Based on observations, record review, and interviews during the extended recertification and abbreviated (NY00376311) surveys conducted 4/6/2025 - 4/18/2025, the facility failed to ensure resident's right to choose activities and health care services consistent with their interests, assessments, and plan of care and the right to participate in social and community activities for two (2) of three (3) residents (Resident #50 and #162) reviewed. Specifically, Residents #50 and #162 were Deaf and were not provided their preferred method of communication and thus were unable to communicate their needs and preferences to staff, socialize with other residents, or participate in meaningful activities. This resulted in actual psychosocial harm to Resident #50 that was Immediate Jeopardy and Substandard Quality of Care. Findings include: The facility policy Language Assistance, last reviewed 7/2021, documented each resident's language access needs would be reviewed and monitored during their comprehensive care plan review and conference. Language assistance would be provided through use of competent bilingual staff, staff interpreters, contracts or formal arrangements with local organizations providing interpretation or translation services, communication boards, or technology and telephonic interpretation services. If an internal staff member who was fluent in the needed language was not available, Language Line or other local agencies would be contracted for assistance. Family members or friends of a Limited English Proficiency resident would not be used as an interpreter unless specifically requested by the resident and after they understood that an offer of an interpreter at no charge to the resident had been made by the facility. The facility policy Resident Rights, reviewed 8/2023 documented residents had the right to choose activities, schedule, and health care consistent with their interests and plan of care. The facility must promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of their individuality. 1) Resident #50 had diagnoses including deafness, non-speaking and anxiety disorder. The 3/4/2025 Minimum Data Set assessment documented the resident was cognitively intact, had absence of useful hearing and spoken words, their preferred language was sign language, and they sometimes felt lonely or isolated from those around them. The answer to the question How often do you need to have someone help you when you read instructions, pamphlets, and other written material from your doctor or pharmacy? was blank. The Comprehensive Care Plan revised 12/14/2024 documented the resident had highly impaired hearing, absence of useful hearing, did not have the ability to produce speech, was able to understand American Sign Language, and had the ability to read and write. Interventions included anticipate needs due to communication barrier, use simple language and yes/no questions when communicating, ensure access to writing material/white board, utilize picture board for simple American Sign Language communication if requested, writing equipment was available at bedside/table, and make attempts to understand the resident's frustrations, when necessary. The 4/5/2024 Speech Language Pathologist #34 progress note recommended for all communication staff/family continued to utilize live American Sign Language interpreting service via tablet which could be obtained in Administration. Should staff be unable to access live American Sign Language services, it was recommended to utilize written language via whiteboard to ensure Resident #50 was able to effectively communicate wants/needs. Invoices provided by the facility documented interpreting services were contracted twice for Resident #50 on 7/12/2024 for two (2) hours, and on 2/21/2025 for two (2) hours. During an interview on 4/7/2025 at 12:42 PM, Resident #50 communicated via simple word document and gestures. They wanted a tablet to help with interpretation for everyday communication and socialization. The resident provided the surveyor with contact information for interpretation services and asked for them to be contacted to help with communication. During a telephone interview on 4/8/2025 at 11:13 AM, Deaf Services Manager #18 (from local advocacy agency for the Deaf) communicated the facility had a tablet they were supposed to regularly use for interpretation for Resident #50. During an interview on 4/8/2025 at 9:12 PM, Certified Nurse Aide #4 stated Resident #50 communicated with gestures or whiteboard and marker. Certified Nurse Aide #4 took the surveyor to the resident's room to show the whiteboard and Resident #50 began to use signing to communicate. Certified Nurse Aide #4 stated the resident had a tablet for interpreting services but did not use it. The Certified Nurse Aide stated they did not know how to use the tablet. It was important to know how to communicate with the resident to know their needs. Certified Nurse Aide #4 interrupted after overhearing the interview and stated the only means of communication for Resident #50 was the whiteboard and the resident did not use the tablet for communication. During an interview on 4/8/2025 at 11:08 PM, Certified Nurse Aide #19 stated the resident's care instructions documented to use a writing board for communication. The facility had used video services for the residents during the COVID-19 pandemic, but it was not specific for Resident #50. They did not have a tablet on the unit for communication and the Supervisor would have to be called to use that. They did not know how to get video interpretation for Resident #50. They should use the resident's preferred method of communication because it was familiar to them, and it would let staff know what the resident needed. During an interview on 4/8/2025 at 11:08 PM, Certified Nurse Aide #20 stated Resident #50 wrote on a whiteboard for the staff. The