**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #5) of 5 ( R #'s 1, 2, 3, 4 and 5) residents when they failed to administer anti-seizure medication (medication used to prevent or stop seizures [sudden burst of electrical activity in the brain]) as ordered. This deficient practice likely resulted in the resident experiencing seizures requiring hospitalization. The findings are: A. Record review of R #5's face sheet revealed an admission date of 11/21/24 and included a diagnosis of epilepsy (seizure disorder). B. Record review of Prepare to Admit document dated 11/20/24 for R #5 revealed that R #5's current medications included Lacosamide (medication used to prevent or treat seizures) 200 milligrams (mg). C. Record review of Minimum Data Set (MDS - federally mandated assessment instrument completed by facility staff) dated 12/04/24 for R #5 revealed the following: - Section I - Active Diagnoses: Seizure Disorder or Epilepsy. - Section N - Medications: Anticonvulsant (medication used to prevent and manage seizures) was included. D. Record review of Care Plan dated 11/25/24 for R #5 revealed, Focus: Risk for seizure activity related to diagnosis of epilepsy. Goal: There will be no complications from seizure activity over the next ninety days. Interventions . 4) Medicate as ordered assessing the effectiveness and for any adverse effects. E. Record review of physicians admission medication orders for R #5 included the following order: - Lacosamide oral tablet, 200 mg. Give 200 mg orally every 12 hours for epilepsy. Start date: 01/16/24. [no end date] F. Record review of medication administration record (MAR), dated November 1 through 30, 2024 for R #5 revealed no documentation that R #5 received Lacosamide Oral Tablet 200 mg from 11/21/24 through 11/30/24. G. Record review of the Facility Hospital Transfer form dated 11/25/24 for R #5 revealed that he was transferred to the hospital due to seizures. H. Record review of the hospital discharge paperwork dated 11/25/24 for R #5 revealed that R #5 was admitted to the hospital for seizure activity. Documentation confirmed that the nursing facility did not have lacosamide on formulary and therefore R #5 had not received this medication over the past four days. Documentation also revealed R #5 was noted to have generalized tonic-clonic seizures (type of seizure that causes loss of consciousness and violent muscle contractions) this afternoon; when emergency medical services (EMS) arrived, R #5 was actively seizing. Per the hospital H&P revealed his [R #5] seizures had been stable over the course of the last year. I. On 04/03/25 at 3:53 pm during an interview with the Director of Nursing (DON), the Administrator (ADM), and Nurse Educator/Unit Manager (NE/UM) revealed the following: DON stated that R #5 arrived in the evening on 11/21/24 and all his medications were received except for the seizure medication; R #5 had several seizures in a row and was sent out to the hospital. DON stated that no one was aware that the seizure medication had not come in until R #5 was sent to the hospital. DON also stated that the nurse on duty was supposed to call and follow up with the pharmacy. NE/UM stated that R #5 was transferred from another facility and the prescription was not sent to the new facility. She stated that R #5's insurance was not going to pay for the medication because the prior facility had already received the prescription. She stated that they contacted the prior facility and requested that the facility either return the medication to the pharmacy or send it to this facility. DON stated that the nurse on duty is supposed to contact the physician to reconcile the resident's admission medications to make sure the physician agrees with the medications. He stated that the order for lacrosamide was listed on the medication list but was not on the hard copies that arrived with the resident. J. On 04/03/25 at 4:14 pm during an interview, the Nurse Practitioner (NP) confirmed that she reconciled/verified the admission medications, for R #5, with Registered Nurse (RN) #1 which included the orders for Lacosamide. The NP confirmed that she was not aware that R #5 was not receiving this medication until he was sent to the hospital on [DATE]. K. On 04/03/25 at 4:31 pm during an interview, RN #2 stated that when she reached out to the the pharmacy regarding R #5's Lacosamide she was told that the medication would be delivered to the facility by the evening on 11/22/24. The facility was later informed by the pharmacy that they could not fill the prescription because it had been filled by the previous facility from which R #5 transferred. The facility reached out to the prior facility requesting that the medication be sent to them or returned to the pharmacy to which the prior facility refused. Based on record reviews and interviews, an Immediate Jeopardy (IJ) was identified. The facility administrator was notified on 04/03/25 at 5:45 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR). The Plan of Removal was approved on 04/04/25 at 12:15 pm. Plan of removal: All residents have the potential to be affected by this alleged deficient practice. The following identification/corrections will be completed