**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure direct care staff provided basic life support, including Cardiopulmonary Resuscitation(CPR) per the facility's policy and procedure, to a resident requiring emergency care according to the resident's advance directive and physician's order for 1 (Resident #1) of 5 (Residents #1, #2, #3, #4, and #5) sampled residents. On [DATE], at approximately 11:48 p.m., an Immediate Jeopardy occurred for Resident #1 when the resident, who was a full code, did not receive CPR upon being found pulseless, breathless, and unresponsive. Review of Resident #1's Power of Attorney's (POA) video camera footage of Resident #1's room on [DATE] from 11:48 p.m. through [DATE] at 12:03 a.m. revealed S4RespiratoryTherapist (RT) and S5RegisteredNurse(RN) were present in Resident #1's room throughout his medical emergency and chest compressions were not initiated until [DATE] at 12:03 a.m. Resident #1 was transported to the hospital and was admitted . Hospital records, dated [DATE], revealed Computed Tomography (CT) findings of anoxic encephalopathy (a process that begins with the cessation of cerebral blood flow to brain tissue), and Emergency Department physician's impression was ischemic bowel related to post cardiac arrest hypo-perfusion (low blood flow). The resident did not regain consciousness, was removed from life support, and expired on [DATE] at 6:09 p.m. The Immediate Jeopardy continued when S4RT and S5RN failed to take immediate action to ensure Resident #1's code status was acted on according to their advance directives, the physician's order, American Heart Association Guidelines, and the facility's policy and procedures. S1Administrator was notified of the Immediate Jeopardy on [DATE] at 4:46 p.m. The Immediate Jeopardy was removed on [DATE] at 6:59 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. This deficient practice had the likelihood to cause more than minimum harm to the remaining 26 residents (Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21,#22, #23, #24, #25, and #26) who were in the care of S5RN and S4RT on Hall Z identified as residents with an advanced directive that indicated staff would need to provide basic life support. Findings: Review of the facility's Emergency Procedure- Cardiopulmonary Resuscitation (CPR) policy revealed, in part, the chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. Review revealed, if an individual was found unresponsive, the resident should be briefly assessed for abnormal or absence of breathing. If sudden cardiac arrest was likely, CPR should be initiated. Review revealed, The facility's procedure for administering CPR incorporated the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Career facility basic life support (BLS) training material. Further review revealed, the basic life support sequence of events was referred to as C-A-B (chest compressions, airway, and breathing). Review of 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Career facility BLS training manual revealed, in part, chest compressions should be started immediately. Review revealed, opening an airway and providing ventilation may cause significant delay. Review revealed, without effective chest compressions oxygen flow to the brain and the heart stops. Review of MedlinePlus.gov's online article CPR - Adult and Child after Onset of Puberty dated [DATE] revealed, in part, time is very important when an unconscious person is not breathing. Further review revealed, permanent brain damage begins after only 4 minutes without oxygen, and death can occur as soon as 4 to 6 minutes later. Review of Resident #1's medical record revealed, in part, an admission date of [DATE] with diagnoses that included: Acute Respiratory Failure, Hypoxia, and Tracheostomy Status. Review of Louisiana Physician Orders for Scope of Treatment (LaPost) dated [DATE] revealed, in part, if Resident #1 was unresponsive, pulseless and was not breathing, CPR or an attempt at resuscitation should be performed. Further review revealed, Resident #1's financial and medical power of attorney (POA) signed and dated the form on [DATE]. Review of Resident #1's [DATE] physician orders revealed, in part, an order dated [DATE] for Code Status: Full Code. Review of Resident #1's Minimum Data Set with an Assessment Reference Date of [DATE] revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated Resident #1 was severely cognitively impaired. Review revealed, Resident #1 had no behaviors of rejection of care, and was dependent with moderate to maximal assistance with activities of daily living. Further review revealed Resident #1 had an active diagnosis of Tracheostomy Status. Review of Resident #1's Comprehensive Plan of Care with a Target Completion Date of [DATE] revealed, in part, Resident #1 was a full code. Further review of Resident #1's Plan of Care with a Target Completion Date of [DATE] revealed, in part, a Resident #1's tracheostomy tube and airway would be maintained. Review of Resident #1's Power of Attorney's (POA) video camera footage of Resident #1's room on [DATE] from approximately 11:48 p.m. through [DATE] at approximately 12:03 a.m. revealed, in part, Resident #1 lying supine with his tracheostomy (a device surgically inserted into the trachea to allow air to fill the lungs) lying on Resident #1's right side on top of his blanket. S4RT entered Resident #1's room, applied gloves, and attempted to replace Resident #1's tracheostomy into his stoma (an opening in the neck where the tracheostomy is inserted). After being unsuccessful, S4RT opened a new tracheostomy kit, inserted the tracheostomy into Resident #1's stoma, and secured the tracheostomy around Resident #1's neck. S4RT obtained an Ambubag (a hand held device used to provide positive pressure ventilation to residents who are not breathing) and began bagging (imitation of positive pressure ventilation to an individual with insufficient breathing) Resident #1. S4RT stopped bagging Resident #1, shook Resident #1, exited Resident #1's room, and returned with a pulse oximeter (a device used to measure oxygen saturation in the blood). S4RT placed the pulse oximeter on Resident #1's finger and then exited Resident #1's room, leaving Resident #1 alone. S5RN passed Resident #1's door and S4RT reentered Resident #1's room with a portable oxygen cylinder. S5RN then entered Resident #1's room, placed her hands on Resident #1's chest, immediately removed her hands from Resident #1's chest, and exited Resident #1's room. S4RT then connected the portable oxygen cylinder to the Ambubag. At this time, S26Certified Nursing Assistant was observed passing Resident #1's door. S4RT placed the Ambubag on Resident #1, and began bagging Resident #1. S4RT exited Resident #1's room again, leaving Resident #1 unattended. Review of Resident #1's Power of Attorney's (POA) video camera footage of Resident #1's room on [DATE] from 12:03 a.m. through [DATE] at approximately 12:10 a.m. revealed S4RT reentered Resident #1's room with S5RN, S26CNA, and S27CNA and S5RN started chest compressions. S5RN, S26CNA, and S27CNA alternated performing chest compressions until the fire department arrived. Further review revealed, the fire department entered Resident #1's room, immediately placed him on the floor, and began chest compressions. Review of Resident #1's nursing progress noted dated [DATE] at 11:49 p.m. written by S5RN revealed, in part, S5RN was called to Resident #1's room by S4RT. Further review revealed, Resident #1 was found unresponsive with no pulse, no respirations, and no blood pressure. Further review revealed, S4RT stated Resident #1 pulled out his tracheostomy tube, and S5RN initiated CPR and called 911. Further review revealed S5RN continued with CPR until the arrival of EMS on [DATE] at 12:15 a.m. when Resident #1 was transported to the hospital for evaluation and treatment. Review of Resident #1's respiratory progress note dated [DATE] at 12:48 a.m. written by S4RT