Based on observations, interviews, record review, and facility policy review, the facility failed to implement measures to prevent Resident #76 from having unsupervised access to smoking materials, including lighters, cigarettes, and marijuana. This failure affected 1 (Resident #76) of 5 total residents identified by the facility as smokers. The facility allowed Resident #76 to have unsupervised visits with Visitor #28, who repeatedly provided the resident with smoking materials despite having been educated on the facility's smoking policies multiple times. After the facility had educated both Resident #76 and Visitor #28 on the facility's smoking policies, the resident and visitor continued to be noncompliant. The facility had assessed Resident #76 as requiring supervision while smoking and the facility was required to store all of the resident's smoking materials due to non-compliance with the facility's smoking policy, including a history of smoking inside the facility and in non-designated smoking areas. It was determined the provider's non-compliance with one or more requirements of participation had caused or was likely to cause serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy (IJ) was related to the State Operations Manual, Appendix PP, 483.25(d) Accidents, at a scope and severity of J. The IJ began on 01/02/2024 at 11:16 AM when Resident # 76 was observed in the hallway of the facility with smoking materials, including cigarettes and a lighter, in their possession. The Administrator and Director of Nursing (DON) were notified of the IJ on 01/21/2024 at 10:55 AM and provided a copy of the IJ template on 01/21/2024 at 11:18 AM. A removal plan was requested. The removal plan was accepted by the State Survey Agency on 01/22/2024 at 10:05 AM. The IJ was removed on 01/22/2024 at 4:44 PM after the survey team performed onsite verification that the removal plan had been implemented. Noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that was not immediate jeopardy for F689. Findings included: A review of a facility policy titled Smoking Policy - Residents, revised in August 2022, revealed, This facility has established and maintains safe resident smoking practices. The policy further indicated, 2. Smoking is only permitted in designated resident smoking areas which are located outside of the building, 7. The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 9. Any smoking-related privileges, restrictions, or concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues, and 14. Residents without independent smoking privileges, may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision. The policy specified, This facility maintains the right to confiscate smoking items found in violation of our smoking policies. A review of Resident #76's admission Record revealed the facility admitted the resident on 11/19/2021. According to the admission Record, the resident had a medical history that included diagnoses of tobacco use, senile degeneration of the brain, delirium due to known physiological condition, and muscle wasting and atrophy. A review of Resident #76's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/28/2023, revealed Resident #76 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. A review of Resident #76's comprehensive care plan revealed a Focus area, initiated on 11/20/2021 and revised on 09/01/2023, that indicated the resident was a smoker and does not follow the scheduled smoking times. Very impulsive and screaming at staff to take [him/her] to smoke. The Goals were that Resident #76 would not suffer injury from unsafe smoking practices and Resident #76 would smoke at the designated area through the next review date of 03/13/2024. Resident #76's smoking care plan included the following active interventions created on 12/10/2021: - Complete smoking assessment. Reassess resident quarterly, annually, and with change of condition, - Educate resident and family about the facility policy on smoking: locations, times, and safety concerns, - Monitor resident's safety during smoking, - Notify charge nurse immediately if it is suspected resident has violated facility smoking policy, - The resident requires SUPERVISION while smoking, and - The resident's smoking supplies should not be stored at bedside. A review of Resident #76's quarterly Smoking - Safety Screen, dated 03/12/2023, revealed the resident could light their own cigarettes and was safe to smoke without supervision in designated areas. The Smoking - Safety Screen indicated the resident had prior episodes of smoking inside the facility, and the facility was to store the resident's cigarettes and lighter in the nurses' cart. A review of Resident #76's quarterly Smoking - Safety Screen, dated 05/30/2023, revealed Resident #76 could light their own cigarette but needed supervision and one-on-one assistance. According to the Smoking - Safety Screen, the resident was not safe to smoke without supervision, and the resident had a history of noncompliance with the designated smoking area and smoking inside the facility. The