**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4). Resident #20 had diagnoses of dementia, psychotic disturbance, anxiety, and delirium. Fall Assessments dated 03/29/2024, 3/11/2024, 3/1/2024, 12/28/2023, 10/10/2023, 10/7/2023, and 10/1/2023 all identified Resident #20 to be a High Fall Risk. Resident #20 had a BIMS of 7, as identified on a MDS dated [DATE], which indicated Resident #20 had severe cognitive impairment. Resident #20 ' s Care Plan dated 04/03/2024 identified Resident #20 to be at risk for falls and dates for falls of 10/01/2023; 10/07/2023; 10/20/2023; 01/03/2024; 02/01/2024; 03/11/2024. The Care Plan initiated 09/20/2023 with revision of 04/08/2024 documented: Resident #20 will be free of falls through the review date. Date Initiated: 04/03/2024. 10/01/2023 encouraged to use the call light for assistance; 10/20/2023 blanket was removed from w/c [wheelchair], encouraged to lock brakes on w/c; 10/07/2023 fall mat to floor right side of bed; 02/01/2024 maintenance inspected threshold to door. And 03/11/2024 fall mat to floor, new low bed ordered by hospice. A Nursing Progress Note dated 03/11/2024 at 19:43 (7:43) PM documented, The elder was reaching for a drink off the nightstand, and she slid out of the bed hitting her head on the bedside table. She has a small laceration to the top of the scalp on the left side. The area was cleaned, and the bleeding stopped. She was assessed and assisted to a wheelchair. Neuros [neurological checks] started at this time. The hospice nurse was notified and came to see the elder also. MD [Medical Doctor] was notified of the fall along with family member . A Nursing Progress Note dated 03/13/2024 at 11:23 PM documented, .Continues on observation for fall. No c/o [complaints of] px [pain] or discomfort voiced at this time. Currently resting in bed with bed in lowest position. No acute distress noted. Will continue with current plan of care. C/L [call light] in reach. A MDS Progress Note dated 04/03/2024 at 03:07 PM documented, Quarterly MDS Assessment Completed. Elder requires staff assistance with some functional abilities . Fall X2 noted during the look back period. No skill therapy services, referrals or plan of discharge. Elder continues with [named provider] hospice services. On 04/22/2024 at 10:25 AM, Resident #20 was observed lying in bed, the bed was not in the lowest position, the bed was at normal height. On 04/22/2024 at 11:50 AM, Resident #20 was observed lying in bed, the bed was not in the lowest position. On 04/22/2024 at 02:05 PM, Resident #20 was observed lying in bed, the bed was not in the lowest position. On 04/23/2024 at 10:15 AM, Resident #20 was observed in bed, the bed was not in the lowest position. The bed height was that of a normal hospital bed. On 04/23/2024 at 2:20 PM, Resident #20 was observed in bed. The bed was at normal height, and not in low position. The bed height was that of a normal hospital bed. On 04/23/2024 at 03:15 PM, Resident #20's bed height was that of a normal hospital bed. During continued rounds in the cottage, the resident was observed attempting to get out of bed. On 04/23/2024 at 03:18 PM, CNA #4 stated that staff keep Resident #20 ' s bed in its lowest position when Resident #20 is not eating or drinking. On 04/23/2024 at 03:20 PM, LPN #1 stated the bed was to be kept in the lowest position when the resident was in it, this was an intervention after a fall. It is supposed to be kept down, at all times, except when they are changing the resident. On 04/25/2024 at 08:59 AM, Resident #20's bed was observed not to be in the lowest position. CNA #4 measured the bed to be at 69 inches, the height was verified by CNA #11. On 04/25/2024 at 02:45 PM, the ADON stated they do not have a policy on bed height. The Surveyor asked the ADON, How do you expect the staff to use the Hi-Low bed for Resident #20? The ADON stated, They are to leave it in the lowest possible position. They are not to leave her in a high position. The Surveyor asked, If the resident requested to remain in the high position, how would you instruct the staff? The ADON stated, We can't leave her up because if she fell at that height, it could cause a serious injury. It is for her safety. 3). On 04/22/2024 at 10:50 AM, the Surveyor observed keys in the doorknob of a closet. The Surveyor opened the door and noted full and empty portable oxygen tanks sitting on the floor behind boxes of items to provide care (razors, saving cream, gloves, oral swabs, incontinence briefs, toilets paper). On 04/22/2024 at 10:53 AM, the Surveyor asked Registered Nurse (RN) #1 if the door should be unlocked? RN #1 stated, No. The Surveyor asked why is it important that the door remains locked? RN #1 stated, There is stuff in there like mouth wash, razors, and oxygen that the elders could get into and it could be harmful to them. The Surveyor asked whose keys were in the door. Certified Nursing Assistant (CNA) #1 walked up and stated, mine and removed the keys from the doorknob. On 04/25/2024 at 10:37 AM, the Surveyor asked the Assistant Director of Nursing (ADON), if the door to the closet used to store items to provide care, clean linens, and portable oxygen tanks should be locked? The ADON stated, Yes. The Surveyor asked with the closet containing portable oxygen tanks, could it be a danger to the residents? The ADON stated, Yes. On 04/25/2024 at 11:39 AM, the Surveyor was provided a policy titled, Accident Hazards Prevention that documented Resident Environment. The Environment will be free from accident hazards as is possible. A Life Safety manual will be maintained. Based on observation, interview and record review, the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (Resident #82) of 1 sampled resident reviewed for elopement. The lack of an effective monitoring plan resulted in Resident #82 eloping from the facility and being found walking in the grass on the side of a public highway, approximately 100 yards from the resident's residence. 