resident did not speak and was Deaf. They did not have interpreting services on the overnight shift. During an interview on 4/9/2025 at 9:42 AM, Licensed Practical Nurse #21 stated if a resident's language was other than English, they could not see that information in the computer. Resident #50 used a whiteboard for communication. If the resident needed something they came out of their room carrying their whiteboard. It was important for Resident #50 to be able to communicate with them and feel comfortable asking for things and have open communication. During an interview on 4/9/2025 at 2:20 PM, Resident #50 communicated via in-person certified American Sign Language Interpreter #53 (from local advocacy agency for the Deaf). The resident communicated they felt isolated in the facility because the staff only used a whiteboard to communicate with them. Staff did not acknowledge them when they came to their room because they were Deaf. Their preferred method of communication was American Sign Language, either with use of staff that used American Sign Language, an in person interpreter, or video phone interpretation. English was not their primary language, and they were not comfortable writing in English. They stated they were isolated on the 4th floor, because they could not explain their needs in detail. The video relay phone interpreter would allow them to communicate with Deaf peers outside the facility as well as people in the facility. If the activity programs had an interpreter they would attend, but interpretation was not provided. When medication changes were made, such as adding a new medication, or a change in their regular medication, it was not explained to them. They were expected to take whatever was given to them. There was one point they refused to take their medications because the facility added two (2) pills, and no one explained what they were. The resident stated Deaf Services Manager #18 came to visit, and the facility explained the medication was because other residents in the building had the flu and it was ordered for everyone. The resident stated they lived a very structured life at home, and the routine kept them comfortable. They ate lunch at noon, and the lunch trays at the facility were not delivered until 2:00 PM or 2:30 PM, which caused a stomachache from hunger. They stated they were suffering in the facility, because they could not communicate when they were hungry, did not feel good, or if they had specific needs. They stated they were just alone and that no one cared about them. During an observation on 4/10/2025 at 11:23 AM, Resident #50 walked out of their room and down the hall to the dining area. They passed two (2) unidentified staff members, went to the kitchenette, got coffee and ice from the machine, and there was no staff interaction. The resident walked back towards their room, past the staff at the nurse's station, and no staff interacted with them. An unidentified staff crossed in front of the resident with no interaction. During an interview on 4/10/2025 at 11:30 AM, Licensed Practical Nurse Unit Manager #22 stated the expectation for residents that spoke a language other than English was to use their primary language. The resident's preference for communication should be honored. They stated Resident #50's primary language was English. If they wanted to use a tablet for communication, they should be allowed, and Activities had a tablet that could be used. Use of the whiteboard for communication was done by trial and error. The facility had not set up interpreting services for Resident #50. Resident #50 was a loner and preferred to stay in their room. When there were facility-wide or floor-wide activities there was no interpreter present. The resident should not have to ask for interpreting services to participate in activities. They stated they did not ask the resident if they would attend activities if an interpreter were present. There were three (3) residents on the 4th floor that used American Sign Language. The medical providers did not use an interpreter when they visited the residents. The resident did not have means of communication with friends outside the facility and was not asked if they wanted to communicate with people outside the facility. The resident should not have to ask to communicate with people. During a telephone interview on 4/10/2025 at 12:55 PM, Nurse Practitioner #23 stated the expectation for residents with English as a second language was to use the language line tablet from the business office. The resident's communication preferences should be honored. It was important to allow the resident to speak openly and freely. Resident #50's primary language was English, and they preferred to use the whiteboard for communication. They were not sure how the determination was made the whiteboard was the preferred method. They ensured understanding with teach back methods (return demonstration) and reinforcements of writing on the whiteboard and the resident would respond. If medical consent was needed, they would ensure the interpreting service was contacted first, and the interpreting service was aware of all medication changes for the resident. During a telephone interview on 4/10/2025 at 1:03 PM, the Medical Director stated staff could be used as interpreters and translators, but if that was not available, they could get additional translators. The resident's communication preference should be honored. It was important to get good, detailed information from the resident. The resident needed to be able to explain their concerns freely. During an interview on 4/10/2025 at 2:59 PM American Sign Language Interpreter #53 stated they knew the resident well. The resident had very limited English proficiency and the best access for the resident was live American Sign Language interpretation. If no interpreter was available, a tablet with