNA #19 could not give an exact date that she gave RI #286 Klonopin, she gave an approximate time of end of November or beginning of December, when she first started working at the facility. CNA #19 said RI #286 had followed her around all day asking her what medications she was taking. RI #286 pinched her hard enough to leave a bruise and then she gave RI #286 a Klonopin 0.5 milligram. CNA #19 was aware she was not to administer medication to RI #286 or any resident in the facility. On 05/31/2024 at 11:01 AM an interview was conducted with the Social Services Director (SSD). The SSD said she was responsible for the behavior care plans for residents. The SSD stated she did not utilize any diagnosis or behaviors prior to admission to develop a behavior care plan. The SSD stated the behavior would have to have occurred in the facility before she implemented a behavior care plan for a resident. The SSD said she had not been trained to handle substance abuse residents and she did not know if other staff had been trained either. Further the SSD stated RI #286 was not care planned for staff to be aware of what to watch for substance abuse signs and symptoms or issues. The SSD stated RI #286 did not have any behavior care plans developed before March 8th, 2024. The SSD said RI #286 was not care planned for substance abuse issues. On 06/01/2024 at 9:10 AM an interview was conducted with the DON. The DON said staff were not trained and no education had been provided to staff directing them how to provide care to resident with substance abuse disorder. The DON did not know why staff had not been trained, but said it should have been done. The DON was asked, how were staff supposed to respond to a resident with a history with substance abuse begging for a pill, pinching and pleading for a pill to respond. The DON said, after the fact we told her she should have came to us but she did not know what to do. The DON said RI #286 had visitor restrictions because he/she did not want the temptation of the old friends coming in to see him/her. The DON stated after investigating the incident with CNA #19 administering Klonopin to RI #286, CNA #19 was terminated for practicing beyond her scope of service for the medication. DON reported CNA #19 to the local police department, ombudsman, and to State. On 06/03/2024 at 08:04 PM an interview with ADM was conducted. ADM stated the condition of substance abuse was not covered on the facility assessment and when RI #286 was admitted the facility assessment should have been revised for substance abuse. ADM stated substance abuse should have been addressed to provide the care, resources, and the education for a resident with a history of substance abuse. ***************************************************************************** On 06/03/2024 at 4:55 PM, the facility submitted an acceptable removal plan, which document: Safety 1. Visitor was immediately removed from the center and resident's safety ensured. Notification 1. Administrator immediate reported incident to AP on 12/21/2023 2. Residents responsible party was notified of the incident and responded to the center 3. Local Law Enforcement Department was notified and responded to the center 4. The facility County Sheriff Department was notified and responded to the center. 5. Facility medical director was notified of the incident Assessments 1. RI #27 was immediately assessed by charge nurse on 12/2/2023 and no injuries were noted. 2. All patients/residents with a BIMS of 8 and above were interview by Activities Director on 06/02/2024 and no patient/right reported ever being abused by a staff member, patient/resident or visitor. 3. A full body audit was completed by the charge nurse on 06/01/24, on all patients/residents with a BIMS of 7 and below and no injuries noted. In-Services 1. Abuse in-services initiated on 06/02/24 including sexual, physical, verbal, psychosocial, financial, misappropriation of resident's funds, abandonment, and neglect, as well as practices, including reporting requirements, and notifying the Abuse Coordinator/Administrator immediately regarding any allegation of abuse. This abuse education was provided by the director of nursing to all staff, with 126 out of 132 staff educated 6/2/24. a) HH Health Systems Director of Operations provided education to the facility's administrator and Director of Nursing b) The Director of Nursing provided education to 126 out of 132. This inservice was provided for nurses, certified nursing assistants, department leaders/management, contract therapy services, housekeeping services and dietary services. All staff will be in-service prior to start of shift. All staff that did not receive the in-service by 6/3/24 at 12 noon, will be denied access from clocking into the facility. These staff have been notified either by voice mail or text send to their cellular devices. This notification states that they are not permitted to work until receiving the mandated abuse education per the Director of Nursing. 2. The Abuse Coordinator will hold weekly in services on reporting and identifying abuse to the Department Managers for four weeks, then monthly thereafter. The Department Manager will provide in-services on reporting and identifying abuse with their staff weekly for four weeks, then monthly thereafter. An attendance sheet will be maintained on each in-service to ensure full staff compliance. All attendance sheets will be given to the Abuse Coordinator/Administrator. 3. Effective 6/3/2024, A Receptionist/Door Greeter position will allow for closer monitoring of visitors to the facility. This position will be occupied 7 days per week for 12 hours per day from 6 am to 6 pm. The receptionist will be responsible for ensuring guest sign in/out. A Restricted Visitor List of people not allowed in facility will be located at the Receptionist Desk that includes photos, if available, general identification information of unwanted guest. If anyone on the list tries to enter the building, the receptionist will be trained to not allow them to enter the building. If the visitor refuses to comply, the local police department will be notified. 