**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate basic life support, including cardiopulmonary resuscitation (CPR, a lifesaving technique that's used in emergencies in which someone's breathing or heartbeat has stopped) for one (Resident #1) of three sampled residents, who was found by staff without a pulse. Staff started CPR on a resident with full code orders but stopped before Emergency Medical Services (EMS) arrived. The Certified Nurse Aides (CNAs) on duty said they did not know how to determine code status. EMS was not notified timely, the resident was discovered without pulse at 5:10 A.M. and EMS was not contacted until 6:14 A.M. The resident expired. Additionally, the facility failed to provide CPR qualified staff for 14, full eight hour shifts between [DATE] through [DATE]. The Staffing Coordinator (SC) did not know he/she was responsible to ensure one CPR certified staff person was available on each shift. Fifty-four residents were listed as full code residents. The census was 71. The Administrator was notified on [DATE] at 12:45 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's Medical Emergency Response policy, revised [DATE], showed: -Policy: It is the policy of this facility to respond to medical emergencies for residents, staff and visitors; -Policy Explanation and Compliance Guidelines: -1. The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance; -2. CPR will be initiated unless: -a. There is a DNR order in place. -b. There are obvious signs of clinical death (rigor mortis (stiffening of the joints and muscles of a body a few hours after death), dependent lividity (the pooling of blood in the lower parts of the body after death. This causes the skin to appear discolored, usually in a shade of purple), decapitation (head removed from the body), transection (horizontal cross-section that divides the body into two parts), or decomposition (gradual process that begins at death and continues until the body is reduced to a skeleton)); -c. Initiating CPR could cause injury or peril (being in danger of injury) to the rescuer; -3. A nurse will: -a. Assess the situation and determine the severity of the emergency; -b. Stay with the resident; -c. Designate a staff member to announce emergency code, if necessary, notify the physician and call 911 as needed; -4. A Code will be announced, if necessary; -5. All available staff will respond to the emergency accordingly; -6. A nurse will bring the Emergency Cart to the code site, ensure accurate documentation of the event and delegate any other duties or tasks needed; -7. If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services, and: -a. In accordance with the resident's advance directives, or; -b. In absence of advance directives or a Do Not Resuscitate order, and; -c. If the resident does not show obvious signs of clinical death; -8. The Charge Nurse or designee will ensure emergency medications and equipment are inventoried and restocked after the event; -9. The emergency carts and equipment shall be checked daily; -10. The facility will ensure that CPR certified staff are always available; -11. Current certified staff must maintain CPR-Certification for Healthcare Providers through a CPR provider whose training includes hands-on skills practice and in-person assessment and demonstration of skills. Online certification is not acceptable; -12. This facility will not implement a No CPR policy. Review of the facility's CPR policy, revised [DATE], showed: -Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR); -Policy Explanation and Compliance Guidelines: -1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR; -2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: -a. In accordance with the resident's advance directives, or; -b. In the absence of advance directives or a Do Not Resuscitate order; and; -c. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition); -3. CPR certified staff will be available at all times; -4. Staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration of skills. CPR certification which includes an online knowledge component yet still requires in-person skills demonstrations to obtain certification or recertification is also acceptable. 1. Review of Resident #1's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included chronic obstructive pulmonary disease (COPD, a condition caused by damage to the airways or other parts of the lung), emphysema (a chronic lung disease that damages the lungs, making it difficult to breathe), dependence on supplemental oxygen and high blood pressure. Review of the resident's current care plan, showed: -Focus: Advanced directive care; -Goal: Advanced directive will be honored through the end of review period; -Interventions: -Call 911 immediately; -Code status: Full code; -Initiate CPR immediately; -Notify family immediately; -Notify physician immediately; -Review advanced directives quarterly and with any change in condition. Resident to be asked about any desired changes to current advanced directives or whether they wish to execute any. During an interview on [DATE] at 2:11 P.M., the Social Worker (SW) said the resident was alert and oriented. He/She wanted to be a full code (in the event of no pulse, initiation of CPR and summoning 911) and told the SW to bring (him/her) back. They had a clear conversation, and this was maybe in October, 2024. It is the resident's right to choose to have everything done. Review of the resident's physician orders, dated [DATE], showed a full code order. Review of the resident's progress notes, dated [DATE] at 8:50 A.M., showed, Licensed Practical Nurse (LPN A) went into the resident's room to pass early morning medication. After calling out the resident's name without response, LPN A proceeded to apply tactile queue (uses physical touch) as well as higher calling sound but found the resident was not responding. The resident was cold to touch. The nurse contacted another nurse (LPN B) in the building who responded promptly. Both nurses attempted resuscitation per protocol to no avail. LPN A and LPN B concluded with no heartbeat and zero oxygenation further resuscitation could not revive the resident. LPN A called the resident's family and physician to notify them what happened without any signs/symptoms of sudden death. The family member was not available on phone, the physician was called via exchange, message was left that there was