**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings related to R #6 Cross reference to F684. R. Record review of R #6's Wound Evaluation, dated 11/28/24, revealed the following: - Burn, third degree. - Staged by in-house nursing. - Located on sacrum (a large flat bone in the lower part of the spine.) - Minutes old and acquired in-house (at the facility.) - Measurements: length 6.64 centimeters (cm), width 4.2 cm, depth 0.2 cm, area 15.95 cm². - Wound bed: Epithelial tissue (a thin, continuous layer of cells) present, granulation tissue (new connective tissue and blood vessels, a sign of wound healing) present. - Moderate serosanguineous (clear or light pink, thin, watery fluid) exudate (body fluid discharged by the body in response to tissue damage and wound healing.) - Edges attached, surrounding tissue erythema (redness.) - Temperature was hot, localized. - Resident reported pain at a 7 out of 10 during dressing. - Treatment: Generic wound cleanser, composite dressing, and Xeroform bordered gauze. - Notes: Resident's skin was hot to touch with a heating pad under her. The resident's skin was thin and fragile. Removed the heating pad. - Education: The resident was educated about the risk factors involved in using a heating pad. Resident was strongly advised to discontinue use of the heating pad and to shift weight in bed frequently. - Notification: None documented. - Digitally signed by the facility's Skin Health Team Lead (SHTL) on 11/29/24 at 12:33 pm. S. Record review of R #6's medical record revealed the following the record did not contain documentation staff notified the resident's doctor of the third degree burn on the resident's sacrum. T. Record review of R #6's Progress Note, dated 12/02/25, revealed the following: - Visit type was acute follow-up. - Chief complaint and nature of the presenting problem: Follow-up of admitting medical diagnoses, including depression. - Resident was a fairly inconsistent historian but at time of encounter denied complaint or concern. - Nursing staff denied new or worsening behaviors, recent fall or injury, unstable vital signs, or other complaint or concern. - The record did not mention the resident's sacrum burn or treatment for the burn. - Digitally signed and dated by the Nurse Practitioner on 12/03/24 at 4:55 pm. U. Record review of R #6's Wound Evaluation, dated 12/04/24, revealed the following: - Burn, third degree. - Staged by in-house nursing. - Located on sacrum. - Six days old and acquired in-house. - Measurements: length 6.24 cm, width 3.9 cm, depth 0.2 cm, area 18.24 cm². - Wound bed 70 percent (%) epithelial, 70% granulation, 20% slough (yellow stringy tissue adhered to wound bed.) - Evidence of infection: increased drainage, increased pain. - Bleeding. - Moderate serosanguineous exudate with faint odor after cleaning. - Edges attached, surrounding tissue erythema. - Resident reported pain at a 7 out of 10 during dressing. - Dressing appeared saturated. - Treatment: Vashe (wound cleanser), Medihoney (wound and burn gel), foam, incontinence management. - Healable. - Stable. - Notification: None documented. - Digitally signed and dated by the facility's SHTL on 11/4/25 at 1:05 pm. V. Record review of R #6's Progress Note, dated 12/06/25, revealed the following: - Visit type: Discharge. - Chief complaint and nature of the presenting problem: Discharge summary and plan. - The resident was initially to be seen today for discharge summary and plan. The NP was contacted by the wound care nurse and notified the resident had a burn to her back. The burn reported had an odor and greenish discharge. The resident was asymptomatic without indication of sepsis or systemic infection. Patient lay in bed, and did not appear to be in acute distress. Resident was a poor historian secondary to dementia, and the NP was unable to reposition the resident at the time of the encounter in order to examine the resident's back. Order to apply silver sulfadiazine cream (antibiotic cream for serious skin infections and burns) 1% placed with wound care nurse. No other concerns noted at time of encounter. - Discharge home. - Discharge condition stable. - Diagnosis: Superficial burn. - Plan for superficial burn: No signs of systemic infection. Continue silver sulfadiazine 1% cream twice daily. Follow-up with primary care physician for further management. - Digitally signed by the NP on 12/9/25 at 8:24 pm. W. On 03/05/25 at 2:17 pm, during an interview, R #6's daughter stated her mother was admitted to the facility on [DATE] for rehabilitation to get her strength up. She stated she was not aware of any of her mother's wounds when her mother arrived at the facility. The daughter stated there was a care plan meeting on 11/18/24, and the staff told her about her mother's pressure ulcers. The daughter stated she visited her mother almost every day, sometimes in the morning and sometimes in the afternoon. She stated she visited her mother early in the day on 12/04/24, and the wound nurse stated she did not like the way her mother's sacrum wound looked because it was turning green. The daughter stated the wound nurse took a picture and sent it to her and told her she would send the picture to the doctor. The daughter stated it had been four days since she saw her mother and it looked a lot worse than the last time she saw the wound. She stated she asked the wound nurse what she was looking at in the picture, and the wound nurse told her it was slough, which could lead to infection. The daughter stated she spoke to a Certified Nursing Assistant (CNA) on 12/07/25, and the CNA stated her mother was not feeling well and did not go to dialysis. The daughter stated the CNA reported she applied a salve to her mother's wound twice a day, and her mother's wound had a smell to it. The daughter stated over the next couple days her mother did not look well. She stated by the day she discharged (12/09/24) her mother looked horrible and was sweating. She stated the CNAs did not know why her mom was sweating. The daughter stated they tried to move her mother into a chair, but her mother begged to get back into bed. The daughter stated her mother was supposed to discharge from the nursing home at noon on 12/09/24, but she was not ready on time. She stated her mother was in an unusual amount of pain when the two CNAs transferred her into a wheelchair, and her mother was confused and agitated. She stated her mother was not mentally herself, and her back was covered with sweat. The daughter stated the facility did not have transportation to take her mother to the Assisted Living Facility (ALF) which was right down the street from the facility. She stated two CNAs from the facility were not able to transfer her mother into her car, because her mother was in a lot of pain. She stated her mother was propelled in a wheelchair up the street to the ALF. She stated when her mother got to the ALF, staff put her right to bed, and her mother calmed down. The daughter stated her mother was in too much pain to sit up. The daughter stated her mother was scheduled for dialysis on 12/10/24, but the dialysis center sent her mother to the emergency room, because her heart rate was very low. The daughter stated her mother was admitted to the hospital with a diagnosis of septic shock. They told her that her mother had a racing heart rhythm, low blood pressure, and was incoherent. The daughter stated her mother was too weak for a full session of dialysis, and she passed away in the hospital eight days later. X. On 03/06/25 at 11:26 am, during an interview, the Physician Assistant (PA) stated she was at the facility Monday through Friday, every week; and she was responsible for seeing each resident, evaluating new conditions, diagnosing, prescribing treatments, and following-up with the residents. She stated it was expected for staff to notify her if a resident had a change of condition, medication issue, or a physical condition which required her attention. She stated staff could notify her while she was at the facility or call her at the on-call number if she was not at the facility. The PA reviewed R #6's initial wound documentation, dated 11/28/24, and stated she would expect staff to notify her of a wound like that. The PA stated she would have prescribed a barrier cream for the wound. Y. On 03/07/25 at 11:38 am, during an interview, the Medical Director (MD) stated she has been the facility's MD for several years. She stated she was not familiar with R #6, but she reviewed the resident's discharge summary. The MD reviewed R #6's initial wound documentation, dated 11/28/24, and stated she would expect staff to notify her of the wound. She stated she did not recall if staff notified her of the wound. She stated the wound care nurse would decide and implement the treatment for the wound, but she still wanted to be notified of the wound. The MD reviewed R #6's wound documentation, dated 12/03/24, and stated she was not notified of the resident's wound at this point. She stated the wound appeared to be worsening, and the measurements did not appear to be accurate. The MD stated she needed to see and smell the resident's wound in order to make a treatment decision. She stated she