revealed, in part, at 11:30 p.m. Resident #1 was found apneic (absence of breathing) and without a pulse with his tracheostomy tube completely pulled out. S4Respiratory Therapist inserted tracheostomy tube back in the trachea and began bagging Resident #1. The nurse called 911 and Certified Nursing Assistant (CNA) helped with compressions. The firemen and emergency medical technicians (EMTs) arrived and performed machine compressions, gave epinephrine, and were able to regain a pulse back. Resident #1 was sent to the hospital. Review of Resident #1's hospital records revealed a computerized tomography (CT) scan dated [DATE] at 2:04 a.m. with results that read, concerning for anoxic encephalopathy (a process that begins with the cessation of cerebral blood flow to brain tissue). Review of Resident #1's emergency room records revealed a physician's note dated [DATE] at 2:25 a.m. that read suspected bowel ischemia (evaluated by gastrointestinal team) and related it to a post cardiac arrest hypoperfusion (lack of blood flow) state. Review of Resident #1's hospital physician progress note dated [DATE] at 1:13 p.m. revealed, the physician notified Resident #1's family of concerning findings on head CT which showed an anoxic brain injury. Review of Resident #1's hospital respiratory progress note dated [DATE] at 11:33 a.m. revealed, in part, Resident #1 was placed on comfort care and his ventilator was turned off at 11:00 a.m. Review of Resident #1's death certificate revealed, in part, an expiration date of [DATE] at 6:09 p.m. In an interview on [DATE] at 9:40 a.m., S5RN stated she was the nurse responsible for Resident #1 on [DATE] from 7:00 p.m. to 7:00 a.m. S5RN stated after reviewing the above mentioned camera footage, on the night of [DATE], S5RN was notified by S4RT, that Resident #1 was pulseless and unresponsive. S5RN stated upon entering Resident #1's room, she instructed S4RT to initiate chest compressions. S5RN stated she did not start chest compressions on Resident #1 because her main priority was to call 911. S5RN stated the facility's protocol was to yell out for help and immediately start CPR. S5RN confirmed CPR should be performed on a hard surface or a CPR board should be used. S5RN confirmed chest compressions should have been started on Resident #1 immediately. S5RN further confirmed anyone in the facility can call 911 and her priority should have been Resident #1. In an interview on [DATE] at 10:13 a.m., S4RT stated he was the Respiratory Therapist caring for Resident #1 on [DATE] from 7:00 p.m. to 7:00 a.m. S4RT stated after reviewing the above mentioned camera footage, when he entered Resident #1's room at approximately 11:48 p.m., Resident #1 was pulseless and breathless. S4RT stated he visualized Resident #1's tracheostomy tube was not in place and he immediately attempted to replace it. S4RT stated during the above mentioned time frame, he was doing the tasks he was capable of doing while he was by himself in Resident #1's room. S4RT further stated because he was the respiratory therapist, his main focus was Resident #1's airway. S4RT confirmed following the initial assessment of Resident #1, he should have immediately begun chest compressions and he did not. S4RT further confirmed he should not have left Resident #1 alone at any time. In an interview on [DATE] at 4:00 p.m., S2Director of Nursing (DON) stated after reviewing the above mentioned video footage, S4RT and/or S5RN failed to perform chest compressions for Resident #1 for approximately 15 minutes. S2DON stated the above action by S4RT and S5RN was against the facility's policy and procedure for emergency procedures related to CPR, which was to begin chest compressions immediately. S2DON further stated S4RT and S5RN's actions left the remaining 26 residents on Hall Z who had an advanced directive status of full code at risk for serious injury, harm, or death. In an interview on [DATE] at 11:30 a.m., S1Adminstrator stated after reviewing the above mentioned video footage, S4RT and S5RN failed to perform chest compressions for Resident #1 for approximately 15 minutes. S1Adminstrator further stated the above actions by S4RT and S5RN were against the facility's policy and procedure for emergency procedures related to CPR, which was to begin chest compressions immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews; the facility failed to protect residents' right to be free from abuse for 3 (Resident #8, Resident #27, and Resident #104) of 7 (Resident #8, Resident #21, Resident #27, Resident #82, Resident #83, Resident #100, and Resident #104) residents investigated for abuse. The facility failed to protect: 1. Resident #27 from sexual and psychosocial abuse by Resident #100; 2. Resident #104 from sexual abuse by Resident #100; and 3. Resident #8 from physical abuse by Resident #21. This deficient practice resulted in an Immediate Jeopardy situation on 06/01/2023 at 12:50 p.m. when Resident #100, a cognitively impaired resident, lifted Resident #27's shirt and attempted to put his face to Resident #27's breast causing Resident #27 to have increased anxiety when anyone enters her room. The Immediate Jeopardy situation continued for the following: on 07/13/2023, S5LPN witnessed Resident #100 pucker his lips and attempt to kiss Resident #27 and on 07/17/2023, S6Certified Nursing Assistant (CNA) witnessed Resident #100 sexually abuse Resident #104 by attempting to touch Resident #104's genital area. S1Administrator was notified of the Immediate Jeopardy on 07/19/2023 at 12:45 p.m. The Immediate Jeopardy was removed on 07/22/2023 at 12:21 p.m., after it was determined through observation, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included in part; notifying residents responsible parties, in-service staff on reporting sexually inappropriate behavior to management immediately upon witnessing. Began abuse training with staff on identifying and preventing abuse with Staff unable to work until they had been in-serviced on reporting sexually inappropriate behavior and abuse training. Resident #100 was placed 1:1 supervision with S24Certified Nursing Assistant (CNA), due to the potential to cause harm to other residents until Resident #100 was sent to hospital for psych evaluation and treatment due to sexually inappropriate behavior. The deficient practice had the potential to cause serious harm or injury to all 109 residents identified on the facility's Resident Census and Conditions of Residents form, CMS-672. Findings: Review of the facility's Abuse, Neglect, Exploitation and Misappropriation policy, revised March 2023, revealed, in part, resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Resident #27 Review of the facility's incident report list dated 2023 revealed, in part, no incident report for Resident #27. Review of the facility's Statewide Incident Management System report dated 06/01/2023 revealed, in part, Resident #100 went into Resident #27's room and placed his tongue into her mouth. Resident #100 was trying to touch Resident #27 but unsuccessful. Further review revealed a follow-up was conducted with three female residents on the unit and there was no evidence of any previous incidents with Resident #100. The appropriate amount of staff was on the unit at the time of the incident, 2 nurses and 4 CNAS. The police were not notified as Resident #27 requested not to do so. S2Director of Nursing (DON) would follow-up with the nursing staff on Resident #100's behaviors for 3 months. Review of Resident #27's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/12/2023 revealed, in part, Resident #27 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated Resident #27 was severely cognitively impaired. Review of Resident #27's progress note dated 06/01/2023 at 1:33 p.m. revealed, in part, S2DON was notified at 12:50 p.m. that a male resident was found in Resident #27's room, Resident #27 stated the male resident kissed her and attempted to touch her pointing to her vaginal