1. Resident #82 followed two other residents out to the back patio for their smoke break and staff only checked on residents every 5 to 10 minutes when they were outside the residence. Resident #82 was admitted on [DATE] with a diagnosis of Alzheimer's disease and had an admission Assessment which indicated the resident was at risk of wandering. On 04/23/2024, Resident #82 verbalized to staff that she lived close by and wanted to walk home. Staff were instructed to closely monitor the resident due to making that statement. At the time of the survey, there were 35 residents residing in the cottages who were identified as at risk for elopement. 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 (Quality of Care) at a scope and severity of J; 2. failed to ensure hazardous chemicals and equipment were secured in a closed, locked room, from wandering residents. This failed practice had the potential to affect 1 (Resident #29) of 8 residents in Cottage 4 that ambulated or self-propelled; 3. failed to ensure adequate supervision was provided, assistive devices were in place, and interventions were implemented to decrease the potential for accidents for 1 (Resident #20) of 1 resident who was at risk for falls; 1.) Resident #82 was admitted on [DATE] and had an admission Assessment which indicated the resident was at risk of wandering. On 04/23/2024, Resident #82 verbalized to staff that [Resident #82] lived close by and wanted to walk home. A staff member was instructed to closely monitor Resident #82 due to making that statement. At the time of the survey, there were 35 residents residing in the cottages who were identified as at risk for elopement. 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 (Quality of Care) at a scope and severity of J. The IJ began on 04/23/2024 around 6:00 PM when Resident #82 was seen walking in the grass on the side of a public highway approximately 100 yards from the resident's residence by a facility staff member who was walking to her vehicle after work. The resident was seen exiting the building with two other residents by a staff member. However, the resident left the area without staff knowledge. The Administrator, Administrator Assistant, Assistant Director of Nursing (ADON) and Nurse Consultants were notified of the IJ on 04/25/2024 at 12:39 PM. A Plan of Removal was requested. The Removal Plan was accepted by the State Survey Agency on 04/26/2024 at 3:29 PM. The IJ was removed on 04/30/2024 at 3:00 PM after the survey team performed onsite verification that the Removal Plan had been implemented. The findings are: Resident #82 was admitted on [DATE] with a diagnosis of Alzheimer's disease as documented on the Order Summary. A Care Plan initiated 04/24/2024 documented Resident #82 was an elopement risk/wanderer and was transitioned to the Secure Cottage and was to be observed for any changes in wandering or exit seeking behaviors. On 04/23/2024 at 8:04 PM, the facility submitted an Incident and Accident report to the Office of Long-Term Care that documented Resident #82 had walked away from the campus and was found by the admission and Marketing Director and brought back to the campus. A Wandering Risk Scale dated 04/23/2024 documented Resident #82 had a score of 9 (9-10 indicates at risk for wandering/elopement). On 04/24/2024 at 12:43 PM, Resident #82 was sitting in a chair in the room looking at a book. Resident #82 was asked if Resident #82 knew why resident was moved to a new room and resident replied, I may have wandered off. Resident #82 had no memory of the incident on 04/23/2024. On 04/24/2024 at 1:04 PM, the Admissions and Marketing Director was interviewed, and she was asked to describe the incident regarding Resident #82, and she stated, I was getting ready to leave around six o'clock. I was going to my car to leave and looked up and I saw [Resident #82]. I didn't know who it was at first. I took off running when I saw [Resident #82] to stop [Resident #82] and redirect [Resident #82] back to the facility. She admitted the resident was on the road going to [Resident #82]'s right. She added Resident #82 was still on the left side of the street and was about 30-40 yards from the stop sign. She stated [Resident #82] stated [Resident #82] was fine and that [Resident #82] stated [Resident #82] was trying to get to a cousin's house because the resident's spouse was supposed to be there to pick up [Resident #82]. The admission and Marketing Director stated when Resident #82 was told they needed to go back to the facility, Resident #82 immediately came with her. She added that the Minimum Data Set (MDS) Coordinator and Administrator saw her running, knew something was wrong and came to her and [Resident #82] after they were back on facility grounds, and