expected the NP to give the resident some pain medication and look at the wound. She stated the NP should not have prescribed a treatment without looking at the wound. The MD stated it was not acceptable to treat the wound without looking at it. She stated she would not have discharged the resident with a wound like that, because the resident needed care. Z. On 03/06/25 at 1:27 pm and 03/07/25 at 1:45 pm, during an interview, the Skin Health Team Lead stated a Certified Nursing Assistant (CNA) told her about R #6's sacrum wound. She stated after she looked at the wound, she contacted a wound care company and the facility's Administrator regarding the wound. She stated she tried to text a number the nurse gave her for R #6's doctor. The SHTL stated she did not contact the facility's NP or the Medical Director, because she did not have a number for them. She stated she did not follow-up with the number the nurses gave her for the resident's doctor to ensure she had the right number or information. The SHTL stated she did not contact the resident's family regarding the wound. Based on record reviews and interviews, an Immediate Jeopardy (IJ) was identified. The facility Administrator was notified on 03/05/25 at 3:21 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR). The Plan of Removal was approved on 03/06/25 at 12:10 pm. Plan of Removal All residents have the potential to be affected by this alleged deficient practice. - A whole house audit of heated electrical devices, completed on 02/27/25. - A whole house skin sweep audit to identify any undocumented wounds, completed on 12/30/25. - A second whole house skin sweep was conducted to identify undocumented wounds, completed on 02/03/25. - Direct care staff were educated on wound documentation, starting 01/08/25. - CNAs were educated on the Stop and Watch Process, from 01/21/25 through 01/27/25. - Nurses and CNAs were educated on prohibiting on the use of electrical appliances, completed 02/27/25. - Center Nurses were re-educated on skin assessments weekly per schedule, starting on 03/05/25. - Nurses were educated on their responsibility with communication with management and provider for the change in condition process/documentation, starting on 03/05/25. - Nurses were educated on the facility's wound processes, timely and accurate identification of wounds, documentation for wound/wound changes, change in condition process, and appropriate treatment/intervention implementation upon identification of new or worsening wounds, starting on 03/05/25. - CNAs were educated on change in condition process for CNAs and Stop and Watch, starting on 03/05/25. - The DON/Designee will perform audit education sign-off sheets to ensure all nursing staff receive education as outlined, starting 03/05/25. - The DON/Designee will conduct five random audits on heated electrical devices and skin assessment accuracy weekly for wound care process abidance, starting 03/05/25. - An Ad Hoc QAPI meeting was held on 03/05/25 to approve the POR. - The DON/Designee and the Administrator/Designee will bring the results of the audits to the QAPI committee for three months. - The Administrator will oversee the QAPI committee. Implementation of the POR was verified onsite on 03/07/25 by conducting observations, record reviews, and staff interviews. Scope and Severity was reduced to Level 2, G. Implementation was verified through: Record review of skin sweeps, dated 12/30/25 and 02/03/25. Record review of electrical appliance audits, dated 02/27/25. Record review of skin assessment audits, date 03/05/25. Observations of wound care on 03/06/25 at 1:27 pm for R #4 and on 03/06/25 at 2:40 pm for R #5. Record review for R #4 and R #5 regarding wounds and wound care. Interviews of four CNAs regarding in-services and Stop and Watch process. Interviews of two nurses regarding in-services and wound documentation and communication. Interview with the SHTL regarding in-services and processes regarding wound documentation and orders for treatment. Interview with the Administrator and DON regarding POR, audits, and wound processes. Based on observation, record review, and interview, the facility failed to notify the resident's physician for 2 (R #2 and #6) of 2 (R #2 and #6) residents reviewed when: 1. R #2 began having difficulty feeding herself with low meal intake percentages 2. R #6 developed a sacrum wound These deficient practices likely resulted in R #2 not getting the assistance she needed resulting in a decrease in meal intake and a delay in treatment and deterioration in R #6's wound likely resulting in the wound becoming septic. The findings are: Findings for R #2 A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE]. B. Record review of R #2's care plan dated 01/27/25 revealed the following: 1. R #2 exhibits impaired swallowing related to dementia; Provide assistance during meals and provide supervision during meals. 2. R #2 is a nutritional risk related to skin breakdown; Weigh per policy and as needed, and alert dietitian and physician to any significant weight loss or gain. C. Record review of the facility meal consumption percentage (%) tracking form dated 02/03/25 through 02/20/25 (breakfast), revealed the following: - 02/03/25: R #2 ate 25% of her breakfast, 50% of her lunch, and 25% of her dinner. - 02/04/25: R #2 ate 50% of her breakfast, 75% of her lunch, and 25% of her dinner. - 02/05/24: R #2's meal intake was not recorded. - 02/06/25: R #2 ate 50% of her breakfast, 50% of her lunch, and 75% of her dinner. - 02/07/25: R #2 ate 50% of her breakfast, 25% of her lunch, and 75% of her dinner. - 02/08/25: R #2 ate 100% of her breakfast, 25% of her lunch, and 25% of her dinner. - 02/09/25: R #2 ate 50% of her breakfast, 25% of her lunch, and 75% of her dinner. - 02/10/25: R #2 ate 50% of her breakfast, 50% of her lunch, and 75% of her dinner. - 02/11/25: R #2 ate 50% of her breakfast, 50% of her lunch, and 75% of her dinner. - 02/12/25: R #2 ate 50% of her breakfast, 25% of her lunch, and 50% of her dinner. - 02/13/25: R #2 ate 25% of her breakfast, 25% of her lunch, and 0% of her dinner. - 02/14/25: R #2 ate 25% of her breakfast, 25% of her lunch, and 25% of her dinner. - 02/15/25: R #2 ate 50% of her breakfast, 25% of her lunch, and 100% of her dinner. - 02/16/25: R #2 ate 75% of her breakfast, 25% of her lunch, and 25% of her dinner. - 02/17/25: R #2 ate 25% of her breakfast, 50% of her lunch, and 25% of her dinner. - 02/18/25: R #2 ate 50% of her breakfast, 50% of her lunch, and 50% of her dinner. - 02/19/25: R #2 ate 100% of her breakfast, lunch was not recorded, and 100% of her dinner. - 02/20/25: R #2 ate 75% of her breakfast. R #2's meal consumption percentage was not recorded prior to 02/03/25. D. Record review of R #2's Electronic Health Record (EHR) banner reviewed on 02/19/25 revealed Set-up for all meals and no feeding assistance required. E. On 02/19/25 at 2:08 pm during an interview with R #2's Power of Attorney (POA; authority to act for another person in specified or all legal or financial matters), she stated that on multiple occasions, R #2's meal tray was left in front of her untouched by R #2. R #2's POA also stated that R #2 requires assistance with feeding, but the facility is not helping with that. F. On 02/19/25 at 3:41 pm during an interview with Licensed Practical Nurse (LPN) #2, she stated that R #2 is a set-up help only for meals. LPN #2 confirmed that she was not aware of R #2 experiencing difficulty feeding herself. G. On 02/19/25 at 4:37 pm during an interview with LPN #3, she stated that the majority of the time the facility CNAs (Certified Nursing Assistant's) will only set up R #2's meal and they will not assist her with feeding. LPN #3 also stated that R #2 usually needs help with feeding, and will require supervision when eating as well. LPN #3 confirmed she would help R #2 with feeding as often as she could, but R #2 required feeding assistance and meal supervision on a consistent basis. H. On 02/19/25 at 5:14 pm during a dinner observation, R #2 was observed lying in bed and then being woken up by CNA #3 for dinner. CNA #3 moved R #2's bed up so R #2 could eat. I. On 02/19/25 at 5:15 pm during an interview with CNA #3, she stated that R #2 was a set-up assist only and the CNAs will check on R #2 as often as they can during the meal service. CNA #3 was observed leaving R #2's room shortly after the interview to continue to pass out resident meal trays in the unit. J. On 02/19/25 at 5:19 pm during a dinner observation, R #2 was observed sitting upright in her bed attempting to eat without staff presence. R #2's spoon was in the middle of her plate and she was trying to eat her orange dessert by licking the side of the dessert dish. R #2 was not successful in doing so. K. On 02/19/25 at 5:28 pm during a dinner observation, CNA #3 is observed returning to R #2's room to assist R #2 with her meal. L. On 02/19/25 at 5:30 pm during an interview with CNA #3, she stated that R #2 was just playing with her food and not eating it, which R #2 does a lot. CNA #3 also stated that R #2 is more dependant on staff assisting her with her meals because she can't feed herself that well anymore. M. On 02/20/25 at 11:49 