area, provider was notified. Observation on 07/18/2023 at 9:37 a.m. revealed as surveyor entered Resident #27's room Resident #27 began to ask who is here, why are you here? In an interview on 07/18/2023 at 9:37 a.m., Resident #27 stated a man entered her room several weeks ago, fondled my breast. Resident #27 stated she started waving her arms while yelling I don't want that, stop and then he went away. Resident #27 further stated she now becomes anxious when anyone enters her room. In an interview on 07/18/2023 at 2:00 p.m., S56Licensed Practical Nurse (LPN) stated Resident #27 voiced being scared of a man who entered her room and touched her. In an interview on 07/18/2023 at 3:09 p.m., S4Certified Nursing Assistant (CNA) stated she entered Resident #27's room and saw Resident #100 had lifted Resident #27's shirt trying to put his mouth on her breast. S4CNA further stated Resident #27 began to fight him by trying to push him away with her arms. S4CNA stated she removed Resident #100 from Resident #27's room. S4CNA further stated she reported the incident to S40LPN. In an interview on 07/19/2023 at 9:40 a.m., S39Social Worker stated on 06/01/2023 she was notified that Resident #100 kissed and attempted to touch Resident #27. S39Social Worker stated since the incident, Resident #27 was scared and nervous. S39Social Worker stated when staff entered Resident #27's room she would immediately ask Who was present in her room and why they were entering her room? S39Social Worker stated after the incident when Resident #100 kissed Resident #27, staff were educated to knock and identify self and why they are entering Resident #27's room and to close the door upon exiting the room. S39Social Worker stated staff should report any inappropriate sexual behaviors to social services. S39Social Worker stated when these behaviors occur immediate action should be taken. S39Social Worker stated she was not aware of Resident #100 touching Resident #104 and immediate action should have been taken. In an interview on 07/19/2023 at 11:25 a.m., S40LPN stated on 06/01/2023 S4CNA reported she witnessed Resident #100 attempting to touch Resident #27's breast with his mouth. Observation on 07/20/2023 at 9:37 a.m. revealed as surveyor entered Resident #27's room Resident #27 began to ask who is here, why are you here? In an interview on 07/21/2023 at 12:04 p.m., S39Social Worker stated she did not complete any follow-up assessments with Resident #27 after the incident that occurred on 06/01/2023 with Resident #100. In an interview on 07/21/2023 at 12:20 p.m., S2DON stated she spoke with Resident #27 on several occasions to assess Resident #27's emotional state. S2DON stated she did not have any documentation of follow-up assessments completed for Resident #27 after the incident of sexual abuse that occurred on 06/01/2023 with Resident #100. S2DON further stated she did not have any documentation of staff education completed following the incident that occurred on 06/01/2023 when Resident #100 placed his tongue into Resident #27's mouth. Observation on 07/22/2023 at 11:00 a.m. revealed as surveyor entered Resident #27's room Resident #27 began to ask who is here, why are you here? Resident #100 Review of Resident #100's MDS with an ARD of 04/13/2023 revealed, in part, a BIMS was not conducted because Resident #100 was rarely or never understood. Review of Resident #100's progress note dated 06/01/2023 at 12:30 p.m., revealed, in part, Resident #100 was displaying inappropriate behavior with residents and staff by touching them in sexual ways, kissing, and wandering into female resident's rooms. Review of Resident #100's progress note dated 07/13/2023 revealed, in part, Resident #100 displayed inappropriate behaviors the entire shift by touching female staff members and puckering his lips wanting to kiss Resident #27. Review of Resident #100's progress notes dated 07/13/2023 revealed, in part, Resident #100 was able to propel himself via wheelchair throughout the facility. Review of Resident #100's care plan last updated on 05/15/2023 revealed, in part, no documented evidence and the facility did not present any documented evidence that a plan of care was developed with goals and/or interventions related to Resident #100's sexually inappropriate behaviors after the above mentioned 06/01/2023 incident or after Resident #100's above mentioned behaviors on 07/13/2023. Review of Resident #100's July 2023 physician's orders revealed, an order with a start date of 06/13/2023, to monitor Resident #100 for inappropriate behaviors every two hours and document any inappropriate behaviors noted. Review of Resident #100's June 2023 electronic medication administration record (eMAR) revealed, in part, no documentation that behaviors were monitored at 12:00 a.m. on 06/15/2023, 06/19/2023, 06/24/2023, 06/28/2023; 2:00 a.m. on 06/16/2023; 4:00 a.m. on 06/16/2023; 6:00 a.m. on 06/16/2023 and 06/27/2023; 8:00 a.m. on 06/14/2023 and 06/18/2023; 10:00 a.m. on 06/16/2023 and 06/22/2023; 12:00 p.m. on 06/16/2023, 06/22/2023, and 06/26/2023; 2:00 p.m. on 06/13/2023; 4:00 p.m. on 06/13/2023; and 6:00 p.m. on 06/13/2023 and 06/16/2023. Review of Resident #100's July 2023 eMAR revealed, in part, no documentation that Resident #100's inappropriate behaviors were monitored at 12:00 a.m. on 07/02/2023, 07/03/2023, 07/06/2023, 07/07/2023, 07/11/2023, 07/15/2023, 07/16/2023, 07/17/2023, 2:00 a.m. on 07/18/2023, 6:00 a.m. on 07/05/2023 and 07/14/2023, 8:00 a.m. on 07/14/2023, and 6:00 p.m. on 07/02/2023. Review of Resident #100's June and July 2023 eMAR revealed in part, Resident #100 displayed inappropriate sexual behaviors on the night shift 7:00 p.m. to 7:00 a.m. on 06/20/2023, and displayed inappropriate behaviors on 07/11/2023 at 12:00 p.m There was no documented evidence, and the facility did not present any documented evidence of supporting documentation of the facility acting upon Resident #100's inappropriate behaviors displayed on 06/20/2023 and 07/11/2023. In an interview on 07/18/2023 at 4:00 p.m., S48LPN stated Resident #100 was monitored every two hours for inappropriate behaviors due to a previous incident with Resident #27. S48LPN further stated Resident #100 should have one on one supervision by staff. In an interview 07/18/2023 at 4:22 p.m., S53CNA stated she was unaware Resident #100 had inappropriately touched Resident #27. S53CNA was unaware that he was supposed to be monitored for inappropriate behaviors In an interview on 07/18/2023 at 5:50 p.m., S2DON stated Resident #100 was the perpetrator in an incident of sexual abuse on 06/01/2023 with Resident #27. S2DON stated since Resident #100's return to the facility on [DATE]. Resident #100 should have been monitored by staff every hour for inappropriate sexual behavior. S2DON further stated staff had not reported Resident #100 had displayed sexually inappropriate behavior or had any additional instances of sexual abuse. In an interview on 07/19/2023 at 9:13 a.m., S45Assistant Director of Nursing (ADON) stated Resident #100 can move around the facility freely. S45ADON stated staff did not report any sexually inappropriate behavior from Resident #100 since his return from the psychiatric hospital on [DATE]. S45ADON stated Resident #100 should have been monitored every 2 hours for sexually inappropriate behaviors. S45ADON stated Resident #100 was monitored because of an incident where he tried to kiss Resident #27 and touched her breasts. S45ADON stated all staff that worked with Resident #100 should have been aware that Resident #100 had to be monitored for sexually inappropriate behaviors. S45ADON further stated Resident #100 needed one on one monitoring in order to keep other residents free from sexual abuse. In an interview on 07/19/2023 at 9:57 a.m., S2DON stated Resident #100's care plan should have been updated when Resident #100 first displayed inappropriate sexual behaviors. S2DON stated Resident #100's care plan should have been updated with each inappropriate