by 04/03/25. - Audit all residents with a diagnosis of seizures to ensure medication therapy is in place as ordered. - A 14 day look back audit of recent admissions to ensure accurate medication reconciliation, review and continuation of medications and treatments. - All licensed staff education to include medication transcription/medication reconciliation upon admission with documentation in the residents chart and steps to follow for medication availability with an emphasis on: validating with the pharmacy on arrival time, pulling from Ekit (emergency kit - contains a small quantity of medications that can be dispensed when pharmacy services are not available) if available, notification of provider for additional orders or medication adjustments, requesting medications from backup pharmacy if needed. - DON/Designee during morning clinical meetings, medication reconciliation audits occur for all new admissions and medication order changes. - DON/Designee to review medications not available during morning clinical meetings. - Nurse Practice Educator/Designee will begin education on 04/03/2025 and continue until all licensed nursing staff have been educated prior to their next shift. Any licensed staff member on leave of absence (FMLA- family medical leave act), vacation, or PRN (as needed) staff will be re-educated prior to returning to duty. New hires will be educated on this process upon hire. - The Director of Nursing/designee will audit 5 random residents 3 x (times) week to ensure all medications reconciliation have occurred. - DON and/or designee will bring results of audits to QAPI (quality assurance and performance improvement) committee for further recommendations based on tracking and trending presented monthly for the next 2 months or until ongoing compliance is achieved. The QAPI committee is overseen by the Administrator. Implementation of the POR was verified onsite on 04/04/25 by record reviews, and staff interviews. Scope and Severity was reduced to Level 2, D. Implementation was verified through: Record review of the facility's new admissions audit from 03/21/25 through 04/04/25 to ensure accurate medication reconciliation, review and continuation of medications and treatments. Record review of the facility's audit of all current residents with a diagnosis of seizures to ensure medication therapy was in place as ordered. Record review of staff signature sheets for the education provided to the licensed staff, to include medication transcription/medication reconciliation upon admission with documentation in the residents' chart and steps to follow for medication availability with an emphasis on: validating with the pharmacy on arrival time, pulling from Ekit if available, notification of provider for additional orders or medication adjustments, requesting medications from backup pharmacy if needed. Interviews of two nurses verified the in-service they received on 04/03/25 and 04/04/25 included medication transcription/medication reconciliation upon admission with documentation in the residents' chart and steps to follow for medication availability with an emphasis on: validating with the pharmacy on arrival time, pulling from Ekit if available, notification of provider for additional orders or medication adjustments, requesting medications from backup pharmacy if needed. Interview with the Administrator and DON regarding POR, audits new admissions audit from 03/21/25 through 04/04/25 to ensure accurate medication reconciliation, review and continuation of medications and treatments; audit of all current residents with a diagnosis of seizures to ensure medication therapy was in place as ordered; and education provided to the licensed staff, to include medication transcription/medication reconciliation upon admission with documentation in the residents' chart and steps to follow for medication availability with an emphasis on: validating with the pharmacy on arrival time, pulling from Ekit if available, notification of provider for additional orders or medication adjustments, requesting medications from backup pharmacy if needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is a past noncompliance. Based on record review and interview, the facility failed to ensure nursing staff demonstrated competency in skills and techniques necessary to safely administer medications to residents for 1 [Licensed Practical Nurse (LPN #1)] of 4 [LPN #1, LPN #2, Registered Nurse (RN) #1, and Certified Medication Assistant (CMA) #1] employees sampled for training. This deficient practice likely resulted in R #1 receiving another resident's medication, which resulted in R #1 being admitted to the hospital on [DATE] for accidental overdose and hypotension (low blood pressure). The findings are: A. Record review of the facility's Medication Management Clinical procedures, undated, revealed safe practices for giving medicines. Clinicians are required to follow policies and standards of practice when giving medicines. Staff directed to review the five rights of administering medicine: 1. The right person, 2. The right medicine, 3. The right dose, 4. The right route, 5. The right time. B. Record review of the facility's Complaint Narrative Investigation: A Follow-up Report (5 day), undated, revealed upon interview with LPN #1, she reported having pre-poured the medications in a cup, become distracted, and handed the medications to R #1 instead of R #2. LPN #1 reported she immediately realized she handed the medications to the wrong resident. Resident #1 did not ingest all of the medications, so she retrieved the remaining medications in the Sharp's container. RN #1 did not report the medication error to the physician or the Director of Nursing (DON). During a follow-up interview several days later, LPN #1 said she gave R #1 Prilosec (medication used for heart burn) and lisinopril (a medication used to lower blood pressure). C. Record review of the R #1's change of condition for medication error, dated 3/22/24, revealed the following: 1. On 03/22/24 at 5:46 am, staff documented R #1's blood pressure as 117/65 mmHG (millimeters of mercury; Normal blood pressure is 120/80 mmHG.) 2. On 03/22/24 at 10:37 am, staff documented R #1's blood pressure as 80/46 and sent the resident out to the emergency room (ER). D. Record review of R #1's hospital records, dated 03/22/24, revealed: 1. On 03/22/24 at 3:58 pm, R #1 was evaluated at the ER. 2. Chief Complaint: LPN accidentally gave the patient the wrong medications, hypotensive. 3. History of Present Illness: Patient is a [AGE] year-old-male in a nursing home with no significant past medical history besides dementia. Patient came in the Emergency Department (ED) after he was accidentally provided with the wrong patient medication. Medication list from R #2 included lisinopril (used to lower blood pressure), isosorbide (used for heart related chest pain, heart failure, and esophageal spasms), Lasix (used to treat fluid retention and high blood pressure), prazosin (used to treat high blood pressure), metformin (used to treat diabetes type 2). Patient was found to be hypotensive as a result, and he was transferred to the ED here. Patient did not have any other complaints, falls, or pain. Patient denied any complaint. He denied any headache, blurred vision, abdominal pain, chest pain, or shortness of breath. Telemetry (vital sign machine) showed normal blood pressure, normal saturation on room air (oxygen in the blood), ED reached out to Poison Control who recommended the addition of comprehensive metabolic panel (CMP; a blood test that measures 14 substances in the blood) and an electrocardiogram (EKG; a test that records the electrical signals in the heart, helps detect heart problems, and monitors heart health) later in the evening. Patient admitted for observation to monitor for many medication side effects that might arise. 4. At 3:58 pm, R #1's blood pressure was 115/55 mmHG. 5. Assessment: Medication overdose, hypotension. Patient noted to be hypotensive after receiving home medication of another patient. 6. Plan: Repeat CMP and EKG per Poison Control recommendations. Get physical therapy to evaluate the patient in the morning. 7. On 03/23/24 at 1:12 pm, R #1 was admitted overnight for observation to monitor of any medication side effects. He remained stable without any overnight events. He will be discharged to the nursing home. E. Record review of LPN #1's competency assessment record revealed the following: 1. Initial training and competency (the application and demonstration of appropriate knowledge, skills, behaviors, and judgment in a clinical setting) on medication administration completed on 03/24/2022. 2. Re-education competency completed on 01/26/24. F. On 05/07/24 at 2:37 pm, during an interview with the DON, he stated LPN #1 confused R #1 and R #2, who sat in two different places in the dining room. The DON stated the LPN #1 handed R #1 the medication and then she saw R #2 who was supposed to receive the medication. He stated R #1 was ambulating between the 100 and 200 hall towards the front office, on 03/22/24 at approximately 10:30 am, when he got dizzy and fell. He said a housekeeper saw the resident trying to get up from the floor by using the handrails in the hallway. The DON stated staff kept R #1 on the floor, because the resident was still dizzy. He said the housekeeper ran to his nurse, and his nurse evaluated R #1. The DON stated LPN #1 went to Unit Manager (UM) #1 and reported the medication error that occurred at breakfast in the dining room, and LPN #1 reported she gave R #1 a multivitamin and that was all. He said staff called Emergency Medical Services (EMS). He said by the time EMS arrived R #1's vital signs were back to his baseline, and R #1 went to the hospital for an overnight observation. The DON stated, during the facility's investigation, LPN #1 reported R #1 only received a multivitamin. Further investigation revealed she had given a Prilosec and lisinopril. The DON stated LPN #1 has been written up for pre-pouring medications on a previous occasion. G. On 05/08/24 at 8:26 am, during an observation with RN #1 while she passed medications, RN #1 reviewed the medications for R #3, asked R #3 his name, checked the medication, the route, the dosage, and time. RN #3 watched R #3 take his medication. RN #1 documented the medication she gave to R #3. H. On 05/08/24 at 3:31 am, during observation and interview, RN #1 passed medication to R #4. RN #1 asked the resident his name, checked the medication, the route, the dosage, and time. RN #3 stated R #4 had a crush medication order. RN #3 watched R #4 take his medication. RN #3 stated if the resident was unable talk or give his name then she could compare the resident to the photo that was in the resident's medical record. RN #3 said she did not go off the name on the door of a resident's room, because another resident might be in there and answer to the name. RN #3 said if she was unsure about the right resident she would ask another nurse or teammate that might know who the resident was before she gave the medications. RN #1 stated they had an in-service on the seven rights of medication administration on 03/25/24. I. On 05/08/24 at 11:56 am, during an observation and interview with CMA #1 during a medication pass, CMA #1 checked medication with the order on the computer, identified the right resident, the right medication, right route, right dose, and right time. CMA watched R #5 take her medication. CMA #1 stated if she was unsure of the identity of a resident then she would ask another nurse or look at the resident photo that was in the resident's medical record. CMA #1 stated she attended an in-service recently on the rights of medication administration on 03/25/24. J. On 05/08/24 at 12:17 pm, during an interview with the DON, he stated new staff shadow a senior nurse (a nurse in the facility longer than others.) During this time, it would depend on the new nurse's knowledge of the system and how comfortable they were using the electronic medical record program. The DON stated new staff shadow for a maximum of three days on the medication cart, in order to allow them to get to know the residents and the electronic medical record program. The DON stated staff complete a competency annually, and the facility had one in early 2024 for medication pass. The DON stated staff have not reported any other medication errors since he became DON on 01/12/24, and he was not aware of any other medication errors. K. On 05/09/24 at 830 am, during observation and interview with LPN #2 during a medication pass, the LPN checked the medication to the order, confirmed the right route, right dose, right time, and asked the resident his name. LPN #2 stated if this was a resident that he did not know then he would ask the resident to say their name and date of birth . LPN #2 stated if the resident could not tell him the information, then he would take the resident back to his cart to look at the picture in the resident's medical record. LPN #2 stated he could also get another staff who knew the resident to confirm the resident's identity. LPN #2 stated they have been getting in-serviced on the right of medication administration, and the education was in March 2024. Based on the facility's investigation of the medication error the following interventions were implemented and placed in an Improvement Action Plan: 1. LPN #1 was immediately suspended pending investigation for delayed notification of medication error. Completed 03/22/24. 2. All residents on LPN #1's assignment for 03/22/24 were evaluated for changes in status and screened for concerns related to their medication to rule out the potential of other medication errors. All resident audits were completed by nursing staff. The residents did not have changes from their baseline. 3. All nurses and CMAs to be educated on the five rights of medication administration related to resident identification. In-service on 03/24/24 and ongoing. 4. Random medication administration observations to be completed by DON or Designee three times per shift for four weeks. Evaluate and bring results to Quality Assurance Performance Improvement (QAPI; this is a data driven and proactive approach to quality improvement) monthly until determination of stop. Start date 03/22/24 and ongoing. 5. LPN #1 was terminated from the facility on 03/22/24 and turned into the New Mexico Board of Nursing on 03/24/24.

Based on observation, interview, record review, and facility policy review, the facility failed to 1. provide adequate monitoring and supervision for a resident that was smoking while using oxygen (Resident (R)167). This failure of allowing a resident to smoke while using oxygen resulted in an Immediate Jeopardy due to the increased likelihood to cause serious harm or death in the event R167 being exposed to burns. 2. The facility also failed to provide adequate monitoring and supervision for residents in the smoking area while oxygen was in use (R6, R31, R34, R46, R117, and R218). 3. The facility further failed to provide adequate monitoring and supervision for eight (R117, R218, R46, R34, R6, R31, R13, and R7) of 15 residents that required supervision per the smoking evaluation. 