am during an interview with the Physician's Assistant (PA), she stated that she was not made aware of R #2's inability to feed herself and she would expect the facility nursing staff to notify the facility providers, including the DON of this, especially if there is weight loss. N. On 02/20/25 at 12:38 pm during an interview with the RD, she stated that she was unaware of R #2's low meal consumption percentage and she was also unaware of R #2's self feeding limitations. The RD stated that had not reviewed the facility meal consumption percentage tracking form, and would find out about dietary issues from the facility nursing staff. The RD confirmed that she should have been made aware of R #2's inability to consistently feed herself, and R #2 should be reassessed by the speech therapist to get a better understanding of R #2's feeding limitations. O. On 02/20/25 at 1:04 pm during an interview with the Administrator (ADM), he stated that he would expect the RD to be monitoring the facility meal consumption percentage tracking form. The ADM also stated that the CNAs should be notifying the nursing staff, who should be notifying facility providers of a residents decline in self feeding so it can be addressed in the morning clinical meeting. P. On 02/20/25 at 2:41 pm during an interview with Registered Nurse (RN) #1, she stated that R #2 can raise her hand and wipe her mouth, but she does not believe that R #2 could feed herself successfully. RN #1 stated that she does not think the RD has been made aware of this, but she was unsure. Q. On 02/20/25 at 3:07 pm during an interview with the DON, she stated that if CNAs notice R #2 is struggling to feed herself, then they need to notify nursing staff who should then notify her, the RD, and any provider that needs to be informed of that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings related to R #7 L. Record review of the complaint allegation received by the State Agency on 01/09/25 revealed that during the holiday (Christmas), three different family members visited R #7 either in person of via Zoom and all three mentioned that her eyes were red, irritated and making R #7 uncomfortable. The cousin who visited in person alerted staff to this and they brought some eye drops. The complainant stated that she specifically requested care for R #7's eyes via email on 12/24/24 and 12/31/24 however there was no response until 01/07/25. M. On 02/15/25 at 12:33 pm during interview with R #7 when asked about her eyes being irritated, she stated Only thing I remember was they were cutting grass and the window was open. She confirmed that her eyes were itchy but it wasn't painful. R #7 remembered the symptoms only lasting one day. N. On 03/05/25 during interview with R #7's daughter, she stated that she her mother has stroke damage and struggles with short term memory loss. She reported that her cousin and niece had visited her mother in December and noticed that her eye was red and bothering her. R #7's daughter stated that she made outreach to the Director of Nursing during Christmas week and she [DON] didn't get back to her. She stated that R #7 looks forward to her hair appointments and was told she was not allowed to go to her hair appointment she had pink eye. This was on 01/07/25. She stated that she came to visit in January and everyone including the executive Director (Administrator) apologized. She stated that when she came to the facility [on 01/07/25], the issue was finally addressed. O. Record review of email provided by R #7's daughter dated 12/26/24 identified that R #7's other daughter had informed her sister that R #7 had itchy runny eyes that was assumed to be attributed to allergies. Another email identified that R #7's daughter had emailed the Unit Manager on 12/31/24 regarding R #7's eyes and received no response until 01/07/25. P. Record review of the Change in Condition Evaluation for R #7 dated 01/07/25 revealed Eye are red along the upper and lower lids. Inside her eyes they are full of mucus. Dr. (Doctor) seen her today and prescribed medicine for 10 days. Date and time of of clinician notification was identified as 01/07/25. Q. Record review of the Medication Administration Record for R #7 dated January 2025 identified an order Pataday Ophithalmic Solution 0.1 % (antihistamine) one drop in both eye s two times a day for allergic conjunctivitis (pink eye) for 10 days started on 01/07/25. R. On 03/05/25 at 12:33 pm during interview with the Administrator regarding R #7, he stated the issue with her eyes was brought up in the morning clinical meeting as a change in condition (01/07/25) and that the provider saw R #7 and then prescribed an ointment. When asked if the family had brought concerns to his attention prior to 01/07/25, he stated that no one had told him about it but that the Activities Director did received an email on 12/26/24 and should have informed the nurse to tell the doctor. The Administrator confirmed that it would be his expectation that staff should have immediately informed the nurse of a change in condition to the resident however there was no evidence that this was done for R #7. R #6 Cross reference to F580, F641, F658, F686, and F880. Z. Record review of R #6's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 11/19/24, revealed the following: - admission date of 11/13/24 from hospital. - Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact. - Always incontinent of bladder and bowels. - Diagnoses of end stage renal disease (ESRD; chronic irreversible kidney failure), dependence on renal dialysis renal dialysis (the process of removing extra fluid and waste products from the blood when the kidneys are not able to function properly), and depression. - The resident was at risk of developing pressure ulcers (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin.) - The resident had two Stage 1 pressure ulcers (intact skin over a bony prominence with a reddened, painful area of skin that does not turn white when pressed.) - The resident had one Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) present on admission. - The resident had a skin tear (a type of injury where the skin is torn from the body.) - Staff did not document any other skin issues, ulcers, or wounds. AA. Record review of R #6's Wound Evaluation, dated 11/28/24, revealed the following: - Burn, third degree. - Staged by in-house nursing. - Location: Sacrum (a large flat bone in the lower part of the spine.) - Minutes old and acquired in-house (at the facility.) - Measurements: length 6.64 centimeters (cm), width 4.2 cm, depth 0.2 cm, area 15.95 cm² (square centimeters.) - Wound bed: Epithelial tissue (a thin, continuous layer of cells) present, granulation tissue (new connective tissue and blood vessels, a sign of wound healing) present. - Moderate serosanguineous (clear or light pink, thin, watery fluid) exudate (body fluid discharged by the body in response to tissue damage and wound healing.) - Edges attached, surrounding tissue erythema (redness.) - Temperature was hot, localized. - Resident reported pain at a 7 out of 10 during dressing. - Treatment: Generic wound cleanser, composite dressing, and Xeroform bordered gauze. - Notes: Resident's skin was hot to touch with a heating pad under her. The resident's skin was thin and fragile. Removed the heating pad. - Education: The resident was educated about the risk factors involved in using a heating pad. Resident was strongly advised to discontinue use of the heating pad and to shift weight in bed frequently. - Notification: None documented. - Electronically signed by the facility's Skin Health Team Lead (SHTL) on 11/29/24 at 12:33 pm. BB. Record review of R #6's Physician Orders, dated November 2024, revealed the following: - Order dated 11/13/24, pressure redistribution cushion to chair. - Order dated 11/13/24, pressure redistribution mattress to bed. - Order dated 11/29/24, wound care for sacrum lower back. Cleans with generic wound cleanser, pad dry, apply small amount of xeroform, and apply bordered gauze. CC. Record review of R #6's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated November 2024, the record did not contain wound care orders or documentation staff administered the orders, dated 11/28/25, for the resident's third degree burn to the sacrum. DD. Record review of R #6's medical record revealed the record did not contain any documentation staff administered wound treatments, dated 11/28/25, for the resident's third degree burn to sacrum. EE. Record review of R #6's care plan revealed the following: - Dated 11/13/24, last updated 11/19/24. - The resident was at risk for skin breakdown related to advanced age, decreased activity, frail fragile skin, and limited mobility. - The resident would not show signs of skin breakdown for 90 days. - Interventions: Pressure redistribution surface to chair and bed, weekly skin check by licensed nurse, offload heels while in bed, observe skin condition daily with ADL care and report abnormalities, apply barrier cream with each cleansing. - The record did not document the resident's third degree burn on her sacrum. FF. Record review of R #6's Nursing Skilled Evaluation, dated 11/29/24, revealed the