sexual behavior. S2DON stated Resident #100's eMAR should have documentation every 2 hours of Resident #100's sexually inappropriate behaviors. S2DON further stated blank documentation indicates the monitoring was not done. In an interview on 07/19/2023 at 10:13 a.m., S1Administrator stated when Resident #100 displayed inappropriate sexual behaviors, Resident #100 should have been placed on 1 on 1 supervision, Resident #100's physician should have been contacted, and a discharge/transfer plan should have been started. S1Administrator stated Resident #100 had the potential to have inappropriate sexual behaviors with other residents when not on 1 on 1 supervision and residents were not safe. In an interview on 07/19/2023 at 9:10 a.m., S5LPN stated Resident #100 was known for trying to touch staff. S5LPN stated Resident #100 had to be monitored due to trying to touch other residents inappropriately. S5LPN stated that her nursing note on 07/13/2023 was in regards to Resident #100 trying to get close to Resident #82 puckering his lips at her. S5LPN stated that neither Resident #82 nor Resident #100 had the mental capacity to consent to sexual behavior. S5LPN stated Resident #100 can roll himself backwards in his wheelchair to get off of the unit to go smoke by himself. S5LPN stated she monitored Resident #100 every two hours while he was on unit for inappropriate behaviors. S5LPN further stated that she had not reported the sexually inappropriate behaviors to S45ADON or S2DON. In an interview on 07/19/2023 at 10:46 a.m., S47LPN stated Resident #100 tried to kiss other residents, especially Resident #82. S47LPN stated her documentation of inappropriate behaviors on 06/20/2023 was in regards to Resident #100 puckering at Resident #82, trying to get close to her, and having to be separated. S47LPN further stated that she had not informed S45ADON or S2DON of Resident #100's behavior. Resident #104 Review of Resident #104's MDS with an ARD of 06/22/2023 revealed, in part, Resident #104 had a BIMS of 14, which indicated Resident #104 was cognitively intact. In an interview on 07/18/2023 at 1:45 p.m., Resident #104 stated Resident #100 tried to grab her private area on 07/17/2023. Resident #104 further stated she told Resident #100 to stop touching her. Resident #104 stated S6CNA was present when Resident #100 tried to grab her private area. In an interview on 07/18/2023 at 2:53 p.m., S6CNA stated on 07/17/2023 she witnessed Resident #104 sitting in her wheelchair by the desk when Resident #100 rolled his wheelchair by Resident #104 and attempted to touch Resident #104. S6CNA further stated Resident #104 told Resident #100 to stop touching her. S6CNA stated she then instructed Resident #100 to move away from Resident #104. In an interview on 07/19/2023 at 9:57 a.m., S2DON stated Resident #104 informed her this morning that Resident #100 attempted to touch her in between her legs on Monday 07/17/2023 and staff was present when it happened. S2DON stated the staff that were present when Resident #100 attempted to touch Resident #104, should have notified her immediately. S2DON stated Resident #100 should have been placed on 1 on 1 supervision and Resident #100's physician should have been notified. S2DON stated because she was not informed of Resident #100 touching Resident #104, Resident #100 was not placed on 1 on 1 supervision and Resident #100 was able to continue to have inappropriate sexual behaviors toward and with female residents. Resident #21 Review of Resident #21's MDS with an ARD of 05/11/2023 revealed, in part, Resident #21 had a BIMS score of 12 which indicated Resident #21 had moderate cognitive impairment. Review of Resident #21's Care Plan initiated on 04/29/2021 revealed, in part, Resident #21 exhibited abnormal behaviors which included cursing staff and playing with her feces with interventions initiated on 05/20/2021 to include: approach resident in a calm and non-judging manor, notify physician and family of behaviors, attempt to divert attention during outburst, remove Resident #21 from area of agitation, attempt to find causes of agitation, psychiatric evaluation as needed, and smile and talk with Resident #21 when approaching and/or giving care. Further review of Resident #21's Care Plan initiated on 04/01/2023 revealed, in part, Resident #21 entered Resident #8's room and began hitting Resident #8 while Resident #8 was in his bed. Resident #21 was removed from Resident #8's room and staff redirected her behavior. New orders given to send to emergency room for psych evaluation. Further review of Resident #21's Care Plan revealed no documentation of new goals or interventions Resident #21's return to the facility from an admissions to a psychiatric facility on 08/18/2022 and 04/01/2023. Review of Resident #21's progress notes revealed, in part, an entry dated 08/18/2022 at 11:00 a.m., read Resident #21 was observed in another resident's room destroying their personal property and throwing the bed mattress on the floor. Review of Resident #21's progress notes revealed an additional entry date of 04/01/2023 at 8:19 a.m. entered by S57LPN which read, Resident #21 up in wheelchair observed going toward Resident #8's door way fussing. S57LPN walked and closed the door to avoid confrontation. Further review of Resident #21's progress notes revealed an additional entry dated 04/01/2023 at 12:38 p.m. entered by S57LPN which read, monitoring Resident #21's activity on the unit. Resident #21 complained that Resident #8 was a devil and trying to attack her mind. Further review revealed, in part, an additional entry dated 04/01/2023 at 3:15 p.m. entered by S57LPN which read, called to Resident #8's room where Resident #21 was seen hitting Resident #8 while he was in his bed. Nurse rolled Resident #21 to her room. Resident #21 was angry and stated she does not like to be lied too. Resident #21 said when she is mad she would hurt someone. Review of a Statewide Incident Management Systems report dated 04/03/2023 revealed, in part, on 04/01/2023 at 2:00 p.m., S61CNA witnessed Resident #21 enter Resident #8's room and punch Resident #8 in his arm and side of chest. Resident #21 was removed from room immediately and placed under one-on-one supervision. The Nurse Practitioner, responsible party and S2DON were immediately notified. Interviews were conducted by S1Administrator. Resident #8 was assessed and no redness, bruising or swelling noted. Resident #8 stated he felt safe and did not have any complaints at that time. Resident #8 could not give a description of why the incident occurred. Further review revealed Resident #21 was removed from Resident #8's presence and returned to her room while Resident #8 was assessed and medical doctor and nurse practitioner were notified. Orders were given for Resident #21 to be sent out for a psych evaluation at the emergency department and she left the faciity on [DATE] for psych evaluation. Further review revealed upon Resident #21's return to the facility more frequent nursing rounds would be scheduled, and a care plan for Resident #21 would be completed on her behaviors. In an interview on 07/18/2023 at 2:40 p.m., Resident #21 stated she gets angry with Resident #8 at times and she had hit him in the past. In an interview on 07/18/2023 at 2:50 p.m., S3LPN stated she had observed Resident #21 fuss and curse at Resident #8 and other residents. S3LPN further stated Resident #21 had previously went into Resident #8's room and pulled the mattress for Resident #8's bed on the floor. S3LPN also stated Resident #21 threw Resident #8's personal items on the floor because she was angry with him. In an interview on 07/19/2023 at 3:05 p.m., S57LPN stated on 04/01/2023 at 3:15 p.m., Resident #21 was angry with Resident #8 and hit him. S57LPN further stated the CNA who witnessed Resident #21 hitting Resident #8 removed Resident #21 from Resident #8's room and brought Resident #21 to her room. S57LPN stated she notified S2DON and the physician