4. The facility also failed to assess three (R13, R34, R218) of 15 residents who smoke. On 03/29/22 at 7:25 PM, the Center Executive Director (CED), Interim Center Executive Director (ICED), Director of Nursing (DON), and the Regional Administrator (RA) was notified of the Immediate Jeopardy (IJ) at F689-J Accidents. The Immediate Jeopardy began on 03/29/22 when the survey team identified R167 smoking while using oxygen. The facility provided an acceptable removal plan on 03/31/22 at 8:29 AM. The removal plan included education to residents and staff on the dangers of smoking while using oxygen, education on the smoking policy, review of smoking assessments, alarm to the door to the smoking area, revision of smoking times to have staff available, and collaboration with Ombudsman to assist with safe smoking in the facility. Through interviews with facility staff, observation of supervised smoking, clinical record review of revised smoking assessment, and review of staff in-services, the survey team verified all elements of the facility's IJ Removal Plan and therefore removed the IJ. On 03/31/22, during the exit conference, the survey team notified the Center Executive Director, and the facility staff present at the exit conference that the IJ was removed and reduce to level, E. The survey team exited the facility on 03/31/22 at 3:15 PM. Findings include: 1. Review of the facility's policy titled, Smoking, reviewed 11/04/19, indicated, Oxygen use is prohibited in smoking areas. Review of the list of residents who smoke, provided to the survey team by the facility, revealed a list 14 residents. R167 was not listed. During an observation on 03/29/22 at 11:58 AM, R167 was observed, in the smoking area, smoking while using oxygen via nasal cannula. Resident R167 was observed to be supervised by Certified Nursing Assistant (CNA)1. During an observation on 03/29/22 at 12:02 PM, R167 was observed entering the facility from the smoking area. At the time of observation, R167's nasal cannula was dragging on the floor behind her wheelchair. R167 removed her oxygen concentrator from the back of her wheelchair and put it on the floor near the beginning of the hallway and proceeded to return to the designated smoking area. Review of R167's admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed an admission date of 03/01/22 with medical diagnoses that included hemiparesis and hemiplegia (weakness and paralysis) following cerebral infarction (stroke) and nicotine dependence. Review of R167's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 03/07/22, revealed R167's Brief Interview for Mental Status (BIMS) score was not assessed. Review of R167's Physician Orders, dated 03/03/22 and located in the EMR under the Orders tab revealed, Oxygen via N/C [nasal cannula] to titrate to 90%. DX: oxygen dropping with exertion. Review of R167's Smoking Evaluation, dated 03/01/22, located in the EMR under the Assessments tab, revealed the following: Smoking decision: Supervised smoking is required per facility policy, however resident has been counseled not to smoke d/t [due to] recent CVA [Cerebral Vascular Accident]/CHF [congestive heart failure]; resident unable to locate designated smoking area; resident unable to smoke safely without use of smoking apron. During an interview on 03/29/22 at 12:10 PM, CNA1 stated that staff supervised residents that smoke about once per day. CNA1 stated the residents do not use aprons and she was unsure of which residents needed aprons. CNA1 stated she was supervising R6, R31, R167, R117, and R218 at the time of interview. CNA1 stated the facility kept smoking supplies in a lockbox, which was kept in the medication room. CNA1 stated smoking supplies for R31, R117, and R218 are kept in the lockbox. CNA1 stated R6 keeps his own supplies because he is an independent smoker. CNA1 stated R167 did not have her own personal cigarettes and would borrow cigarettes from other people. As the interview ended, CNA1 was heard saying, Who has a lighter so I can light her cigarette for her? During an interview on 03/29/22 at 12:17 PM, R46 stated he had just come from outside smoking and stated R167 was smoking while using her oxygen. R46 stated CNA1 did not say anything to R167, so he told R167 that she could not smoke while using oxygen and to go back inside the facility. During an interview on 03/29/22 at 12:56 PM, CNA1 stated she was supervising the designated smoking area while R167 was smoking while using oxygen via nasal cannula. CNA1 stated she did not know who lit the cigarette for R167. CNA1 further stated R46 brought to her attention that R167 was smoking while using oxygen and CNA1 instructed R167 to go inside the facility. During an interview on 03/29/22 at 12:30 PM, Licensed Practical Nurse (LPN) 1 stated on 05/03/21, R117 was smoking in his room while using nasal cannula oxygen and set his face on fire. LPN1 stated the nasal cannula melted and R117 received burns to his nose and face. LPN1 stated the facility then started monitoring all residents who smoke and kept the residents' smoking materials. LPN1 stated after some time, the facility became relaxed, residents were allowed to keep their cigarettes and lighters, and facility stopped monitoring the residents that smoke. Review of R117's Progress Notes, dated 05/03/21, located in the EMR under the Notes tab, revealed: Resident was wearing his oxygen and lit a cigarette in his room. Recommendations: Monitor. Clean burns and apply antibiotic. A review of the unfinished incident report provided by the Infection Preventionist revealed, Describe the circumstances of the event and immediate