**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure nursing staff communicated a significant change in status to the resident's physician for 2 (#3 and #R4) of 8 (#1, #2, #3, #R1, #R2, #R3, #R4, and #R5) residents reviewed for notification of change. This deficient practice resulted in an Immediate Jeopardy situation on 05/31/2024 at 4:00 a.m. when S4LPN failed to notify Resident #3's physician when the resident had no urine output. On 05/30/2024 at 2:56 p.m., Resident #3 was observed to be lethargic and weak, which resulted in S6NP ordering 500 cc normal saline via intravenous infusion and lab work in the morning. On 05/31/2024 at 4:00 a.m., S4LPN attempted to collect urine from Resident #3 with an in and out catheter which resulted in no urine. The resident's brief was also observed to be dry at that time. S4LPN did not notify the resident's physician or nurse practitioner that Resident #3 had no urine output. On 05/31/2024 at 7:00 a.m., Resident #3 was lethargic, his body was rigid, and extremities were twitching. On 05/31/2024 at 8:30 a.m., Resident #3 was transferred to the hospital. Resident #3 was diagnosed with Acute Metabolic Encephalopathy, Hypernatremia, and Acute Cystitis with Hematuria. Resident #3 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. S1ADM and S2DON were notified of the Immediate Jeopardy situation on 06/21/2024 at 2:41 p.m. The Immediate Jeopardy was removed on 06/23/2024 at 2:53 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at more than minimal harm for any resident residing in the facility. Findings: Review of the facility's undated Resident Rights and Quality of Life Policy and Procedure revealed, in part: Policy: A resident has the right: 11. To be notified, and his or her physician notified of significant changes in condition, of a need to significantly alter treatment, or of a decision to be transferred. Resident #3 Review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with the following diagnoses, in part, Unspecified Dementia, Schizophrenia, Benign Prostatic Hyperplasia with lower urinary tract symptoms, Metabolic Encephalopathy, Sepsis, Acute Embolism and Thrombosis of left Peroneal Vein. Review of Resident #3's Progress Note dated 05/30/2024 by S6NP revealed, in part, vital signs: P 99, BP 178/91, T 98, R 18, O2 sat 95% RA. Staff reports that resident stayed in bed most of the day yesterday; today he is weak and required help with eating. BP elevated prior to medications, looks comfortable. Staff reports Resident #3 was weak, requiring assistance with feeding, not talking but tracks people and follows command, poor intake yesterday. Give IV bolus 500cc NS today, check CBC, CMP, UA. Review of Resident #3's Physician Orders dated May 2024 revealed, in part, the following: An order dated 05/30/2024 CBC, CMP, and UA in the morning for diagnoses: lethargy; An order dated 05/30/2024 for 500 cc Normal Saline IV one time only for dehydration for 1 day; An order dated 05/31/2024 for send to emergency room for evaluation. Review of Resident #3's Administration Note dated 05/31/2024 at 4:00 a.m. by S4LPN revealed, in part, Resident #3 was in bed and alert to nurse's voice. Resident #3's adult brief was dry. In and Out catheter attempted, no urine output, abdomen soft and non-tender, resident weak and fatigued more than normal. Report given to oncoming nurse of resident status. Further review revealed the NP and/or physician were not notified that the resident had no urine output. Review of Resident #3's Nurse's Note dated 05/31/2024 at 7:00 a.m. by S3LPN revealed, in part, Resident #3 was in bed with eyes closed, lethargic, body rigid, extremities twitching, refusing any oral fluids, 0.9% sodium chloride infusing at 20 ml/hr in IV noted to right arm. Night shift reported he had no urine output during the night shift and was unable to obtain urine when attempted to catheterize him this a.m. S6NP was informed of resident's condition. Received orders to send to hospital. Review of Resident #3's emergency provider note dated 05/31/2024 revealed, in part, Resident #3's chief complaint was weakness, increased weakness for 2 days, normally walking. Further review revealed, apparently on 05/28/2024 Resident #3 began to become more weak and less talkative, resident is non-communicative, so history was provided through EMS. Further review revealed, diagnoses included encephalopathy, weakness, and acute cystitis with hematuria. Review of Resident #3's hospital history and physical dated 05/31/2024 revealed, in part, acute metabolic encephalopathy-suspect from volume depletion and acute cystitis; hypernatremia- sodium elevated at 148, suspect volume depletion; acute cystitis with hematuria-UA consistent with acute cystitis and patient grossly encephalopathic. Review of Resident #3's hospital Discharge summary dated [DATE] revealed, in part, Resident #3 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. On 06/20/2024 at 8:10 a.m., an interview was conducted with S6NP. She stated on 05/30/2024 the nurse notified her Resident #3 was weak and lethargic, so she ordered a normal saline bolus via IV with labs to be completed in the morning. She stated she instructed the staff to notify her if there was no improvement or any decline. She stated she was not notified Resident #3 had no urine output, on 05/31/2024 at 4:00 a.m., when the nurse attempted to collect urine for the urinalysis. She stated she should have been notified of no urine output immediately. On 06/20/2024 at 9:20 p.m., an interview was conducted with S4LPN. She stated the provider should be notified of any changes in a resident's status. She stated on 05/31/2024 at 4:00 a.m. Resident #3's brief was dry, and there was no urine output noted when an In and Out catheter was used to collect the urine specimen. She stated she didn't notify the NP of no urine output at 4:00 a.m. on 05/31/2024, and should have. On 06/20/2024 at 11:25 a.m., an interview was conducted with S3LPN. She stated when she arrived to work on 05/31/2024 for the 6:00 a.m. to 6:00 p.m. shift, S4LPN asked her to assess Resident #3 during report since he had no urine output during the night shift. She stated Resident #3 was walking on Tuesday, 05/28/2024 and on 05/31/2024 he was lethargic. She stated Resident #3's blood pressure and heart rate were elevated so she called the S6NP and received orders to send him out. Resident #R4 Review of Resident #R4's medical record revealed Resident #R4 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus with Diabetic Nephropathy, Morbid Obesity, and Chronic Obstructive Pulmonary Disease. Review of Resident #R4's MAR dated May 2024 revealed, in part, the following: Normal Saline Intravenous Solution 1000 ml/hr with a note to see progress note dated 05/02/2024. Review of Resident #R4's Progress Note dated 05/02/2024 by S6NP revealed, in part, Resident #R4 was confused and lethargic. Further review revealed, start IV NS; infuse 1 liter over 4 hours and encourage fluid intake. Review of Resident #R4's Nurse's Note dated 05/02/2024 at 7:03 p.m. by S7LPN revealed, in part, unable to start IV, could not access vein, attempted three times. On 06/21/2024 at 6:00 p.m., an interview was conducted with S7LPN. She stated she confirmed she was not able to obtain IV access on 05/02/2024 and she did not administer the IV fluids as ordered on 05/02/2024. She also stated she did not notify the NP and should have. On 06/21/2024 at 6:15 p.m., an interview was conducted with S6NP. She stated she ordered IV fluids for Resident #R4 on 05/02/2024. She confirmed was not notified of the IV not being able to be obtained and she should have been. On 06/24/2024 at 10:30 a.m., an interview was conducted with S2DON. She confirmed providers should be notified immediately when orders are not able to be followed or for any significant change in a resident's condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to a resident received treatment and care in accordance with professional standards of practice and each resident's physical needs including assess, monitor, and record accurate intake/output for a resident receiving IV therapy for 1 (#3) of 5 (#3, #R1, #R2, #R3, and #R5) residents reviewed for IV therapy. This deficient practice resulted in an Immediate Jeopardy situation on 05/30/2024 at 2:56 p.m., when Resident #3 began receiving IV fluids as ordered for lethargy and weakness. On 05/31/2024 at 4:00 a.m., S4LPN attempted to collect urine from