a video relay interpreter was the best choice. The resident was unable to reach out to Deaf friends in the community or communicate with anyone from the facility. The video relay interpreter was a free service. During an interview on 4/10/2025 at 2:30 PM, the Administrator stated they expected to accommodate residents with English as a second language. They used the language line and picture boards provided by speech therapy. A resident's communication preference should be honored. The language line was easily accessible and accommodating. They stated they had never attempted to communicate with Resident #50. The resident's primary language was American Sign Language and the preferred method of communication for the resident was the whiteboard. They did not know how that was determined. They were not sure if the provider used an interpreter during medical exams, and did not know how they ensured informed consent. The facility did not set up interpreting services to ensure effective communication. They stated the Deaf advocacy organization should have advocated for the resident. They stated they did not feel the resident was socially isolated, even though they did not provide means of communication or means to participate in activities or meaningful discussion. During an interview on 4/10/2025 at 2:48 PM, the Assistant Administrator stated Resident #50's primary language was American Sign Language, and they used a whiteboard for communication. They did not know how the whiteboard was determined to be the resident's preferred method of communication, but that was what the facility used for all residents that could read and write. The providers in the facility did not use an interpreter for every visit, but did have the whiteboard available. They did not use an interpreter to get a better understanding of the resident's needs. Informed consent was done with the whiteboard. When the facility held activities, they did not provide an interpreter, and the resident should not have to ask for interpreting service for activities that were provided to all residents. 2) Resident #162 had diagnoses including degenerative disorder of the retina (part of the eye) and stroke. The 1/20/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition, had absence of useful hearing and spoken words, and had highly impaired vision. Their preferred language was sign language; and they needed or wanted an interpreter to communicate with a doctor or health care staff. The Comprehensive Care Plan, revised on 4/10/2025, documented the resident had a communication deficit related to absence of useful hearing, was able to speak and communicate their wants or needs, had vision deficits, and had cognitive impairment related to stroke which affected their ability to understand despite using communication intervention. The 3/21/2025 interventions included to provide and encourage use of communication board, ensure writing equipment was available, and encourage use of and utilize live American Sign Language interpreter services, tablet was available in Administration. The 4/10/2025 interventions included to arrange in-person interpreter services, speech therapy as needed and utilize picture board for simple American Sign Language communication. The 2/1/2024 Speech Language Pathologist #34 progress note documented Resident #162 was provided with basic important medical signs on their wall, in their primary language, American Sign Language. All staff were encouraged to use American Sign Language when communicating with the resident. The 2/2/2024 Social Worker #33 progress note documented Resident #162 was Deaf and communicated through American Sign Language. The resident was able to answer 2-3 word questions with a white board; however, their handwriting was not legible. Speech therapy staff would provide the resident with a white board for short term use. The 3/5/2024 Speech Language Pathologist #34 progress note documented they recommended the facility pursue live, in-person American Sign Language interpreting services, which was also recommended by the resident's Case Manager and an American Sign Language speaking peer. Pending interpreting service, the recommendation was for staff to continue communicating with the resident through 1-3 large written words via whiteboard. The 4/9/2024 Social Worker #35 progress note documented Resident #162's third party social worker had concerns the resident's wishes were not being heard due to the language barrier. The 6/12/2024 Social Worker #36 progress note documented Resident #162 could not hear and had very bad vision, therefore, could not hear staff during assessments nor see when they wrote a question on the white board. The cognition assessment was done by staff. Invoices provided by the facility documented interpreting services were contracted for Resident #162 twice, on 4/5/2024 for 2 hours, and 6/26/2024 for 1 hour. There were no invoices provided for interpreting services in 2025. The 4/8/2025 Speech Language Pathologist #34 Therapy Progress Report documented Resident #162 had precautions listed for low vision, Deaf, and American Sign Language as the primary modality of communication. During an observation on 4/15/2025 at 10:37 AM, Resident #162 was in the hallway with the Assistant Administrator and an in-person interpreter. Resident #162 communicated they needed their ears cleaned, they wanted to go home soon to their own family, and that they knew another person in the building that signed well. During a telephone interview on 4/15/2025 at 11:33 AM, Resident #162's family stated the resident's preferred method of communication was American Sign Language. They could use a tablet for video interpretation, and the facility used one in the beginning, but not anymore. If the resident had concerns, they could not alert staff to their needs. They were told by the former social worker