facility was to store the resident's cigarettes and lighter in the nurses' cart. A review of Resident #76's medical record revealed a Smoking - Safety Screen had not been completed since 05/30/2023. A review of Resident #76's Progress Notes revealed the following entries: - A COMMUNICATION - with Resident note, dated 04/01/2022 and documented by the Social Services Director (SSD), that indicated the SSD spoke with the resident to remind them of the facility's smoking policy after a nurse found a cigarette in the resident's possession. According to the note, the SSD discussed the following information with the resident: 1) [Resident #76] can't keep a cigarette and a lighter on [sic] [Resident #76's] possession. It must be kept by the charge nurse and will only be given to [Resident# 76] before smoking. 2) There is only one designated smoking area- outside by the end of the driveway/ left end side of the building. 3) [Resident #76] will be escorted by the staff for safety monitoring. The note indicated the resident understood, denied ever smoking inside the building, and said the cigarette that was found was an extra from the previous smoke break. - A COMMUNICATION - with Resident note, dated 07/01/2022 and documented by the SSD, which indicated the SSD spoke with and counseled the resident regarding an incident earlier in the morning on the same day in which the resident lit and smoked inside the facility. The SSD informed the resident the incident was a major fire safety concern and that their actions could endanger the resident, as well as everyone else in the facility. According to the note, the resident was again reminded of the facility's smoking policy, specifically, 1) Smoking in any part of the building is strictly prohibited. 2) Smoking should only be in the designated area - outside the building by the parking garage 3) Smoking is limited to 3x [times] per day/ one time every shift and [he/she] should be escorted depending on the availability of the staff while smoking. 4) [His/her] cigarette and lighter should be kept at the nurses' cart and will only be given to [him/her] during smoking schedules. 5) Violation of the Smoking Policies will result in the cancellation of [Resident #76's] smoking rights. The note indicated the resident understood and agreed. - A CARE CONFERENCE OR IDT [interdisciplinary team] NOTES entry, dated 09/28/2022 and documented by the SSD, that indicated the SSD facilitated a care conference on 09/27/2022 with Resident #76 in the presence of Visitor #28, the Ombudsman, and the Registered Nurse (RN) Supervisor (currently Assistant Director of Nursing (ADON)/Infection Preventionist (IP) #23) and discussed the resident's plan of care, and the resident's violation of facility house rules. According to the note, they also discussed that the resident was verbally aggressive and non-compliant with care, and the resident was continuously violating the house rules as far as smoking cigarettes and street drugs (marijuana). The note revealed the resident was again reminded of the facility's smoking policy, including that their cigarettes and lighter would be kept by the nurse, and the resident would have access only during scheduled smoking times to prevent the resident from lighting cigarettes in non-designated smoking areas. The note indicated, This restriction was violated by the resident several times despite frequent counseling and reminder. They also reminded Visitor #28 that all personal items brought to the facility should be endorsed by facility staff for inventory purposes and would allow cigarettes to be supervised and accounted for. The note also indicated the Ombudsman informed Resident #76 and Visitor #28 that federal law prohibited organizations such as nursing facilities from allowing the use of street/prohibited drugs on their premises. The note revealed the Ombudsman informed the resident that this violation was grounds for eviction from the nursing home, and that while smoking was a resident's right, the nursing home had the right to make their own rules to accommodate the right to smoke. The note also indicated Resident #76 and Visitor #28 were advised to look for alternative placement as soon as possible because the resident's physical and medical condition were stable and did not require the services provided at the nursing home. - A CARE CONFERENCE OR IDT NOTES entry, dated 12/21/2023 and documented by the SSD, that indicated the Nursing QA Director, RN Supervisor, SSD, Ombudsman, and Abuse Coordinator met with Resident #76 and Visitor #28 to discuss the resident's plan of care and other concerns related to violation of the facility's house rules. According to the note, the SSD informed the resident and Visitor #28 that during the deep cleaning of the resident's room over the weekend, a significant amount of marijuana cigarettes were found on top of [his/her] bedside table and bed by maintenance staff, and the RN Supervisor was informed and confiscated the items. The note revealed Resident #76 and Visitor #28 were reminded of the prior meeting on 