actions taken: wasn't thinking and lit a cigarette. Part of the resident's mustache is burned off, and he has burns above his lip, on his cheeks and nose. Resident gave this LN [Licensed Nurse] his cigarettes and gave his lighter to the other nurse. During an interview on 03/29/22 at 5:05 PM, the Center Executive Director (CED) revealed that the potential risk of smoking while wearing oxygen, is that the oxygen could combust or cause a fire. During an interview on 03/29/22 at 5:05 PM, the DON stated, The possible risks of smoking with oxygen on are they could get burnt real easily because oxygen and fire don't mix; then there is a possible harm for others around the oxygen if a fire started; a lot of potential damage to the person's lungs, face and any other body parts that may be exposed to the fire; and then there is the possibility of falls and subsequent injuries from trying to get away from the fire. When asked what the possible risks were of residents having lighters in their rooms, the DON stated, they might be tempted to light a cigarette in their room - then it opens up all the risks I just said. During an interview on 03/30/22 at 9:12 AM, CNA42 stated there was an incident last year with R117. CNA42 stated R117 was smoking in his room. He didn't want to wait until his scheduled smoking time. He had oxygen on. He caught his face on fire. During an interview on 03/30/22 at 8:46 PM, LPN19 stated there had been an incident in 2010 where a resident received third degree burns while smoking using oxygen. LPN19 stated a second incident happened in 2021, when R117 received facial burns while smoking in his room while using oxygen. LPN19 stated residents should never smoke while using oxygen. Review of the facility's policy titled, Smoking, reviewed 11/04/19, indicated, Patients will be assessed on admission, quarterly, and with change in condition for the ability to smoke safely and, if necessary, will be supervised. The policy also indicated, Supervised smoking is defined as The observer must be in the direct area of the smoker, within eye contact, and able to respond to emergency situations. During an observation on 3/29/22 at 11:58 AM, R167 was observed in the smoking area, in the presence of staff and other residents, to be smoking while using oxygen via nasal cannula. At the time of this observation, R6, R31, R34, R46, R117, and R218 were also observed to be smoking. Residents were observed to be supervised by CNA1. During an interview on 03/29/22 at 12:56 PM, CNA1 stated she was supervising the designated smoking area while R167 was smoking while using oxygen via nasal cannula. CNA1 confirmed R6, R31, R34, R46, R117, and R218 were also in the designated smoking area while R167 was smoking. Review of the facility's policy titled, Smoking, reviewed 11/04/19, indicated, The admitting nurse will perform a Smoking Evaluation on each patient who chooses to smoke. The facility policy also indicated, Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, 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. The policy indicated, Patients will not be allowed to maintain their own lighter, lighter fluid, or matches. Review of R117's admission Record, located in the EMR under the Profile tab, revealed an admission date of 12/20/20 with medical diagnoses that included chronic obstructive pulmonary disease and dementia with behavioral disturbance. Review of R117's annual MDS located in the EMR under the MDS tab with an ARD of 12/20/21, revealed R117's BIMS score was six out of 15, indicating severe cognitive impairment. Review of R117's Smoking Evaluation, dated 11/04/21, located in the EMR under the Assessments tab, revealed the following: Smoking decision: supervision is required due to resident uses oxygen and is unable to keep a lighter due to history of setting himself on fire.; res uses oxygen, has dementia, has poor memory, history of setting fire/arson, history of unsafe smoking habits, history of sharing/selling cigarettes. Review of R117's Care Plan, dated 01/15/22, located in the EMR under the Care Plan tab revealed: may smoke with supervision per smoking assessment; Intervention: Ensure that there is no oxygen use in smoking area(s). Review of R218's admission Record, located in the EMR under the Profile tab, revealed an admission date of 03/15/22 with medical diagnoses that included chronic obstructive pulmonary disease and dementia without behavioral disturbance. Review of R218's admission MDS located in the EMR under the MDS tab was incomplete and R218's BIMS had not been assessed. R218's EMR revealed no evidence of a completed Smoking Evaluation. Review of R218's Care Plan, dated 03/16/22, located in the EMR under the Care Plan tab revealed: may smoke with supervision per smoking assessment; Interventions: Monitor patients' compliance to smoking policy; Ensure that there is no oxygen use in smoking area(s). Review of R46's admission Record, located in the EMR under the Profile tab, revealed an admission date of 06/05/17 with medical diagnoses that included heart failure and diabetes. Review of R46's quarterly MDS located in the EMR under the MDS tab with an ARD of 02/16/22, revealed R46's BIMS score was 15 out of 15, indicating