the facility was working on getting a full-time interpreter for the facility. The facility had not attempted to use the tablet or interpreter service since the resident's re-admission after surgery in 3/2025. The facility would call the family when they did not understand what the resident needed, but not everyone in the family used American Sign Language. The family depended on the facility to ensure the resident's needs were met. During an interview on 4/17/2025 at 1:26 PM, Certified Nurse Aide #38 stated Resident #162 had a tablet of their own, it was in the resident's closet. They always had it, but they were not sure if staff knew how to use it. During an interview on 4/17/2025 at 1:27 PM, [NAME] Clerk #39 stated Resident #162 preferred to use the tablet for interpreting or signing. They did not have a tablet for interpreting before this week; it was not available to them. The staff would write or Google signs to help understand. They were taught about the language line but had not used it before this week. During an interview on 4/17/2025 at 1:32 PM, Licensed Practical Nurse Assistant Unit Manager #40 stated Resident #162 did not own a tablet and was provided a tablet by the facility this week. The tablet was not readily available to the resident before then. The resident could see with their glasses on or off, but it was more beneficial when they wore them. Their right eye was much stronger and if staff used the right side the resident could communicate. 10 NYCRR 415.5(b)(1-3) *********************************************************************************************** The facility was notified of the Immediate Jeopardy on 4/11/2025 at 12:42 PM. The Immediate Jeopardy was removed on 4/16/2025 at 10:50 AM prior to the completion of the survey. The facility implemented the following to remove the immediacy: - Initial plan of immediacy was approved on 4/11/2025 at 5:50 PM and included the facility providing Residents #50 and #162 tablets programmed with the video relay interpreting service that were always accessible to the resident. Education was provided to the staff and residents on their use. The tablets were to be kept in the resident's rooms. - The second plan for immediacy was approved on 4/12/2025 at 11:14 PM, following determination staff and residents were unable to use the tablet for communication. - The facility provided in-service education to 89.5% of staff as of 4/16/2025 at 10:50 AM, with plans for ongoing education of staff not currently on the schedule, prior to the start of their next shift. - Multiple interdisciplinary staff were interviewed during onsite visits through 4/16/2025. All staff demonstrated knowledge of the education provided regarding the communication devices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 4/6/2025 - 4/18/2025, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six (6) of eight (8) residents (Residents #160, #417, #425, #461, #485, and #790) reviewed. Specifically: - Resident #485 was on contact precautions for clostridium difficile (a resistant contagious bacterium) colitis (inflammation of the colon) and droplet precautions for COVID-19 (a contagious respiratory disease) and did not have the appropriate isolation precaution signs, precautions were not consistently followed, and contaminated laundry items were not separated from general population laundry. - Resident #790 tested positive for COVID-19 on 4/4/2025 and isolation precaution signs were not observed on 4/6/2025. - Resident #417 tested positive for metapneumovirus (respiratory virus) on 4/4/2025 and did not have an isolation precaution sign displayed until 4/7/2025. - Resident #425 tested positive for metapneumovirus and the isolation precaution sign erroneously identified their roommate as being on isolation precautions and isolation precautions were not followed. - Residents #160 and #461 droplet isolation precautions were not followed. - Housekeeper #105 was observed transferring refuse in an unsanitary manner. These practices resulted in the likelihood of serious harm, serious impairment, or death due to the potential transmission of communicable diseases and infections for all 485 residents of the facility. Findings include: The facility policy Infection Control-Policy #1 revised 1/2024, documented the facility would develop prevention, surveillance and control measures to protect residents and staff from institution-acquired infections. The infection control nurse would monitor infection control practices and employee compliance. The facility policy Infection Control-Policy #3 revised 5/2024, documented three (3) categories of transmission-based precautions: contact precautions, droplet precautions, and airborne precautions. The appropriate sign was to be placed on the resident's door. The contact precaution signs were yellow except for the ones for clostridium difficile colitis (C-diff), which were purple. If a resident was on contact precautions, an effort should be made to utilize disposable items when able and any resident equipment was to be wiped down with the appropriate germicidal wipes upon leaving the room. All personal protective equipment utilized should be removed and disposed of prior to leaving the resident's room. Linen was to be placed into green bags in the bin in the resident's room, tied and then removed and placed in the linen bin in the Soiled Utility Room. Droplet precaution signs were green and were to be placed outside the resident's room. In addition to standard precautions, a mask and eye protection needed to be worn. Staff were to limit movements of the resident outside their room to essential purposes only. The facility policy Infection Control-Policy #14, revised 6/2019, documented residents would be monitored at the first sign of respiratory illness-like symptoms and have exposure to other residents restricted and droplet/contact