Resident #3 with an in and out catheter which resulted in no urine. The resident's brief was also observed to be dry at that time. There was no documentation of each shift's total intake and output. On 05/31/2024 at 7:00 a.m., Resident #3 was lethargic, his body was rigid, and extremities were twitching. On 05/31/2024 at 8:30 a.m., Resident #3 was transferred to the hospital. Resident #3 was diagnosed with Acute Metabolic Encephalopathy, Hypernatremia, and Acute Cystitis with Hematuria. Resident #3 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. S1ADM and S2DON were notified of the Immediate Jeopardy situation on 06/21/2024 at 2:39 p.m. The Immediate Jeopardy was removed on 06/23/2024 at 2:53 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at more than minimal harm for any resident residing in the facility requiring IV therapy residing in the facility. Findings: Review of the facility's undated Documentation and Charting Guidelines Policy revealed, in part, Purpose: The purpose of charting and documentation is to provide the following: A complete account to the resident's care, treatment, response to the care, signs, symptoms, and progress of resident care. Guidance to the physician in prescribing appropriate medication and treatment, assistance in the development of a plan of care for the resident. Procedure: 6. Intake and Output: a. consistent and accurate documentation and measurement of the resident's intake/output. b. each shift's total intake c. each shift's total output d. The 24-hour total intake/output for all shifts. e. Intake/output documentation shall be recorded when a resident has an IV. 7. IV therapy: d. 24-hour intake/output record. Review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses, in part, Unspecified Dementia, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Metabolic Encephalopathy, and Sepsis. Review of Resident #3's Physician Orders dated May 2024 revealed, in part, the following: An order dated 05/30/2024 for labs: CBC, CMP, and UA in the morning for diagnosis: Lethargy; An order dated 05/30/2024 for 500 cc Normal Saline IV one time only for Dehydration for 1 day; An order dated 05/31/2024 to send emergency room for evaluation. Review of Resident #3's MAR dated May 2024 revealed, in part, 500 cc normal saline IV one time only for dehydration for 1 day administered on 05/30/2024 at 10:13 a.m. Review of Resident #3's Nurse's Note dated 05/30/2024 by S6NP revealed, in part, Staff reports Resident #3 was weak, requiring assistance with feeding, not talking but tracks people and follows command, poor intake yesterday. Give IV bolus 500cc NS today, check CBC, CMP, UA. Review of Resident #3's Administration Note dated 05/31/2024 at 4:00 a.m. by S4LPN revealed, in part, adult brief dry, In an Out catheter attempted, no urine output, resident weak and fatigued more than normal. Report given to oncoming nurse of resident status. Further review revealed the NP was not notified. Review of Resident #3's medical record failed to reveal documentation of each shift's total intake and output on 05/30/2024 and the facility failed to provide any documentation of each shift's total intake and output. On 06/20/2024 at 9:20 p.m., an interview was conducted with S4LPN. She stated on 05/31/2024 at 4:00 a.m. Resident #3's brief was dry, and there was no urine output noted when an In and Out catheter was used to collect the urine specimen. She stated she was not monitoring intake/output of Resident #3 and should have been. On 06/20/2024 at 11:25 a.m., an interview was conducted with S3LPN. She stated when she arrived to work on 05/31/2024 for the 6:00 a.m. to 6:00 p.m. shift, S4LPN asked her to assess Resident #3 during report since he had no urine output during the night shift. She stated Resident #3 was walking on 05/28/2024 and on 05/31/2024 he was lethargic and not walking. She stated Resident #3's blood pressure and heart rate were elevated, so she called the S6NP and received orders to send him out. Review of Resident #3's Nurse's Note dated 05/31/2024 at 7:00 a.m. by S3LPN revealed, in part, Resident #3 was in bed with eyes closed, lethargic, body rigid, extremities twitching, refusing any oral fluids, 0.9% sodium chloride infusing at 20 ml/hr in IV noted to right arm. Night shift reported he had no urine output during the night shift and was unable to obtain urine when attempted to catheterize him this a.m. S6NP was informed of resident's condition. Received orders to send to hospital. Review of Resident #3's emergency provider note dated 05/31/2024 revealed, in part, Resident #3's chief complaint was weakness, increased weakness for 2 days. Further review revealed, on 05/28/2024 Resident #3 began to become more weak and less talkative, resident was non-communicative. Review of Resident #3's history and physical dated 05/31/2024 revealed, in part, Acute Metabolic Encephalopathy-suspect from volume depletion and Acute Cystitis; Hypernatremia- sodium elevated at 148, suspect volume depletion; Acute Cystitis with Hematuria-UA consistent with Acute Cystitis and patient grossly Encephalopathic. On 06/21/2024 at 10:20 a.m., an interview was conducted with S10CNA. She stated she did not monitor or document intake & output amounts. She stated she did not document how many times a resident had gone to the bathroom. She was only required to document incontinence once a shift. She stated she was not instructed to monitor intake/output for any residents. On 06/21/2024 at 10:35 a.m., an interview was conducted with S8LPN. She stated supplemental fluid with meals was not tracked. She stated the CNAs monitored how many times the resident urinated and was unsure if that was documented. On 06/21/2024 at 10:37 a.m., an interview was conducted with S9LPN. She stated she was not tracking intake/output for residents who may have been dehydrated. She stated she didn't know how urine output was measured for incontinent residents. On 06/21/2024 at 10:50 a.m., an interview was conducted with S5LPN. She stated she did not monitor intake or output for residents receiving IV fluids. On 06/20/2024 at 8:10 a.m., an interview was conducted with S6NP. She stated on 05/30/2024 the nurse notified her Resident #3 was weak and lethargic; she ordered a normal saline bolus via IV with labs to be completed on 05/31/2024 in the morning. She stated she instructed the staff to notify her if there was no improvement or any decline. She stated she expected nursing staff to document and assess a resident's fluid intake and output if she ordered IV fluids for dehydration or if the resident had decreased intake. On 06/21/2024 at 11:40 a.m., an interview was conducted with S2DON. She confirmed the documenting and charting policy indicated to track intake and output for residents receiving IV therapy. On 06/24/2024 at 10:30 a.m., an interview was conducted with S2DON. She stated Resident #3 should have had accurate intake and output monitoring while receiving IV fluids. She also stated the nurse practitioner should have been notified immediately when Resident #3 had no urine output from the in an out catheter attempt.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to be administered in a manner that enabled it use its resources effectively and efficiently by failing to implement a system to provide quality care to meet the needs of each resident by failing to: 1. Ensure nursing staff communicated a resident's significant change in condition to the physician after having no urine output while receiving IV therapy for 1 (#3) of 5 (#3, #R1, #R2, #R3, and #R5) residents reviewed for receiving IV therapy; and 2. Ensure a resident received treatment and care in accordance with professional standards of practice and each resident's physical needs including assess, monitor, and record accurate intake/output for a resident receiving IV therapy for 1 (#3) of 5 (#3, #R1, #R2, #R3, and #R5) residents reviewed for IV therapy. This deficient practice resulted in an Immediate Jeopardy situation on 05/30/2024 at 2:56 p.m., Resident #3 was observed to be lethargic and weak, which resulted in S6NP ordering 500 cc normal saline via intravenous infusion and lab work in the morning. On 05/31/2024 at 4:00 a.m., S4LPN attempted to collect urine from Resident #3 with an in and out catheter which resulted in no urine. The resident's brief was also observed to be dry at that time. S4LPN did not notify the physician of this significant change in status for