09/28/2022 in which it was discussed that street/illegal drugs were not permitted on the premises of the facility per federal law and were grounds for eviction. The note revealed the RN Supervisor also reminded Visitor #28 that they had previously discussed that marijuana use could increase the resident's heart rate and blood pressure and lead to an increased risk of stroke, heart disease, and other vascular diseases, and combined with the resident's ongoing cardiovascular and coagulation issues, could lead to death. According to the note, Resident #76 admitted they used marijuana, promised not to do it again, and said they would not light and smoke cigarettes inside the building. On 01/02/2024 at 11:16 AM, Resident #76 was observed in the hallway waiting on the elevator. The surveyor rode the elevator to the first floor with the resident, and the resident then wheeled themself to the back door with their cigarettes and lighter in their pocket. No staff members were present, and Resident #76 said they could go out to smoke on their own and did not need any help. At 11:21 AM, the Chief Executive Officer (CEO) was entering the facility through the back door and stopped the resident from going outside. She instructed RN #1 to go with Resident #76 outside because the resident needed someone to be always with them while smoking. Once outside, Resident #76 pulled their cigarettes and a lighter out of their pocket and lit a cigarette. When Resident #76 finished smoking, Resident #76 put their cigarette out on their wheelchair tire and threw the cigarette butt onto the ground. RN #1 assisted Resident #76 back into the facility. During a subsequent interview with Resident #76, on 01/02/2024 at 11:38 AM, the resident's cigarettes and lighter were observed on the resident's bedside table. During the interview, the resident stopped a staff member and asked for a cup of hot water to make coffee. The staff member returned with the hot water, and the resident made a cup of coffee using instant coffee from their drawer and stirred it with the end of their cigarette lighter. On 01/05/2024 at approximately 2:10 PM, Resident #76 was observed sitting outside in their wheelchair next to the gate to the parking lot, not in the designated smoking area, and no staff members were present while the resident was smoking. Continued review of Resident #76's Progress Notes revealed the following entries: - A CARE CONFERENCE OR IDT NOTES entry, dated 01/10/2024, that indicated the IDT, including the Medical Director (MD), Administrator, DON, ADON #6, ADON/IP #23, SSD, Activity Director, and Director of Staff Development (DSD), met to discuss issues and concerns involving Resident #76. The note reflected the following, ISSUES AND CONCERNS: Resident is a cigarette smoker. [He/she] has also had episodes of smoking illicitdrug [sic] (marijuana). [He/she] was assessed and determined to be unsafe to smoke independently, the facility imposed smoking restrictions on [him/her] that [he/she] cannot smoke without support and supervision of visitors, family or staff and cannot keep smoking items (cigarette, tobacco, lighter or other smoking paraphernalia). Despite the restrictions, resident secretly, continuously and intentionally possessing cigarette, illicit drug and lighter to have easy access when needed. On several occasions, resident was reminded and counseled about the House Rules particularly Smoking (cigarette and illicit drugs) and Alcohol Consumption. Care conferences were conducted several times in the presence of [his/her] friend [Visitor #28], Ombudsman and IDT. Resident admitted and acknowledged [his/her] violation of House Rules specifically: 1) The use and possession of illicit frug (Marijuana) 2) Smoking inside the building (in bed, inside the bedroom, 2nd floor hallway and ground floor hallway) 3) Consumption of alcohol. The note revealed During those care conferences and counseling during actual incidents, resident apologized and promised that [he/she] will not do it again. However, those promises had never been fulfilled and there was no indication of following the facility House Rules. With these serious violations of the facility House Rules, the resident was putting [his/her] self and other residents to a [sic] significant danger by causing a potential fire in the building. This note reflected the following RECOMMENDATIONS from the IDT: To offer accommodation to escort and supervise the resident to the smoking area based on smoking schedules two to three times a day, not allow the resident to have possession of cigarettes, illicit drugs, lighter, or any other smoking materials, cigarettes and lighter will be under the safekeeping in a medication cart and will only be given to the resident during the agreed smoking schedules, the resident's room would be checked regularly to ensure that they did not have possession of any cigarette, lighter, and other smoking materials, and a 30-day discharge notice would be issued if the resident repeatedly violated the smoking policy. - A Licensed Nurse's Notes entry and a Psychosocial