4. After hours (6pm-6am) the front doors will be locked and the charge nurse or designee will be responsible for monitoring entrance into the facility. The will ensure visitors sign into the Guest Registry and screen visitors to confirm they are not on the Resident Visitor List. If the visitor is restricted, the Charge Nurse or designee will inform then they are not permitted in the facility. If the visitor does not comply with leaving premises, the local police will be notified. 5. Residents Council meeting conducted on 6/2/2024 provided education to residents on facility abuse policy and reporting process. All patient/residents reported they feel safe at the center. *************************************************************************************************** After review of documentation supporting the above correction actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implemented corrective actions on 06/03/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, a Facility Reported Incident (FRI) received by the Alabama Department of Public Health, the U.S. (United States) Food and Drug Administration's article titled Tips to Help Avoid Vape Battery or Fire Explosions, the facility's form titled Safe Smoking Evaluation, and a facility policy titled Smoking Policy the facility failed to ensure: 1) a system was in place to ensure residents' safety while smoking 2) a system was developed and implemented to ensure electronic cigarettes or vape devices were stored and charged safely. RI #286 was admitted on [DATE], upon admission, RI #286's hospital discharge papers indicated that he/she was a daily smoker. The facility's activity log indicated that RI #286 went out to smoke at the facility beginning on 10/28/2023. The facility did not assess RI #286 to be a smoker and did not complete an assessment to determine that RI #286 was safe to smoke. Further on 03/04/2024 staff found multiple vape devices in RI #286's room. Staff also reported that RI #286 slept in the bed with a vape device on his/her chest and at times while the device was charging. The staff indicated RI #286 used a cell phone charger to charge the vape devices which posed a safety risk. During the investigation the staff revealed that RI #286 had been seen with a vape in his/her room on multiple other occasions and no actions were taken. The facility's investigation also revealed that Director of Nursing (DON) had found a vape in RI #286's room on two separate occasions weeks prior to 03/04/2024. The facility's smoking policy indicated all e-cigarettes were to be stored with other smoking materials. The facility's smoking policy further indicated that after a resident was found to be non-compliant with the smoking policy on two occasions, a 30-day discharge would be issued. The facility did not issue a 30-day discharge until 03/12/2024. Further, the facility failed to ensure RI #286, RI #25, RI #48, and RI #80's smoking assessments were completed properly. Further, the facility failed to ensure interventions were developed to ensure RI #25, RI #48, RI #34, and RI #80 were safe while smoking after being assessed as not safe to smoke. These deficient practices affected RI #25, RI #34, RI #48, and RI #80, four of five current residents sampled smoking safety; and RI #286 one of one discharged resident sampled for smoking and vaping safety. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 Accidents at a scope and severity of K. On 06/01/2024 at 10:08 PM, the Administrator, the Director of Nursing/Director of Nursing Services, Corporate Registered Nurse (CRN), and the Director of Care Services (DCS), were provided a copy of the Immediate Jeopardy (IJ) template and notified of the findings of Immediate Jeopardy and substandard quality of care in the area of Quality of Care at F 689- Accidents. The IJ began on 03/04/2024 and continued until 06/02/2024 when the facility implemented corrective actions to prevent re-occurence. On 06/03/2024 the IJ was removed, F 689 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not IJ, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. These deficient practices were cited as a result of the investigation of a Facility Reported Incident, complaint/report number AL00047176. Findings Include: Cross reference F 835, F 837, F 867, and F 926. On 03/06/2024 the State Survey Agency received a Facility Reported Incident which included that RI #286 was non-compliant with the facility's smoking policy and was found with multiple vape devices in his/her room. The facility's policy titled Smoking Policy, with a Review/Revision Date: 11/28/2017, documented: 1. POLICY: This facility has adopted a smoking policy that will promote safety for residents, visitors and families'. The smoking policy will be explained upon admission. Smoking is with supervision only. No smoking and/or electronic smoking is allowed inside the building. 2. PROCEDURE: a. Smoking will be allowed in the designated outside areas only. All residents who smoke will have a smoke assessment done upon admission or request to smoke at the facility. If smoking aprons are needed, the approach will be added to the care plan. 3. SAFETY: a. Residents found smoking at any time other than a scheduled smoke break will be subject to a search of resident him/herself, the resident's room and personal belongings. 4. ASSESSMENT AND CARE PLAN a. Per facility policy, on admission all residents who smoke or desire to smoke will have a smoking assessment completed. b. Updates to smoking assessments and care plans will be made when there is a change. Or, at annual MDS review. The smoking care plan will be reviewed quarterly or upon a significant change. 