Resident #3. There was no documentation of each shift's total intake and output. On 05/31/2024 at 7:00 a.m., Resident #3 was lethargic, his body was rigid, and extremities were twitching. On 05/31/2024 at 8:30 a.m., Resident #3 was transferred to the hospital. Resident #3 was diagnosed with Acute Metabolic Encephalopathy, Hypernatremia, and Acute Cystitis with Hematuria. Resident #3 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. S1ADM and S2DON were notified of the Immediate Jeopardy situation on 06/21/2024 at 2:42 p.m. The Immediate Jeopardy was removed on 06/23/2024 at 2:53 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at more than minimal harm for any resident residing in the facility. Findings: Cross Reference F580 and F684 Review of the facility's In-service Training Record Documentation revealed, in part, the following: Names of Person giving the training: S2DON Date of Training: 01/01/2024 Purpose of Training: Educating nursing staff on notifying physician/nurse practitioner of incident. Attachment: Documentation and Charting Guidelines Name of Person giving the training: S3ADON Date of Training: 04/09/2024 Purpose of Training: Hydration Attachment: Hydration Policy and Procedure Review of the facility's undated Documentation and Charting Guidelines Policy revealed, in part, the following: Purpose: The purpose of charting and documentation is to provide the following: A complete account to the resident's care, treatment, response to the care, signs, symptoms, and progress of resident care. Guidance to the physician in prescribing appropriate medication and treatment, assistance in the development of a plan of care for the resident. Procedure: 6. Intake and Output: a. consistent and accurate documentation and measurement of the resident's intake/output. b. each shift's total intake c. each shift's total output d. The 24-hour total intake/output for all shifts. e. Intake/output documentation shall be recorded when a resident has an IV. 7. IV therapy: d. 24-hour intake/output record. Review of the facility's undated Hydration Policy and Procedure revealed, in part, the following: Purpose: To assure that the resident receives sufficient amount of fluid based on individual needs to prevent dehydration. Procedure: 3. Intake and Output will be done every shift on residents that have: e. Any other condition that warrant possible dehydration or as ordered by the physician. Review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses, in part, Unspecified Dementia, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Metabolic Encephalopathy, and Sepsis. Review of Resident #3's Physician Orders dated May 2024 revealed, in part, the following: An order dated 05/30/2024 for labs: CBC, CMP, and UA in the morning for diagnosis: Lethargy; An order dated 05/30/2024 for 500 cc Normal Saline IV one time only for Dehydration for one day; An order dated 05/31/2024 to send emergency room for evaluation. Review of Resident #3's Nurse's Note dated 05/30/2024 by S6NP revealed, in part, Staff reports Resident #3 was weak, requiring assistance with feeding, not talking but tracks people and follows command, poor intake yesterday. Give IV bolus 500cc NS today, check CBC, CMP, UA. Review of Resident #3's Administration Note dated 05/31/2024 at 4:00 a.m. by S4LPN revealed, in part, adult brief dry, In and Out catheter attempted, no urine output, resident weak and fatigue more than normal. Report given to oncoming nurse of resident status. Review of Resident #3's Nurse's Note dated 05/31/2024 at 7:00 a.m. by S3LPN revealed, in part, Resident #3 was in bed with eyes closed, lethargic, body rigid, extremities twitching, refusing any oral fluids, 0.9% sodium chloride infusing at 20 ml/hr in IV noted to right arm. Night shift reported he had no urine output during the night shift and was unable to obtain urine when attempted to catheterize him this a.m. S6NP was informed of resident's condition. Received orders to send to hospital. Review of Resident #3's emergency provider note dated 05/31/2024 revealed, in part, Resident #3's chief complaint was weakness, increased weakness for 2 days. Further review revealed, on 05/28/2024 Resident #3 began to become more weak and less talkative, resident was non-communicative. Review of Resident #3's history and physical dated 05/31/2024 revealed, in part, Acute Metabolic Encephalopathy-suspect from volume depletion and Acute Cystitis; Hypernatremia- sodium elevated at 148, suspect volume depletion; Acute Cystitis with Hematuria-UA consistent with Acute Cystitis and patient grossly encephalopathic. On 06/20/2024 at 9:20 p.m., an interview was conducted with S4LPN. She stated the provider should be notified of any changes in a resident's status. She stated on 05/31/2024 at 4:00 a.m. Resident #3's brief was dry, and there was no urine output noted when an In and Out catheter was used to collect the urine specimen. She stated she didn't notify the NP of no urine output at 4:00 a.m. on 05/31/2024, and should have. On 06/20/2024 at 8:10 a.m., an interview was conducted with S6NP. She stated on 05/30/2024 the nurse notified her Resident #3 was weak and lethargic; she ordered a normal saline bolus via IV with labs to be completed on 05/31/2024 in the morning. She stated she instructed the staff to notify her if there was no improvement or any decline. She stated she expected nursing staff to document and assess a resident's fluid intake and output if she ordered IV fluids for dehydration or if the resident had decreased intake. She stated she was not notified Resident #3 had no urine output, on 05/31/2024 at 4:00 a.m., when the nurse attempted to collect urine for the urinalysis. She stated she should have been notified of no urine output immediately. On 06/21/2024 at 11:40 a.m., an interview was conducted with S2DON. She stated intake and output was only tracked if there was an order from the provider. She confirmed the facility's documenting and charting policy indicated to track intake and output for all residents receiving IV therapy. She stated she expected nursing staff to contact the provider for any change in condition. She confirmed she conducted an in-service for nursing staff to notify the physician/nurse practitioner of any resident incidents which included the Documentation and Charting Guidelines Policy on 01/01/2024 and ADON conducted an in-service on the Hydration Policy on 04/09/2024. She stated she was not monitoring compliance of the in-services conducted on 01/01/2024 and 04/09/2024. On 06/24/2024 at 10:30 a.m., an interview was conducted with S2DON. She stated Resident #3 should have had accurate intake and output monitoring while receiving IV fluids. She also stated the nurse practitioner should have been notified immediately when Resident #3 had no urine output from the in an out catheter attempt.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility neglected to provide needed services to residents by failing to ensure: 1. Nursing staff supervised and monitored residents who utilized the outdoor smoker's patio to ensure their safety in accordance with the residents care plan for 9 (#1, #3, #4, #5, R1, R2, R3, R4, R5) of 10 (#1, #2, #3, #4, #5, R1, R2, R3, R4, R5) residents reviewed for supervision; and 2. Staff (S6CNA and S7CNA) did not sleep when responsible for caring for residents during their shift. The deficient practice resulted in an Immediate Jeopardy on [DATE] at approximately 2:00 a.m., when Resident #1, who was moderately cognitively impaired and care planned as requiring supervision when smoking, was last seen by staff (S5CNA). Resident #1 was later found outside behind a storage shed near the smoker's patio on Hall A by another facility resident (R6). R6 notified S5CNA who then found Resident #1 to be lying face down on the ground with no pulse at 5:46 a.m. Resident #1 was pronounced dead at 6:51 a.m. with causes of death listed as Dilated Cardiomyopathy and Hypothermia. On [DATE] at 10:36 p.m. video surveillance revealed 8 residents (#3, #5, #4, R1, R2, R3, R4, R5), who were care planned as requiring staff supervision while smoking, were seen outside smoking without staff supervision on the smoker's patio between the times of 9:00 p.m. and 10:36 p.m. Further review of the video revealed Resident #5, who was severely cognitively impaired, remained outside unsupervised on the smoker's patio on [DATE] from 11:50 p.m. through 2:27 a.m., when the resident independently ambulated into the facility. S1ADM was notified of the Immediate Jeopardy on [DATE] at 5:10 p.m. The Immediate Jeopardy Plan of Removal included the following: 1. Residents identified as having the potential to be affected or have been affected will be monitored and observed every 2 hours to ensure safety by the assigned nurse for every shift for 30 days, and rounds will be documented on a monitoring form, re-evaluated after receipt of the 2567, review of the policies and procedures, review of the smoking risk assessments, and QA identified issues. a. Monitoring forms were observed by surveyors as completed for each hall and resident. 