precautions implemented. The facility policy Infection Control-Policy #17 revised 6/2019, documented for clostridium difficile colitis, contact precautions would be utilized and handwashing with soap and water after glove use was to be done prior to leaving the resident's room. 1) Resident #485 had diagnoses including COVID-19 and enterocolitis (inflammation of the digestive tract) due to clostridium difficile. The 3/16/2025 Minimum Data Set documented the resident had intact cognition and was dependent for toileting hygiene. The resident's bowel continence was not rated. A 4/1/2025 physician order entered by Registered Nurse Unit Manager #9 documented the resident was on contact isolation precautions for diarrhea associated with clostridium difficile. The 4/4/2025 Registered Nurse Unit Manager #9 progress note documented the resident's polymerase chain reaction (a laboratory test) result for COVID-19 was positive. The resident had nasal congestion and a sore throat, was seen by the nurse practitioner, their care plan was updated, and precaution orders were in place. Observations and interviews: - On 4/06/2025 at 10:16 AM, Resident #485 had a contact precaution sign (for the clostridium difficile) on their door however, there was no droplet precaution sign for the COVID-19. Certified Nurse Aide #79 entered the room without personal protective equipment, took the resident's meal tray and touched the bedding, then exited the room without performing hand hygiene. At 10:22 AM, Certified Nurse Aide #106 donned a gown and handed a gown to Certified Nurse Aide #79 before entering the resident's room. Certified Nurse Aide #106 informed Certified Nurse Aide #79 they had to wear a gown due to the resident having clostridium difficile colitis. Both certified nurse aides left the room with their gowns balled up in their hands with gloves on. Certified Nurse Aide #106 disposed of their gown and gloves in the trash can at the nurses' station. They did not perform hand hygiene and walked to the other unit. At 10:24 AM, Certified Nurse Aides #95 and #79 entered the resident's room without donning personal protective equipment. - On 4/06/2025 at 11:39 AM, the resident's room had a droplet/contact precaution sign and a stop sign. Licensed Practical Nurse #17 stated the resident had tested positive for COVID-19 on 4/4/2025, but they did not have the sign posted that morning, so they had [NAME] Clerk #88 get the appropriate sign. - On 4/07/2025 10:28 AM, Physical Therapist #85 entered Resident #485's room and exited the room wearing full personal protective equipment, took a phone call, and paced up and down the short hallway, touching the handrail. Physical Therapist #85 entered and exited Resident #485's room twice to take a phone call and did not change their personal protective equipment. The resident's door was shut during the physical therapy visit. At 10:35 AM, [NAME] Clerk #88 entered the resident's room without personal protective equipment and asked therapy to turn off the call light. At 10:41 AM, Physical Therapist #85 disposed of their personal protective equipment prior to exiting the resident's room with the exception of their N95 mask which they disposed of at the nurses' station. - On 4/07/2025 at 11:10 AM, Registered Nurse Unit Manager #9 entered the resident's room wearing only a surgical mask for protection and was at the resident's bedside. At 11:15 AM, Registered Nurse Unit Manager #9 exited the resident's room, removed their gown, balled it up with gloves on, and carried the balled-up gown, with one glove on, into the soiled utility room down the hall. At 11:40 AM, Certified Nurse Aide #94 entered the resident's room wearing only a surgical mask for protection. - On 4/08/2025 at 10:52 AM, Certified Nurse Aide #96 entered the resident's room wearing a gown, gloves and a surgical mask. Certified Nurse Aide #96 was in the room with the door open and was about to go into the resident's bathroom. They removed one arm from the gown with gloves on. The resident asked for something, and the certified nurse aide went back toward the resident's window and adjusted something. The certified nurse aide entered the resident's bathroom, threw out their gloves and gown, and left the room. When interviewed, Certified Nurse Aide #96 stated they did not wear an N95 mask because there were none in the personal protective equipment caddy. They stated they did not wash their hands in the resident's room, as there were no paper towels. - On 4/08/2025 at 11:27 AM, Physical Therapy Assistant #97 exited the resident's room with the resident's water cup and a to-go container of food, dispensed ice from the communal ice machine into the resident's cup, put the cup on the counter in the unit kitchenette, emptied the to-go container onto a plate, and microwaved the food. Physical Therapy Assistant #97 brought the cup and plate back to the resident and handed it to staff in the room. During an interview at 11:33 AM, Physical Therapy Assistant #97 stated they should not have brought the pitcher out of the room to use communal equipment to refill the cup as items coming out of the resident's room could be contaminated. - On 4/08/2024 at 11:42 AM, Licensed Practical Nurse #98 removed their gloves outside the resident's room and put them in the garbage bag on the housekeeper's cart. They did not wash their hands after removing their gloves and prior to going to the medication cart to access their computer. During an interview Licensed Practical Nurse #98 stated the resident was just on precautions for COVID-19. They were unaware the resident was on precautions for clostridium difficile colitis until they read the resident's orders in the computer and then they went to wash their hands. - On 4/09/2025 at 4:34 PM, Certified Nurse Aide #100 was in the resident's room with the door partially open. Their hands were ungloved and touching