following: - Pain: Indicators of pain: None. - The record did not contain any information in the following areas: skin, special care, safety, completed clinical suggestions, comments. - The record did not address the resident's third degree burn on her sacrum and her wound treatments. - Electronically signed by an agency licensed nurse. GG. Record review of R #6's Progress Note, dated 12/02/25, revealed the following: - Visit type was acute follow-up. - Chief complaint and nature of the presenting problem: Follow-up of admitting medical diagnoses, including depression. - Resident was a fairly inconsistent historian but at time of encounter denied complaint or concern. - Nursing staff denied new or worsening behaviors, recent fall or injury, unstable vital signs, or other complaint or concern. - The record did not address the resident's third degree burn on her sacrum and her wound treatments. - Electronically signed by the Nurse Practitioner on 12/03/24 at 4:55 pm. HH. Record review of R #6's nutrition progress note, dated 12/03/24, revealed the following: - Resident had multiple pressure wounds. - The record did not address the resident's sacrum wound. II. Record review of R #6's Wound Evaluation, dated 12/04/24, revealed the following: - Burn, third degree. - Staged by in-house nursing. - Located on sacrum. - Six days old and acquired in-house. - Measurements: length 6.24 cm, width 3.9 cm, depth 0.2 cm, area 18.24 cm². - Wound bed 70 percent (%) epithelial, 70% granulation, 20% slough (yellow stringy tissue adhered to wound bed.) - Evidence of infection: increased drainage, increased pain. - Bleeding. - Moderate serosanguineous exudate with faint odor after cleaning. - Edges attached, surrounding tissue erythema. - Resident reported pain at a 7 out of 10 during dressing. - Dressing appeared saturated. - Treatment: Vashe (wound cleanser), Medihoney (wound and burn gel), foam, incontinence management. - Healable. - Stable. - Notification: None documented. - Electronically signed by the facility's SHTL on 11/04/24 at 1:05 pm. JJ. Record review of R #6's Physiatry (related to physical medicine and rehabilitation) progress notes, date 12/05/24, revealed the following: - The resident's plan and progress was discussed with nursing staff and therapy. Resident was sitting up in bed and she reported pain at right leg. Resident stated she slept on and off throughout the night. No complaints of fever, chills, nausea, vomiting. - Pain: Resident reported pain at right lower extremity at hip region. Continue lidocaine patch to affected area once daily. - Electronically signed by the Consultant. KK. Record review of R #6's Physician Orders, dated December 2024, revealed the following: - Order dated 12/04/24, for lower back sacrum wound. Cleanse wound with Vashe, soak gauze in Vashe. Lace on wound and allow to soak area for 20 minutes. Pat dry. Apply Medihoney and cover with bordered gauze. Every day and night shift, and as needed for when soiled or dressing is removed. - Order dated 12/05/24, silver sulfadiazine cream 1%. Apply to burn on sacrum topically every day and night shift for wound care. Cleanse with generic wound cleanser, pat dry. Apply thin layer of silver sulfadiazine cream, cover with border gauze. - Order dated 12/05/24, lidocaine external patch. Apply to right hip topically in the morning for pain. End date 12/12/24. - Order dated 12/05/24, remove lidocaine patch from right hip at bed time for pain. End date 12/12/24. LL. Record review of R #6's MAR and TAR, dated December 2024, revealed the following: - Silver Sulfadiazine cream 1%. Staff did not document they applied the cream on the night of 12/06/25. - Lidocaine external patch. Apply to right hip topically in the morning for pain. Staff documented they applied the patch 12/06/24, 12/07/24, 12/08/24, and 12/09/24. - Remove lidocaine patch from right hip at bedtime for pain. Staff documented they removed the patch on 12/05/24, 12/06/24, 12/07/24, 12/08/24, and 12/09/24. - The record did not contain the wound care orders or documentation staff administered the orders, dated 12/04/24, for the resident's third degree burn to sacrum. MM. Record review of R #6's medical record revealed it did not contain any documentation staff administered the wound treatments, dated 12/04/24, for the resident's third degree burn to sacrum. NN. Record review of R #6's Progress Note, dated 12/06/25, revealed the following: - Visit type: Discharge. - Chief complaint and nature of the presenting problem: Discharge summary and plan. - The resident was initially to be seen today for discharge summary and plan. The NP was contacted by the wound care nurse and notified the resident had a burn to her back. The burn reported had an odor and greenish discharge. The resident was asymptomatic without indication of sepsis or systemic infection. Patient lay in bed, and did not appear to be in acute distress. Resident was a poor historian secondary to dementia, and the NP was unable to reposition the resident at the time of the encounter in order to examine the resident's back. Order to apply silver sulfadiazine cream (antibiotic cream for serious skin infections and burns) 1% placed with wound care nurse. No other concerns noted at time of encounter. - Discharge home. - Discharge condition stable. - Diagnosis: Superficial burn. - Plan for superficial burn: No signs of systemic infection. Continue silver sulfadiazine 1% cream twice daily. Follow-up with primary care physician for further management. - Electronically signed by the NP on 12/09/24 at 8:24 pm. OO. Record review of R #6's Nursing Skilled Evaluation, dated 12/07/24, revealed the following: - Pain: Indicators of pain: None. - The record did not contain any information in the following areas: skin, special care, safety, completed clinical suggestions, and comments. - The record did not address the resident's third degree burn on her sacrum and her wound treatments. - Electronically signed by an agency licensed nurse. PP. Record review of R #6's discharge progress note, dated 12/09/24, revealed the following: - Wound care: redness on buttock bilaterally. - Medications were given to daughter at discharge. - Resident was transferred by wheelchair and two nurse aides assisted. - Resident remained stable. - Resident was discharged to assisted living with family support. QQ. Record review of R #6's Discharge Plan Documentation, dated 12/09/24, revealed the following: - Discharge time 12:00 pm. - Next doctor appointment with primary care doctor on 12/23/24. - No other doctor appointments were documented. - Skin intact. - Infections: Not applicable. - Resident was stable at time of discharge. - Electronically signed by facility nurse on 12/10/24. RR. Record review of R #6's discharge MDS, dated [DATE], revealed staff documented the following: - Discharge, return not anticipated. - discharge date [DATE]. - discharged home under care of organized home health service organization. - Staff did not mark the resident was discharged to Home/Community to include assisted living facility. - Did not receive scheduled pain medication regimen. - Staff did not document the resident received schedule lidocaine external patch. - The resident had one unstageable pressure ulcers, noted at the time of admission. - The resident had one Stage 4 pressure ulcer, noted at the time of admission. - The resident had one unstageable pressure ulcer that was not present at admission. - Staff did not document the resident's sacrum wound. SS. On 03/05/25 at 2:17 pm, during an interview, R #6's daughter her mother was admitted to the hospital on [DATE] for peritonitis (inflammation of the tissue that lines the abdomen), which made her blood pressure drop. She stated her mother was in the hospital from [DATE] through 11/12/24. The daughter stated her mother was admitted to the facility on [DATE] for rehabilitation to get her strength up. She stated she was not aware of any of her mother's wounds when her mother arrived at the facility. The daughter stated there was a care plan meeting on 11/18/24, and the staff told her about her mother's pressure ulcers. The daughter stated she visited her mother almost every day, sometimes in the morning and sometimes in the afternoon. She stated she visited her mother early in the day on 12/04/24, and the wound nurse stated she did not like the way her mother's sacrum wound looked because it was turning green. The daughter stated the wound nurse took a picture and sent it to her and told her she would send the picture to the doctor. The daughter stated it had been four days since she saw her mother and it looked a lot worse than the last time she saw the wound. She stated she asked the wound nurse what she was looking at in the picture, and the wound nurse told her it was slough, which could lead to infection. The daughter stated she spoke to a Certified Nursing Assistant (CNA) on 12/07/25, and the CNA stated her mother was not feeling well and did not go to dialysis. The daughter stated the CNA reported she applied a salve to her mother's wound twice a day, and her mother's wound had a smell to it. The daughter stated over the next couple days her mother did not look well. She stated by