of the occurrence. S57LPN stated the physician ordered Resident #21 for a psychiatric consult. S57LPN further stated Resident #21 was visually supervised by staff until she left the facility for a psych consult at the emergency department on 04/01/2023 at 4:53 p.m. S57LPN stated Resident #21 was admitted for psychiatric treatment following that occurrence. In interview on 07/21/2023 at 3:00 p.m., S3LPN stated when Resident #21 returned to the facility from her psych admission, no new approaches or interventions such as, increased supervision, were ordered. In an interview on 07/25/2023 at 11:30 a.m., S2DON confirmed Resident #21 physically abused Resident #8 on 04/01/2023. S2DON further confirmed new interventions were not put into place after new episodes of abusive behaviors on 08/18/2022 and 04/01/2023. S2DON further stated Resident #21's care plan should have included new interventions after each new abusive behavior episode. In an interview on 07/25/2023 at 11:50 a.m., S63Owner confirmed Resident #100 sexually abused Resident #27 on 06/01/2023. S63Owner further stated once Resident #100 returned to the facility, there should have been a plan in place for monitoring of Resident #100's inappropriate sexual behaviors and if inappropriate behaviors were noted, S2DON and S1Administrator should have been notified of Resident #100's sexually inappropriate behaviors. S63Owner confirmed all residents were at risk for sexual abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to: 1. Ensure staff identified and supervised residents (Resident #24, Resident #80, Resident #83, and Resident #85), who displayed unsafe smoking habits, as unsafe smokers; and, 2. Ensure residents, who displayed unsafe smoking habits, did not have access to smoking materials and/or cigarettes was not in their possession for 4 (Resident #24, Resident #80, Resident #83, and Resident #85) of 4 (Resident #24, Resident #80, Resident #83, and Resident #85) smokers reviewed for safe smoking. The facility documented 16 residents who were smokers. The deficient practice resulted in an Immediate Jeopardy situation for Resident #80 on 07/17/2023 at 10:10 a.m. when Resident #80, a resident who previously displayed unsafe smoking habits, was sitting in his wheelchair in the designated smoking area smoking a cigarette without supervision of staff and without a smoker's apron in place. Resident #80 was observed smoking a cigarette with visible ashes noted falling on Resident #80's shirt, shorts, and hoyer pad. The Immediate Jeopardy situation continued for the following: On 07/17/2023 at 10:12 a.m. when Resident #83 was smoking a lit cigarette with ashes falling onto her shirt and right arm. Resident #83's geri chair was observed with black ash marks to the right armrest and ashes noted to the foot rest. On 07/17/2023 at 10:19 a.m., Resident #24, a visually impaired resident, was smoking a lit cigarette outside without supervision of staff and without a smoker's apron in place. Resident #24 was observed with a lit cigarette in his hand with visible ashes noted on Resident #24's right upper leg. On 07/18/2023 at 11:01 a.m., Resident #85 put Resident #80's cigarette to his mouth, used his orange lighter to light the cigarette, then gave the cigarette back to Resident #80. S1Administrator was notified of the Immediate Jeopardy on 07/18/2023 at 4:30 p.m. The Immediate Jeopardy was removed on 07/20/2023 at 4:09 p.m., after it was determined through observations, interviews, and record reviews that the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included in part: *All residents who smoke were reassessed for smoking safety. Smoking assessments will be done on admit, quarterly and as needed. *All staff were in-serviced on the smoking policy,(a copy of the policy given to all staff), at risk residents, smoking times for unsafe residents and what to do with non-compliant residents, to ensure all smoking materials are not left with unsafe smokers and to report to management immediately. No resident is allowed to smoke after 8pm. Staff were not allowed to work their next assigned shift until they have been in-serviced on the above. *The facility assigned a staff member in place to monitor residents while smoking in the east court yard (assigned smoking area) to ensure that the residents smoking are safe until 8:00 p.m. *Care plans were updated to reflect if the resident was safe or unsafe while smoking and update as needed. *S2DON/designee will monitor compliance of interventions of unsafe smokers randomly at least once a day x 4 weeks beginning 07/19/2023 until 08/20/2023. Random checks of smoker's rooms to ensure no lighters are available 3 times a week for 4 weeks. Families notified that no resident is allowed to have a lighter and that the facility will provide lighters. *A meeting was held with all 16 residents that smoke to inform them of the smoking hours (7:00 a.m.-8:00 p.m.), smoking policy, and educate them on the possibilities of infection with sharing cigarettes. Findings: Review of the facility's Smoking and Lighters Policy and Procedure revealed, in part Smoking is not permitted in the resident's room. If resident is caught smoking in a non-designated area, the social worker will counsel the resident on risks and safety factors. Lighters, matches, or other items that ignite a fire are not allowed in resident rooms. Any such items found in a resident's room will be confiscated. Residents who are deemed safe to smoke will be allowed to keep their cigarettes in their room. Residents who need assistance to smoke will be required to leave their cigarettes at the station with their nurse. The facility's employees on Nurse's Station g and Nurse's Station f will be supplied with lighters purchased by the facility. Any resident who would like to go smoke in the designated smoking area must retain one of these employees to go outside with them and light their cigarette. Review of the facility's smoking list revealed Resident #24, Resident #80, Resident #83, and Resident #85 were smokers. In an interview on 07/17/2023 at 9:38 a.m., S1Adminstrator stated all the smokers in the facility are safe smokers. 1.) Resident #80 Review of Resident #80's face sheet revealed, in part, Resident #80 was admitted on [DATE] with diagnosis that included: Tobacco abuse counseling and Nicotine Dependence. Review of Resident #80's Minimum Data Set with an Assessment Reference Date of 05/15/2023 revealed, in part, Resident #80's Brief Interview for Mental Status Score was 6 which indicated Resident #80 had severe cognitive impairment. Review of Resident #80's Comprehensive Care Plan, with a start date of 03/31/2023, revealed, in part, Resident #80 would be free from complications and/or injury from smoking. Review revealed interventions that included: Resident #80 and/or Resident #80's family were to provide Resident #80's cigarettes and lighters, smoking assessments were to be done upon admission to the facility, quarterly, and as needed, staff are to remind/encourage resident to only smoke in designated smoking area, assure that resident is properly dressed for weather conditions when outside in smoking area, encourage resident not to spend extended time in smoking area related to excessive heat or cold, assure/encourage resident to be well hydrated when spending time in smoking area, assist resident to smoking area, encourage resident to stay out of direct sunlight, and provide a smoking jacket as needed. Review revealed an additional intervention was added on 05/18/2023 to include staff were to make rounds every hour while in smoking area and as needed. Further review revealed Resident #80's care plan was last reviewed and/or revised on 05/22/2023 at 11:01 a.m. by S7Careplan Nurse. Review of Resident #80's nurses' notes revealed, in part, a nurse's note with a date of 07/13/2023 and time of 5:55 p.m. written by S7LPN which stated Resident #80 was noted smoking in his room. Further review revealed Resident #80's mother