5. STORAGE OF SMOKING MATERIALS: a. All smoking materials, e.g., . electronic cigarettes are required to be deposited and kept at nurses' station or locked smoking cart. 6. EDUCATION: . c. Failure to adhere to this smoking policy will result in 1st offense suspension of smoking privileges, and 2nd offense, the resident receiving a 30 day discharge from the facility due to being a safety threat to themselves and others. The policy did not address residents with the desire to vape except as referenced above with the storage of electronic cigarettes. The facility's Safe Smoking Evaluation form included instructions to perform evaluation for residents with the desire to smoke on admission, quarterly, annually, and at significant change, or if there was an incident of unsafe smoking observed or reported to the facility. The first page of the form included 12 questions to assess RESIDENT STATUS and five OBSERVATIONS. Each of the 17 evaluation criteria were on a row and corresponded with columns to indicate yes or no. The form had four columns, and each had an evaluation date at the top of each column. The form indicated that If a No is indicated for any response, a smoking care plan may be indicated. The bottom of the form had four areas for signatures, initials, and date of person completing the form. The second page of the form was labeled with SUMMARY OF EVALUATION and had four areas for documentation including the date and signature of person completing. Each area included a section to indicate whether the resident demonstrated the ability to smoke, a section to indicate any recommended interventions including smoking apron, and a section to document if notifications were made and if care plan was updated. The U.S Food and Drug Administration's article titled Tips to Help Avoid Vape Battery or Fire Explosions indicated the content in the article was current as of 04/12/2024 was reviewed. The article revealed, . The tips below may help you avoid a vape battery fire or explosion. 3. Never charge your vape device with a phone or tablet charger. Always use the charger that came with it. 4. Don't charge your vape device overnight or leave it charging unattended. What Else Can I do? . your best protection against vape battery fires or explosions may be knowing as much as possible about your device and how to properly handle and charge its batteries. Make sure you read and understand the manufacturer's recommendations for use and care of your device. Charge your vape on a clean, flat surface, away from anything that can easily catch fire and someplace you can clearly see it-not a couch or pillow where it may more easily overheat or get turned on accidentally.Protect your vape from extreme temperatures by not leaving it in direct sunlight or in your car on a hot summer day or freezing cold night, and do not charge it in extreme temperatures . A review of the facility's document titled CHR Smokers List listed 16 residents that smoked at the facility including RI #25, RI #34, RI #48, and RI #80. There were no safety interventions or instructions for smoking on the list provided to the survey team. RI #286's medical records from the hospital included a Hospitalist H&P signed on 10/01/2023 by a Medical Doctor indicated RI #286 was a current smoker who smoked ten cigarettes per day and had a high level of nicotine dependence. RI #286 was admitted to the facility on [DATE]. RI #286 had diagnoses that included Paraplegia and Muscle Weakness. RI #286 was discharged on 04/20/2024. RI #286's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/02/2023 revealed that RI #286 had a Brief Interview for Mental Status (BIMS) score 15 of 15 which indicated he/she did not have impaired cognition. RI #286's Smoking Safety Evaluation (SSE) form was not completed. The first column of the form had a wavy line down the Yes/No column and was not dated. The first signature was Registered Nurse (RN) #22 and was dated 10/27/2023. The second and third columns were dated 01/26/2024 and 04/04/2024 and both also had a wavy line down the Yes/No column. LPN #15 signed and dated the form on 01/26/2024 and 04/04/2024. The second page of the form had an X to indicate Resident has demonstrated ability to safely smoke without supervision on each of the four sections. None of the sections were dated. The first, second, and third section were not signed. The fourth section was signed by RN #22. RI #286's activity log revealed the activity staff took RI #286 out to smoke 18 times beginning on 10/28/2023 through 03/22/2024. A review of Departmental Notes for RI #286 revealed a note on 10/31/2023 at 10:29 AM which documented . RESIDENT PARTICIPATES IN SMOKE BREAKS . signed by the Wound Nurse (WN), RN #23. The facility timeline regarding RI #286 documented that approximately two weeks prior to 03/04/2024 the DON found vapes in RI #286's room on two separate occasions. Further review of Departmental Notes revealed a note dated 03/05/2024 at 02:46 AM which documented 03/04/2024 .2115 . observed a vape at bedside . brought out it out to lock up . 2225 . vape . brought them to the desk to lock up . 2320 . vape in hand. This vape was taken and locked up. signed by RN #11. On 06/01/2024 at 11:22 AM the DON and the AD were both present when then DON was asked why she did not know why there was a care plan for RI #286 to smoke and no Smoking Safety Evaluation completed. The DON said she did not know. On 05/30/2024 at 10:18 AM an interview was conducted with RN #11. She stated three or four vapes were found in RI #286's room on 03/04/2024. During an interview on 05/31/2024 at 06:52 PM, RN #11 stated RI #286 was found asleep with the vape on his/her chest in the bed. On 05/30/2024 at 10:29 AM a phone interview with CNA #17 was conducted. She stated that different staff would bring RI #286 vapes. CNA #17 stated RI #286 was always asleep with a vape on his/her chest. CNA #17 she told RI #286 that he/she was going to get in trouble if someone saw him/her with a vape. According to CNA #17, RI #286 responded by stating the DON had seen the vape in the room and did not say anything about the vape to him/her. CNA #17 stated that she was aware RI #286 was not supposed to have the vape in the facility and did not report the vape to anyone. CNA #17 saw vapes in RI #286's pillow and in his/her hand. CNA #17 stated she should have reported seeing the vapes in RI #286's room when she first saw them. On 05/31/2024 at 05:16 