the day she discharged (12/09/24) her mother looked horrible and was sweating. She stated the CNAs did not know why her mom was sweating. The daughter stated they tried to move her mother into a chair, but her mother begged to get back into bed. The daughter stated her mother was supposed to discharge at noon on 12/09/24, but she was not ready on time. She stated her mother was in an unusual amount of pain when the two CNAs transferred her into a wheelchair, and her mother was confused and agitated. She stated her mother was not mentally herself, and her back was covered with sweat. The daughter stated the facility did not have transportation to take her mother to the Assisted Living Facility (ALF) which was right down the street from the facility. She stated two CNAs from the facility were not able to transfer her mother into her car, because her mother was in a lot of pain. She stated her mother was propelled in a wheelchair up the street to the ALF. She stated when her mother got to the ALF, staff put her right to bed, and her mother calmed down. The daughter stated her mother was in too much pain to sit up. The daughter stated her mother was scheduled for dialysis on 12/10/24, but the dialysis center sent her mother to the emergency room, because her heart rate was very low. The daughter stated her mother was admitted to the hospital with a diagnosis of septic shock. They told her that her mother had a racing heart rhythm, low blood pressure, and was incoherent. The daughter stated her mother was too weak for a full session of dialysis, and she passed away in the hospital eight days later. The daughter stated while her mother was at the facility, she brought a heating pad for her mother to use. She stated her mother used it for a little while, but then the heating pad disappeared. She stated that was around the beginning of December. The daughter stated she did not remember staff telling her that her mother was burned by the heating pad. She stated her mother used it all the time at home and was responsible with it. TT. On 03/06/25 at 11:26 am, during a record review and interview, the Physician Assistant (PA) stated she began working at the facility in January 2025, and she was not present when R #6 was at the facility. The PA stated she worked at the facility Monday through Fridays, and she conducted resident visits every day. She stated her responsibilities included evaluating the residents, following up on diagnosis, and prescribing treatments. She stated staff update her on resident conditions while she is at the facility or they call her on the on-call number. She stated she would expect staff to notify her of any changes in condition, medication issues, and physical conditions. The PA reviewed R #6's wound documentation dated 11/28/24. She stated she would not have said the wound was a burn, because it looked like skin breakdown to her. She stated if it was a burn due to a wet brief on a heating pad then it would be a bigger area. She stated all the areas in contact with the heating pad should have burn marks. She stated she would have expected staff to notify her of that wound. She stated she would have prescribed a barrier treatment for the wound. The PA reviewed R #6's wound documentation dated 12/04/24, and stated she saw necrosis (dead tissue), an enlarging of the wound, and she thought the tissue looked different. She stated the wound looked deeper, but it was hard to tell if there was depth with that type of ulcer. She stated the wound was getting worse, and it was not a burn wound at that point. She stated she would have wanted to see the wound, and she would have sent the resident out to the ER if she had seen it. The PA stated a prescription for burn cream would not have hurt the resident's wound, but it would not have helped it either. She stated a wound like that could result in osteomyelitis (inflammation of bone and bone marrow) and sepsis. She stated the signs of sepsis was tachycardia, fever, confusion, and sweating. She stated R #6 should not have been discharged to an ALF with that wound. She stated the resident should have went to the hospital. UU. On 03/07/25 at 11:38 am, during a record review and interview, the Medical Director (MD) stated she has been the facility's MD for several years. She stated she was not familiar with R #6, but she reviewed the resident's discharge summary. The MD reviewed the R #6's wound documentation dated 11/28/25. She stated she agreed with the wound assessment of a burn. She stated she would expect the staff to report the wound to her, but she did not recall staff notifying her. She stated she did not provide treatment orders. She stated the wound care nurse decided and implemented treatments for wounds. She stated she expected the treatment for the wound to begin at this stage. The MD reviewed R #6's wound documentation dated 12/4/24. She stated the wound was getting worse and bigger. She stated the wound should have been reported to her before it got to that state. She stated treatments should have been implemented before the wound got to that state. The MD stated the wound was not reported to her. She stated the measurements in the record did not appear to be accurate. She stated the wound needed to be debrided. She stated she needed to see and smell the wound to determine the best course of action. She stated she expected the PA to administer pain medication and observe the resident's wound before prescribing treatment. She stated the PA should not have prescribed a medication without looking at the wound. She stated she was not aware the PA did not look at the wound because she could not turn the resident due to pain. The MD stated that was not acceptable. The MD stated the resident should not have been discharged to an ALF. She stated R #6 needed care for her wound. The MD stated she was not aware of staff's failure to follow protocol and processes for R #6. She stated she was not aware the resident was in too much pain to get in a car for discharge to the ALF or of what happened to the resident after discharge. She stated the resident's care was egregious and was not indicative of the care she provided and expected. VV. On 03/06/25 at 1:27 pm and 03/07/25 at 1:45 pm, during a record review and interview, the Skin Health Team Lead (SHTL) stated she began working at the facility on 11/18/24. She stated she was in training at that time. She stated she began working immediately as the SHTL. She stated her duties included identifying wounds at admission, conducting a full assessment of the resident's skin, taking measurements of any wounds she finds, documenting the wound in the resident's record, putting orders in for treatments, and collaborating with the doctor on the treatments. She stated her training involved observing another SHTL at a sister facility. She stated she trained at the sister facility to see what the other SHTL's day looked like, how to measure and take pictures of wounds, wound care, and entering orders. She stated she did rounds with the doctor. She stated at the end of her training she came to the facility for a couple hours and did audits. She stated she thought it was important to begin working at her facility. She stated she came into the facility on her day off, 11/27/24, to take pictures and complete audits. She stated the facility's previous SHTL stopped working at the facility months before she began employment, and the Unit Managers were doing the resident skin assessments. The SHTL stated her job duties included seeing residents with wounds once weekly and entering treatments into the resident's record. She stated the facility nurses provided the resident's treatments on the days in between her visits. The SHTL stated she was familiar with R #6, and she met the resident on her first day at the facility. The SHTL stated a CNA notified her of R #6's sacrum wound on 11/28/24, and she sent an email to the Administrator regarding what she found. She stated she believed the wound was caused by a heating pad. She stated she immediately removed the heating pad from under the resident and notified the primary nurse. The SHTL stated the picture of the wound in the resident's record was a good representation of the wound. She stated heat from the heating pad and the resident's wet brief caused the wound to the resident's skin. She stated the other areas had less pressure on them than the resident's sacrum, and that was why they were not red. She stated she referred to her own burns when she made the diagnosis of a burn. She stated the resident's skin was still very hot. The SHTL stated the first thing she did was call a wound care company which trained her and was a resource for her. She stated she reported what she found on R #6, and they assisted her with making a treatment decision. She stated she then emailed the Administrator. She stated she asked the nurses for R #6's physician's contact information, and they gave her a number. She stated she texted R #6's physician, but she did not follow up with the physician to confirm receipt of the text message. The SHTL stated she did not contact R #6's family. The SHTL stated she did not contact the facility's Medical Director or