R46 was cognitively intact. Review of R46's Smoking Evaluation, dated 01/05/22, located in the EMR under the Assessments tab, revealed the following: Smoking decision: supervision is required. No reason was given as to why R46 required supervision during smoking. Review of R46's Care Plan, dated 11/02/21, located in the EMR under the Care Plan tab revealed: May smoke per facility smoking policy; Interventions: Ensure that there is no oxygen use in smoking area(s); Maintain patients smoking materials at nurses' station; Monitor patients [sic] compliance to smoking policy. Review of R34's admission Record, located in the EMR under the Profile tab, revealed an admission date of 10/28/21 with medical diagnoses that included schizoaffective disorder and nicotine dependence. Review of R34's admission MDS located in the EMR under the MDS tab with an ARD of 11/03/21, revealed R34's BIMS score was seven out of 15, indicating severe cognitive impairment. R34's EMR revealed no evidence of a completed Smoking Evaluation. Review of R34's Care Plan, dated 02/08/22, located in the EMR under the Care Plan tab revealed no evidence of a care plan that addressed smoking. Review of R6's admission Record, located in the EMR under the Profile tab, revealed an admission date of 12/04/20 with medical diagnoses that included nicotine dependence and alcohol abuse. Review of R6's quarterly MDS located in the EMR under the MDS tab with an ARD of 03/10/22, revealed R6's BIMS score was 11 out of 15, indicating R6 had moderate cognitive impairment. Review of R6's Smoking Evaluation, dated 03/04/22, located in the EMR under the Assessments tab, revealed the following: Smoking decision: supervision is required Per facility policy; Resident has a history of sharing/selling cigarettes or smoking material. Review of R6's Care Plan, dated 02/24/22, located in the EMR under the Care Plan tab revealed: may smoke with supervision per smoking assessment; Interventions: Educate patient/health care decision maker on the facility's smoking policy; Inform of and reinforce smoking restriction. Review of R31's admission Record, located in the EMR under the Profile tab, revealed an admission date of 04/14/21 with medical diagnoses that included traumatic brain injury and paraplegia. Review of R31's quarterly MDS located in the EMR under the MDS tab with an ARD of 10/18/21, revealed R31's BIMS score was 13 out of 15, indicating R31 was cognitively intact. Review of R31's Smoking Evaluation, dated 01/14/22, located in the EMR under the Assessments tab, revealed the following: Smoking decision: supervised smoking Resident puts the butts in her bra, she takes others cigarettes & puts the cigarettes out on her leg; poor memory, unsafe smoking habits, sharing/selling cigarettes; does not properly dispose of ashes/butts. Review of R31's Care Plan, dated 09/13/21, located in the EMR under the Care Plan tab revealed: May smoke with supervision per smoking assessment; Interventions: Ensure that there is no oxygen use in smoking area(s). Review of R13's admission Record, located in the EMR under the Profile tab, revealed an admission date of 11/05/21 with medical diagnoses that included epilepsy (seizures) and diabetes. Review of R13's quarterly MDS located in the EMR under the MDS tab with an ARD of 03/18/22, revealed R13's BIMS score was 14 out of 15, indicating R13 was cognitively intact. R13's EMR revealed no evidence of a completed Smoking Evaluation. Review of R13's Care Plan, dated 01/14/22, located in the EMR under the Care Plan tab revealed: May smoke with supervision per smoking assessment; Interventions: Monitor patients [sic] compliance to smoking policy; Inform and remind patient of location of smoking areas and times; Educate patient/health care decision maker on the facility's smoking policy. Review of R7's admission Record, located in the EMR under the Profile tab, revealed an admission date of 03/26/20 with medical diagnoses that included quadriplegia (paralysis of all four limbs) and nicotine dependence. Review of R7's quarterly MDS located in the EMR under the MDS tab with an ARD of 12/10/21, revealed R7's BIMS score was 15 out of 15, indicating R7 was cognitively intact. Review of R7's Smoking Evaluation, dated 02/04/22, located in the EMR under the Assessments tab, revealed the following: Smoking decision: supervision per facility policy; res has history of selling/sharing cigarettes or smoking materials; does not dispose of ashes/butts properly. Review of R7's Care Plan, dated 02/25/22, located in the EMR under the Care Plan tab revealed: May smoke with supervision per center protocol; Interventions: Maintain patients smoking materials at nurses' station. During an interview on 03/28/22 at 11:26 AM, R6 was observed to be in his bedroom and stated he keeps his lighter and cigarettes in his shirt pocket. R6 showed the survey team his cigarettes and lighter in his top left shirt pocket. During an interview on 03/28/22 at 12:54 PM, the Infection Preventionist (IP) and DON stated there were about 15 residents in the facility that smoke. The DON stated the cigarettes and lighters are kept in a box that is locked in the medication room. The IP stated there were four residents that