the resident's clothing and linen piled in a chair. They took a roll of garbage bags from inside the room, came to the personal protective equipment door caddy to get gloves, and shut the door. At 4:39 PM, Certified Nurse Aide #100 opened the resident's door wearing personal protective equipment and put a plastic bag with the resident's under-pad and linen and a trash bag with briefs on the ground while they removed their personal protective equipment. They did not wash their hands prior to donning new gloves and picking the trash bags off the ground. They placed the resident's linen bag into the regular laundry bin in the soiled utility room. They washed their hands in the soiled utility which did not have paper towels. At 4:44 PM, Certified Nurse Aide #100 stated the isolation precautions a resident was on were listed on the resident's door. They stated gowns, gloves, a mask, and a face shield should be worn in a droplet precaution room. The linen for Resident #485's room should be put in the red precaution bin inside the dirty utility room. Gloves should always be worn in a contact precaution room and handwashing should be completed after taking off personal protective equipment and prior to leaving the resident's room. Wearing the appropriate personal protective equipment helped prevent the transmission of germs to other employees and residents. During an interview on 4/10/2025 at 11:47 AM, Registered Nurse Unit Manager #9 stated if a resident needed to be on precautions, they checked the labs in the computer to see if a resident had a positive result for whatever was tested. They would put signs on the door, place a precaution order in the computer, and then put in a request for central supply to bring up the personal protective equipment. They went into Resident #485's room with just a surgical mask and not an N95 because they could not locate a N95 mask in the resident's personal protective equipment caddy. If a resident was on precautions for clostridium difficile colitis, the only time the red biohazard bags and bin were utilized was if the resident had items saturated with bowel movements. For residents on precautions for clostridium difficile colitis, staff should wash their hands in the resident's bathroom, put on gloves to take out the trash bags, then wash their hands again in the soiled utility room. If a staff member did not wear the correct personal protective equipment, they could transmit the disease to someone else. 2) Resident #425 had diagnoses including COVID-19, acute cough, and pneumonia. The 1/23/2025 Minimum Data Set assessment documented the resident was cognitively intact. A 4/5/2025 laboratory report documented a specimen sample was collected on 4/3/2025 at 2:00 PM and received by the lab on 4/4/2025 at 3:59 AM. The results were reported on 4/5/2025 at 6:58 AM and human metapneumovirus was detected. A physician order documented droplet isolation precautions for metapneumovirus was discontinued on 4/14/2025. The orders did not include the start date for isolation precautions. During an observation and interview on 4/08/2025 at 9:34 AM, Dietetic Technician #102 entered Resident #425's room without donning personal protective equipment or performing hand hygiene. Dietetic Technician #102 stated they were trained on infection control annually and were familiar with the signs for isolation precautions. The sign on the door documented what personal protective equipment was needed when caring for a resident. They stated they did not see the sign on the resident's door to indicate they were on precautions and did not perform hand hygiene because there was no hand sanitizer outside of the room. If the precaution signs were not followed, they could spread the infection. During an observation and interview on 4/09/2025 at 9:15 AM, Licensed Practical Nurse Assistant Unit Manager #40 stated Resident #425 was on droplet precautions for human metapneumovirus and that it started with their roommate, but the roommate was off droplet precautions as it had been 10 days. The sign on the door documented the precautions were for the resident's roommate, not the resident who was currently on precautions. 3) Resident #461 had diagnoses including cough, fever, pneumonia, and COVID-19. The 1/26/2025 Minimum Data Set assessment documented the resident was cognitively intact. A physician order documented the resident was on isolation contact/droplet precautions pending a polymerase chain reaction (lab test) test for COVID-19. The order was discontinued 4/7/2025 (the resident was hospitalized from [DATE]-[DATE]). The orders did not include the start date for isolation precautions. The 4/7/2025 Nurse Practitioner #48 progress note documented the resident was seen for cough, nasal congestion, and a fever. The plan was a chest x-ray, cough medicine, nebulizer treatment, and a respiratory panel. The 4/7/2025 untimed Registered Nurse Unit Manager #9 progress note documented the resident had a cough and nasal congestion. Lungs with crackles bilaterally. A rapid COVID-19 test swab was done with negative results, a polymerase chain reaction (a laboratory test for COVID-19) was obtained and sent to the laboratory, and a chest x-ray was ordered. During an observation on 4/7/2025 at 10:45 AM, the resident's door had a droplet/contact precaution sign. There was no personal protective equipment outside the resident's room. During an observation on 4/7/2025 at 11:36 AM, Certified Nurse Aide #106 walked into the resident's room to talk to the resident, turned their call light off, and left the room. Certified Nurse Aide #106 did not apply personal protective equipment or perform hand hygiene. 