PA. She stated it was her first week, and she was not aware of the process at that time. The SHTL stated she put the treatment orders for R #6's sacrum wound into the program the next day (11/28/24.) She stated the nurses were supposed to continue the treatment in between her weekly skin assessments. The SHTL stated the nurses did not continue the treatment, because the order did not go into R #6's MAR/TAR. The SHTL stated there was a drop down box in the program, and she choose auxiliary in the drop down. She stated she was not aware she should have chosen TAR in order for the order to carry over to R #6's TAR. The SHTL stated the nurses referred to the resident's TAR in order to provide treatment for wounds in between her visits. She stated since the treatment was not transferred, there was not any evidence that staff completed R #6's sacrum wound treatments. The SHTL reviewed R #6's wound documentation, dated 12/04/24. She stated the wound was worse, and it opened. She stated R #6's daughter was standing in the room when she saw the wound on 12/04/24. She stated she told the daughter about the resident's heating pad. She stated the daughter seemed aware of the wound at this time. She stated she showed the daughter the sacrum wound, and the daughter did not say anything. She stated the daughter said R #6 was discharging from the facility the following Monday. The SHTL stated she contacted the NP regarding the resident's wound. She stated she reported to the NP the sacrum wound had some growth, was light green in color, and had odor. She stated she asked the NP if she wanted a culture (a test to identify the cause of an infection) or any other interventions. She stated the NP ordered silver sulfadiazine cream twice a day, and the NP asked if the resident was symptomatic (showed symptoms of an infection.) She stated she told the NP the resident was not symptomatic, and NP did not order a culture. The SHTL stated she could not recall if she saw R #6 again before the resident was discharged . She stated she did not have any other notes regarding R #6's sacrum wound. The SHTL stated she questioned if the resident should be discharged and if the ALF could care for R #6's sacrum wound. WW. On 03/07/25 at 3:00 pm, during an interview, the Social Services Director (SSD) stated she began employment at the facility on 02/28/24. She stated her job duties included the post admission care conference and the discharge plan documentation. The SSD stated she worked with R #6 and her family during admission and discharge. She stated the post admission care conference included the MDS Coordinator, Recreation, Director of Rehabilitation, and the Unit Manager Nurse. She stated during the post admission care conference they discussed the resident's medication, therapy, and discharge plan. She stated R #6 wanted to go home, but the resident's daughters were not able to care for the resident at home. She stated the resident agreed to go to an Assisted Living Facility. She stated they did not discuss the resident's wounds at that time, but they did discuss the resident's wounds at her care plan meeting on 11/18/24. The SSD stated she was the only one in R #6's discharge meeting. She stated she consulted with rehabilitation staff and spoke to the family. The SSD stated the nurses discussed R #6's wounds and treatment with the family. The SSD stated she did not pay much attention to that part. The SSD stated R #6's daughters did most of the work at discharge. She stated the facility gave the family a packet with the physician's orders and current needs. She stated they ordered a hospital bed, home health, therapies, skilled nursing, and made a primary care appointment. She stated they did not arrange transportation for the resident, because the daughter said they did not need transportation, a week prior to discharge. The SSD stated she saw the resident earlier in the day before discharge (12/09/24), and the resident appeared to be herself. She stated R #6 appeared happy to leave. XX. On 03/07/25 at 4:01 pm, during an interview with the Administrator (ADM) and the Director of Nursing (DON), the DON stated she began her position on 12/24/24, and the Administrator stated he began his position 11 months ago. The DON stated the SHTL received training from the SHTL at a sister facility, she trained with the Corporate SHTL, and she had health stream trainings she completed. The DON stated the SHTL received training at hire and quarterly. She stated the SHTL received training on how to enter the residents' treatment orders during clinicals. The DON and the Administrator stated the SHTL was responsible to oversee the residents' wounds, take pictures of the wounds, conduct skin and wound evaluations, enter wound care orders, and oversee the interventions for potential or actual issues. They stated the SHTL evaluated the residents on admission, weekly thereafter, and as needed. The DON stated the facility nurses were responsible to provide wound care in between the SHTL visits and to document the treatment administration in the residents' records. The DON stated the wound care orders should be on the resident's TAR, and the nurses should sign off that the treatment was administered. The DON stated if there was not any documentation in the resident's MAR/TAR, then she would question the staff. She stated she reviewed the MAR/TAR when she had a concern, and she did not have a set schedule. The DON stated she was not at the facility while R #6 was a resident, but the Administrator was. The Administrator stated he was present while R #6 was at the facility, and he spoke to the resident several times. The DON stated staff did not complete Braden assessments at the time she began (12/24/24), and that was why R #6 did not have a Braden assessment in her record. The Administrator stated R #6 did not have an initial wound assessme

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of R10's quarterly MDS located in the EMR under the MDS tab with an ARD of 04/29/24 indicated R10 scored a 15 out of 15 on the BIMS, indicating no cognitive impairment. Review of Physician Orders, dated 07/17/24 and located in R10's EMR under the Orders tab, indicated, Oxygen at 3 lpm via Nasal Cannula continuously. Review of the Smoking Evaluation, dated 07/18/24 and located in R10's EMR under the Assessments tab, indicated, Independent smoking is allowed. It further indicated, Upon observation, R10 is able to light, smoke, and dispose of smoking materials safely. Review of the Care Plan, initiated on 07/18/24 and located in R10's EMR under the Care Plan tab, indicated, Patient may smoke independently per smoking evaluation. Interventions are: Ensure that there is no oxygen use in smoking area(s), monitor patients' compliance to smoking policy, inform and remind patient of location of smoking areas and times. During an interview on 07/18/24 at 5:40 PM, R10 stated he kept two to three cigarettes in his room in his eye glass case. He further revealed staff did not lock up his cigarettes or lighter. 4. Review of R31's admission MDS located in the EMR under the MDS with an ARD date of 06/19/24, indicated R31 scored a 12 out of 15 on the BIMS, indicating no cognitive impairment. Review of the Smoking Evaluation, dated 07/03/24 and located in R31's EMR under the Assessments tab, indicated R31 did not wear oxygen, and independent smoking is allowed. Review of the Care Plan, initiated on 07/03/24 and located in R31's EMR under the Care Plan tab, indicated . Patient may smoke independently per smoking evaluation . educate patient on the facility's smoking policy . monitor patients' compliance to smoking policy. During an observation and interview on 07/18/24 at 7:28 PM, R31 stated he was a smoker. R31 revealed he kept his cigarettes and lighters, and they were not locked up by staff. 