they (Administrator and MDS Coordinator) walked the resident the rest of the way and she left. On 04/24/2024 at 2:50 PM, Certified Nursing Assistant (CNA) #11, was asked when she saw Resident #82 last and she stated it was after 5:30 PM and going on 6:00 PM after supper. She stated Resident #82 had got up from the table and followed two residents to the back patio to smoke. She added Resident #82 did not smoke when asked and that she thought the resident liked the company but usually came back it. She confirmed that no staff member went outside with the residents and that she was not aware that the nurse had told a co-worker to keep an eye on Resident #82. CNA #11 was asked how she knew which residents needed supervision and she stated she had not been told about anyone who needed supervision. On 04/24/2024 at 3:17 PM, CNA #12 was asked if residents were allowed to be on the porch alone and he stated, Yes, if they are not visually disoriented, but we have to keep an eye on them, depending on who they are. If it's someone new, we try to check on them every 5 to 10 minutes. He confirmed that CNAs were responsible for watching the residents when they were on the porch. He was asked if he was familiar with [Resident #82] and he stated it was his second day with the resident since the resident's admission. CNA #12 denied knowing if the resident had any exit seeking behavior. He admitted the last time he saw Resident #82 was about 5:30 PM to 5:45 PM when Resident #82 was sitting at the dinner table eating. He confirmed that he was told by the nurse to keep an eye on Resident #82 because the resident could possibly wander off. On 04/24/2024 at 4:39 PM, Registered Nurse (RN) #1 was asked to describe the incident regarding Resident #82 and she stated, About 4:50 [pm] I was packing up my things and an aide brought [Resident #82] in from the back porch to the library and the aide stated she didn't want [Resident #82] to get hurt because they were mowing and then [Resident #82] stated [Resident #82] thought [Resident #82] lived pretty close down the street and [Resident #82] thought [Resident #82] could walk there. So, we re-orientated [Resident #82] and took [Resident #82] back to [Resident #82]'s room. Then I was about to go across the street and the aide, at the CNA [documentation area], I told to keep an eye on the elder because [Resident #82] made a comment that [Resident #82] lived down the street and thought [Resident #82] could walk there and I didn't want [Resident #82] to try to leave, thinking that [Resident #82] lived there from the Alzheimer's. At that point the resident was in [Resident #82]'s room and [Resident #82]'s door was visible from the [documentation area]. After that, I went to [NAME] Cottage for my 5 o'clock med [medication] pass. She confirmed Resident #82 did not show any exit seeking behaviors on her shift, but the night nurse stated Resident #82 commented about wanting to go home. On 04/24/2024 at 05:34 PM, the Administrator was interviewed and stated that she and the MDS Coordinator were walking to their vehicles around 5:50 PM and observed the Admissions and Marketing Director talking to Resident #82. She stated they met Resident #82 and the Admissions and Marketing Director and walked Resident #82 back and Resident #82 was taken to the Secure Cottage and [Resident #82]'s belongings moved. The Administrator stated she met with the staff and had the MDS Coordinator start running risks assessments. The Administrator added, I sent nursing, ADON, to do a body audit immediately and the Nurse Practitioner was on the phone with the ADON, and the 15 minutes checks were started, and all notifications were being done and family was notified. She stated she sent the Dietary Assistant/CNA to the cottages with the in-services to make sure they understood and to let them know that she would follow before she left but she needed them [in-services] to go out immediately. She had another staff nurse to get witness statements. She stated, After I left 3 [Cottage #3], I did go find the nurse and I told her to do an I&A [incident and accident] and that I needed her to make sure [Resident #82] meds and belongings got transferred to Cottage 1. The Immediate Jeopardy was removed on 04/26/2024 at 03:00 PM when the following Plan of Removal was implemented by the facility: Upon notification to Administrator that Resident #82 was observed off campus, the Resident was returned to the campus by the admission Coordinator, a body audit was conducted by a Licensed Practical Nurse with no negative findings and Resident #82 was placed in the secure cottage on 04/23/2024 at 06:15 PM. Resident #82's wandering risk assessment was reassessed by the Minimum Data Set Coordinator and the plan of care was updated to include risk of wandering on 04/23/2024. CNA in Secure Cottage Began 15 minute checks on Resident #82 on 04/23/2024. These 15-minute checks will continue until Resident #82 no longer exhibits exit seeking behavior. The Administrator and Assistant Administrator began in-service training for all staff on duty on 04/23/2024 related to abuse, neglect, and elopement. All other staff will be trained before coming on duty on abuse and neglect and elopement. The training included if an elder seems more confused, is exit seeking, found to have an increase in wandering or any change of condition, staff are to