2. DON/designee will review all smoking resident care plans to ensure residents are monitored base on risk assessments as determined by the IDT and residents' needs. 3. Care plan will be updated as needed. 4. Nurses educated by DON/ADON on rounding on residents and monitoring for safety every 2 hours for every shift, beginning [DATE] at 6:00 p.m. for 30 days. Reevaluation will occur when facility receives the 2567. a. In-services/Education started on [DATE] at 6:00 p.m. and will have an expected completed dated of [DATE]. i. In-services started reviewed by surveyors. b. Nurses will be educated before working scheduled assignments. 5. Nurses/CNAs educated by DON/ADON on observing residents while smoking, and to report any resident with cigarettes and/or smoking paraphernalia to administration. Reevaluation will occur when facility receives the 2567. a. In-services/Education started on [DATE] at 6:00 p.m. and will have an expected completed dated of [DATE]. b. In-services started reviewed by surveyors. c. Nurses will be educated before working scheduled assignments. 6. Nurses/CNAs educated by DON/ADON on observing video monitors at nurses station and observing residents to ensure safety. a. Video monitoring initiated [DATE] at 6:00 p.m. and will continue until the receipt of the 2567 when reevaluation will occur. b. Additional rounding documentation by CNAs beginning [DATE] at 6:00 p.m. until [DATE] at 6:00 p.m. c. In-services/Education started on [DATE] at 6:00 p.m. and will have an expected completed dated of [DATE]. In-services started reviewed by surveyors. d. Nurses will be educated before working scheduled assignments. 7. Nurses/CNAs are to document monitoring form when round is complete, and residents are accounted for. a. Nurses will sign the monitoring form next to the time/monitoring complete. b. If any resident is not accounted for, nurses and CNA/designee will make rounds outside the perimeter of the facility. c. In-services/Education started on [DATE] at 6:00 p.m. and will have an expected completed dated of [DATE]. d. Nurses will be educated before working scheduled assignments. 8. Monitoring/documentation of monitoring of resident every 2 hours will be initiated [DATE] at 6:00 p.m. and will continue to for 30 days, and as deemed necessary by the QAPI team after receipt of the 2567. The Immediate Jeopardy was removed on [DATE] at 1:10 p.m., when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the Plan of Removal had been initiated and/or implemented prior to exit. The deficient practice continued at more than minimal harm for the 18 residents identified by the facility as ambulatory and requiring supervision when smoking. Findings: Review of the facility's Abuse Prevention and Prohibition policy revealed the following, in part: Neglect is defined as the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may include, but is not limited to: Failure to provide adequate supervision and staffing Resident #1 Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses, which included Multiple Subsegmental Pulmonary Emboli without Acute Coronary Pulmonale, Other Symptoms and Signs Involving Cognitive Functions Following Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cardiac Arrest due to Underlying Cardiac Conditions, Acute and Chronic Combined Systolic and Diastolic Congestive Heart Failure, Chest Pain, Unspecified Convulsions, Paranoid Schizophrenia, Bipolar Disorder, Major Depressive Disorder Recurrent Moderate, Vascular Dementia Moderate with Other Behavioral Disturbances, Generalized Anxiety Disorder, Impulse Disorder, Unspecified Intellectual Disabilities, Other Seizures, Mild Cognitive Impairment of Uncertain or Unknown Etiology, Cardiomyopathy due to Drug and External Agent, and Cerebral Infarction. Review of the Quarterly MDS with an ARD of [DATE] revealed Resident #1 had a BIMS of 12, which indicated the resident was moderately cognitively impaired. Further review revealed Resident #1 was ambulatory without assistive devices. Review of the current Care Plan for Resident #1 revealed the following, in part: Date Initiated: [DATE] Problem: Resident was a smoker. Safe to smoke with staff supervision. At risk for injuries and issues related to smoking. Interventions: Supervise and assist with smoking as needed. Date Initiated: [DATE] Problem: Resident had impaired cognitive functions or impaired thought processes related to vascular dementia, mild neurocognitive disorder. Interventions: Cue, reorient and supervise as needed. Review of Resident #1's smoking assessment dated [DATE] revealed Resident #1 was a smoker and required staff supervision with all smoke breaks. Review of Resident #1 nurse's notes dated [DATE] at 5:34 a.m. revealed the following, in part: Nurse on Hall A doing morning rounds and noticed Resident #1 was not in his room. Staff found the resident lying outside behind a shed unresponsive. Staff initiated CPR and called 911. Response team arrived at 5:59 a.m., CPR was continued. Resident #1's time of death was 6:44 a.m. Signed by S4LPN Review of the Coroner's Fact of Death Letter for Resident #1 revealed the following, in part: Decedent: Resident #1 date of death : [DATE] Time of death: 6:51 a.m. Cause of death: Dilated Cardiomyopathy and Hypothermia. Review of the weather app, Accuweather, revealed the following: [DATE] - Low of 45 degrees Fahrenheit [DATE] - Low of 53 degrees Fahrenheit Review of the police detective's investigation notes of video surveillance from [DATE] revealed the following, in part: 2:18 a.m. Resident #1 was noted to go outside on Hall A smoker's patio and smoke a cigarette. 2:27 a.m. Resident #1 was noted to go behind a storage shed and was no longer seen on camera. 5:41 a.m. R6 was noted to go outside on Hall A smoker's patio. 5:45 a.m. R6 was noted to go inside the facility. 5:46 a.m. R6 was noted to go outside with staff member, S5CNA. They were noted to walk around the storage shed. An interview was conducted on [DATE] at 4:10 p.m. with S3ADON. S3ADON stated the doors to the outside smoking areas stay unlocked at all times to allow residents freedom to go in and out, as they please. She stated Resident #1 was a smoker and was allowed to go outside at all times of the day and night. She stated he did not need to be supervised unless he was smoking, but staff was expected to round on him every 2 hours. An observation was made of Hall A's smoker's patio on [DATE] at 3:45 p.m. The door leading to the smoker's patio was solid with a small rectangular window. It was noted that only a small portion of the patio was visible through the window from inside the facility. About 20 feet and directly in front of the smoker's patio was a storage shed. Immediately outside of the door, the smoker's patio was noted to extend into a large fenced-in perimeter that enclosed all the facility halls smoker's patios. Surveyor was unable to visualize the entirety of the area, including the gazebo area, to see residents from inside the building. An observation was made of Hall B's smoker's patio on [DATE] at 3:50 p.m. The door leading to the smoker's patio was solid with a small rectangular window. It was noted that only a small portion of the patio was visible through the window from inside the facility. About 100 feet to the right of the smoker's patio was a gazebo area. Surveyor was unable to visualize the entirety of the area, including the gazebo area, to see residents from inside the building. An interview was conducted on [DATE] at 12:08 p.m. with the local police detective. He stated dispatch was called at 5:59 a.m. on [DATE]. He confirmed he reviewed the facility's video surveillance from [DATE], which revealed Resident #1 smoking outside unsupervised multiple times prior to 2:18 a.m. He stated at 2:27 a.m. Resident #1 was observed to walk