emergency news and requested a call back. While waiting for the physician to call back the family called back and gave the name of the funeral home to collect the body. After learning the patient had passed, LPN A called 911 to assess. Administration was notified early after the incidence, and they assisted in making contacts. Review of the 911 phone call placed on [DATE] at 6:14 A.M., showed: -911 Operator: Tell me exactly what happened; -SC: They found a full code resident passed away and 911; -911 Operator: OK, so are you guys doing CPR or?; -SC: Yes, they are doing CPR in there, they was yes; -911 Operator: Ok alright, and I just have to ask he/she is not awake is that correct? -SC: No; -911 Operator: And he/she is not breathing is that correct?; -SC: No, no (he/she) is not; -911 Operator: Ok, do you guys need any further assistance? We are sending the ambulance. Do you need CPR instructions or anything like that?; -SC: No. Review of the EMS report, dated [DATE], showed: -Call type: Cardiac arrest/death; -Disposition: Patient dead at scene no resuscitation attempted; -Dispatch notified: 6:14 A.M.; -Unit dispatched: 6:15 A.M.; -Enroute: 6:17 A.M.; -At scene: 6:21 A.M.; -At patient: 6:22 A.M.; -Depart: 6:34 A.M.; -Narrative: Upon arrival resident was found unresponsive, no CPR in progress, and resident lying supine (lying face up) in bed. Staff stated they had last seen the resident awake and breathing at approximately 2:00 A.M., when giving the resident his/her night medication. Staff came back into the room at approximately 5:10 A.M., to find the resident unresponsive and not breathing. LPN A preceded to state the resident was a full code, they did 10 minutes of manual CPR, no automated external defibrillator used (AED, device designed to analyze the heart rhythm and deliver an electric shock). After the 10 minutes they stopped with compressions stating, there was no signs of life so we stopped. Staff then left the room waiting to call EMS at 6:14 A.M. 4 lead electrocardiogram (EKG, four electrodes to record the heart's electrical activity) was placed showing asystole (heart not beating), extremities and jaw were rigor (stiffening of the joints and muscles of a body after death). Review of the Fire Department's After-Action Report, dated [DATE], showed: -Alarm: 6:15 A.M.; -Arrival: 6:19 A.M.; -Remarks: Responded for report of cardiac arrest, CPR in progress. First to arrive on scene and make patient contact. No CPR was being performed upon arrival at the patient and two workers appeared to be cleaning the patient's body and bedding space. A nurse of the facility was present in the patient's room. The nurse stated that when he/she came into the room this morning at 5:10 A.M. to administer the patient's morning medications the patient was found unresponsive and not breathing. He/She then went to get another nurse and began CPR. Upon arrival in the room, the nurse stated, we have given up, stating the patient had no response to CPR and he/she felt cold. The nurse stated the patient was a full code and that he/she was last seen alive at 2:00 A.M. Performed an initial assessment. Patient was unresponsive, pulseless, not breathing, skin tone very pale, and pupils were fixed and dilated to the extent the patient's iris was almost entirely covered by the size of pupils. Applied a 4-lead EKG showing asystole in lead 2 which was confirmed in lead 3. Another emergency service ambulance arrived on scene and assumed the lead role in patient care. The patient was pronounced deceased on the scene and was not transported. The police department was on the scene and conducting an investigation of the incident. During an interview on [DATE] at 8:27 A.M., LPN A said early in the morning on [DATE], he/she went into the resident's room to give him/her medication. LPN A said when he/she called out the resident's name, the resident didn't respond. LPN A said he/she called the resident's name out loud several times and received no response. LPN A checked on the resident because the resident normally responded when spoken to. LPN A said he/she knew the resident was a full code so he/she started doing CPR for approximately 10 minutes. LPN A did CPR on the resident in bed. When asked if a back board was placed behind the resident, LPN A then said he/she got the crash cart and placed the back board behind the resident while he/she was in bed before starting CPR. LPN A said the resident was on continuous oxygen at two liters and LPN A turned the concentrator up to the highest level, at five liters on the nasal cannula. After doing 10 minutes of CPR, LPN A said he/she verbally called to LPN B who came immediately. LPN A and LPN B both performed CPR on the resident until approximately 5:30 A.M. When LPN A and LPN B found no response to the CPR, they stopped performing CPR. LPN A said he/she called out for CNA C and CNA D and they came into the room. LPN B left and went back to his/her nurse's station because they had given up on resuscitation of the resident. CNA C began chest compressions on the resident and CNA D was giving breaths with the ambu bag. LPN A called the family, the physician, and the Assistant Director of Nurses, who instructed LPN A to contact 911. When EMS came in, everyone had given up and staff were not doing CPR. Staff gave up because the body had no life and was cold and kind of stiff. LPN A said the resident's body was not discolored except some blue discoloration to the lips. LPN A said he/she called 911 to let EMS know what happened and that the resident was a full code. LPN A said he/she removed the back board before EMS arrived. LPN A said when a resident is found unresponsive, start CPR immediately if full code, if the resident starts breathing again then LPN A would call 911. LPN A said the reason for the delay in calling 911 was because in this case, a bit of time passed because there were doubts all along if this was going to be positive effect. During an interview on [DATE] at 9:48 A.M., LPN B said around 5:30 A.M. on [DATE], CNA C ran over to his/her nurse's station and was yelling for him/her and said resident in distress. LPN B said he/she grabbed the crash cart and saw CNA C standing at the door of the resident's room. LPN A and CNA D were doing CPR on the resident. LPN A was doing compressions and CNA D was standing over the resident's head. LPN B pushed CNA D out of the way and hooked the ambu bag up. LPN B