PM during a follow-up interview, CNA #17 stated she had seen RI #286 charging the vapes with his/her type phone charger. The vape would be charging in the bed with RI #286 and plugged in the outlet beside his/her head. CNA further stated that RI #286 had a tin container full of vapes in his/her room. On 05/30/2024 at 2:53 PM, CNA #18 was interviewed. CNA #18 said the DON had found a vape in RI #286's room before the incident on 03/04/2024. She further stated that the Former Administrator (FADM) was aware RI #286 had vapes in the room. CNA #18 stated that a vape was on RI#286's chest even when he/she was asleep. CNA #18 said when RI #286 was first admitted to the facility, the FADM gave her money to go buy vapes for RI #286, because the FADM and the DON did not know anything about vapes. CNA #18 further stated that she had seen RI #286 vaping in his room every time she had cared for him/her. She did not tell anyone that she had seen RI #286 had been vaping because everyone was already aware that he/she had been vaping inside the facility. Further CNA #18 stated that nothing was done about RI #286 vaping in the facility. On 05/30/2024 at 04:01 PM a phone interview was conducted with CNA #19 who said she had seen the vapes in RI #286's room. CNA #19 said she thought RI #286 was allowed to have the vapes in the room because everyone was aware he/she had them in the room. On 05/31/24 at 09:44 AM a phone interview was conducted with the MDSC. The MDSC said she was aware RI #286 smoked cigarettes and vaped. The MDSC stated she understood the same procedures applied for vaping and cigarettes according to facility policy. On 05/31/2024 at 3:56 PM an interview with the Activity Assistant (AA) was conducted. The AA said she occasionally took residents out for smoke breaks. The AA stated on 12/01/2023 she took out RI #286 out for a smoke break and he/she had cigarettes and a vape. On 05/31/2024 at 11:30 AM interview with LPN #15 revealed she completed the SSE for RI #286. LPN #15 stated she had not been trained by the facility on completing the SSE forms. She stated she did not know how to assess for smoking safety. LPN #15 stated the wavy lines on the Yes/No columns on the SSE dated 01/26/2024 and 04/04/2024 indicated the resident did not smoke. LPN #15 said that she had seen RI #286 go outside during the smoking break with the rest of the smokers at the end of December 2023 or the first of January 2024. LPN #15 stated RI #286 was not asked if he/she vaped because she did not think to ask about vaping. LPN #15 stated RI #286 should have been assessed for smoking safety because he/she could have burned himself/herself or someone else. On 06/01/2024 at 09:10 AM an interview was conducted with the DON. The DON stated she had removed vape devices from RI #286's room. The DON said she removed vape devices twice several weeks prior to the incident on 03/04/2024. The DON said after she removed the devices, she warned RI #286 not to do it again. Further the DON stated the smoking policy did not indicate how to address vaping. The DON said she did not follow the same guidelines for resident's vaping as resident's smoking. RI #25 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #25 had diagnoses to include Difficulty in Walking, Muscle Weakness, Hemiplegia affecting the right dominant side. RI #25's SSE dated 02/06/2024 and 05/06/2024 documented RI #25 was unable to light a cigarette safely with a lighter, resident was unable to smoke safely, and resident was unable to extinguish cigarette safely and completely. LPN #15 signed and dated the form on 02/06/2024. There was no signature for the 05/06/2024 evaluation. The SUMMARY OF EVALUATION on the second page was not completed. RI #25's care plan for SMOKING with onset date of 04/15/2022 included the following approaches, May smoke in designated areas . Lighters and cigarettes are to be kept in the locked cart and to be distributed by staff only. Re-evaluate annually to correspond with MDS or at significant change. Smoke Break Schedule . RI #25's care plan did not include interventions to ensure RI #25's safety while smoking. RI #25 was observed on 05/30/2024 at 11:02 AM smoking outside in the smoking area without a smoking apron. A staff member with Activities, (ACT) #1, was outside with the resident while smoking. A second interview with LPN #15 was conducted on 06/01/2024 at 8:29 AM. LPN #15 said she assessed RI #25 for smoking and completed the SSE on 02/16/2024. LPN #15 stated she did not go outside to the smoking area to observe RI #25 smoking, but she looked through the window at RI #25. LPN #15 said she did not observe RI #25 for the entire smoking time. LPN #15 said she completed the SSE form for RI #25 and put the evaluation in the chart. LPN #15 said based on the SSE, RI #25 was not able to smoke safely and needed to wear a smoking apron. LPN #15 said the SSE notified the Activity Director (AD) that RI #25 was not able to smoke safely. LPN #15 said the AD was supposed to check the chart to review the smoker's completed SSE. According to LPN #15 the AD would know a resident needed an apron if she read the SSE. LPN #15 said if staff members supervising the residents who smoked were to see residents being careless or dropping ashes, the staff member would go and notify the AD. On 06/01/2024 at 6:08 PM during a follow up interview with the DON, the DON said RI #25's SSE dated 05/6/2024 indicated that he/she smoked, he/she could not light his/her cigarette, he/she was not safe to smoke, he/she did not put his cigarette out. The DON said based on the assessment it did not look like he/she was safe to smoke without a device. The DON was asked, what device RI #25 needed based on the SSE. The DON said RI #25 needed a smoking apron. The DON said the nurse that completed the SSE would communicate the need for a smoking apron to the AD, and she would add it to the care plan. The AD would also get an apron and put the resident's name on it and put it outside in the smoking area. The DON was asked, why that was not done for RI #25 and the DON said the assessment was