behind the storage shed and out of site of the camera. He said the resident remained behind the shed from 2:27 a.m. to 5:46 a.m. He confirmed staff were not seen on the surveillance video until 5:46 a.m., when R6 and S5CNA walked into view and found Resident #1 behind the shed. He stated the coroner report revealed the resident died of Dilated Cardiomyopathy and Hypothermia. An interview was conducted on [DATE] at 9:45 a.m. with S4LPN. She confirmed being responsible to care for Resident #1 the night of [DATE]. She said Resident #1 was cognitive, could walk on his own with no assistive devices, had no behaviors, was a smoker, and needed supervision when smoking. She stated the facility expected the staff to lay eyes on each resident about every 2 hours during their shift. She stated the last time she saw Resident #1 was approximately 2:00 a.m. on [DATE]. She stated at that time he was in bed. She stated she did not make rounds on Resident #1 until around 5:30 a.m. when she realized he was not in his bed. She stated she began looking for Resident #1 when R6 found her. She stated R6 told her a body was outside. S4LPN said she went outside onto Hall As smoker's patio and walked around the storage shed where saw Resident #1 face down on the ground. She stated Resident #1 did not have a pulse. She explained 2 other nurses helped flip the resident over and began CPR while she called 911. She confirmed she did not make rounds on Resident #1 between the hours of 2:00 a.m. to 5:30 a.m. She said she assumed S5CNA had made rounds and checked on him. An interview was conducted on [DATE] at 9:00 a.m. with R6. R6 stated early every morning he walked outside onto the smoker's patio to see how the weather was. He said on [DATE] around 5:40 a.m., he walked outside and noticed something on the ground behind the storage shed that was located near Hall A's smoking patio. He stated he walked inside and told S5CNA there was something on the ground. He stated they walked outside together and S5CNA said, That's a body. He said he then went inside and told S4LPN there was a body on the ground. He stated S4LPN went outside after that. An interview was conducted on [DATE] at 9:12 a.m. with S5CNA. She confirmed being responsible to care for Resident #1 on the night of [DATE]. She described Resident #1 as polite and cognitive. She stated he was a smoker, which needed supervision when smoking. She stated the facility expected the staff to make rounds on each resident about every 2 hours during their shift. She stated the last time she saw Resident #1 on [DATE] was at 2:00 a.m. and Resident #1 was standing in his bedroom doorway. She stated she did not see Resident #1 again until about 5:46 a.m. when he was found outside on the ground. She explained R6 found her and said something was outside on the ground so she walked outside to see what it was. She stated she saw Resident #1 was on his stomach face down on the ground behind the storage shed. She said she and asked R6 to go get help. She stated S4LPN came outside shortly after and then two other nurses. She stated the nurses began CPR and called 911. An interview was conducted on [DATE] at 11:45 a.m. with the coroner. She confirmed she completed the Fact of Death Letter for Resident #1 dated [DATE]. She stated Resident #1's autopsy showed the causes of death as Dilated Cardiomyopathy with Hypothermia being a contributing factor to his demise. She confirmed the time of death for Resident #1 was 6:51 a.m. on [DATE]. An interview was conducted on [DATE] at 1:48 p.m. with S3ADON. She confirmed she reviewed the video surveillance dated [DATE] with the local police detective. She confirmed Resident #1 exited the building from Hall A onto the smoker's patio at 2:18 a.m. and smoked a cigarette unsupervised. She said Resident #1 then walked behind the shed and out of sight of the surveillance camera at 2:27 a.m. She confirmed no staff were seen to go out of the building to round on Resident #1 from 2:18 a.m. to 5:46 a.m. She confirmed the staff went out at 5:46 a.m. and found the resident on the ground. She confirmed Resident #1 died from Dilated Cardiomyopathy and Hypothermia. She stated the facility encouraged staff to round on residents at least every 2 hours and confirmed on [DATE] the staff did not round on Resident #1 for over 3 hours. She stated staff were in-serviced regarding making rounds on residents every 2 hours after this incident. She stated no new policies, procedures, or monitoring was implemented after Resident #1 died because he died of natural causes. She stated Resident #1 should not have had access to cigarettes or a lighter without supervision. An interview was conducted on [DATE] at 2:11 p.m. with S2DON. He stated the nurses and CNAs were encouraged to round on residents every 2 hours. He stated early on [DATE] he was notified Resident #1 was found outside on the ground. He stated staff reported CPR was started, 911 was called and the time Resident #1 was pronounced dead. He stated he reviewed the video surveillance with the local police detective. He confirmed Resident #1 was outside smoking unsupervised at 2:18 a.m. He verified Resident #1 should have been supervised while smoking. He confirmed at 2:27 a.m., the resident went behind the storage shed and out of sight. He confirmed no staff rounded on the resident until after R6 alerted S5CNA. He confirmed Resident #1 was found outside at 5:46 a.m., over 3 hours later. He stated staff were in-serviced regarding rounding on residents every 2 hours, but nothing new was implemented. He stated he did not investigate the circumstances surrounding the resident's death because this resident was very sick and it was not surprising he had passed. He confirmed nothing new was implemented because the resident had died of natural causes. He confirmed the coroner's report said the cause of death was Dilated Cardiomyopathy and Hypothermia. An interview was conducted on [DATE] at 2:34 p.m. with S1ADM. She stated she encouraged staff to put their eyes on the residents at a minimum of every 2 hours. She stated on [DATE] staff notified her prior to 8 a.m. that Resident #1 was found outside on the ground, behind the storage shed near Hall As smoker's patio. She said staff reported CPR was initiated, the paramedics were called, and staff continued CPR for 45 minutes until Resident #1 was pronounced dead. She stated she did not watch the video surveillance dated [DATE]. She stated she spoke with the nurses and CNAs on duty the night of [DATE] about the series of events, but did not find anything that would make her think the facility did anything wrong. She confirmed there was no further investigation into this event. She stated she did not know Resident #1 was smoking outside and unsupervised at 2:18 a.m. She confirmed he should have been supervised while smoking. She stated during her investigation, she did not specifically ask staff what times they had last seen Resident #1 and did not know none of the staff had laid eyes on him from 2:18 a.m. to 5:46 a.m. She confirmed had she known this she would have considered this as potential neglect. She explained S3ADON in-serviced all staff to round on the residents at least every 2 hours, but there were no new interventions or changes to policies. She denied increasing supervision of residents outside on the smoker's patio or rounding. Resident #5 Review of the Clinical Record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses, which included Type 2 Diabetes Mellitus without Complications, Schizophrenia, Major Depressive Disorder, and Multiple Fractures of Ribs on Left Side. Review of the Quarterly MDS with an ARD of [DATE] revealed Resident #5 had a BIMS of 8, which indicated the resident was moderately cognitively impaired. Further review revealed Resident #5 was able to independently propel when in the wheelchair. Review of the current Care Plan for Resident #5 revealed the following, in part: Date Initiated: [DATE] Problem: The resident was a tobacco smoker and was at risk for complications. Refuses to come inside after smoking at times. Resident requires supervision at all smoke breaks. Date Initiated: [DATE] Problem: At risk for wandering and elopement related to anxiety disorder, schizophrenia, depression. Intervention: monitor behavior/behavior changes, redirect as appropriate Date Initiated: [DATE] Problem: Resident has impaired cognitive function or impaired thought processes related to BIMS 8 Intervention: cue, reorient, and supervise as needed, monitor for change in cognition function. Review of Resident #5's smoking assessment dated [DATE] revealed Resident #5 was a smoker and required staff supervision with all smoke breaks. The facility's video surveillance of Hall B's outdoor smoker's patio dated [DATE] to [DATE] was observed with S3ADON on [DATE] at 1:45 p.m. The following was confirmed by S3ADON. 10:17 p.m. Resident #5 was observed on the patio watching tv. 10:36 p.m. Resident #5 was observed smoking a cigarette on the patio with no supervision. 