put the ambu bag over the resident's mouth and hooked it up to the concentrator. LPN B said he/she did not know how many liters the concentrator was set to. LPN B said CNA C and CNA D took over CPR until 911 showed up. LPN B said another resident needed something so LPN B left the room. LPN B did not know when LPN A called 911. LPN B was not in the room when 911 showed up. LPN B said he/she did not see any color difference in the resident's skin or rigor mortis. The resident was cool to the touch. During an interview on [DATE] at 8:59 A.M., CNA D said the last time he/she saw the resident was at 12:00 A.M. on [DATE]. CNA D said CNA C was assigned to the resident because the CNA who would have been assigned to the resident did not show up for the shift. On the morning of [DATE], LPN A called that he/she needed help because the resident was unresponsive around 5:30 A.M. CNA D called for CNA C and they went into the resident's room. The resident was lying on his/her back on the bed. CNA D said CNA C started doing chest compressions while LPN A started making phone calls. CNA D said he/she did not do chest compressions or do any type of rescue breaths. CNA D said he/she was clearing stuff out of the way. CNA D said nobody ever said to move the resident to the floor, CNA D said LPN B came in the room and made the comment that the resident should have been moved to the floor and said CNA C was not doing the compressions hard enough. CNA C stopped doing compressions when EMS came into the building. CNA D said the resident was between cold and warm and was not freezing cold. CNA D said he/she did not remember if the crash cart was in the resident's room. CNA D said an artificial manual breathing unit (ambu) bag was not used when CNA C did compressions. CNA D said he/she was not CPR certified. CNA D did not know how to access a resident's code status. During an interview on [DATE] at 7:15 A.M., CNA D said he/she saw LPN A and LPN B talking in the hallway around 5:00 A.M. LPN A had two carts in the hallway near the resident's room. One cart was the nurse's medication cart, and the other cart was the Certified Medication Technician's (CMT) medication cart. The nurses do not have CMTs on the night shift, so the nurses have to use both carts when passing medication. LPN A was standing next to the medication cart and LPN B was standing on the back side of the medication cart. CNA D did not see LPN B in the resident's room. Around 5:30 A.M. LPN A was standing outside the resident's doorway and called out for that he/she needed assistance. CNA D called out for CNA C and both went to the resident's room. LPN A started making phone calls and was stepping in and out of the resident's room. CNA C started doing chest compressions on the resident in the bed and CNA D moved the pillows that were propped around the resident and grabbed the bed controller and moved the bed up because it was in a low position. CNA D did not remember if there was a back board behind the resident. During an interview on [DATE] at 5:38 A.M., CNA C said he/she was not assigned to the resident the morning of [DATE]. CNA C said he/she did not see the resident that night, [DATE] or the morning of [DATE] until he/she overheard LPN A say the resident passed away while standing at the nurse's station making phone calls. CNA C said he/she went into the resident's room and CNA D followed. CNA C started doing chest compressions because nobody was doing anything on the resident. CNA C said someone said he/she was not doing chest compressions hard enough. CNA C did chest compressions for 15 to 20 minutes and stopped because LPN A said stop, and asked why he/she was doing CPR. LPN A said the resident was gone so CNA C stopped doing compressions. CNA C said when he/she was doing chest compressions, nobody was giving breaths to the resident. CNA C said it was around 30 minutes after he/she stopped doing compressions before EMS arrived. When EMS arrived, he/she left the room. CNA C said the resident did not have any discoloration to his/her skin that looked like mottling (discoloration on the skin that can appear red, purple, blue, or brown). CNA C did not know if the resident was a full code or a DNR and CNA C did not know how to access a resident's code status. CNA C said he/she was not CPR certified. CNA C said he/she did not see LPN A or LPN B do CPR on the resident. CNA C said there was no backboard under the resident or in the resident's room. CNA C said the crash cart was not in the resident's room. During an interview on [DATE] at 9:19 A.M., the Staffing Coordinator (SC) said he arrived at the facility around 6:15 A.M. on [DATE]. SC said when he arrived, LPN A, LPN B, CNA C and CNA D were in the resident's room. SC said he thought LPN B was doing CPR, but he was not sure. The SC asked LPN A if he/she called 911 and LPN A said he/she was getting ready to call and SC said he needed to call. SC told LPN A he/she needed to call 911 from the nurse's station. SC said the person on the phone could not understand LPN A, so he got on the phone and spoke with 911. During an interview on [DATE] at 9:00 A.M., Emergency Medical Technician (EMT) F said he/she was the first on the scene. EMT F said he/she was dispatched to the facility for CPR in progress. When he/she arrived at the resident's room, three staff members were in the room, LPN A and 2 other staff members. EMT F said CPR was not in progress. The two staff members appeared to be rolling the resident around and cleaning the resident. EMT F told LPN A they were dispatched for a CPR in progress. LPN A told EMT F that he/she found the resident unresponsive at 5:10 A.M. LPN A got another nurse, and they started CPR together. LPN A told EMT F they gave up because the resident had no response to CPR and felt cold. During an interview on [DATE] at 9:09 A.M., EMT E said they were the second on scene. When he/she arrived, no CPR was being performed. LPN A told EMT E he/she found the resident unresponsive at 5:10 A.M. LPN A got another nurse, and they started CPR together. LPN A said CPR was administered for 10 minutes and when the resident showed no signs of life, they stopped CPR. EMT E asked LPN A what they did between 5:10 and 6:00 A.M. LPN A began yelling and said he/she did CPR for 10 minutes and the resident showed no signs of life, so they stopped. EMT E asked why they waited to call 911, but could not get an answer from LPN A. EMT