notify a supervisor/nurse immediately and staff to perform more frequent checks on them. This has a completion date of 04/26/2024. Facility Registered Nurse and Licensed Practical Nurse reassessed all other elders on current census for their wandering risk assessment on 04/23/2024. Resident's care plans and wandering assessments will indicate if a resident is at risk for wandering. All corrections were completed on 04/26/2024. The Administrator provided a Missing Resident/Elopement Protocols policy on 04/24/2024 that documented, .It is the policy of the [NAME] House Cottages of Southern Hills to provide a safe and secure environment for all residents. In the event of resident elopement, it is the policy of the [NAME] House Cottages of Southern Hills to implement its elopement protocols immediately to locate the resident in a timely manner . On 04/26/2024 at 12:30 PM, the Administrative Assistant provided an Inservice Education Report on Elopement, a second one on Abuse and Neglect Investigation and Reporting and a third one that documented, All elders are to be monitored every 15 minutes . with different signatures and titles on each in-service. Onsite Verification: The IJ was removed on 04/26/2024 at 03:00 PM after the survey team performed an onsite verification that the Removal Plan had been implemented. On 04/30/2024 at 10:45 AM, the Surveyor entered the facility to verify removal of the immediate jeopardy. Reviewed Resident #82's placement, verified resident census for the secure cottage. Resident #82's wandering risk assessment was reassessed by the Minimum Data Set Coordinator and the plan of care was updated to include risk of wandering on 04/23/2024. Reviewed Certified Nursing Assistant (CNA) in Secure Cottage l5 minute checks on Resident #82 on 04/23/2024. The checks began on 04/23/2024 at 7:00 PM, and ended on 04/24/2024 at 7:00 PM, with no notation of exit seeking behavior since 04/24/2024 at 10:30 AM, noted Resident 'beating on door.' On 04/30/2024 at 2:10 PM, Resident #82 observed sitting in the resident's room of the secure cottage pleasantly visiting with a peer. No exit seeking or wandering behaviors observed. Reviewed staff in-service related to abuse, neglect, and elopement that began on 04/23/2024. The Assistant Administrator provided an audit list of employees for the facility to verify all staff were in-serviced by 04/26/2024. The Assistant Administrator reported the audit list was compared to staff signatures and phone calls to staff so they could verify every staff member had been in-serviced. On 04/30/2024 between 12:00 PM and 2:40 PM, 20 Certified Nursing Assistants, 3 Licensed Practical Nurses and 1 Registered Nurse that work various shifts, were interviewed to verify they received and understood the in-service. They were able to verbalize the training included that if a resident seemed more confused, is exit seeking, found to have an increase in wandering or any change of condition, staff are to notify a supervisor/nurse immediately and staff to perform more frequent checks on them. This had a completion date of 04/26/2024. Reviewed resident audit list for wandering risk assessment on 04/23/2024. Two residents were identified with a change in risk, verified both resident's care plans were updated to indicate resident is at risk for wandering. The Administrator and the Regional Consultant were informed of the Immediate Jeopardy Plan of Removal with a Completion Date of 04/26/2024 verified removal on 04/30/2024 at 03:00 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure safety and supervision to prevent elopement from the secure unit for 1 (Residents #1) of 3 (Resident #1, #2, #3) sampled residents. This failed practice resulted in Past non-compliance at Immediate Jeopardy. The Administrator was informed of the Immediate Jeopardy on 07/12/2023 at 2:00 PM. The findings are: 1. Resident #1 was admitted to the secure unit in the facility on 02/24/2023 with diagnosis of dementia, anxiety disorder, and chronic obstructive pulmonary disease and repeated falls. According to The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/03/2023, Resident #1 had a BIMS (Brief Interview for Mental Status) of 03 (indicates severe impairment) and required supervision for ambulation on unit and off unit. a. The Plan of Care with an initiated date of 2/24/23 showed, Resident #1 was an elopement risk/wanderer related to history of wandering. Interventions included resident to reside in a secure cottage, and staff to observe for any changes in wandering or exit seeking behaviors. b. Review of the Wandering Risk Scale assessment dated [DATE] revealed Resident #1 had a history of wandering and resides in the secure unit. The Resident was scored as a high risk for wandering. c. Review of the Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long Term care Facilities (Form DMS-762) noted on 7/4/23 Resident #1 left the facility without supervision. The document noted the resident was last observed by staff at approximately 12:40 PM in the day room, and at 12:30 PM according to the report, a man saw the resident and called the sheriff's office at 12:43 PM. The resident was taken by ambulance from the apartment complex area, where he was found, to the local hospital for evaluation. d. Witness statements from the DMS-762 revealed Certified Nursing Assistant (CNA) #4 last saw Resident #1 