Note dated 01/13/2024 that indicated Resident #76 reported to a nurse that their roommate (Resident #404) threatened to hit them. According to the note, the nurse went to speak with Resident #404, who reported Resident #76 asked them to buy the resident cigarettes, and Resident #404 denied the request. Further, the SSD (via phone) and RN #27 spoke with the roommate, and the roommate denied having made such a threat but said Resident #76 kept asking the roommate for cigarettes, even at night, and Resident #76 got upset when they did not get one. - A Plan of Care Note documented by a physician for a date of service of 01/16/2024 that indicated the nurses reported Resident #76 was smoking cigarettes and marijuana outside and inside their room. The note revealed nursing staff reported to the physician that there had been a past incident of the resident smoking in their room, and they had already had a meeting with the resident, in which the resident admitted they violated the facility's policy. The note revealed the nursing staff told the physician that Resident #76 needed to be discharged or transferred to another facility. - A CARE CONFERENCE OR IDT NOTES entry, dated 01/18/2024, that indicated the Administrator, SSD, and RN# 27 met with Resident # 76 and Visitor #28 to discuss the resident's continued non-compliance with the facility's smoking policy and procedure. The note indicated, The resident has been witnessed smoking inside the facility, against the facility's policy, jeopardizing the health and safety of other residents. The resident was educated several times before and continues to be non-compliant. The facility expressed concerns regarding the resident's safety and the health of other residents. The resident agreed to 4 times daily smoking schedule with direct supervision of staff. The resident was offered a smoking cessation program and refused. The Resident also agreed not to keep any smoking materials on [his/her] person or in [his/her] room. - A COMMUNICATION - with Resident note documented by the Administrator and a Licensed Nurse's Notes entry, dated 01/19/2024, that indicated the Administrator witnessed the resident smoking inside the facility in the waiting area on the second floor. The note revealed the resident was immediately stopped, smoking materials were confiscated from the resident, and the resident gave verbal consent for their room to be searched. Per the note, a room search was conducted by RN# 27 and the Administrator, and no additional smoking materials were found. - A COMMUNICATION - with Resident note dated 01/20/2024 and documented by the Administrator revealed that the Administrator observed Resident #76 holding a cigarette lighter returning from the smoking area at approximately 4:45 PM. According to the note, the resident was out on pass and went to the smoking area with Visitor #28. The note indicated the Administrator reminded the resident they could not have any smoking materials, and the resident agreed to hand over a lighter. During an interview on 01/19/2024 at 4:02 PM, Resident #404, Resident #76's roommate, stated they had been at the facility for about two weeks, and Resident #76 did not follow the rules when it came to smoking. Resident #404 said Resident #76 had smoked in their room and had smoking materials in their room. Resident #404 further stated staff seemed to allow Resident #76 to do anything the resident liked. During an interview on 01/05/2024 at 9:33 AM, Certified Nurse Aide (CNA) #5 said she knew how much assistance a resident needed when smoking from the machine on the wall (kiosk), and the resident could usually tell her. CNA #5 stated she had not seen Resident #76 smoking independently because she was a new employee and took the resident to the smoking area herself when she was assigned to them. During an interview on 01/05/2024 at 9:41 AM, CNA #4 stated she stayed with smoking residents the whole time they were outside smoking. CNA #4 said she had never seen Resident #76 smoking independently and stated residents were not supposed to keep their cigarettes and lighters in their rooms, but some try to sneak them. CNA #4 could not recall the date of her last staff training on smoking safety. During an interview on 01/05/2024 at 1:14 PM, the DON stated it was her expectation that residents be assessed for their smoking capabilities upon admission, with any significant change, and quarterly. She stated if the assessments were not done or were not done accurately, residents could be at risk for injury while smoking. The DON said residents were educated about smoking safety and the facility's smoking rules upon admission. She further stated she thought all residents' lighters and cigarettes were kept at the nurses' station and staff members were responsible for returning the smoking materials back to the nurses' station after smoke breaks, but she was not sure and indicated ADON #6, the previous DON, would be able to clarify. During an interview on 01/05/2024 at 1:43 PM, ADON #6 stated residents were assessed for smoking safety upon admission