E said if LPN A would have called in a reasonable time, even if the resident had signs that he/she had deceased , EMS could have gone through the CPR protocol and the life saving measures. However, with the amount of time that passed before 911 was called, EMS was unable to do the life saving measures. During an interview on [DATE] at 11:23 A.M., the Assistant Fire Chief (AFC) said he spoke to the Administrator on [DATE]. The AFC was concerned that CPR was not in progress when they arrived. He was also concerned regarding the large time lapse in calling 911 after the resident was found unresponsive. The AFC said once the staff started CPR, it should have been continued until EMS arrived. Once CPR is started, it cannot be stopped until someone more qualified arrives to take over or pronounce the resident. During interview on [DATE] at 12:46 P.M., the Administrator said he received a call from the AFC on Thursday [DATE] around 1:00 P.M. in the afternoon. AFC stated when they arrived, nobody was doing CPR on the resident. The Administrator said once the nurses started CPR, they should not have stopped until EMS arrived and took over. On [DATE] at 10:28 A.M., the Administrator said he expected physician orders to be followed. During an interview on [DATE] at 2:27 P.M., the resident's Primary Care Physician (PCP) said the nurse should start CPR immediately with a full code patient and have someone call 911 immediately. Anyone can call 911. Compressions should continue until EMS arrives. LPNs need to follow the supervision of EMS and not pronounce death, and they should continue CPR until EMS arrives and takes over care. During an interview on [DATE] at 10:22 A.M., the Medical Director (MD) said the purpose of CPR is to resuscitate the patient. The patient code status wishes should be followed. If a patient is found unresponsive, verify code status if full code, 911 should be called immediately and CPR should be initiated immediately. CPR should be continued until EMS arrives and takes over CPR. 2. Review of the facility's staffing sheets from [DATE] through [DATE], showed: -14 out of the 30 days the facility did not have a CPR certified staff member on the night shift (11:00 P.M. - 7:00 A.M.): -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift; -[DATE]: No CPR certified staff member on night shift. During an interview on [DATE] at 9:57 A.M., the SC said he did not know which staff members were CPR certified. He thought all the nurses were CPR certified. During an interview on [DATE] at 10:12 A.M., Human Resources (HR) said she does orientation with new employees and asks for CPR cards at that time. HR said the previous Director of Nursing (DON) used to keep the CPR cards and when they didn't have a DON around [DATE], HR started keeping the CPR cards. HR had not given the SC a list showing what staff were CPR certified. During an interview on [DATE] at 9:19 A.M., the SC said he did not know what staff members where CPR certified. He was not aware he was supposed to have one CPR certified staff member on each shift until [DATE], after talking with state. When the SC spoke to the Administrator, he told the SC there needed to be one on each shift. Currently there is nothing on the staffing sheets to identify what staff members are CPR certified. During an interview on [DATE] at 5:20 A.M., LPN G said he/she does not know who is CPR certified and he/she would not have time to ask in an emergency. The resident would be LPN G's top concern at that time. During an interview on [DATE] at 6:45 A.M., LPN H said the facility did not have LPN H's CPR certification at the facility. During an interview on [DATE] at 3:15 P.M., the Administrator said he expected a CPR certified staff member to be on staff at all times. The Administrator said the SC knows that all nurses are CPR certified. He expected the facility to have the current, up-to-date CPR certifications for staff who are CPR certified. Staff would be considered not CPR certified if the facility did not have the staff members current up-to-date CPR certification. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00247107

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remained free from hazards and residents received supervision per the facility's smoking protocol and individual resident smoking assessments when five residents were left unattended in the outside courtyard without staff available to let them back in for approximately 30 minutes during freezing weather conditions, with a temperature of 22 degrees Fahrenheit (F) and wind speeds of nine miles per hour (mph) (Residents #69, #58, #65, #63 and #68). One resident (Resident #69) required supervision at all times for safety. The door to the outside courtyard could only be opened from the inside and once closed, residents and staff could not get back inside unless let in by someone inside the building, or by using a slanted walkway through the courtyard to get to a back gate that exited to a driving path where vehicles traveled. In addition, one resident (Resident #65) was observed to enter the code on the keypad used to open the courtyard door without staff assistance, and staff reported knowledge of some residents knowing the code and not reporting it to the Interim Administrator. The Interim Administrator said it is required that all residents be supervised when smoking. The facility identified eight residents who smoke. The census was 69. The Interim Administrator was notified on 1/17/24 at 3:54 P.M. of an immediate jeopardy (IJ) which began on 1/17/24. The IJ was removed on 1/19/24 as confirmed by surveyor onsite verification. Review of the facility's Smoking policy, revised 11/24/23, showed: -Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents; -Policy Explanation and Compliance Guidelines included: -Smoking is prohibited in all areas expect the designated smoking area. A Designated Smoking Area sign will be prominently posted; -Safety measures for the designated smoking area may include, but not limited to, protection from weather; -Residents who smoke shall be further assessed to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all; -Any resident who is deemed safe to smoke, with or without supervision, shall be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan; -All safe smoking measures shall be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who shall be responsible for supervising residents while smoking. Supervision shall be provided as indicated on each resident's care plan. 1. Review of the signs posted on the door leading to the outside courtyard from the facility's dining room, showed: -This door is only allowed to be open by staff. No resident should open this door. Residents are only allowed to go out with staff; -Smoking times, updated 1/8/24: --6:30 A.M., Housekeeping; --8:30 A.M., Dietary; --10:30 A.M., Activities; --1:30 P.M., Activities; --3:30 P.M., Admissions; --6:30 P.M., CNA- East Wing; --8:30 P.M., CNA-West Wing; --10:30 P.M., CNA-East Wing; --Smoking times may differ depending on situation. Residents are not allowed to smoke without staff, smoking without staff could cause facility to become a non-smoking facility. 