at 12:38 PM and did not realize he was missing until 12:45 PM. CNA #1 noted the last time she saw Resident #1 was approximately 12:36 PM and noted the resident was walking around in the cottage. e. On 7/11/2023 at 1:05 PM interview with the administrator who stated, Resident #1 went to the apartments, which are next to the facility, through the woods by a small trail. She stated the resident went out with family members from the locked/secured unit. She further stated, Resident #1 looks fine, and you would not know that he must be supervised just to look, he is able to walk without hands on assist, he just needs supervision. The administrator stated the secure code was in place, but the staff had given it out to the families because the families had to wait for staff and it takes a bit for them to get to the door. She further stated the code will be changed, and will not be given to the families, they will have to wait for staff to let them in. f. On 7/11/2023 at 1:45 PM observed all exterior doors in the secure cottage. The front entrance door, the back entrance that leads to a fenced in yard (library area), the side door by the laundry room entrance and the side door by the sprinkler system entrance, both side doors that face the wooded area (Resident #1 exited from) have the secure code entrance-exit locking system. There were no sounding alarms for any of the doors in and out of the locked cottage, there was no signage noted on the doorways alerting visitors or staff to not allow residents to follow them out of the secure unit. g. On 7/11/2023 at 4:00 PM observed the trail area from the facility cottage grounds to the apartment complex that resident #1 walked through on 7/4/2023. The trail appeared to be [NAME] red dirt with pine straw on the ground, the trail was 20 to 22 feet long and 3-4 feet wide with large, tall pine trees on both sides of the trail area. There was muddy water along the trail. The apartment complex had multiple 2 story buildings and a concrete walk path around into the car parking lot area that was surrounded by the buildings. h. On 7/12/2023 at 7:30AM the surveyor walked up to the secure unit to enter. A staff member exited through the front entrance, and offered the surveyor the code to enter the cottage. i. On 7/12/2023 at 9:55AM interview with Licensed Practical Nurse (LPN) #1 who stated on 7/4/23 she received a call from the ambulance service requesting Resident #1's date of birth , and stated they had the Resident in route to the hospital. She stated from her understanding the CNA's in the secure cottage had been looking for Resident #1 for about 10 minutes and had not called to notify her because they wanted to make sure the Resident was not just in a room somewhere. LPN #1 stated, I think the Resident followed the family of one of the other residents out when they left, Resident #1 can walk very good and really doesn't look like a nursing home resident. j. On 7/13/2023 at 9:40AM the surveyor asked CNA #3, who had the code to the secure cottage entrance/exit front door on 7/4/2023? CNA #3 stated, the staff of course, and some of the families that come regularly. She stated there were two families visiting on 7/4/23, one left at 12:30 PM and the other left about 12:40 PM. She stated the doors have not malfunctioned in the past, and always lock and stated she thinks the resident walked out with one of the families. She stated the Resident has not attempted to exit in the past, and stated the resident does go out to smoke. k. On 7/13/2023 at 10:20 AM interview with the Director of Nursing (DON) revealed the LPN working on the day of the elopement believed the resident exited with the visitors. She stated the staff and the families who visit regularly have the door code, and further stated the staff provided the code to the family members. The DON confirmed there was no signage on the exit doors related to not letting the residents out of the door. l. Review of the website www.timeanddate.com/weather, accessed on 7/13/23 revealed the temperature for 7/4/23 at 12:00 PM to be 90 degrees and partly sunny, with humidity at 61 percent. m. On 7/13/2023 at 10:30AM review of policy titled, Missing Resident/Elopement Protocols, no date of. The policy stated, .It is the policy of the facility to provide a safe and secure environment for all residents. In the event of resident elopement, it is the policy of the facility to implement its elopement protocols immediately to locate the resident in a timely manner. 2. The facility implemented the following to correct the non-compliance: a. On 7/4/2023 Abuse and neglect training was completed in the secure cottage. b. On 7/4/2023 Resident #1 was placed on a 48-hour l -on 1supervision until the secure cottage door code could be changed. Only staff will have the secure door code. Staff will let visitors in and out. Staff will be required to stand by the door to assure they hear door closure clicks and locks. Staff must put in secure key code to allow any entrance to the secure cottage or exit from the secure cottage and the staff have been instructed not to give out the code to visitors. c. On 7/4/2023 All staff on all shifts will review the care plans, and will follow the care plans. d. On 7/4/2023 Inservice on Elopement / missing resident and protocols. e. On 7/4/2023 the Maintenance Director checked all locks and keypad lock number