was notified by her answering machine and the social services department would be notified. Review of Resident #80's electronic Medication Administration Record (eMAR) revealed no evidence of documentation of one hour monitoring of Resident #80. Review of Resident #80's Activities of Daily Living (ADL) documentation revealed no evidence of documentation of one hour monitoring of Resident #80. Review of Resident #80's current Physician Orders revealed an order with a start date of 01/15/2023 that read Resident #80 was to be up out of bed in his wheelchair daily and he was to be brought outside. Review of Resident #80's Safe Smoking Assessment Form with a completion date of 05/15/2023 revealed, in part, Resident #80 was safe to smoke unsupervised. Review revealed incomplete questions that consisted of- The resident requires 1:1 supervision while smoking, the resident requires a fire proof smoking apron while smoking, and all smoking material will be kept at the nurse's station. Further review revealed staff were to round on Resident #80 every hour and as needed. Review of Resident #80's medical record revealed no documented evidence and the facility did not present any documented evidence of a Safe Smoking Assessment completed after Resident #80 was observed smoking in his room on 07/13/2023. Review of Resident #80's Social Services Notes revealed no documented evidence of counseling or education provided to Resident #80 after Resident #80 was observed smoking in his room on 07/13/2023. Observation on 07/17/2023 at 10:10 a.m. revealed, Resident #80 gave Resident #83 a cigarette. Further observation revealed Resident #83 lit Resident #80's cigarette with her lighter and Resident #80 began smoking a lit cigarette in his wheelchair with cigarette ashes falling onto his shirt, blue hoyer pad, and khaki shorts. In an interview on 07/17/2023 at 10:13 a.m., Resident #80 stated he smoked cigarettes on a daily basis. Resident #80 stated he does not wear an apron, he does not need staff to supervise him when he smokes, and he keeps his own smoking materials. Resident #80 stated he is also able to keep his own lighter, but if he does not have his lighter he will get a light from Resident #83 or other residents on the smoking patio. Resident #80 further stated he got caught smoking a lit cigarette in his room last week, but the facility told him he can still keep his smoking material. In an interview on 07/17/2023 at 10:20 a.m., Resident #83 stated her and Resident #80 smoke every day together in the designated smoking area. Resident #83 stated Resident #80 has his own cigarettes and lighter. Resident #83 stated if Resident #80 does not have his lighter, she would light his cigarette for him. Resident #83 stated Resident #80 does not have to be supervised by staff when smoking or wear a smoking apron. Resident #83 stated staff does not have to supervise any of the smokers. Resident #83 stated when any of the residents smoke, they are usually by their self. In an interview on 07/17/2023 at 11:30 a.m., S10CNA stated Resident #80 goes outside and smoked frequently in the designated smoking area. S10CNA stated Resident #80 does not require supervision when he smokes and he was allowed to keep his smoking material. S10CNA stated Resident #80 needed assistance to the smoking area, but once he was outside he liked to sit outside, smoke, and socialize with other residents. In an interview on 07/17/2023 at 12:38 p.m., S3LPN stated she had multiple smokers on her hall. S3LPN stated Resident #40, Resident #61, Resident #68, Resident #73, Resident #80, Resident #83, and Resident #85 were all smokers and were allowed to keep their smoking materials. S3LPN stated when Resident #80 needed his cigarette lit, he would go outside and get another resident to light his cigarette. S3LPN stated Resident #80 did not require supervision when smoking nor did he require a smoking apron when smoking because he was not an unsafe smoker. In an interview on 07/17/2023 at 1:21 p.m., S11CNA stated she had been working at the facility about 2 weeks and the facility had not informed her of any residents on her hall that were unsafe smokers or that needed to be supervised when smoking. S11CNA stated Resident #80 kept his smoking material on his person and he smoked multiple cigarettes throughout the day. S11CNA stated Resident #80 goes outside with Resident #83 and Resident #85 to smoke. S11CNA stated Resident #80 can smoke unsupervised and does not require a smoking apron because he is not an unsafe smoker to her knowledge. Observation on 07/17/2023 at 3:30 p.m., revealed Resident #80 lying in his bed with a green pack of [NAME] cigarettes on his bedside table. In an interview on 07/18/2023 at 2:00 p.m., S58CNA stated Resident #80 was a safe smoker. S58CNA stated Resident #80 could go outside without supervision and smoke. S58CNA stated Resident #80 had never had any incidents that warranted him being an unsafe smoker. S58CNA further stated Resident #80 had to be assisted outside by staff to the designated smoking area, but once Resident #80 was outside he could smoke unsupervised. In an interview on 07/17/2023 at 3:32 p.m., Resident #80 stated he kept his packs of cigarettes in his two drawer dresser next to his bed. Observation on 07/17/2023 at 3:34 p.m. revealed, Resident #80 had two packs of green [NAME] cigarettes in the two drawer dresser located next to his bed. In an interview on 07/18/2023 at 10:00 a.m., S3LPN stated she was the nurse for Resident #80 when he was observed smoking in his room. S3LPN stated she removed a lit cigarette and a lighter from Resident #80's possession, but she allowed him to keep his smoking materials in his possession because she assumed without a lighter, Resident #80 could not smoke in his room. S3LPN further stated she notified Resident #80's mother and S2DON. Observation on 07/18/2023 at 11:01 a.m. revealed, Resident #80 gave Resident #85 a cigarette. Observation revealed Resident #85 put Resident #80's cigarette to his mouth, used his orange lighter to light the cigarette, then gave the cigarette back to Resident #80. Observation revealed Resident #80 began to smoke the lit cigarette dropping ashes onto his shirt. Observation revealed circular piles of gray ash noted on Resident #80's pink fleece blanket lying on his lap and his blue hoyer pad. Further observation revealed a green pack of [NAME] cigarettes with two cigarettes in the pack lying in the crease of Resident #80's left arm. In an interview on 07/18/2023 at 11:05 a.m., S64Housekeeper stated the facility does not have a smoking aide. S64Housekeeper stated the residents in the facility do not require supervision when smoking. In an interview on 07/18/2023 at 11:18 a.m., S60SSD stated she did not counsel Resident #80, file an incident report, notify the DON or Administrator, or educate any staff after she was notified Resident #80 was smoking in his room. S60SSD stated she should have counseled Resident #80 and notified S2DON or S1Administrator of the incident. In an interview on 07/18/2023 at 1:18 p.m., S7Careplan Nurse stated she was responsible for performing smoking assessments and updating careplans for residents who smoke. S7Careplan stated when she completed Resident #80's smoking assessment, she interviewed the CNA that was assigned to Resident #80 that day. S7Careplan Nurse further stated any questions the CNA was not able to answer, she would ask Resident #80. S7Careplan Nurse stated she did not visualize Resident #80 smoke when she completed his smoking assessment. S7Careplan Nurse stated a resident should be deemed an unsafe smoker if they drop ashes on themselves while smoking, if they attempt to smoke in area that was not a designated smoking area, if they cannot dispose of their ashes properly, and/or if the resident has had any accidents/incidents while smoking. S7Careplan Nurse stated she was not informed Resident #80 was observed smoking in his room so a smoking assessment was not completed. S7Careplan