10:53 p.m. Resident #5 was observed going back into the facility. 11:50 p.m. Resident #5 was observed going back out onto the smoker's patio, and watching tv. 2:27 a.m. Resident #5 was observed going back into the facility. It is noted from 11:50 p.m. to 2:27 a.m. no staff were observed supervising or monitoring Resident #5. An interview was conducted on [DATE] at 4:00 a.m. with S15CNA. She stated was assigned to care for Resident #5 on the night shift of [DATE]. She stated Resident #5 should not be smoking outside alone, nor should he have access to cigarettes without a CNA giving them to him. She stated she was unaware this resident was outside smoking unsupervised on [DATE] and should not had been. She confirmed Resident #5 should not be outside smoking without supervision. Resident #3 Review of the clinical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease, Asthma, Bradycardia, Major Depressive Disorder, Disease of Upper Respiratory Tract, Old Myocardial Infarction, and Tobacco Use Review of the Quarterly MDS with an ARD of [DATE] revealed Resident #3 had a BIMS of 11, which indicated the resident was moderately cognitively impaired. Further review revealed Resident #3 was ambulatory without assistive devices. Review of the current Care Plan for Resident #3 revealed the following, in part: Date Initiated: [DATE] Problem: The resident was a tobacco smoker. Safe to smoke with supervision. Interventions: Resident requires supervision when smoking Date Initiated: [DATE] Problem: The resident has impaired cognitive function and though processes related to Dementia. Interventions: Cue, reorient and supervise as needed Date Initiated: [DATE] Problem: the Resident was at risk for mood and behavior episodes related to diagnosis of bipolar schizoaffective disorder, OCD, anxiety and behavior issues; picks up cigarette butts off of the ground and look for people to light them for him Intervention: staff will encourage resident to not pick up cigarette butts off the ground Review of Resident #3's smoking assessment dated [DATE] revealed Resident #3 was a smoker, and required staff supervision while smoking. The facility's video surveillance of Hall B's outdoor smoker's patio dated [DATE] to [DATE] was observed with S3ADON on [DATE] at 1:45 p.m. S3ADON confirmed Resident #3 was outside smoking without staff supervision at 9:09 p.m. and should not have been. An interview was conducted on [DATE] at 10:56 a.m. with S12CNA. She stated Resident #3 was a smoker and had to be supervised when smoking. Resident #4 Review of the clinical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses, which included Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Tobacco Use, Major Depressive Disorder, Bipolar Disorder, Atherosclerotic Heart Disease of Native Coronary Artery With Unspecified Angina Pectoris, Angina Pectoris, Schizoaffective Disorder, Unspecified Psychosis not due to a Substance or Known Physiological Condition, and Unspecified Convulsions. Review of the Quarterly MDS with an ARD of [DATE] revealed Resident #4 had a BIMS of 13, which indicated the resident was cognitively intact. Further review revealed Resident #4 was ambulatory without assistive devices. Review of the current Care Plan for Resident #4 revealed the following, in part: Date Initiated: [DATE] Problem; Resident smokes daily. Resident requires staff supervision. Chews on cigarette butts at times. Resident had periods where he quit smoking and then start back again. At risk for injury related to smoking. Interventions: supervise and assist with smoking Date Initiated: [DATE] Problem: Nurse informed MD of my complaint of frequent nausea related to eating cigarette butts. Interventions: staff will encourage not to chew cigarette butts, staff will counsel resident on effects of eating cigarette butts when needed. Date Initiated: [DATE] Problem: At risk for mood and behavioral problems related to Depression, Schizoaffective Disorder, Mood Disorder, Anxiety, Bipolar disorder, and Psychosis; Eats cigarette butts out of ashtray and off ground; Interventions: supervise resident during smoke breaks to ensure resident was not eating cigarette butts. Review of Resident #4's smoking assessment dated [DATE] revealed Resident #4 was a smoker and required staff supervision while smoking. The facility's video surveillance of Hall B's outdoor smoker's patio dated [DATE] to [DATE] was observed with S3ADON on [DATE] at 1:45 p.m. S3ADON confirmed Resident #4 was outside smoking without staff supervision at 9:09 p.m. and should not have been. An interview was conducted on [DATE] at 12:30 p.m. with S13LPN. She stated Resident #4 had a habit of eating cigarette butts. She stated he should be supervised when outside because he has pica and would eat strange things. An interview was conducted on [DATE] at 11:30 a.m. with S14CNA. She stated when Resident #4 goes outside during smoking times; he would pick up cigarette butts and eat them. She confirmed the resident required supervision when smoking. R1 Review of the clinical record revealed R1 was admitted to the facility on [DATE] with diagnoses, which included Venous Insufficiency Chronic Peripheral, Osteonecrosis, Idiopathic Aseptic Necrosis of Right and Left Femur, Idiopathic Aseptic Necrosis of Bone in Multiple Sites, Anxiety Disorder, Borderline Intellectual Functioning, Other Fracture of Upper and Lower End of Right Fibula, Subsequent Encounter for Closed Fracture with Routine Healing, Tobacco Use, Bipolar Disorder, in Partial Remission, Most Recent Manic Episode, Other Schizophrenia, Other Psychoactive Substance Abuse with Psychoactive Substance Induced Mood Disorder, Major Depressive Disorder, Borderline Personality Disorder, Extrapyramidal and Movement Disorder, Peripheral Vascular Disease, Osteoarthritis, and Epilepsy. Review of the Quarterly MDS with an ARD of [DATE] revealed R1 had a BIMS of 15, which indicated the resident was cognitively intact. Further review revealed R1 was able to self-propel with the assistance of a wheelchair. Review of R1's care plan revealed the following, in part: Date Initiated: [DATE] Problem: Resident smokes daily. Intervention: supervise and assist with smoking as needed Date Initiated: [DATE] Problem: The resident has impaired cognitive function or impaired thought processes related to Schizophrenia, borderline intellectual functioning, & Borderline personality disorder. At risk for complications. Interventions: cue, reorient, and supervise as needed Review of R1's smoking assessment dated [DATE] revealed R1 was a smoker and required staff supervision while smoking. The facility's video surveillance of Hall As outdoor smoker's patio dated [DATE] to [DATE] was observed with S3ADON on [DATE] at 1:45 p.m. S3ADON confirmed R1 was outside smoking without staff supervision at 9:00 p.m. and should not have been. R2 Review of the clinical record revealed R2 was admitted to the facility on [DATE] with diagnoses, which included Rheumatic Tricuspid Valve Disease, Opioid Dependence, Other Psychoactive Substance Abuse, Major Depressive Disorder, Biventricular Heart Failure, Dysphagia, Tobacco Use, and Critical Illness Myopathy Review of the Quarterly MDS with an ARD of [DATE] revealed R2 had a BIMS of 13, which indicated the resident was cognitively intact. Further review revealed R2 was ambulatory without assistive devices. Review of the current Care Plan for R2 revealed the following, in part: Date Initiated: [DATE] Problem: The resident was a tobacco smoker. Safe to smoke with supervision. Interventions: the resident required supervision while smoking. Review of R2's smoking assessment dated [DATE] revealed R2 was a smoker and required staff supervision while smoking. The facility's video surveillance of Hall Bs outdoor smoker's patio dated [DATE] to [DATE] was observed with S3ADON on [DATE] at 1:45 p.m. S3ADON confirmed R2 was outside smoking