was changed. f. On 7/4/2023 a plan for a fence to be placed around the property. On 7-11-2023 at 1:30 PM observed maintenance staff with heavy equipment in the area of the planned fence, clearing small trees and dirt for construction to begin. g. On 7-12-23 at 8:30 AM the Administrator stated the facility has ordered and will be putting low sounding alarms on all the doors to the secure unit that will sound if the door is open for a specified length of time to alert the staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the care planned level of supervision was provided to a resident with a history of burning himself while smoking and staff responsible for the resident's care were aware of the need to provide supervision and secure cigarette lighters to prevent further potential injury for 1 (Resident #47); and failed to ensure smoking safety assessments were conducted and documented upon admission and at least quarterly to determine the level of supervision necessary to ensure resident safety for 2 (Residents #47 and #20) of 3 (Residents #47, #20 and #34) sampled residents who resided in the [NAME] Cottage and smoked. The facility also failed to ensure cigarette lighters were kept in a secure location and regular monitoring was conducted to ensure compliance with the residents' care planned needs and the facility's smoking policy to prevent potential fire or further potential burn injuries for residents who resided in 1 ([NAME] Cottage) of 6 cottages. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #47, and had the potential to cause more than minimal harm to all 12 residents who resided in the [NAME] Cottage, as documented on the Census by Cottage list provided by the Administrator on 1/3/22 at 9:50 a.m. The Administrator was notified of the immediate jeopardy situation on 1/3/22 at 3:43 p.m. The findings are: 1. Resident #47 had diagnoses of Nicotine Dependence, Other Tobacco Product, Depressive Episodes, Paranoid Schizophrenia, and Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/2/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required setup and supervision with locomotion on and off the unit, was independent with transferring, used a wheelchair for mobility, had an active diagnosis of Non-Alzheimer's Dementia, and had no open lesions or second or third-degree burns in the past 7 days. a. The Smoking Safety Screening dated 8/30/21 documented, .Can resident light own cigarette? Yes . Resident need for adaptive equipment: Smoking apron . Does resident need nursing facility to store lighter and cigarettes? Yes . Plan of care is used to assure resident is safe while smoking? Yes . IDTC [Interdisciplinary Team Conference] decision: .Elder dropped cigarette on right thigh and has ongoing treatment to area. Elder will now smoke with apron and supervision as needed. Will re-evaluate at later date. Team decision: Safe to smoke with supervision . b. The Care Plan dated as revised 8/30/21 documented, [Resident #47] chooses to smoke, had dx [diagnosis] of nicotine dependence . 3/20/19 staff to keep and store lighter up per facility policy . 8/30/2021 [Resident #47] voiced that he dropped his cigarette on his leg . 8/30/2021 When notified of smoking assessment update to wear smoking apron and supervision, he refused . There was no documentation on the Care Plan to indicate any alternate interventions were discussed or developed after the resident refused the smoking apron. c. The Shahbaz Care Plan updated 8/30/21 documented, .Special needs: .Smoker - staff to keep / store lighter per facility policy. d. A Nursing MDS Progress Note dated 8/31/21 documented, This nurse was notified to conduct another smoking assessment 8/30/21, elder stated to staff that he dropped a cigarette on his leg. Smoking assessment was updated to wearing a smoking apron and supervision. When elder was notified he became upset and states, 'Y'all can't make me wear that, I'm not going to and there is no one here that can make me'. This nurse notified DON [Director of Nursing] and Admin [Administrator]. e. On 12/13/21 at 11:19 a.m., the resident was sitting in his wheelchair on the front porch of the cottage, smoking a cigarette, with no smoking apron on. Various nursing staff went in and out the front door, but no staff member was providing continuous supervision to the resident while he smoked. The resident did not drop the cigarette or ashes on himself during the surveyor's observation. f. On 12/14/21 at 8:48 a.m., Certified Nursing Assistant (CNA) #1 was asked, In the [NAME] Cottage, who gets [Resident #47] his cigarettes and lighter when he wants to smoke, and who takes him out? CNA #1 stated Oh, he keeps them in his room, and he takes himself out whenever he wants to go smoke. g. On 12/14/21 at 12:51 p.m., the resident was in his room and was asked, Who takes you to smoke, and do you wear an apron when you are smoking? He stated, I take myself to smoke and no, I don't wear that apron. They wanted me to, but I am not going to. There were 2 packs of cigarettes and a lighter on the bedside table at the end of the bed. There were also 2 old lighters on a shelf in the room. The cigarettes and lighters were within reach of any resident who came into the resident's room. A list provided by Director of Nursing (DON) #1 on 12/16/21 at 1:00 p.m. documented there were 6 residents who resided in the [NAME] Cottage