2. Review of Resident #69's medical record, showed diagnoses included central cord syndrome (spinal cord injury) at unspecified level of cervical spinal cord, spastic hemiplegia (involuntary contractions affecting one side of the body) affecting unspecified side and depression. Review of the resident's smoking assessment, dated 9/14/23, showed: -Does the resident currently smoke: Yes;. -Smoking care plan intervention: Smoking materials are kept secured by staff; -Is the resident cognitively intact: Yes; -Can the resident light a cigarette independently: No; -All residents must be supervised when smoking. Review of the resident's smoking acknowledgement form, undated, showed: -Effective 11/24/23, the facility is now a smoking facility; -A staff member will be present for your safety during the times listed; -Signed by the resident. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/5/23, showed: -Cognitively intact; -Upper and lower extremity impairment on both sides; -Use of wheelchair. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident is a smoker; -Goal: Resident will maintain safety while following smoking protocol; -Interventions: Smoking materials are kept secured by staff; -The care plan did not identify the facility's smoking protocol for supervision while smoking, resident's inability to light a cigarette independently, and the resident's use of an apron while smoking. 3. Review of Resident #58's medical record, showed: -Diagnoses included high blood pressure, acquired absence of right toe, polyneuropathy (decreased ability to move and feel due to nerve damage), sleep apnea, shortness of breath, anxiety and depression. Review of the resident's smoking assessment, dated 10/19/23, showed: -Does the resident currently smoke: Yes; -Smoking care plan intervention: Educate resident about smoking risks and hazards; -Is the resident cognitively intact: Yes; -Can the resident hold a cigarette safely: Yes, is capable but this is a non-smoking facility; -Does the resident only smoke in designated areas at designated times: No; -All residents must be supervised when smoking. Review of the resident's smoking acknowledgement form, undated, showed: -Effective 11/24/23, the facility is now a smoking facility; -A staff member will be present for your safety during the times listed; -Signed by the resident. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Lower extremity impairment to one side; -Use of wheelchair and walker; -Two or more falls since prior assessment. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident is dependent on tobacco and continues to smoke after being made aware this is a smoke free facility; -Goal: Resident will have minimized risk of injury from unsafe smoking practices through review date; -Interventions: Educate resident about smoking risks and hazards; -The care plan did not identify the facility's smoking protocol for supervision while smoking. During an interview on 1/16/24 at 9:42 A.M., the resident said residents smoke in the facility's courtyard during the smoke times posted on the door. Staff have to let the residents outside to smoke, but this is a problem because it's always hard to find staff around to supervise at smoke time. The facility's rule is staff are supposed to supervise and go outside with residents during smoke time, but some of the staff stay inside. 4. Review of Resident #65's medical record, showed diagnoses included dementia, encephalopathy (brain disease), muscle weakness and unsteadiness on feet. Review of the resident's smoking assessment, dated 10/28/23, showed: -Does the resident currently smoke: Yes; -Smoking care plan interventions: Resident is supervised while smoking, smoking per facility protocol; -Is the resident cognitively intact: Yes; -All residents must be supervised when smoking. Review of the resident's smoking acknowledgement form, undated, showed: -Effective 11/24/23, the facility is now a smoking facility; -A staff member will be present for your safety during the times listed; -Signed by the resident. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Use of walker. Review of the resident's care plan, in use at the time of survey, showed no documentation related to the resident smoking. 5. Review of Resident #63's medical record, showed diagnoses included colon cancer, brain cancer, weakness, anxiety and depression. Review of the resident's smoking assessment, dated 10/22/23, showed: -Does the resident currently smoke: Yes; -Smoking care plan interventions: Smoking per facility protocol; -Is the resident cognitively intact: Yes; -All residents must be supervised when smoking. Review of the resident's smoking acknowledgement form, undated, showed: -Effective 11/24/23, the facility is now a smoking facility; -A staff member will be present for your safety during the times listed. -Signed by the resident. Review of the resident's significant change MDS, dated [DATE], showed: -Cognitively intact; -Use of wheelchair. Review of the resident's care plan, in use at the time of survey, showed no documentation related to the resident smoking. 6. Review of Resident #68's medical record, showed diagnoses included respiratory failure and depression. Review of the resident's smoking assessment, dated 9/13/23, showed: -Does the resident currently smoke: No; -All residents must be supervised when smoking. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Use of walker. Review of the resident's smoking acknowledgement form, undated, showed: -Effective 11/24/23, the facility is now a smoking facility; -A staff member will be present for your safety during the times listed; -Signed by the resident. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident is a smoker; -Goal: Resident will maintain safety while following smoking protocol; -Interventions: Smoking per facility protocol; -The care plan did not identify the facility's smoking protocol for supervision while smoking. 7. Observation on 1/17/24, showed: -At 10:30 A.M., Residents #58, #63, and #69, sat in wheelchairs, and Resident #68 sat on a wheeled rollator, outside in the facility's courtyard, adjacent to the facility's dining room. All four residents wore coats and were smoking cigarettes. No residents wore smoking aprons. No staff were present in the courtyard or dining room. -Review of weather data for that time, showed a temperature of 22 degrees F with wind at nine mph; -At 10:32 A.M., Resident #65 ambulated with a walker through the dining room and approached a keypad on the dining room wall in front of the courtyard door. During an interview, the resident said he/she had to get outside to smoke before time was up. The resident entered a code on the keypad and exited through the door of the dining room, to the outside courtyard; -At 10:41 A.M., Resident #65 knocked on the courtyard door leading to the dining room. No staff were present in the dining room. Seconds later, two unknown employees entered the dining room from the facility's main hall. One employee turned around and exited the dining room through the main hall, while the other employee entered the kitchen, adjacent to the dining room; -At 10:44 A.M., Resident #65 knocked on the courtyard door leading to the dining room. No staff were present in the dining room; -At 10:45 A.M., Housekeeper E walked through the dining room, entered a code on the keypad next to the courtyard door, and exited through the door to the courtyard. The door closed. He/She turned around, knocked on the door to the dining room, and tried the doorknob. The door was locked and no staff were present in the dining room. Housekeeper E walked down a slanted sidewalk through the courtyard and exited through a back gate; -At 10:49 A.M., Resident #63 knocked on the courtyard door leading to the dining room and tried the doorknob. No staff were present in the dining room; -At 10:59 A.M., the residents were back inside the facility from the courtyard. During an interview on 1/17/24 at 10:59 A.M., Resident #58 said he/she and the other four residents who were just outside smoking, had to wait for staff to let them back in. Residents do not have a way to get back inside the facility from the courtyard without staff letting them in. Staff are supposed to be outside with residents during smoke times, but some staff do not want to go outside with the residents. During an interview on 1/17/24 at 11:30 A.M., Resident #63 said staff use the keypad in the dining room to let residents out to the courtyard at smoke time. Unless staff go out with them, residents have to wait outside for staff to let them back in. A cook let him/her and several other residents out to the courtyard this morning, before the 10:30 A.M. smoke time. A different dietary employee let the residents back in. The residents were outside for around 45 minutes. It was cold outside. During an interview on 1/17/24 at 1:00 P.M., Residents #58 and #63 said residents do not have the code for the keypad used to open the door going out to the courtyard. Once outside, there is no way to open the door from the courtyard to get back into the dining room. Staff are supposed to supervise smoke breaks and let residents back in when the smoke break is over, but that does not always happen and residents have been locked outside before today. Resident #63 said he/she once waited 45 minutes to get back inside. Resident #58 said he/she once waited 30 minutes to get back inside. During an interview on 1/17/24 at 1:07 P.M., Resident #65 said it's always the same problem with smoking times. Staff are supposed to go outside with residents during smoking time, but then sometimes they don't. Residents will wait outside for 15 to 20 minutes before staff let them back in. This morning, dietary staff let him/her out to the courtyard at smoking time and then left. He/She was not supervised while smoking and had to wait outside for over 20 minutes before staff let him/her back in. During an interview on 1/17/24 at 1:12 P.M., Resident #65 said residents are not supposed to have the code to use the keypad in the dining room for the courtyard door. Staff are supposed to be with residents during smoking times. If staff are not at the courtyard door when residents are ready to come back inside after smoking, maybe a dietary employee will walk by and open the door. He/She has been left waiting to get back inside for 30 minutes before. During an interview on 1/17/24 at 1:13 P.M., Resident #69 said he/she has limited mobility. He/She can hold a cigarette, but cannot light it. He/She has to be supervised and is supposed to wear an apron while smoking. There is a smoking schedule on the courtyard door for staff and residents to follow. A dietary employee let him/her and other residents outside to the courtyard for the 10:30 A.M. smoke break, but did not stay to supervise. He/She smoked one cigarette and was ready to come back in. He/She had to wait outside for about 30 minutes before staff let him/her back inside. Staff are supposed to stay and supervise smoking, then let the residents back inside. It doesn't make sense because the door locks when it closes and then staff cannot get back inside, either. If there is an emergency while residents are outside smoking and no staff with them, there is nothing the residents can do. Residents have been locked outside in the courtyard before today. On one occasion, a resident who walks went through the courtyard's back gate, around the building, and through the front door to let the other residents back inside. During an interview on 1/17/24 at 11:34 A.M., [NAME] D said designated smoking times are posted on the door leading from the dining room to the courtyard. Smoking is supposed to be supervised by staff. A specific staff member is assigned to supervise smoke times posted on the schedule. There is a keypad to open the door from the dining room to the courtyard and only staff should know the code; however, some residents are observant and have learned the code to let themselves out. The door to the courtyard cannot be opened from the outside and staff have to