not correct. RI #34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD), Need for Assistance with Personal Care, and Nicotine Dependence, Cigarettes. RI #34's SSE dated 04/16/2024 had NO selected for: Alert and oriented. Consistently performs safe smoking techniques. Has total or limited range of motion of both arms and hands . Has fine motor skills needed to securely hold cigarette . Resident is able to light cigarette safely with a lighter . Resident smokes safely (Does not allow ashes or lit material to fall. Remains alert and aware while smoking . Does not endanger self or others while smoking . The form was signed by LPN #24 and dated 04/16/2024. The SUMMARY OF EVALUATION section was also signed by LPN #24 and dated 04/16/2024. The summary indicated Resident exhibits poor safety awareness when smoking, and a care plan must be in place to promote smoking safety . and .Resident must wear smoking apron at all times. RI #34's care plan for SMOKING with admit date of 02/26/2024 and no onset date included the following approaches, May smoke in designated areas . Lighters and cigarettes are to be kept in the locked cart and to be distributed by staff only. Re-evaluate annually to correspond with MDS or at significant change. Smoke Break Schedule . On 06/01/2024 at 6:08 PM during a follow up interview with the DON, the DON was asked about RI #34's SSE's dated 03/01/2024 and said it meant he/she was not safe to smoke. The DON said at that time the resident was falling asleep during smoke breaks. The DON said the assessment indicated the resident would need to wear an apron while smoking. The DON RI #34 had not been care planned as needing a smoking apron while smoking. The DON said the nurse should have communicated the need for smoking apron to the AD. The DON said she did not know how staff would know RI #34 needed a smoking apron since it was not care planned. RI #48 was admitted to the facility on [DATE] with diagnoses of Hemiplegia following Cerebral Infarction and Muscle Weakness. RI #48's SSE form had NON SMOKER hand written down the column dated 04/02/2024. LPN #15 signed and dated the form on 04/02/2024. The column dated 04/22/2024 had NO selected for five of the evaluation criteria and no answer selected for seven of the evaluation criteria. The form was signed by RN #13 and dated 04/22/2024. The SUMMARY OF EVALUATION section was also signed by RN #13 and dated 04/22/2024 and indicated Resident must wear a smoking apron at all times. RI #48's care plan for SMOKING with onset date of 05/30/2024 included the following approaches, May smoke in designated areas . Lighters and cigarettes are to be kept in the locked cart and to be distributed by staff only. Re-evaluate annually to correspond with MDS or at significant change. Smoke Break Schedule . On 06/01/2024 at 6:08 PM during a follow up interview with the DON, the DON was asked about RI #48's SSEs 01/10/2024, 04/02/2024, and 04/27/2024. The DON was not sure if RI #48 went out to smoke, but the resident son asked if the resident could go out a smoke. The DON said the assessment indicated RI #48 would have to have an apron if she went to smoke. The DON said the resident could burn himself/herself if he/she went to smoke. The DON did not know why the assessment was not completed and said it was not an accurate assessment. RI #80 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #80 had diagnoses to include Difficulty in walking, Muscle weakness, Lack of coordination, and COPD. RI #80's SSE dated 03/22/24 had NON SMOKER hand written in the assessment column and NON SMOKER hand written on the SUMMARY OF EVALUATION. The form was signed by an RN. RI #80 care plan for SMOKING with onset date of 06/02/2024 included the following approaches, May smoke in designated areas . Lighters and cigarettes are to be kept in the locked cart and to be distributed by staff only. Re-evaluate annually to correspond with MDS or at significant change. Smoke Break Schedule . An observation on 06/01/2024 at 5:09 PM of the smoking cart with an Activities staff (ACT) revealed RI #80 had a plastic bag with cigarettes and a vape in the top drawer labeled with his/her name. On 06/01/2024 at 4:57 PM an interview with the ACT, who said she took residents out for smoke breaks. She stated there was a binder with the names of the residents that smoked. She stated there was a book that had a list of residents that were to wear an apron when smoking. The ACT stated RI #48 and RI #80 were the only two smoking residents at that time that wore an apron. On 06/01/2024 at 10:48 during an interview with the SSD, she said she did not complete smoking care plans and she did not know who completed the smoking care plans. On 06/01/2024 at 6:08 PM during a follow up interview with the DON, the DON was asked about RI #80's SSE dated 03/22/2024. The DON said the SSE indicated she was a non-smoker. The DON said she could not answer why RI #80 had a vape and cigarettes in the smoking cart outside. The DON said she thought RI #80 started smoking on 03/27/2024. The DON said she did not know what would happen if the vape device got too hot from being stored outside. On 05/31/2024 at 02:59 PM an interview with the AD was conducted. The AD said the ward clerks, CNAs, and activities assistants supervised residents on their smoke breaks. The AD said only the activities staff documented when residents went outside to smoke. AD further stated she had never reviewed a SSE before permitting a resident go outside to smoke. On 06/01/2024 at 7:17 AM a second interview was conducted with the AD. The AD said she looked at the care plan to see if the resident had a care plan for smoking and that indicated to her that the resident had been assessed for smoking safety. On 06/01/2024 at 09:10 AM during an interview with the DON, she stated the nurses were not trained on how to complete the SSE form. The DON stated the nurses assessed the residents for smoking safety. The DON stated she had never completed an SSE and did not know what the numbers meant. Further she could not say why the second page of the SSE was