without staff supervision at 9:10 p.m. and should not have been. R3 Review of the Clinical Record revealed R3 was admitted to the facility on [DATE] with diagnoses, which included Hypertensive Heart Disease without Heart Failure, Schizoaffective Disorder, Generalized Anxiety Disorder, Unspecified symptoms and signs involving cognitive functions and awareness, Encephalopathy, Nicotine Dependence, Cigarettes, Other Psychoactive Substance Abuse with Intoxication Delirium, and Stridor. Review of the Quarterly MDS with an ARD of [DATE] revealed R3 had a BIMS of 15, which indicated the resident was cognitively intact. Further review revealed R3 was ambulatory without assistive devices. Review of the current Care Plan for R3 revealed the following, in part: Date Initiated: [DATE] Problem: Resident was active cigarette smoker. Safe to smoke with supervision. Interventions: Supervise and assist with smoking as needed. Date Initiated: [DATE] Problem: The resident has potential for mood and behavioral episodes and issues related to diagnosis of restlessness and agitation, history of psychoactive substance abuse, and brief psychotic disorder. Interventions: intervene as necessary to protect the rights and safety of others. Monitor behavior episodes. Cue, reorient and supervise as needed. Review of R3's smoking assessment dated [DATE] revealed R3 was a smoker and required staff supervision while smoking. The facility's video surveillance of Hall As outdoor smoker's patio dated [DATE] to [DATE] was observed with S3ADON on [DATE] at 1:45 p.m. S3ADON confirmed R3 was outside smoking without staff supervision at 9:15 p.m. and should not have been. R4 Review of the Clinical Record revealed R4 was admitted to the facility on [DATE] with diagnoses, which included Unspecified Psychosis not due to a Substance or Known Physiological Condition, Tobacco Use, Schizophrenia, Anxiety Disorder, Mental Disorder, and Borderline Intellectual Functioning. Review of the Quarterly MDS with an ARD of [DATE] revealed R4 had a BIMS of 4, which indicated the resident was severely cognitively impaired. Further review revealed R4 was ambulatory without assistive devices. Review of the current Care Plan for R4 revealed the following, in part: Date Initiated: [DATE] Problem: Resident request to smoke at facility. Safe to smoke with supervision. Interventions: the resident requires supervision when smoking. Date Initiated: [DATE] Problem: The resident has impaired cognition/thought process related to borderline intellectual functioning, autism, and schizophrenia. Resident was easily distracted at times. Interventions: cue reorient and supervise as needed. Review of R4's smoking assessment dated [DATE] revealed R4 was a smoker and required staff supervision while smoking. The facility's video surveillance[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to be administered in a manner, which enabled it to use its resources effectively and efficiently by failing to ensure administrative staff had systems in place to identify, prevent and monitor resident neglect for 9 (#1, #3, #4, #5, R1, R2, R3, R4, R5) of 10 (#1, #2, #3, #4, #5, R1, R2, R3, R4, R5) residents reviewed for supervision. The deficient practice resulted in an Immediate Jeopardy on [DATE] at approximately 2:00 a.m., when Resident #1, who was moderately cognitively impaired and care planned as requiring supervision when smoking, was last seen by staff (S5CNA). Resident #1 was later found outside behind a storage shed near the smoker's patio on Hall A by another facility resident (R6). R6 notified S5CNA who then found Resident #1 to be lying face down on the ground with no pulse at 5:46 a.m. Resident #1 was pronounced dead at 6:51 a.m. with causes of death listed as Dilated Cardiomyopathy and Hypothermia. On [DATE] at 10:36 p.m. video surveillance revealed 8 residents (#3, #5, #4, R1, R2, R3, R4, R5), who were care planned as requiring staff supervision while smoking, were seen outside smoking without staff supervision on the smoker's patio between the times of 9:00 p.m. and 10:36 p.m. Further review of the video revealed Resident #5, who was severely cognitively impaired, remained outside unsupervised on the smoker's patio on [DATE] from 11:50 p.m. through 2:27 a.m., when the resident independently ambulated into the facility. S1ADM was notified of the Immediate Jeopardy on [DATE] at 5:10 p.m. 1. Residents #1 and #5, Residents #3, #4, #5, R1, R2, R3, R4, R5 and all resident who smoke outside have the potential to be adversely impacted by the result of the noncompliance. 2. Rounding/monitoring every 2 hours initiated on [DATE] at 6:00 p.m. 3. DON/Designee will monitor all documentation to ensure compliance is maintained. 4. Administration will randomly visit facility monthly during the night shift to ensure compliance. 5. Any identified issues will be addressed with re-education and/or progressive discipline. 6. Corporate Compliance will monitor administration monthly to ensure compliance is maintained. 7. Administrator educated Nursing Administration on monitoring documentation to ensure compliance. a. In-service/Education started on [DATE]; expected completion date Thursday, [DATE]. 8. Administrator educated Nursing Administration on random monthly facility visits during night shift to ensure compliance. a. In-service/Education started on [DATE]; expected completion date Thursday, [DATE]. 9. Chief Operating Office educated administrator on monitoring nursing administration and random monthly facility visits during night shift to ensure compliance. a. In-service/Education completed on [DATE]. 10. Monitoring of administration initiated [DATE] by NFA and will continue for 30 days, and as deemed necessary by the QAPI team. The Immediate Jeopardy was removed on [DATE] at 1:10 p.m., when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the Plan of Removal had been initiated and/or implemented prior to exit. The deficient practice continued at more than minimal harm for the 18 residents identified by the facility as unsafe smokers and ambulatory. Findings: Cross Reference F600 Review of the facility's policy titled Safety and Supervision of Residents Policy and Procedure revealed the following, in part: Facility Oriented Approach to Safety 3. When accident hazards are identified, the ID team shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. 5. The facility staff shall monitor interventions to mitigate accident hazards in the facility and modify, as necessary. Individualized, Resident Centered Approach to Safety c. Ensuing that interventions are implemented; and 5. Monitoring the effectiveness of interventions shall include the following a. Ensuring that interventions are implemented correctly and consistently b. Evaluating the effectiveness of interventions c. Modifying or replacing interventions as needed d. Evaluating the effectiveness of new or revised interventions Systems Approach to Safety 2. Resident supervision is a core component of the systems approach to safety. Review of the facility's Abuse Prevention and Prohibition policy revealed the following, in part: Neglect is defined as the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A facility must report incidents of alleged neglect and all situations in which the facility has cause to believe that the physical or mental health and/or welfare or a resident has been or may be adversely affected by neglect by another person. Neglect may include, but is not limited to: Failure to provide adequate supervision and staffing. Resident #1 Review of the Quarterly MDS with an ARD of [DATE] revealed Resident #1 had a BIMS of 12, which indicated the resident was moderately cognitively impaired. Further review revealed Resident #1 was ambulatory without assistive devices. Review of Resident #1's smoking assessment dated [DATE] revealed Resident #1 was a smoker and required staff supervision with all smoke breaks. Review of the current Care Plan for Resident #1 revealed the following, in part: Date Initiated: [DATE] Problem: Resident was a smoker. Safe to smoke with staff supervision. At risk for injuries and issues related to smoking. Interventions: Supervise and assist with smoking as needed. Date Initiated: [DATE] Problem: Resident had impaired cognitive functions or impaired thought processes related to vascular dementia, mild neurocognitive disorder. Interventions: Cue, reorient and supervise as needed. Review of Resident #1 nurse's notes dated [DATE] at 5:34 a.m. revealed the following, in part: Nurse on Hall A doing morning rounds and noticed Resident #1 was not in his room. Staff found the resident lying outside behind a shed unresponsive. Staff initiated CPR and called 911. Response team arrived at 5:59 a.m., CPR was continued. Resident #1's time of death was 6:44 a.m. Signed by S4LPN Review of the Coroner's Fact of Death Letter for Resident #1 revealed the following, in part: Decedent: Resident #1 date of death : [DATE] Time of death: 6:51 a.m. Cause of death: Dilated Cardiomyopathy and Hypothermia. Review of the weather app, Accuweather, revealed the following: [DATE] - Low of 45 degrees Fahrenheit [DATE] - Low of 53 degrees Fahrenheit An interview was conducted on [DATE] at 12:08 p.m. with the local police detective. He confirmed he reviewed the facility's video surveillance from [DATE], which revealed Resident #1 smoking outside unsupervised multiple times prior to 2:18 a.m. He stated at 2:27 a.m. Resident #1 was observed to walk behind the storage shed and out of site of the camera. He said the resident remained behind the shed from 2:27 a.m. to 5:46 a.m. He confirmed staff were not seen on the surveillance video until 5:46 a.m., when R6 and S5CNA walked into view and found Resident #1 behind the shed. He stated the coroner report revealed the resident died of Dilated Cardiomyopathy and Hypothermia. Review of the most recent care plans and smoking assessments for Residents #3, #4, #5, R1, R2, R3, R4, and R5 revealed each resident required supervision while smoking. The facility's video surveillance of Hall A and Bs outdoor smoker's patio dated [DATE] to [DATE] was observed with S3ADON on [DATE] at 1:45 p.m. The video revealed the following, in part: 9:00 p.m. R1 was observed on Hall A's smoker's patio smoking with no supervision. 9:09 p.m. Resident #4 and Resident #3 were observed on Hall B's smoker's patio smoking with no supervision. 9:10 p.m. R2 was observed on Hall B's smoker's patio smoking with no supervision. 9:15 p.m. R3 was observed on Hall A's smoker's patio smoking with no supervision. 9:19 p.m. R4 was observed on Hall B's smoker's patio smoking with no supervision. 10:30 p.m. R4 and R5 were observed on Hall B's smoker's patio smoking with no supervision. 10:36 p.m. Resident #5 was observed on Hall B's smoker's patio smoking a cigarette with no supervision. 11:50 p.m. - 2:27 a.m. Resident #5 was observed on Hall B's smoker's patio watching tv on the patio with no supervision. Review of the CNA assignment sheet revealed Hall A was assigned 2 CNAs, S6CNA and S7CNA, on [DATE] at 4:00 a.m. An observation was made on [DATE] at 4:00 a.m. of S6CNA and S7CNA. Both CNAs were observed sitting in chairs midway down Hall A, outside of resident rooms. Both CNAs were observed to be sleeping. Surveyor woke both CNAs. S7CNA and S6CNA both immediately stated they should not have been sleeping during their shift. An interview was conducted on [DATE] at 1:48 p.m. with S3ADON. She confirmed she observed the video surveillance dated [DATE] with the local police detective. She stated in the video, Resident #1 exited the building from Hall A onto the smoker's patio at 2:18 a.m. and smoked a cigarette unsupervised. She said Resident #1 then walked behind the shed and out of sight at 2:27 a.m. She confirmed no staff were seen to go out of the building to round on Resident #1 from 2:18 a.m. to 5:46 a.m. She confirmed the staff went out at 5:46 a.m. and found Resident #1 on the ground and initiated CPR. She confirmed Resident #1 was care planned as requiring supervision with smoking and should not have been smoking alone. She further confirmed staff did not round on Resident #1 for over 3 hours on the night of [DATE]. She stated after the incident, staff were in-serviced to round on the residents at least every 2 hours. She stated the facility did not implement any new interventions or monitoring due to Resident #1 dying of natural causes. She confirmed Resident #1 expired from Dilated Cardiomyopathy and Hypothermia. S3ADON stated during the video surveillance dated the night of [DATE] to [DATE] 8 residents (#3, #4, #5, R1, R2, R3, R4, and R5) were observed outside on the smoker' patio smoking unsupervised. She confirmed all 8 of the residents were care planned as requiring supervision while smoking and should not have been unsupervised. She stated Resident #5 was outside alone from 11:50 p.m. to 2:27 a.m. unsupervised by staff. She confirmed no staff rounded on Resident #5 during that time frame and should have. S3ADON confirmed being notified of 2 (S6CNA and S7CNA) found sleeping during the night shift on [DATE]. She verified staff should not be sleeping while responsible for caring for residents. S3ADON stated no new interventions or monitoring were implemented after the above findings dated the night of [DATE] to [DATE] and [DATE]. An interview was conducted on [DATE] at 2:11 p.m. with S2DON. He stated the nurses and CNAs should round on residents every 2 hours. He stated early on [DATE] he was notified Resident #1 was found outside on the ground. He confirmed Resident #1 was outside smoking unsupervised at 2:18 a.m. He verified Resident #1 should have been supervised while smoking. He confirmed Resident #1 was found outside at 5:46 a.m., over 3 hours later. He stated staff were in-serviced regarding rounding on residents every 2 hours, but nothing new was implemented. He confirmed nothing new was implemented because the resident had died of natural causes. He stated S3ADON reported the findings of the video surveillance dated the night of [DATE] to [DATE] revealed Residents #3, #4, #5, R1, R2, R3, R4 and R5 were outside smoking unsupervised. He confirmed all residents in the facility required supervision while smoking at all times. He also stated he was informed the video revealed Resident #5 outside from 11:50 p.m. to 2:27 a.m. unsupervised. He stated staff were not expected to sit outside with the residents, but they were supposed to be aware of where they were. He confirmed S3ADON told him S6CNA and S7CNA were found sleeping on their shift on [DATE]. He confirmed the facility did not implement new interventions, processes or monitoring in regards to Resident #1's death on [DATE], the video findings on [DATE] to [DATE], nor on [DATE] when the 2 CNAs were sleeping on duty. He stated no overnight monitoring had been implemented by administrative staff, and the last time he was in the building during the night shift was 2 months ago. An interview was conducted on [DATE] at 2:34 p.m. with S1ADM. She stated she encouraged staff to put their eyes on the residents at a minimum of every 2 hours. She stated on [DATE] staff notified her prior to 8 a.m. that Resident #1 was found outside on the ground, behind the storage shed near Hall As smoker's patio. She stated she spoke with the nurses and CNAs on duty the night of [DATE] about the series of events, but did not find anything that would make her think the facility did anything wrong. She stated she did not know Resident #1 was smoking outside and unsupervised at 2:18 a.m. She confirmed he should have been supervised while smoking. She stated during her investigation, she did not specifically ask staff what times they had last seen Resident #1 and did not know none of the staff had laid eyes on him from 2:18 a.m. to 5:46 a.m. She confirmed had she known this she would have considered this as potential neglect. She explained S3ADON in-serviced all staff to round on the residents at least every 2 hours, but there were no new interventions or changes to policies. She denied increasing supervision of residents outside on the smoker's patio or rounding. She reported being aware of the findings from the video dated the night of [DATE] to [DATE] where Residents #3, #4, #5, R1, R2, R3, R4 and R5 were outside smoking unsupervised. She confirmed all residents should be supervised while smoking. She confirmed Resident #5 should have been rounded on while he was outside on [DATE]. She stated she was informed of S6CNA and S7CNA sleeping during their shift on [DATE]. She stated as a result, S6CNA and S7CNA were sent home with suspension. She confirmed the facility did not implement new interventions, processes or monitoring in regards to Resident #1's death on [DATE], the video findings on [DATE] to [DATE], nor on [DATE] when the 2 CNAs were sleeping on duty. She denied any current administrative monitoring in the facility at night.