use the keypad to open the door and let residents back in. Today at around 10:30 A.M., he/she used the keypad to open the door and let several residents outside to the courtyard to smoke. He/She is unsure which staff member was assigned to supervise the smoke break at that time, but they were not around when the residents wanted to go outside. When he/she let the residents out, he/she told them he/she could not supervise because he/she was the only employee in dietary at the time, and he/she went back to the kitchen. While in the kitchen, staff cannot hear when residents knock on the courtyard door. During an interview on 1/17/24 at 1:47 P.M., [NAME] D said when he/she does smoke breaks, he/she lets the residents outside and goes back to cooking. Staff don't know when residents are ready to come back in. He/She has been outside with the residents before and has gotten stuck, unable to get back inside from the courtyard. He/She had to leave the residents in the courtyard and walk around the building to get back inside. All of the residents should be supervised while smoking. During an interview on 1/17/24 at 11:49 A.M., Housekeeper E said there is a keypad for staff to use when opening the door from the dining room to the courtyard. Residents are not supposed to know the code to the keypad, but some of them do. At the designated smoking times, staff are supposed to use the keypad in the dining room to let residents outside to the courtyard. Staff are supposed to supervise the residents while they smoke. There is no way to open the door to the dining room from the courtyard because it locks when closed. At 10:45 A.M., he/she went outside to the courtyard to get to the back gate. While he/she was in the courtyard, residents were outside smoking with no staff present. Residents asked him/her to let them back in, but the door to the dining room had already closed and locked behind him/her. He/She reentered the facility through a different entrance. During an interview on 1/17/24 at 11:05 A.M., the Activity Director said if Activities staff are unable to make it for their assigned smoke times, the Task Aides help with supervising residents while they smoke. He/She asked Task Aide H to monitor the 10:30 A.M. smoke time today. At minimum, staff must monitor residents from the door. During an interview on 1/17/24 at 11:12 A.M., Task Aide H said the process for smoke time is to get the residents who need help to the smoking area and meet the rest of the residents in the dining room. Staff enter the code on the keypad for the courtyard door and go out to sit with the residents while they smoke. Residents cannot be alone while smoking in the courtyard. Some residents know the code to the keypad, but shouldn't. He/She is unsure how some of the residents got the code, and he/she did not report this. He/She was told he/she was responsible for monitoring the 10:30 A.M. smoke time today. He/She was on the phone during the smoke time, so he/she did not take the residents outside to smoke and he/she is unsure who did. During an interview on 1/17/24 at 1:01 P.M., Housekeeper G said some residents require supervision while smoking, and he/she sometimes assists with supervising. Resident #69 requires supervision while smoking. He/She has a contracted right hand and requires the use of an apron while outside smoking. Resident #63 coughs and is out of breath before he/she goes out to smoke, then tries to catch his/her breath when he/she comes back inside from smoking. He/She requires supervision while smoking for safety reasons due to being weak. Residents cannot go outside to smoke without staff. There is a schedule posted on the door to the courtyard, which shows which staff are responsible for letting residents outside during each smoking time. At smoke time, staff use the keypad in the dining room to let residents outside to the courtyard. Residents do not have the code for the keypad to the courtyard door. Once the courtyard door closes, it locks and cannot be opened from the outside. If he/she was in the courtyard with residents during smoke time and an emergency occurred, he/she would use his/her cell phone to call someone inside the building, or walk out of the courtyard and go around to the next nearest entrance to find help. During an interview on 1/17/24 at 1:23 P.M., the Admissions Director said the facility has a smoking schedule posted, which shows which staff are responsible for monitoring residents at each smoke time. Resident #69 has a history of seizures and cannot use his/her hands. He/She needs to wear a smoking apron and staff have to light his/her cigarette. He/She needs to be monitored while smoking. Resident #63 requires some oversight because he/she gets winded and by the time he/she is done smoking, he/she is breathing hard. Staff should monitor all smoke breaks so they can let residents back inside. Smoking assessments for all residents show residents should be supervised while smoking because there is no way for residents to get back inside on their own from the courtyard. To monitor smoking, staff should hold the door open to let the residents out to the courtyard, light Resident #63's cigarette at the door, and then supervise while standing inside the dining room. If she was outside in the courtyard with the residents and the door closed, she would text someone to let her back in. There is a back gate in the courtyard, but it is locked. If her phone was dead and there was an emergency, she would kick in the glass on the courtyard door and scream for help. During an interview on 1/17/24 at 1:55 P.M., Certified Nurse Aide (CNA) A said residents are unable to smoke outside, unsupervised. There is a schedule posted that tells which employee is assigned to supervise for smoke times. Supervision while smoking entails going outside to the courtyard with the residents while they smoke. The door from the dining room to the courtyard requires a code to get out and residents do not have the code. Once outside in the courtyard, there is no way to get back inside unless someone is waiting inside at the door to open it. Supervision while smoking would require two people; one to go outside and another to let people back in. During an interview on 1/17/24 at 11:16 A.M., the Interim Administrator said she would not be surprised if residents knew the code for the keypad to get outside. If staff are aware that residents have the