were assessed to be independent for smoking and kept their lighter and cigarettes in their room. The IP stated R7, R46, R34, and R6 were assessed to be independent with smoking. Review of the medical records for R7, R46, and R6 revealed none of these residents were assessed as independent smokers but required supervision. Review of R34's medical record revealed no smoking assessment had been completed. During an interview on 03/28/22 at 1:41 PM, R34 stated she kept her lighter and cigarettes in her room. R34 stated the facility used to keep her cigarettes and lighter but she was allowed to keep them when some of her cigarettes went missing. During an observation and interview on 03/28/22 at 2:15 PM, R6 was observed smoking in the designated smoking area. R46 was also observed smoking in the designated smoking area at this time. R46 and R6 stated they both keep their cigarettes and lighters on their person and in their rooms. R46 and R6 stated they were assessed to be independent smoking residents. R6 stated he and R46 were independent, since we haven't did [sic] anything bad, we can keep it. During this time of observation, there were no staff supervising residents in the designated smoking area. During an observation on 03/28/22 at 4:30 PM, R6, R46, and R167 was observed smoking in the designated smoking area. No staff was present at this time of observation. During an interview on 03/29/22 at 12:17 PM, R46 stated he was an independent smoker and kept his lighter and my cigarettes. R46 showed the survey team his lighter and cigarettes in his pocket. R46 stated that he kept his cigarettes and lighter in the bedside drawer at night. R46 stated the facility has some wanders that go in and out of residents' room. R46 stated R167 is one of the wanderers. R46 stated there used to be staff that supervised the residents that smoke but lately there had not been staff supervising residents. During an interview and observation on 03/29/22 at 12:20 PM, the DON stated the box with material for residents that smoke was kept locked in the medication room. When asked to see where the box where kept, the DON found the clear container with residents' cigarettes on the desk at the nurses' station. The container was not in a locked area at the time of observation. In the container of supplies, there were cigarettes for the following residents: R117, R218, R52, R15, R27, and R62. There were no lighters in the box at the time of observation. The DON stated she was unsure how residents lit their cigarettes. During an interview on 03/29/22 at 12:24 PM, Certified Medical Assistant (CMA) 1 stated there were four residents that were assessed to be independent for smoking and were allowed to keep their own lighter and cigarettes in their rooms. CMA1 stated those residents were R6, R7, R34, and R46. CMA1 stated R167 received cigarettes from other residents. During an interview on 03/29/22 at 12:42 PM, the DON stated, No residents should have lighters in their room. During an interview on 03/29/22 at 12:44 PM, when asked about the smoking assessments, the IP stated that a resident that was assessed as supervised meant the cigarettes and lighters should be kept in the smoking box, should say the reason the resident was considered supervised, and should list if the resident should wear an apron. The IP stated a resident that was assessed as independent meant the resident could smoke without supervision and were allowed to keep their cigarettes and lighters in their rooms. During an interview on 03/29/22 at 12:49 PM, the RA stated the policy is generally that residents are not allowed to keep their cigarettes and lighters, but he would defer to the administrator. During an interview on 03/29/22 at 12:51 PM, the ICED stated the facility should keep lighters and cigarettes. The ICED state the predecessor allowed independent smokers to keep their lighters and cigarettes. During an interview on 03/29/22 at 1:17 PM, the IP confirmed there was no smoking evaluation completed for R34, R218, nor R13. During an observation on 03/29/22 at 2:16 PM, R46, R31, R117, R15, R7, R34, R6, R27, and R13 were observed smoking in the designated smoking area. The residents were supervised by CNA44 at the time of observation. During an observation on 3/29/22 at 3:47 PM, R7 was observed smoking in the designated smoking area. There was no staff in the designated smoking area at the time of observation. The DON confirmed R7 was smoking without supervision. During an interview on 03/30/22 at 8:26 AM, R167 stated R34 gives her cigarettes when they are outside in the designated smoking area. R167 stated no other residents give her cigarettes. 4. Reviewed smoking evaluations for each resident. There were no residents that were assessed as independent with smoking on their evaluations. All residents that were evaluated were deemed to need supervision. There were three residents that did not have a smoking evaluation completed: R13, R34, and R218. During an interview on 03/30/22 at 8:46 PM, LPN19 stated there was no such thing as a resident independent with smoking in the facility. LPN19 stated she completed all smoking evaluations that were on file and all residents were assessed to need supervision.