and then reassessed quarterly, usually around the time of the MDS assessments, because they could have had a change in their ability to safely smoke. ADON #6 said two of the three smokers in the facility, including Resident #76, were required to have their smoking materials stored at the nurses' station, and the other one was independent and could keep their own smoking materials. ADON #6 said for the residents whose smoking materials were stored at the nurses' station, they provided them to the residents when requested and sent a staff member with them while the residents smoked. ADON #6 said the staff member was responsible for returning the smoking materials to the nurses' station so they could be locked up until the next smoke break because if they left it up to the residents, they would sneak and keep them. During an interview on 01/19/2024 at 4:30 PM, RN #27 stated smoking assessments were completed quarterly, during admission, and after significant changes. RN #27 revealed Resident #76 had smoked inside the facility, and the facility confiscated the resident's smoking materials. During a follow-up interview on 01/20/2024 at 1:46 PM, RN #27 stated she completed smoking assessments and confirmed Resident #76 had not been assessed for smoking since May 2023. During an interview on 01/19/2024 at 5:43 PM, RN #2 stated she had worked at the facility for six months. She stated that cigarettes and lighters were kept with the nurses, locked in a cart. She stated that when they went outside to smoke, they gave the residents the cigarettes and lighters and retrieved them when they were finished due to safety concerns. During an interview on 01/20/2024 at 9:48 AM, CNA #31 stated she had worked at the facility for three months and was not aware of any residents smoking in the facility. She stated that Resident #76 was allowed to smoke alone and that their family took them. She stated she had seen Resident #76 smoke alone about three months ago. During an interview on 01/22/2024 at 11:39 AM, CNA #5 stated that she was not sure if Resident #76 was allowed to have the smoking items. She stated she had seen the resident smoke in the facility's lobby once. During an interview on 01/20/2024 at 10:28 AM, RN #3 stated that she had worked at the facility since October 2023. She stated that she was not aware of Resident #76 smoking in the facility. She stated that the resident had to be taken down to the smoking area, then she would leave the resident and come back and get the resident. She stated she was not sure if the resident was safe alone. RN #3 stated she had not received training regarding smoking. She stated she last took Resident #76 to smoke last Saturday. RN #3 stated she left the resident and told the resident she would be back in 15 minutes. During an interview on 1/20/2024 at 10:59 AM, ADON/IP #23 stated that the resident had only been observed smoking in the facility once. During an interview on 01/20/2024 at 2:56 PM, the Administrator stated Resident #76 could not smoke inside and stated that the resident had to be supervised when they smoked. He stated the resident could not keep smoking materials their self. He stated that when he caught the resident smoking, the resident stated they received the smoking materials from Visitor #28. The Administrator stated that Visitor #28 came on 12/21/2023 and was formally informed not to bring the resident smoking materials. He said he had spoken with Visitor #28 at least three times about not allowing the resident to smoke unsupervised and having smoking materials. He stated that a family member gave the resident cigarettes today. The Administrator stated that he expected facility staff to make sure the resident got to the smoking area, ensure the resident was being safe, and ensure the cigarettes were placed in the receptacle. He stated that the staff were lighting the cigarettes and that the smoking materials were in the staff's possession. The Administrator stated that even after meeting with the resident and family member, the resident continued to be noncompliant. On 01/22/2024 at 10:05 AM, a removal plan was submitted by the facility and accepted by the State Survey Agency. It read as follows: Plan of Removal F689 - Free of Accident / Hazards 1. How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1.1 Resident #76 still resides in the facility. 1.2 Resident #76's ability to smoke independently was reassessed on 01/19/2024. The resident requires direct supervision to smoke. Resident #76's plan of care was updated to include the need for direct supervision during smoking activity as determined and assigned by the smoking schedule. 1.4 A smoking schedule was implemented on 01/18/2024 for resident #76 by the interdisciplinary team and agreed upon by the resident and friend. Long-Term Care Ombudsman was informed. 1.5 The facility issued resident #76 a 30-day discharge notice on 01/21/2024 for noncompliance with the facility's policy and procedure for smoking. 1.6 The facility implemented new measures for visitation, including requiring direct supervision of each visit with Resident #76 by management staff and/or nursing staff. 