who, have cognitive impairments but can still get around. h. On 12/15/21 at 10:56 a.m., Licensed Practical Nurse (LPN) #1 was asked, Can residents keep their cigarettes and lighters in their rooms? She replied, I don't think they can have their lighter in their rooms; they have to get those from the staff when they want to smoke. i. On 12/16/21 at 3:00 p.m., Director of Nursing (DON) #1 was asked, If [Resident #47] wants to smoke, who does he get his cigarettes and lighter from? She stated, The staff keeps them in a drawer in the kitchen, or in the nurse's desk and sometimes in the med [medication] cart. The DON was asked, Can any of the residents keep their cigarettes and/or lighter in their rooms? The DON stated, No. The DON was asked, Is there a concern regarding safety and accidents if residents are allowed to keep their lighter and cigarettes in their room? She stated, Yes, well they could smoke in their room, and if there is oxygen in use that could be dangerous, and if the other residents get ahold of it that is a true concern. j. On 1/3/22 at 9:45 a.m., surveyors re-entered the facility to further investigate failed practices related to supervision of residents who smoked. DON #1 was no longer available for interview. DON #2 had been employed in the DON position for less than 2 weeks. k. On 1/03/22 at 11:09 a.m., LPN #4 and CNA #1 were asked, Where are the residents' cigarettes and lighters stored? LPN #4 stated, The residents keep their cigarettes in the medication cart and showed the surveyor packs of cigarettes for Resident #20 and another resident who resided in the [NAME] Cottage. The LPN stated she did not have any cigarettes for Resident #47 and, I assume he keeps his own cigarettes. She was asked where he kept them and stated she was not sure if he kept them, in his room or put up. She stated Resident #20, .gets a pack of cigarettes a day and they [residents] smoke whenever they want to . The lighters are kept in the drawer in the kitchen area, generally, and they have to ask for them. CNA #1 stated, The nurse keeps them in the med cart or in the extra medication closet, usually. The LPN and CNA were asked, How do you know what safety precautions are to be used with residents? LPN #4 stated, Oh, I am not sure who assesses that and where to find that information out at this time. CNA #1 stated, The nurses do the assessment on that. They were asked, Is there a smoking schedule for the residents? LPN #4 stated, There is no smoking schedule; they smoke whenever they want to. CNA #1 stated, There is no schedule. They were asked, Who is responsible for supervising the residents when they smoke, if they need it? LPN #4 stated, The aides. CNA #1 stated, Aides. They were asked, How does the facility determine who is safe to smoke alone or with supervision? LPN #4 stated, I am not sure. CNA #1 stated, Social Services Director or the Nurse that is over the cottage does the assessment on the residents. l. On 1/3/22 at 11:33 a.m., DON #2 indicated she was not aware that Resident #47 had cigarettes and lighters in his room on 12/14/21. She was asked to provide a copy of a current smoking assessment for Resident #47 and documentation of what the facility was doing to mitigate the risk of injury to Resident #47 or other residents, related to the resident smoking unsupervised and having lighters found in his room. At 12:30 p.m., the DON provided the smoking assessment dated [DATE] as the most recent smoking assessment for this resident. The DON also provided a typed document that listed the measures to protect residents from potential fire / burn injuries related to smoking residents. It documented, Several safety precautions are in place to ensure that all elders are safe in the event another elder may choose to refuse help or assistance for safety purposes. Red safety smoke cans are placed on each back porch. Lighters are stored by staff so that use can be monitored. Wool fire protection blankets are stored in each library. All residents that chose to not smoke are separated from the designated smoking section by an airlock or two closed doors. All elders are housed in private rooms. The document did not indicate any monitoring was conducted to ensure lighters were secured and residents were supervised in accordance with their assessed and care planned needs. No staff in-servicing or monitoring had been initiated since the original survey exit date of 12/17/21. On 1/3/22 at 5:45 p.m. during the exit conference, the Administrator stated the facility had not initiated any in-services or monitoring prior to 1/3/22 because they were waiting for the 2567 to arrive. m. On 1/3/22 at 11:54 a.m., Resident #47 propelled himself to the back porch to smoke. CNA #1 stated, [Resident #47] won't wear an apron. He's supposed to, but he won't. The resident removed a pack of cigarettes and a lighter from his coat pocket and lit his cigarette. The CNA supervised the smoke break. n. On 1/3/22 at 12:12 p.m., Resident #47 was asked, Where do you keep your cigarettes and lighter when you aren't smoking? He stated, I keep my cigarettes on me, but they keep my lighter at the desk. He was asked, Has anyone ever talked to you about wearing an apron? He stated, Yes, they did, but I'm not going to. He was asked, Have you ever been burned? He stated, Yes, and that's my business. If you want to put me out of here, go ahead. o. On 1/03/22 at 12:20 p.m., CNA #1 was asked where the lighters were kept in the kitchen and stated, They are kept here in this drawer. The CNA opened a drawer and showed the surveyor lighters in Ziplock bags labeled with residents' names. 