Nurse further stated Resident #80 should have had a smoking assessment done on 07/13/2023 when Resident #80 was observed smoking in his room, Resident #80 should have been care planned to be an unsafe smoker, and Resident #80 should not have been allowed to have smoking materials at any time. In an interview on 07/18/2023 at 2:30 p.m., S39Social Worker stated she was not informed of the incident that occurred on 07/13/2023 when Resident #80 was observed smoking in his room. S39Social Worker stated Resident #80 should have had a one on one counseling, S2DON and S1Administrator should have been notified, and a plan to ensure safe smoking should have been implemented. In an interview on 07/18/2023 at 2:38 p.m., S2DON stated she was notified today that Resident #80 was caught smoking in his room on 07/13/2023. S2DON stated Resident #80 should have been reassessed after that incident, his careplan should have been updated, and the interdisciplinary team should have been notified following the incident and they were not. S2DON confirmed Resident #80 was in possession of his smoking material and he should not have been allowed to keep his smoking material, he should have been made an unsafe smoker, and all of the facility's staff should have been educated and they were not. 2.) Resident #83 Review of Resident #83's face sheet revealed, in part, Resident #83 was admitted on [DATE] with diagnosis that included: Bipolar Disorder, Schizophrenia, Cocaine Abuse, Altered Mental Status, and Major Depressive Disorder Review of Resident #83's Minimum Data Set with an Assessment Reference Date of 06/05/2023 revealed, in part, Resident #83's Brief Interview for Mental Status Score was 14 which indicated Resident #83 was cognitively intact. Review of Resident #83's Comprehensive Care Plan, with a start date of 03/13/2023, and a revision date of 06/05/2023, revealed, in part, Resident #83 would be free from complications and/or injury from smoking. Review revealed interventions that included: Resident #83 and/or Resident #83's family were to provide Resident #83's cigarettes and lighters, smoking assessments were to be done upon admission to the facility, quarterly, and as needed, staff are to remind/encourage resident to only smoke in designated smoking area, assure that resident was properly dressed for weather conditions when outside in smoking area, encourage resident not to spend extended time in smoking area related to excessive heat or cold, assure/encourage resident to be well hydrated when spending time in smoking area, assist resident to smoking area, encourage resident to stay out of direct sunlight, and provide a smoking jacket as needed. Review revealed an additional intervention was added on 05/18/2023 to include staff were to make rounds every hour while in smoking area and as needed. Review of Resident #83's Safe Smoking Assessment Form, with an original completion date of 02/01/2022 and a reassessment date of 06/05/2023, revealed, in part, Resident #83 was unable to light her smoking material independently, Resident #83 was unable to dispose of ashes appropriately, and Resident #83 was unsafe to smoke unsupervised. Review of Resident #83's electronic Medication Administration Record (eMAR) revealed no evidence of documentation of one hour monitoring of Resident #83. Review of Resident #83's Activities of Daily Living (ADL) documentation revealed no evidence of documentation of one hour monitoring of Resident #83. Observation on 07/17/2023 at 10:12 a.m. revealed, Resident #83 lit Resident #80's cigarette with her lighter. Observation revealed Resident #83 then lit her cigarette and began to smoke with ashes falling to her shirt and right arm. Observation further revealed Resident #83's right gerichair arm with black marks and visible burn marks. Observation further revealed ash noted to the foot rest on Resident #83's gerichair. In an interview on 07/17/2023 at 10:12 a.m., Resident #83 stated that she was allowed to smoke without staff supervision. Resident #83 stated she was allowed to keep her own cigarettes and lighter. Resident #83 stated the marks noted to the right arm of her gerichair were from when she used her gerichair to tap her ashes off of her cigarette because she cannot reach the ashtray. Resident #83 further stated she assisted other residents that come outside with lighting their cigarettes, if they do not have a lighter. Resident #83 stated Resident #24, Resident #80, and herself are allowed to smoke unsupervised. Resident #83 stated to her knowledge none of the residents who smoke have to be supervised and staff only come into the smoking area if they smoke. Resident #83 stated she did not use a smoking apron and she had never seen Resident #24 or Resident #80 use a smoking apron. In an interview on 07/17/2023 at 1:30 p.m., S11Certified Nursing Assistant (CNA) stated she has been working at the facility about 2 weeks and the facility has not informed her or educated her on any residents on her hall that were unsafe smokers or that needed to be supervised while smoking. S11CNA stated Resident #83 has to be put in her geri-chair and brought outside. S11CNA stated she kept her smoking material on her person and she smoked throughout the day. S11CNA stated Resident #83 could smoke unsupervised and does not require a smoking apron. S11CNA further stated Resident #83 was not an unsafe smoker to her knowledge. Observation on 07/18/2023 at 9:20 a.m. revealed, Resident #83 outside smoking a lit cigarette with ashes falling onto her left arm. Observation on 07/18/2023 at 11:05 a.m., revealed Resident #83 smoking a lit cigarette. Further observation revealed Resident #83 scraped the lit cigarette across the right arm of her gerichair to discard her ash. Observation further revealed ash dropping onto Resident #83's right leg and inside of the right side of Resident #83's gerichair. In an interview on 07/18/2023 at 1:20 p.m., S7Careplan Nurse stated she was responsible for performing Resident #83's smoking assessments and updating Resident #83's smoking careplan. S7Careplan Nurse further stated Resident #83 could not dispose of ashes properly upon assessment and should have been an unsafe smoker. In an interview on 07/18/2023 at 2:40 p.m., S2Director of Nursing (DON) confirmed Resident #83's right arm on her gerichair had ash and burn marks. S2DON confirmed Resident #83 was using the right arm of her gerichair to extinguish her lit cigarette. S2DON stated Resident #83 should have been deemed an unsafe smoker on 06/05/2023 when her re-assessment was completed. S2DON stated Resident #83 should not have been allowed to smoke unsupervised at any time and she should have had a smoking apron in place when smoking. S2DON further stated Resident #83 should not be allowed to have a lighter on her person at any time. 3.) Resident #24 Review of Resident #24's face sheet revealed, in part, Resident #24 was admitted to the facility on [DATE] with diagnoses that included: blindness of both eyes. Review of Resident #24's Minimum Data Set with an Assessment Reference Date of 06/05/2023 revealed, in part, Resident #24's Brief Interview for Mental Status Score was 15 which indicated Resident #24 was cognitively intact. Review of Resident #24's Comprehensive Care Plan revealed, in part, a category of safe smoking with a start date of 09/10/2020. Further review revealed interventions that included: the staff should interview Resident #24 to assure the safety of smoking, monitor Resident #24's room for indication of smoking such as burn marks, cigarette butts, burned matches, educate Resident #24 on smoking safely, inform Resident #24's family of any problems with smoking noncompliance with facility's smoking safety protocol, provide a smoking vest if needed for Resident #24's safety, and the family and/or Resident #24 was to provide their cigarettes and lighters. Review of Resident #24's physician orders for June and July 2023 revealed no documentation of Resident #24 being