1.7 Resident #76's attending physician was notified of the resident's non-compliance with the smoking policy. 1.8 The facility implemented new measures for out-on-pass, which include searching the resident upon return to the facility for any smoking material in his possession with consent. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; 2.1 The facility audited all five residents who smoke and reassessed their ability to smoke independently. 2.2 The facility updated the plan of care to include each resident's ability to smoke independently and safely. 3. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur; 3.1 The Director of Staff Development and Assistant Director of Nursing provided in-service re-education to environmental, dietary, nursing, activities, and management staff on 1/20/24 and 1/21 /24 regarding the facility's policy and procedure titled 'Smoking Policy - Residents' with an emphasis on Resident #76's smoking schedule and interventions due to history of non-compliance. For staff who are not included in the initial training, the facility will provide in-service re-education on an ongoing basis. The facility will compare the in-service documentation with the staff roster to ensure all appropriate staff receive the training. Staff who fail to attend the in-service will be removed from the schedule until completion of the in-service training. 4. How the facility plans to monitor its performance to make sure that solutions are sustained; 4.1 Effective 01/21/2024, the Director of Nursing and/or Designee will complete monthly audits of residents who smoke to ensure the Smoking Assessment and care plans are accurate. Any concerns identified will be addressed immediately. 4.2 Effective 01/21/2024, the Smoking Monitors, as outlined in the resident's smoking schedule, and/or Designee will complete a daily visual audit four times daily to ensure the resident complies with the facility's smoking policy. Documentation of this audit will be maintained in a binder. Any concerns identified will be addressed immediately. 4.3 The Director of Nursing and/or Designee will report significant trends identified in the monthly smoking audit to the QAPI/QAA [quality assurance and performance improvement/ quality assessment and assurance] Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction; or, for the purpose of terminating this plan of correction when substantial compliance has been achieved. 4.4 The Administrator and/or Designee will report significant trends identified in the daily visual audit to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction or for the purpose of terminating this plan of correction when substantial compliance has been achieved. 4.5 Substantial compliance shall be indicated by three consecutive reviews during the QAPI/QAA Committee analysis without findings. 4.6 Allegation of compliance date: 01/21/2024. Onsite Verification: The IJ was removed on 01/22/2024 at 4:44 PM after the survey team verified the implementation of the facility's removal plan as follows: 1.2 Assessment documented Resident #76's need for supervision during smoking. Verified in chart 01/22/2024 at 10:11 AM. Verified through interview with the DON and Administrator on 01/22/2024 at 11:34 AM. 1.3 The care plan documented Resident #76's need for supervision during smoking. Verified in the chart on 01/22/2024 at 10:11 AM. Verified through interview with the DON and Administrator 01/22/2024 at 11:34 AM. 1.4 Reviewed the smoking schedule provided by the facility; the meeting was documented in progress notes and saved by the surveyor. Verified through a telephone interview with Visitor #28 on 01/22/2024 at 10:36 AM. Visitor #28 stated the facility had provided education regarding bringing smoking materials into the facility for Resident #76. The facility had placed Resident #76 on a smoking schedule, allowing the resident to smoke four times each day. The facility explained to Visitor #28 that Resident #76 was not allowed to smoke without being supervised. Resident #76 was not allowed to smoke in any areas within the facility. Verified through telephone interview on 01/22/2024 at 1:58 PM with the Ombudsman, who indicated being made aware of the meeting on 01/18/2024 but was unable to attend. The Ombudsman stated they attended a care plan meeting last month when the resident's smoking issues were discussed and was aware of the resident's behaviors in the facility regarding smoking. 1.5 Review of discharge notice provided to Resident #76 on 01/21/2024 was verified on 01/22/2024 at 11:54 AM. Verified through interview with the Administrator 01/22/2024 at 11:54 AM. He stated the discharge notice had been provided to the resident, but they refused to sign. The discharge notice was signed by two witnessing facility staff. 1.6 Reviewed progress notes and social service notes detailing the visitation guidelines and her discussion with the resident's friend and their family member. Note dated 01/21/2024. Verified through interv[TRUNCATED]