2. Resident #20 had diagnoses of Hypertension, Diabetes Mellitus Type 2, and Alcohol Dependence with Alcohol-Induced Mood Disorder. The admission MDS with an ARD of 3/30/21 documented current tobacco use. The Quarterly MDS with an ARD of 9/30/21 documented the resident scored 15 on a BIMS, was independent with transfer, required supervision and set-up help with walking and locomotion. a. The Shahbaz Care Plan updated 7/6/21 documented, .Special needs: .Smoker - staff to store and keep lighter per facility policy . b. The Care Plan dated 10/4/21 documented, [Resident #20] is a smoker, staff to store and keep lighter per facility policy . 10/20/2021 [Resident #20] becomes upset at times with staff about lighter policy, he states, 'I am a grown man, and I don't need no one telling me that I can't keep my cigarettes and lighter'. [Resident #20] is able to smoke without staff supervision . As of 1/3/22, there was no Smoking Safety Screening available for review in the resident's clinical record. c. On 1/3/22 at 10:51 a.m., Resident #20 was on the back porch of the [NAME] Cottage smoking with no staff present. He was asked, Do you smoke on a schedule or do you smoke whenever you want to? He stated, Whenever I want to. He was asked, Do the staff keep your cigarettes and lighter or do you keep them? He stated, I keep them. The nurses are so busy, I hate to interrupt them from what they are doing, so I keep them myself. The resident did not exhibit any unsafe smoking practices during the surveyor's observation. d. On 1/3/22 at 11:33 a.m., DON #2 was asked for a current smoking assessment for Resident #20. e. On 1/3/22 at 11:54 a.m., Resident #20 propelled himself to the back porch to smoke. CNA #1 assisted him with applying a smoking apron, then the resident used a lighter from his pocket to light his cigarette. The CNA remained on the porch to supervise this smoke break. f. On 1/3/22 at 12:30 p.m., DON #2 provided a smoking assessment for Resident #20 with an effective date of 9/24/21 which documented the resident was able to smoke without staff supervision; however, the lock date on the assessment was 1/3/22 and the assessment was signed by LPN #5 on 1/3/22. DON #2 was asked, Does the lock date [of 1/3/22] mean it was completed today? She stated, I don't know. I would have to find out. She was asked, How often are the smoking assessments completed? She stated, I'm not sure. I will have to check. 3. A Smoking Policy provided by DON #1 on 12/15/21 at 2:15 p.m. documented, It is the policy of this facility to ensure a safe environment for all residents who wish to smoke outside at the facility . Any resident that wishes to smoke while a resident at this facility will be required to keep their lighters, matches, electronic cigarettes, as well as other smoking related items, locked up . All residents that wish to smoke will have a smoking assessment completed upon admission and change in condition to determine safety equipment that is needed . Residents will be allowed to smoke at designated times determine by facility and smoking residents' preferences . The first instance where a resident is caught not following the smoking policy will result in a care plan meeting with resident and responsible party to ensure resident and responsible party understand the policy . Second instance where a resident is caught not following the smoking policy may result in the resident receiving an immediate discharge notice due to safety in facility being jeopardized . On 1/3/22 at 5:45 p.m. during the exit conference, the Administrator stated this policy provided by DON #1 on 12/15/21 was not the facility's policy but did not provide a different smoking policy for the facility at this time. Per the regulation at 483.90(i)(5) - tag F926, facilities are required to establish policies regarding smoking, smoking areas, and smoking safety. 4. The immediate jeopardy was removed, and the scope/severity reduced to E on 1/3/22 at 5:30 p.m. when the facility implemented the following plan of removal: 1/3/2022 Plan of Removal. Department heads made rounds in each cottage all rooms for cigarette and lighters are to be secured by staff - [Activities Director] & [and] [Social Services Director] for residents at all times. Inservice taken around and staff signed. Rounds were conducted 1/3/22. If it is care planned for a resident to wear a smoking apron while smoking, they are to be supervised to ensure that all cigarettes and lighters are being kept by staff. Reviewing Care Plans and interventions to be done by [LPN #5] MDS and [LPN #1] MDS. Every shift should check resident's rooms to ensure that all cigarettes and lighter are being kept by staff. Inservice conducted by [Activities] and [Social Services]. If at any time you observed a resident that appears to need to be given a smoking assessment, please notify your DON and Administrator immediately. All smoking assessments to be done today on all smoking elders - MDS [LPN #5] and [LPN #1] MDS. All these inservices will be done this shift and all shifts x [times] 1 week. Then we will monitor 3 times a week for 8 weeks by all department heads.