5. Review of R34's quarterly MDS located in the EMR under the MDS tab with an ARD date of 07/03/24 indicated R34 scored a 15 out of 15 on the BIMS, which indicated no cognitive impairment. Review of the Smoking Evaluation, dated 07/18/24 and located in R34's EMR under the Assessments tab, indicated R34 did not wear oxygen, and Independent smoking is allowed. The smoking evaluation further indicated R34 is able to safely light, smoke and dispose of smoking materials. Review of the Care Plan, revised on 06/20/24 and located in R34's EMR under the Care Plan tab, indicated, R34 may smoke independently per smoking assessment. Interventions are Educate [name of R34] on the facility's smoking policy, inform and remind patient of location of smoking areas and times, ensure there is no oxygen use in smoking area(s). During an interview on 07/18/24 at 6:00 PM, R34 said he kept his cigarettes and lighter on his person and staff allowed him to do so. Staff has never locked up any of my items for me. During an interview on 07/18/24 at 6:45 PM, CNA15 said R10's cigarettes and lighters are locked up and had never seen them in his room. During an interview on 07/18/24 at 6:53 PM, LPN4 said she thought resident cigarettes and lighters were kept at the desk in a small toolbox. The way it was supposed to work is they would come up to the nurse's desk on the approved smoking time, get a cigarette, and go smoke. During an interview on 07/18/24 at 7:31 PM, CNA14 stated, With R31, he has never kept any of his cigarettes and lighters locked up. He keeps them in his fanny pack. We have never kept them locked up. On 07/19/24 at 9:45 AM, the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy (IJ) existed due to the failure to ensure safety precautions were taken to decrease the risk of burns and/or serious injury when residents were keeping their smoking materials (i.e., cigarettes and lighters) on their person, and smoking in their room with oxygen. This included R78, R36, R10, R31 and R34. The IJ at F689 also constituted Substandard Quality of Care at 42CFR 483,12. The IJ was determined to first exist on 10/29/23 when the Medical Director noted an incident in which staff reported R78 lit a cigarette in her room. The facility presented an acceptable plan for removal of the IJ on 07/19/24 at 4:27 PM. The survey team validated that the IJ was removed on 07/19/24 at 6:50 PM following verification conducted onsite that the facility implemented the plan of removal. The deficient practice remained at an E (pattern with potential for minimal harm) scope and severity following the removal of the IJ. The Plan of Removal included: Resident #78's smoking assessment was updated 7 /19/24 at to ensure accuracy and has been identified as a supervised smoker. Her care plan was updated to reflect this. Her room and person were observed for smoking material and none was found, as she was compliant in providing her smoking material to the staff when asked. She was re-educated on the smoking policy and agreed to follow the policy. Family was notified of policy as well (highlighted on the list of emails provided). She does have a history of non-compliance and was given a behavioral contract on 7 /18/24. If she does not adhere to the policy, she will be given a 30-day discharge notice. All residents who smoke were assessed by licensed nursing staff on 7/18/2024 with no injury identified related to smoking. The Administrator/designee began individual meetings with smokers on 7/18/2024 and completed meeting on 7 /19/24 by 3:00pm for the identified residents who smoke at the center to review the smoking policy/process, and/or initiate behavioral contract which includes the following (notes will be in chart that indicate the smoking policy review, and behavior contracts will be uploaded in the chart) The Administrator/designee compiled a list of residents who smoke at the center 7/19/2024 to be placed at the nurses station and will be updated as needed. A whole house sweep of resident smoking materials will be completed on 7 /19/24 by 3:30pm by the Administrator/designee to ensure no items are observed in the resident rooms or observed on the resident and will be obtained if found, or a behavioral contract will be initiated if they do not agree to give up items. Based on facility policy review, record review, observation, and interview, the facility failed to develop and implement interventions to reduce accident hazards and risk when the facility failed to ensure safety precautions were taken to decrease the risk of burns or injury while smoking for 5 (Residents (R) 78, R36, R10, R31, and R34) of 21 residents reviewed for smoking out of a total sample of 46 residents. Facility policies and procedures related to the storage of smoking material were not enforced, residents were not appropriately assessed for safe smoking, and the facility's smoking area was not adequately supervised. The facility's failure to develop and implement interventions to reduce accident hazards and risks when facility residents were smoking places residents at risk of burns and/or severe injury. The findings are: Review of the facility's Smoking Policy dated most recently revised on 05/01/24 read, Evidence supports the myriad of health risks associated with tobacco and electronic cigarette (e-cigarette) use, both for the smokers and for those exposed to secondhand smoke and aerosol exposure; and For Centers that allow smoking, smoking (including the use of e-cigarettes) will be permitted in designated areas only. Patients/Residents (hereinafter patient) will be assessed on admission, quarterly, and with change in condition for the ability to smoke safely and, if necessary, will be supervised; and 2. For Centers that allow smoking: 2.1 Smoking (including e-cigarettes) will only be allowed in designated areas. 2.1.1 An area designated as a smoking area will be environmentally separate from all patient care areas (e.g., outdoors or a smoking lounge), will be well ventilated, and, if outdoors, will protect patients from weather conditions. 2.1.2 A primary gathering place for patients will not be designated as a smoking area so that non-smokers are not subjected to secondhand smoke. 2.1.3 Oxygen use is prohibited in smoking areas. Precautionary signage will be posted in the designated smoking areas. 2.1.4 Ashtrays made of non-combustible materials and safe design, and metal containers with self-closing covers into which ashtrays can be emptied, shall be provided in al designated smoking areas as well as at all entrances. 2.1.5 Safety equipment such as a fire blanket and portable fire extinguishers will be available within or near the designated smoking area(s). 2.2 The admissions designee will explain the Center's smoking policy to the patients and their families, and inform them that patients will be assessed to determine if supervision is needed. 2.3 The admitting nurse will perform a Smoking Evaluation on each patient who chooses to smoke. 2.3.1 Patients will be re-evaluated with a change in condition. 2.4 The patient will be allowed to smoke only with direct supervision until the interdisciplinary team has evaluated them. 2.5 A care plan for patients who smoke shall include such elements as the need for supervision or physical assistance while smoking and safety devices that are needed, such as a smoking apron to prevent burns. The care plan will be updated, as necessary. 2.6 Smoking supplies (including but not limited to, tobacco, matches, lighters, lighter fluid, batteries, refill cartridges, etc.) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station. 2.7 Center leadership will consider special circumstances on an individual basis (e.g., the need for a smoking apron). 2.8 Patients will be offered education on the risks of smoking. 2.8.1 Education offered/provided will be documented in the medical record. 3. It may be necessary to counsel patients or patient representatives who violate the smoking policy. 4. If there is a willful disregard for safety to others or the Center is jeopardized by a patient's disregard for the smoking policy, termination of smoking privileges and/or initiation of a discharge plan may occur. 4.1 Such action will be documented in the medical record. Review of the facility's Smoking List, provided by the facility, indicated there were 21 smokers in the facility (identified above). 1. Review of R78's admission Record, found in the Electronic Medical Record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of R78's significant change Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/11/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. Review of R78's Social Services Progress Note, dated 07/20/23 and found in the EMR under the Progress Notes tab, read, in pertinent part, Resident was found smoking in her room. Lighters and cigarettes were confiscated by this worker and given to the nurses station for safe keeping. Resident was educated on the dangers of smoking in her room and was educated on building policy on smoking in the building. Review of R78's Physician Order Report, dated 07/19/24 and found in the EMR under the Orders tab, indicated an order for the resident to receive oxygen continuously via nasal cannula 13 liters per minute (lpm) per oxygen concentrator. Review of R78's Smoking Care Plan, dated 06/17/24 and found in the EMR under the Care Plan tab, indicated the following interventions: Patient will smoke safely x [times] 90 days per smoking assessment. Educate patient/health care decision maker on the facility's smoking policy. Ensure that appropriate cigarette/e-cigarette device(s) disposal receptacles are available in smoking areas. Ensure that there is no oxygen use in smoking areas. Inform and remind patient of location of smoking areas and times. Maintain patients smoking materials at nurse's station. Educate patient/health care decision maker on the facility's smoking policy. Inform family and significant others of the patient's inability to smoke. Review of R78's only Smoking Safety Evaluation dated 03/18/24, and found in the EMR under the Assessment tab, revealed the resident was a smoker. The evaluation indicated the resident had a poor memory and had a history of unsafe smoking practices. The assessment indicated supervised smoking was required for the resident. Review of R78's Physician Encounter Note, dated 10/29/23 and found in the EMR under the Progress Notes tab, read, in pertinent part, (R78) is seen sitting up in her wheelchair looking out the window. She states she is not well but does not know why. She denies pain at