code, they should tell her. Staff are responsible for taking residents outside at smoke times. Smoke times are posted throughout the facility to show which staff are assigned at each time. If the assigned staff cannot supervise at their assigned time, they should tell her and she can supervise. Staff are required to watch residents while they are smoking, and residents cannot be unsupervised. She canceled smoke breaks during the last couple of days due to severe cold weather. If residents are left outside and unable to get back in, they are at risk of harm. During an interview on 1/17/24 at 1:00 P.M., the Interim Administrator said smoke times are supervised by one staff. The residents do not require staff to physically stay outside with them. This morning when she supervised the early smoke break, she stood by the door to monitor the residents. The residents used to smoke by themselves, but there is always a risk of injury and that is why the policy changed. All but one of the residents who smoke are independent. Resident #69 cannot be outside by him/herself. Staff have to light his/her cigarette and he/she has to wear an apron while smoking. If something happened while the residents were smoking and she needed to respond by going outside to the courtyard and the door closed, she would have to use her cell phone to call someone to have them come open the door. The residents who smoke can move around, but staff do not want to encourage them to go through the back gate of the courtyard for safety reasons because the walkway is slanted and they might fall. During an interview on 1/19/24 at 8:58 A.M., the Wound Nurse said smoking assessments are done by Social Services (SS). She expected smoking assessments to be completed accurately. The outcome of a smoking assessment should be reflected on the resident's care plan. Care plans are updated by the MDS Nurse. During an interview on 1/19/24 at 9:07 A.M., Licensed Practical Nurse (LPN) B said SS completes smoking assessments. LPN expected smoking assessments to be completed accurately and to be reflected on a resident's care plan. Care plans are updated by the MDS Nurse. During an interview on 1/22/24 at 12:37 P.M., the MDS Nurse said she has worked with the facility for eight months and is new to the position. She is responsible for completing all MDS's and care plans for each resident at the facility. Care plans should be completed upon admission and updated quarterly and with changes. She generates care plans based on resident hospital records, interviews with CNAs and nurses, and resident assessments completed by other departments, including nursing and SS. SS completes smoking assessments. The MDS Nurse expected the assessments to be completed accurately because she uses the responses to identify interventions for the care plans. She expected care plans to accurately reflect a resident's individual needs and preferences related to smoking, including whether or not supervision is required while smoking, or if the resident requires any devices or precautions for smoking safely. During an interview on 1/19/24 at 9:50 A.M., the Director of Nurses (DON) said smoking assessments are completed by SS and the DON assists. Smoking assessments are completed upon admission and readmission, quarterly, and as needed. She expected smoking assessments to be accurate. There is verbiage at the bottom of all current smoking assessments stating all residents must be supervised while smoking. When the DON started working at the facility last year, the facility was non-smoking. In October or November 2023, the facility initiated a smoking protocol due to non-compliance by residents, who were smoking outside the front of the facility. The new smoking protocol moved resident smoking to the courtyard at specific times, supervised by staff. Care plans should reflect a resident's smoking status, and whether or not they should be supervised while smoking. During an interview on 1/19/24 at 10:28 A.M., the Interim Administrator said she has been working as SS with the facility for around seven months. When she first started working with the facility, two residents smoked, but they could not smoke on the facility's premises. Over time, residents started lining up to go outside to smoke and then there were eight residents who smoked. Around October 2023, the previous Administrator implemented a new smoking policy, which was reviewed and signed by residents who smoked. The new policy was for smoking to take place in the courtyard, supervised at specific times by staff. As SS, she is responsible for completing smoking assessments upon admission, quarterly, and with changes. The smoking assessments should be completed accurately and the findings should be reflected on the resident's care plan, which is updated by the MDS Nurse. If a resident should be supervised while smoking, it should be indicated on their care plan. Resident #69 is the only resident who requires supervision while smoking at this time. During an interview on 1/31/24 at 11:47 A.M., the facility's Medical Director said previously, the facility was non-smoking. The facility implemented a new smoking policy in September or October 2023. He was not involved in developing the policy, but did approve the facility's smoking policy. Staff is responsible for assessing residents for their safety while smoking. He expects staff to visually supervise residents while they are outside smoking for safety. This applies to any resident with a physical disability, a diagnosis such as dementia, or any resident who requires some assistance, which includes most residents. The residents who were outside for 30 minutes, unable to get back inside, should have been able to get back inside the facility when they were finished smoking or as desired. He expects the facility to have a system in place for residents to be let out to the smoking area and to be let back inside. He expects there to be a standard protocol for staff to follow in the event of getting locked outside in the courtyard while residents are smoking. Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective actions to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the deficiency was lowered to the E level. This statement does not denote the facility has complied with state law (section 198.026.1 RSMO) requiring that prompt remedial action to be taken to address Class I violation(s). MO00229167