not completed on all the assessments. The DON stated the SSE determined if a resident was safe to smoke. The DON said once the form was completed it was put in the chart. The DON said the AD developed the care plans based on the information on the SSE and any verbal communication. The DON said once the SSE was completed and care plan developed the resident was put on the list for smokers at the facility. The DON said it might be the SSD that developed the smoking care plan. On 06/01/2024 at 11:27 AM an interview was conducted with the FADM. She stated the smoking assessment had a score that indicated whether the resident needed a safety device or not. The FADM stated the nurse brought the SSE to the morning meeting, the DON and the administrative team reviewed the SSE and made sure it was filled out correctly so they could determine what the residents' smoking needs were. ************************************************************* On 06/03/2024 at 05:57 PM, the facility submitted an acceptable removal plan, which documented: 1. All smoking material, to include pipes cigars, vapes, snuff, etc. were removed from patient/resident possession and locked on secure cart monitored by nurse. On 06/01/2024, no smoking contraband was found in residents' personal possession. 2. All smoking paraphernalia will remain locked on cart and only utilized during designated smoking times effective 06/01/2024. 3. E-cigs, vapes and other electronic nicotine distribution systems were reviewed with residents, no residents identified as using these devices as of 06/01/2024. Resident use of these devices will not be permitted at the facility. 4. All smoking assessments and care plans updated by the charge nurse on 06/01/2024 and 06/02/2024, for all patients and residents that identify as a smoker. To include patients and residents that utilize electronic smoking devices. Electronic smoking devices identified as any product containing or delivering nicotine or any other substance that can be used by a person for the purpose of inhaling vapor or aerosol from the product. 5. On 06/01/2024, all patients and residents that use nicotine products to include electronic smoking devices and smokeless tobacco signed acknowledgement of center revised policy and 30-day discharge issuance should policy be violated. 6. All staff in-service on 06/02/2024 regarding the centers revised smoking policy and procedure to include transitioning to a smoke-free campus effective 06/01/2024 for all new admissions, daily smoking schedule, safe smoking interventions to be utilized, and facility action plan should the centers revised smoking policy be violated. 7. Resident council meeting facilitated by the Activities Director on 06/02/2024 to inform all patients and residents of new smoking policy including smoke-free campus effective 06/01/2024 for all new admissions. 8. Smoke detectors were installed in all patient and resident rooms that a current smoker reside in on 06/02/2024. ---------------------------------------------------------------------------------------------------- After a review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implanted corrective actions including ongoing monitoring on 06/03/2024.

Based on record review, interviews, and a facility policy titled Smoking Policy the facility failed to develop and implement a smoking policy that defined vapes, storage of vapes, charging of vapes, where vapes were permitted, addressed noncompliance of vapes, provided instructions for the use of the facility's Smoking Safety Evaluation tool, and the development of person-centered care plans for residents with the desire to vape. This failure affected Resident Identifier (RI) #286, one of one resident sampled for vaping, and RI #25, RI #34, RI #48, and RI #80 who did not have care planned interventions to ensure their safety while smoking as indicated by their Smoking Safety Evaluation tool. These failures had the potential to affect all residents with a desire to vape or smoke in the facility. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.90 Establish Smoking Policy at a scope and severity of K. On 06/01/2024 at 10:08 PM, the Administrator, the Director of Nursing/Director of Nursing Services, Corporate Registered Nurse (CRN), and the Director of Care Services (DCS) were provided a copy of the Immediate Jeopardy (IJ) template and notified of the finding of IJ in the area of Physical Environment at F 926- Smoking Policy. The IJ began on 03/04/2024 and continued until 06/02/2024 when survey team verified onsite that corrective actions had been implemented. On 06/03/2024 the IJ was removed, F 926 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not IJ, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. These deficient practices were cited as a result of the investigation of a Facility Reported Incident AL00047176. Findings Include: Cross reference F 689. The facility's policy titled Smoking Policy, with a Review/Revision Date: 11/28/2017, documented: 1. POLICY: This facility has adopted a smoking policy that will promote safety for residents, visitors and families'. The smoking policy will be explained upon admission. Smoking is with supervision only. No smoking and/or electronic smoking is allowed inside the building. 2. PROCEDURE: a. Smoking will be allowed in the designated outside areas only. All residents who smoke will have a smoke assessment done upon admission or request to smoke at the facility. If smoking aprons are needed, the approach will be added to the care plan. 3. SAFETY: a. Residents found smoking at any time other than a scheduled smoke break will be subject to a search of resident him/herself, the resident's room and personal belongings. 4. ASSESSMENT AND CARE PLAN a. Per facility policy, on admission all residents who smoke or desire to smoke will have a smoking assessment completed. b. Updates to smoking assessments and care plans will be made when there is a change. Or, at annual MDS review. The smoking care plan will be reviewed quarterly or upon a significant change. 