4) Resident #790 had diagnoses of chronic obstructive pulmonary disease (lung disease) and Hodgkin lymphoma (cancer of the lymphatic system). The 3/25/2025 Minimum Data Set documented the resident had intact cognition. The 4/4/2025 Registered Nurse Unit Manager #9 progress note documented the resident was swabbed for COVID-19 and the result was positive. A physician order documented droplet isolation precautions, contact precautions, COVID-19 droplet precautions were discontinued on 4/15/2025. The orders did not include the start date for isolation precautions. During an observation and interview on 4/6/2025 at 10:57 AM, there were no precaution signs posted outside of Resident #790's door and no personal protective equipment caddy hanging on or near the resident's door. There were two gowns on a bedside table outside the resident's room. Certified Nurse Aide #79 stated the resident was not on precautions They thought the resident used to be on precautions but did not think they were presently. During an interview on 4/6/2025 at 11:32 AM, Licensed Practical Nurse #17 stated the resident was on droplet/contact precautions due to testing positive for COVID-19. They were informed yesterday the resident was on precautions, but they did not have a proper sign, so they put up a contact precaution sign that was later removed. Housekeeping: During an observation and interview on 4/9/2025 at 9:19 AM, Housekeeper #105 carried a garbage bag with personal protective equipment slung over their shoulder, down the hallway into the soiled utility at the other end of the hall. They were not wearing personal protective equipment. Housekeeper #105 stated the garbage was from their cart with garbage bags from the resident rooms. The garbage bag became full at the end of the C Unit hallway, which was on precautions for droplet. They stated they did not wait to do the isolation precaution rooms last but emptied the rooms in order. During an interview on 4/10/2025 at 11:12 AM, Housekeeper #143 stated they did not wear personal protective equipment, and all rooms were cleaned the same. They stated they cleaned surfaces with a yellow cleaner with water in a basin and a washcloth. They stated they used to use the same cleaner in the mop bucket, but it messed up the floors, so the mop water was now just plain water in every room. During an interview on 4/10/2025 at 1:02 PM, Housekeeper/Laundry Aide #108 stated there was a bin on each unit for the resident laundry and resident linen. They stated they collected the bins from the unit and then the clothes went into the washer and the dryer. All linen was sent out. They stated they were not told if a resident had an illness. They sometimes got a note on the laundry with the resident's name and to wash the items separately. They wore gloves when the items were removed from the bags, but no other protective equipment. There were no separate water temperatures or different detergents used if someone was sick. Staff were supposed to rinse out any stool prior to putting it into a bag, but that did not always happen. They stated they did not wear personal protective equipment as it was hot in the laundry room. During an interview on 4/11/2025 at 10:22 AM, the Infection Preventionist stated they reviewed the labs every morning for residents and then they delegated to the Nurse Managers and told them whom to put on isolation precautions based on that information. Staff were educated on infection control through orientation and yearly competencies. The last education was March 2025. The spread of infection was lessened by housekeeping doing enhanced cleaning with bleach and not floating staff, if possible. Once a resident tested positive for an infectious disease, whoever tested the resident would write a progress note, get a physician's order for isolation precautions, and place the isolation precautions on the care plan. The ward clerk printed out the appropriate isolation precaution sign and made sure the rooms had personal protective equipment. The off-shift nursing supervisor had a folder with the color-coded isolation precaution signs. Purple contact signs were used for residents with clostridium difficile colitis, pink special droplet/contact precaution signs were utilized for COVID-19, and green droplet signs were used for influenza. The isolation sign would designate if it was the window or door bed, if it was a double room. The signs for Residents #417and #790 for COVID-19 and metapneumovirus should have been on the door on 4/6/2025. The risk of not having the appropriate signage was spread of the infection. Staff were expected to wear the personal protective equipment designated on the sign, remove their personal protective equipment prior to exiting the room, and perform proper hand hygiene. Staff should never enter a room on droplet precautions without wearing personal protective equipment. For rooms on contact for clostridium difficile colitis, they let the Housekeeping Director know so they would clean the room last and use bleach. It was also communicated to the direct care staff to use soap and water for hand hygiene and use bleach to clean equipment. Laundry went into a regular linen bag unless it was saturated. Staff should clean their hands with soap and water prior to donning new gloves to carry the linen bag to the soiled utility room. This would limit the spread of infection. Laundry personnel should be wearing gowns and gloves when handling dirty laundry, as there was no way for them to know if they were handling infectious material. During an interview on 4/11/2025 at 10:40 AM, the Medical Director stated isolation precautions should be initiated when the resident became symptomatic. If a resident had respiratory symptoms, they should be on droplet precautions unless the test came back negative. If a resident was positive for COVID-19, influenza, or clostridium difficile colitis, they expected to be notified when the results came back. There should be appropriate signage, so staff knew what personal protective equipment to use. Staff should follow the use of personal