this time. Patient became upset and refused to answer any more questions. Returned to patient after staff reports patient lit a cigarette in her room. Patient states she lit it to get someone in her room because she has been waiting for assistance hours. She states she called for water since yesterday and is dehydrated. Unable to complete full interview patient upset. Review of R78's Care Plan Meeting Note, dated 01/04/24 and found in the EMR under the Progress Notes tab, read, in pertinent part, Not aloud (sic) to have cigarettes or lighters. has been found smoking in her room to get Certified Nursing Assistant (CNA) attention last month. Review of R78's Care Plan Meeting Note, dated 04/25/24 and found in the EMR under the Progress Notes tab, read, in pertinent part, Discussed residents over all wellbeing, smoking behaviors, weekly activities, and hygiene. Son stated he would talk with his mother about smoking cigarettes in her room is a danger hazard. Review of R78's EMR revealed no evidence that a Behavior Contract had been initiated with R78 related to not following smoking rules. Smoking related incident reports/investigations involving R78 for the previous 12 months were requested of facility Administration on 07/18/24. During an interview with the Director of Nursing (DON) on 07/18/24 at 6:10 PM, she stated she was not aware of any smoking incident occurring in this facility until 07/18/24. Observation of R78 on 07/15/24 at 10:01 AM revealed the resident was in bed sleeping. An unsmoked cigarette was observed in a plastic cup on the resident's overbed table. Smoking related incident reports/investigations involving R78 for the previous 12 months were requested of facility Administration on 07/18/24. During an interview with the Director of Nursing (DON) on 07/18/24 at 6:10 PM, she stated she was not aware of any smoking incident occurring in this facility until 07/18/24. During an interview with R78's family member (FM) 78 on 07/19/24 at 12:55 PM, he stated he had received several calls from the facility related to smoking concerns. He stated staff reported several events, such as when R78 had lit up a cigarette in her room or in her bathroom. He stated the last call he had received related to his mother smoking somewhere other than the designated smoking area had been approximately one month ago (in May or June of 2024). He stated he had been told R78 had been caught smoking in her room, and he was asked to speak to her about it. He stated he told R78 she was going to be in trouble if she continued to smoke in her room. R78's FM stated R78 started a fire at her home prior to being admitted to the facility when she had been smoking with her oxygen on. He stated she had burned the bottom of her foot during the incident and the oxygen tubing had melted during the event. During an interview with CNA 16, Licensed Practical Nurse (LPN)1, and LPN2 on 07/18/24 at 4:34 PM, the staff members were asked if R78 followed the facility's smoking rules, CNA16 stated, I am not going to lie to you. I told them I wouldn't lie. I am not willing to risk my license by not telling the truth. She (R78) gets up at night to smoke and is in bed most of the day. Sometimes, she follows the rules. I have seen cigarettes in her room recently. She usually has them on her person. They are not in the box at the nurse's station. CNA16 removed the metal box used to store resident smoking materials from a drawer at the nurse's station and showed it to the surveyor. The box was empty (no smoking supplies were in the box despite several residents on the unit being active smokers). LPN1 stated all of the residents who smoked on the unit kept their own cigarettes and lighters on their person. LPN2 confirmed R78's oxygen was running in her room continuously all or most of the time due to her order to receive continuous oxygen. LPN2 stated, She has three (oxygen) concentrators there, and she keeps her own lighter and cigarettes in a little black bag in her room. During an interview with the DON on 07/17/24 at 4:07 PM, she stated she did not know what happened with the smokers in the facility because she did not go out there (to the designated smoking area). She confirmed cigarettes had been found in residents' possession, but staff was not allowed to search a resident's room without permission. She stated if smoking materials were found on a resident or in a resident's room and could be confiscated, they would be. She stated, however, an incident report was not generated for any of those events. The DON stated it was not her expectation that staff would tell her or the Administrator when smoking materials were found on a resident or in a resident's room. She stated her expectation was that the nurses would just take the cigarette away from that person. The DON stated she was aware residents were currently not abiding by the facility's smoking rules and that a lot of residents had been found with random cigarettes. The DON stated facility policy was that all resident smoking material was to be kept at the nurse's station. She stated no residents were allowed to keep their own smoking materials. The DON stated residents could be placed on a Behavior Contract related to smoking if they were not following the smoking rules. However, she was unaware of whether R78 had been placed on a behavior contract related to smoking or not. The DON acknowledged residents not following the facility's smoking rules had the potential to lead to fires and/or serious injury/burns. However, she stated, Between you and I, these residents are going to do what they are going to do. During an interview with the Administrator on 07/18/24 at 5:23 PM, he stated he was not aware of any recent incident reports/investigations related to residents not following smoking rules. He confirmed R78 had not been placed on a Behavior Contract related to smoking previously, but that one had been initiated that day (07/18/24). The Administrator stated he was aware smokers had been keeping their own smoking materials on them. He confirmed his expectation was facility policies and procedures would be followed related to smoking. He stated, What is supposed to be happening is we should be monitoring the cigarettes and lighters more closely. 2. Review of the admission Record for R36 found in the EMR located under the Profile tab indicated R36 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia (an absence of oxygen in the tissues to sustain bodily function), and Obstructive Sleep Apnea. Review of the admission MDS admission assessment found in the EMR located under the MDS tab revealed an ARD of 04/22/24. The BIMS score was 15 out of 15, revealing intact cognition. Review of the Care Plan for R36 found in the EMR located under the Care Plan tab revealed a care plan for smoking dated 07/10/24 with an intervention of Monitoring patients' compliance to smoking policy. Review of the Smoking Evaluation for R36 found in the EMR located under the Assessment tab dated 07/10/24 indicated R36 could smoke independently and that R36 was made aware of the smoking policies, time, and location. During an interview on 07/17/24 at 9:56 AM, R36 was up in her motorized wheelchair, returning to her room from outside smoking. R36 wore a lanyard around her neck that held a lighter in it. R36 was asked if she kept her own smoking materials. She stated, Yes, I do. I understand keeping them for residents who are not quite all there, but I am, and I can keep them myself. I know I do not comply with the rules. The resident also stated, Sometimes I go out front and smoke because there are too many that will try and bum a cigarette from me. The resident was asked if she wore oxygen. R36 stated, I do, but not when I'm smoking. During an interview on 07/17/24 at 3:2 PM, Licensed Practical Nurse (LPN)6 revealed R36 could smoke independently, and she would go out and smoke at various times. LPN6 was asked how the resident got her smoking materials to smoke. LPN6 stated, I'm not sure because she does not come to the desk to get them. LPN6 was made aware that R36 kept them with her, and she wears the lighter around her neck. LPN6 stated she was not aware the resident had her own smoking materials. During an interview on 07/17/24 at 3:22 PM, the DON revealed, I am sure that they have their own cigarettes. The staff can do their best to get the materials from the residents, but if we do not have permission to look in their room, then we cannot do anything about it. If the materials are laying out in the open, then we can pick them up. The DON stated, I do not expect an incident report to be done for finding someone with cigarettes. All we can do is talk to the resident, and if it continues, place them on a Behavior Contract. The Administrator makes the decision whether a resident stays or not. I only know of one female resident who has been found with smoking materials, and I cannot remember who it was now. The nurse's station should have everybody's smoking materials. There are blatant people who will not follow the policy. During an interview on 07/18/24 at 7:24 PM, the Administrator said he was not aware of residents keeping smoking materials in their rooms or on their person.