5. STORAGE OF SMOKING MATERIALS: a. All smoking materials, e.g., lighters, matches, cigarettes, cigars, electronic cigarettes are required to be deposited and kept at nurses' station or locked smoking cart. 6. EDUCATION: . c. Failure to adhere to this smoking policy will result in 1st offense suspension of smoking privileges, and 2nd offense, the resident receiving a 30 day discharge from the facility due to being a safety threat to themselves and others. On 03/06/2024 the State Survey Agency received a Facility Reported Incident which included that RI #286 was non-compliant with the facility's smoking policy and was found with multiple vape devices in his/her room. RI #286's Smoking Safety Evaluation (SSE) form was not completed. The first column of the form had a wavy line down the Yes/No column and was not dated. The first signature was Registered Nurse (RN) #22 and was dated 10/27/2023. The second and third columns were dated 01/26/2024 and 04/04/2024 and both also had a wavy line down the Yes/No column. LPN #15 signed and dated the form on 01/26/2024 and 04/04/2024. The second page of the form had an X to indicate Resident has demonstrated ability to safely smoke without supervision on each of the four sections. None of the sections were dated. The first, second, and third section were not signed. The fourth section was signed by RN #22. RI #286's activity log revealed the activity staff took RI #286 out to smoke 18 times beginning on 10/28/2023 through 03/22/2024. A review of Departmental Notes for RI #286 revealed a note on 10/31/2023 at 10:29 AM which documented . RESIDENT PARTICIPATES IN SMOKE BREAKS . signed by the Wound Nurse (WN), RN #23. The facility timeline regarding RI #286 documented that approximately two weeks prior to 03/04/2024 the DON found vapes in RI #286's room on two separate occasions. Further review of Departmental Notes revealed a note dated 03/05/2024 at 02:46 AM which documented 03/04/2024 .2115 . observed a vape at bedside . brought out it out to lock up . 2225 . vape . brought them to the desk to lock up . 2320 . vape in hand. This vape was taken and locked up. signed by RN #11. On 05/30/2024 at 10:18 AM an interview was conducted with RN #11. She stated three or four vapes were found in RI #286's room on 03/04/2024. During an interview on 05/31/2024 at 06:52 PM, RN #11 stated RI #286 was found asleep with the vape on his/her chest in the bed. On 05/31/2024 at 05:16 PM during an interview, CNA #17 stated she had seen RI #286 charging the vapes with his/her type phone charger. The vape would be charging in the bed with RI #286 and plugged in the outlet beside his/her head. CNA further stated that RI #286 had a tin container full of vapes in his/her room. On 05/30/2024 at 2:53 PM, CNA #18 was interviewed. CNA #18 said the DON had found a vape in RI #286's room before the incident on 03/04/2024. She further stated that the Former Administrator (FADM) was aware RI #286 had vapes in the room. CNA #18 stated that a vape was on RI#286's chest even when he/she was asleep. CNA #18 further stated that she had seen RI #286 vaping in his room every time she had cared for him/her. She did not tell anyone that she had seen RI #286 had been vaping because everyone was already aware that he/she had been vaping inside the facility. Further CNA #18 stated that nothing was done about RI #286 vaping in the facility. On 05/30/2024 at 04:01 PM a phone interview was conducted with CNA #19 who said she had seen the vapes in RI #286's room. CNA #19 said she thought RI #286 was allowed to have the vapes in the room because everyone was aware he/she had them in the room. On 05/31/2024 at 11:30 AM interview with LPN #15 revealed she completed the SSE for RI #286. LPN #15 stated she had not been trained by the facility on completing the SSE forms. She stated she did not know how to assess for smoking safety. On 06/01/2024 at 09:10 AM an interview was conducted with the DON. The DON stated she had removed vape devices from RI #286's room. The DON said she removed vape devices twice several weeks prior to the incident on 03/04/2024. The DON said after she removed the devices, she warned RI #286 not to do it again. Further the DON stated the smoking policy did not indicate how to address vaping. The DON said she did not follow the same guidelines for resident's vaping as resident's smoking. RI #25's SSE dated 02/06/2024 and 05/06/2024 documented RI #25 was unable to light a cigarette safely with a lighter, resident was unable to smoke safely, and resident was unable to extinguish cigarette safely and completely. LPN #15 signed and dated the form on 02/06/2024. There was no signature for the 05/06/2024 evaluation. The SUMMARY OF EVALUATION on the second page was not completed. RI #25 was observed on 05/30/2024 at 11:02 AM smoking outside in the smoking area without a smoking apron. A staff member with Activities, (ACT) #1, was outside with the resident while smoking. RI #34's SSE dated 04/16/2024 had NO selected for: Alert and oriented. Consistently performs safe smoking techniques. Has total or limited range of motion of both arms and hands . Has fine motor skills needed to securely hold cigarette . Resident is able to light cigarette safely with a lighter . Resident smokes safely (Does not allow ashes or lit material to fall. Remains alert and aware while smoking . Does not endanger self or others while smoking . The form was signed by LPN #24 and dated 04/16/2024. The SUMMARY OF EVALUATION section was also signed by LPN #24 and dated 04/16/2024. The summary indicated Resident exhibits poor safety awareness when smoking, and a care plan must be in place to promote smoking safety . and .Resident must wear smoking apron at all times. RI #48's SSE form had NON SMOKER hand written down the column dated 04/02/2024. LPN #15 signed and dated the form on 04/02/2024. The column dated 04/22/2024 had NO selected for five of the evaluation criteria and no answer selected for seven of the evaluation criteria. The form was signed by RN #13 and dated 04/22/2024. The SUMMARY OF EVALUATION section was also signed by RN #13 and dated 04/22/2024 and