monitored while smoking. Review of the facility's smoking list revealed Resident #24 was a smoker. Review of Resident #24's electronic Medication Administration Record (eMAR) for June and July 2023 revealed no documentation of Resident #24 being monitored while smoking. Review of Resident #24's Activities of Daily Living record for July 2023 revealed no documentation of Resident #24 being monitored while smoking. Review of Resident #24's Assessment for Safe Smoking with a date of completion of 06/05/2023 revealed, in part, Resident #24 was safe to smoke unsupervised. Review of this assessment revealed Resident #24's visions was impaired, but he was able to smoke safely. Observation on 07/17/2023 at 10:19 a.m. revealed, Resident #24 smoking a lit cigarette outside without supervision of staff and without a smoker's apron in place. Observation revealed Resident #24 had a lit cigarette in his hand with visible ashes noted on Resident #24's right upper leg. In an interview on 07/17/2023 at 10:19 a.m., Resident #24 stated that he is blind in both eyes. Resident #24 stated he was allowed to smoke without staff supervision. Resident #24 further stated he was allowed to keep his cigarettes and lighter at all times. Observation on 07/18/2023 at 9:20 a.m. revealed, Resident #24 sitting outside in his wheelchair in the designated smoking area without staff present. Further observation revealed, Resident #24 with a small pile of ashes on his right upper thigh and left mid-thigh. Observation on 07/18/2023 at 10:45 a.m. revealed, Resident #24 sitting outside in his wheelchair smoking a lit cigarette in the designated smoking area without staff present. Observation revealed, Resident #24 had a small piece of ash noted to his left upper thigh. Further observation revealed ashes scattered on his right and left thigh. In an interview on 07/18/2023 at 11:33 a.m., S28CNA stated Resident #24 could smoke without staff supervision. S28CNA stated that she was unaware if Resident #24's cigarettes needed to be kept on the nurse's medication cart. S28CNA further stated that she was unaware of the facility's process on notifying the staff of resident's smoking status. S28CNA stated she used her best judgment to determine if a resident should be supervised based off of their cognitive status and their mobility needs. In an interview on 07/18/2023 at 11:44 a.m., S62LPN stated she was unaware that unsafe smoker's smoking material should be kept on the nursing cart. S62LPN stated she does not know the facility's process for identifying if a resident was a safe or unsafe smoker. S62LPN further stated she was unaware of the process for a resident's smoking assessment. In an interview on 07/18/2023 at 12:30 p.m., Resident #24 stated he was currently in possession of his lighter and his cigarettes. Resident #24 further stated that he kept his cigarettes in his pocket. In an interview on 07/18/2023 at 1:06 p.m., S62LPN stated she was unaware of Resident #24's smoking status. S62LPN stated that she had witnessed Resident #24 borrow cigarettes from other residents, but she had never seen him with some of his own smoking material. S62LPN further stated if a resident was smoking in their room, holding a cigarette close to their person, falling asleep while smoking, if ashes are falling onto their clothing while smoking, or if burn holes were noted to the resident's clothing, then the resident should be considered an unsafe smoker. In an interview on 07/18/2023 at 1:10 p.m., S2DON stated Resident #24 was an unsafe smoker due to dropping ash on himself. S2DON further stated Resident #24 should have staff supervision when smoking. In an interview on 07/18/2023 at 1:11 p.m., S1Administrator stated Resident #24 was an unsafe smoker due to dropping ash on himself. S1Administrator further stated Resident #24 should be monitored when smoking due to displaying unsafe behaviors. In an interview on 07/19/2023 at 8:27 a.m., S7CarePlan Nurse stated she interviews the nursing staff and the CNA staff to obtain information to complete safe smoking assessments. S7CarePlan Nurse further stated that she does not go outside to observe residents smoking directly because she has a problem with her lungs and the smoke irritates them. S7CarePlan Nurse stated she used the window in the center of the building to assess residents who are smokers. Observation on 07/19/2023 at 8:50 a.m., surveyor walked the distance from the above indicated window to the area Resident #24 has been observed smoking and it was approximately 125 feet. 4.) Resident #85 Review of Resident #85's face sheet revealed, in part, Resident #85 was admitted to the facility on [DATE] with diagnoses that included: Nicotine Dependence Review of Resident #85's Minimal Data Set with an Assessment Reference Date of 06/12/2023 revealed, in part, Resident #85's Brief Interview for Mental status Score was 15 which indicated Resident #85 was cognitively intact. Review of Resident #85's Comprehensive Care Plan, revealed, in part, Resident #85 would be free from complications and/or injury from smoking. Review revealed interventions that included: Resident #85 and/or Resident #85's family were to provide Resident #85's cigarettes and lighters, smoking assessments were to be done upon admission to the facility, quarterly, and as needed, staff are to remind/encourage resident to only smoke in designated smoking area, assure that resident is properly dressed for weather conditions when outside in smoking area, and provide a smoking jacket as needed. Review of Resident #85's physician orders revealed no documentation for smoking or one hour monitoring. Review of Resident #85's electronic Medication Administration Record (eMAR) revealed no evidence of documentation of one hour monitoring of Resident #85. Review of Resident #85's Activities of Daily Living (ADL) documentation revealed no evidence of documentation of one hour monitoring of Resident #85. Review of Resident #85's Safe Smoking assessment dated [DATE] revealed, in part, resident was safe to smoke unsupervised at this time. Observation on 07/18/2023 at 11:01 a.m. revealed, Resident #80 gave Resident #85 a cigarette. Observation revealed Resident #85 put Resident #80's cigarette to his mouth, used his orange lighter to light the cigarette, then gave the cigarette back to Resident #80. In an interview on 07/19/2023 at 8:27 a.m., S7Careplan Nurse stated she interviewed Resident #85's nurse and CNAs in order to get information regarding Resident #85's smoking habits to completed his safe smoking assessment. S7Careplan Nurse further stated she would also view Resident #85 and additional residents through the window in the center of the building to assess residents who smoke.S7Careplan Nurse stated she was unsure if she could see exactly how residents were disposing of ashes from the window in the center of the building. Observation on 07/19/2023 at 8:50 a.m., surveyor walked the distance from the above indicated window to the area Resident #85 has been observed smoking and it was approximately 125 feet. In an interview on 07/20/2023 at 11:45 a.m., S1Administrator stated Resident #24. Resident #80, Resident #83, and Resident #85 should not have been allowed to smoke without staff supervision. S1Adminstrator further stated Resident #80 should have been deemed an unsafe smoker after he was caught smoking in his room, he should have been provided direct supervision when he was smoking, and his smoking material should have been removed from his person following the incident. S1Adminstrator stated Resident #83 should have been deemed an unsafe smoker after she was visualized during her assessment disposing of ashes improperly. S1Administrator stated S60SSD should have notified him or S2DON following the incident, and Resident #80 should have been reassessed immediately. S1Adminstrator further stated Resident #24 and Resident #85 should have staff supervision when smoking and Resident #24 should have a smoking apron on at all times.