indicated Resident must wear a smoking apron at all times. RI #80's SSE dated 03/22/24 had NON SMOKER hand written in the assessment column and NON SMOKER hand written on the SUMMARY OF EVALUATION. The form was signed by an RN. RI #25, RI #34, RI #48, and RI #80's care plan for smoking all included only: May smoke in designated areas . Lighters and cigarettes are to be kept in the locked cart and to be distributed by staff only. Re-evaluate annually to correspond with MDS or at significant change. Smoke Break Schedule . On 06/01/2024 at 09:10 AM an interview was conducted with DON. The DON said there was not a facility policy that addressed safety for residents with the desire to vape. Further DON said a policy would be added for vapes to be addressed like the cigarettes and the staff needed to know what to do. The DON said during the interviews, the staff stated they had been vaping in the facility. The DON stated the CNAs did not know how to respond to a resident with a vape without training. The DON stated the vape devices should have been stored like cigarettes in activities. The DON stated she was unaware the vape devices had to be charged and did not know where the device should have been charged. Further the DON stated it was important to follow the manufacturers guidelines to protect everyone. The DON stated there was no policy concerning how to charge the vape device. On 06/01/2024 at 11:27 AM an interview was conducted with the Former Administrator (FADM). The FADM stated the facility smoking policy did not address vapes. The FADM stated the facility never trained staff how to charge vapes and there was a risk of a fire when manufacturers guidelines were not followed. The FADM stated the CNAs would not know how to respond to a resident with a vape device if there was no training. On 06/01/2024 at 08:01 PM an interview was conducted with the DCS. The DCS said he was not made aware of the incident regarding RI #286 until recently. The DCS stated there was no vaping policy and procedure at the facility to ensure safety, storage, and charging vape device, and storage. Further the DCS stated if the resident was not assessed to be safe while smoking, and it was not addressed in the policy, there should be a care plan implemented to address the resident's safety. ************************************************** On 06/03/2024, the facility submitted an acceptable removal plan, which documented: 1. All smoking assessments and care plans updated by the charge nurse on 06/01/2024 and 06/02/2024, for twelve patients and residents that identify as a smoker. To include patients and residents that utilize electronic smoking devices. Electronic smoking devices identified as any product containing or delivering nicotine or any other substance that can be used by a person for the purpose of inhaling vapor or aerosol from the product. a) 06/01/2024 and 06/02/2024, the nurses conducted the Smoking Assessments with residents who identified themselves as a smoker. The nurse identified risks and interventions that would be needed due to safety concerns for the resident. These assessments are entered into the facility's Electronic Medical Record (EMR) where the assessment outcomes are available for Social Services to develop Smoking Safety Care Plans. Social Services will print the Smoking Assessment and the Smoking or Smokeless Tobacco Care Plan to forward to the Activities Director. b) Beginning 06/01/2024, the Activities Director will maintain a Smokers and Smokeless Tobacco binder for the smoking area storage cart. This binder includes a list of residents who use tobacco products, smoking and smokeless, the smoking assessment, and the appropriate tobacco-use care plan. The Smoking and Smokeless Tobacco Binder will be stored in the locked storage cabinet at the resident's smoking area. This binder, along with the assessments and care plans provide the Smoke Break Supervisors direction on the care of the resident while participating in the tobacco use scheduled activity. Smoking supervisors are to adhere to the recommended smoking interventions and facility's smoking policy during all smoke breaks. 2. On 06/01/2024, all patients and residents that use nicotine products to include electronic smoking devices and smokeless tobacco signed acknowledgement of center policy and 30 day discharge issuance should policy be violated. 3. All staff in-serviced on 06/02/2024 regarding the centers revised smoking policy and procedure to include transitioning to a smoke free campus effective 06/01/2024 for all new admissions, including smokes tobacco, daily smoking schedule, safe smoking interventions to be utilized and facility action plan should the centers smoking policy be violated. 4. E-cigs, vapes and other electronic nicotine distribution systems were reviewed with residents, no residents identified as using these devices as of 06/01/2024. Resident use of these devices will not be permitted at the facility. 5. Resident council meeting facilitated by the Activities Director on 06/02/2024 to inform all patients and residents of new smokefree campus effective 06/01/2024 for all new admissions. 6. Smoke detectors installed in all patient and resident rooms that a current smoker resides in on 06/02/2024. 7. Corporate Clinical Consultant educated the Director of Nursing on 06/02/2024 regarding instructions on how to complete the Safe Smoking Assessment form for all patients and residents. The Director of Nursing was informed that all Licensed Practical Nurses and Registered Nurses can complete and interpret the Safe Smoking Assessment and implement safe smoking interventions. The Director of Nursing implemented education with all Licensed Practical Nurses and Registered Nurses on 06/02/2024 with instructions on how to complete and interpret the Safe Smoking Assessment. --------------------------------------------------------------------------------------------------------------------- After a review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implemented corrective actions including ongoing monitoring on 06/02/2024.