protective equipment per policy. If staff were not using the proper personal protective equipment they could spread the infection. Every staff member needed to follow the isolation signage and wear the proper personal protective equipment. During an interview on 4/11/2025 at 10:43 AM, the Administrator stated there was an Infection Preventionist in the facility that led the process for infection control. During morning report, they discussed any infections in the facility. When a resident presented with symptoms, the Registered Nurse Unit Managers or Nursing Supervisor would assess the resident. If the resident required testing, the Infection Preventionist and the Medical Director were informed. The resident should be on precautions from the time they were symptomatic, and precautions only removed if the test was negative. All residents on precautions should have the appropriate sign and personal protective equipment in a caddy on their door. They expected staff to follow the recommendations of personal protective equipment based on the precaution signage and to perform the correct hand hygiene. Residents on precautions for clostridium difficile colitis should have their rooms cleaned with bleach. If proper personal protective equipment was not worn, proper hand hygiene was not done, and the proper chemicals were not used to clean, there was a potential that a disease could spread. During an interview on 4/11/2025 at 11:46 AM, the Director of Nursing stated if a resident had a cough, they should be assessed by nursing, who then reported to medical. The resident would also be placed on precautions in case anything infectious came back from testing. The order for the precautions was put in by either the Infection Preventionist or the Registered Nurse Unit Manager. The signs for the precautions were put up by the ward clerk. If there was no ward clerk on shift, the precaution signs could be placed by the nurse. The door caddy of personal protective equipment was put up by central supply and there were extra personal protective equipment items in the clean utility room. If the resident had a positive result of an infectious disease, there should be the appropriate signage hung. All staff should review the isolation precaution signs prior to entering the room and follow the directions on the sign. If the appropriate sign was not hung or the staff did not wear the correct personal protective equipment, infection could spread. The rooms of residents on precautions for clostridium difficile colitis should be cleaned with bleach. They were unsure how the laundry was separated for a resident on precautions for clostridium difficile colitis, but laundry staff was required to wear personal protective equipment when handling all laundry. 10 NYCRR 415.19(a)(b) ************************************************************************ The facility was notified of the Immediate Jeopardy on 04/11/2025 at 2:03 PM. The Immediate Jeopardy was removed on 4/15/2025 at 2:40 PM prior to the completion of the survey. The facility implemented the following to remove the immediacy: - Initial plan of immediacy was approved on 4/11/2025 at 4:47 PM and included the facility ensuring all residents on precautions were reviewed and had the appropriate isolation precaution signage in place, all in-house staff were educated on infection control with competency-based training, and all oncoming staff would be educated prior to the start of their shift. - The facility provided in-service education to 85% of staff as of 04/15/25 at 1:25 PM, with plans for ongoing education of staff not currently on the schedule, prior to the start of their next shift. - Multiple interdisciplinary staff were interviewed during onsite visits through 4/15/2025. All staff demonstrated knowledge of the education provided on appropriate infection control precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the abbreviated survey (NY00322098 and NY00323044) the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfers or discharges from the facility for 2 of 3 residents reviewed (Residents #1 and 2). On 9/11/2023, immediate jeopardy was identified during an abbreviated complaint survey. Concerns rising to the level of immediate risk to resident health and safety include the provider's failure to provide a safe and orderly discharge for Residents #1 and 2 which had the potential for serious harm for both residents. Residents #1 and 2 were discharged to the Department of Social Services (DSS), which is not a dischargeable location, without a plan for shelter or services; without a discharge plan; without notice, and without following the proper 30-day notice requirements. Both were homeless following discharge, one is currently residing in a homeless shelter, both are without their prescribed medications, and neither have secured permanent housing. Specifically, on 8/8/2023, Resident #1 was given a notice of discharge and on 8/9/2023 was discharged to a DSS building without money or identification to apply for temporary assistance and shelter. The resident was homeless for over 2 weeks until they were found walking on the wrong side of the highway by New York State Police on 8/23/2023. Interviews with the resident confirm that Resident #1 did not agree to a discharge. Interviews with the Director of Social Work revealed the discharge was directed by the facility's Administration. The resident is currently living with a family member but is unable to stay long term and is working to secure temporary assistance. Additionally, Resident #2 has primary diagnoses including diabetes, anxiety, and dementia with behaviors, and was issued a 30-day notice for discharge on [DATE], but the receiving facility ultimately refused to accept the resident. Documentation stated the discharge date was 8/9/2023 due to medical clearance, episodes of violence, and smoking. The resident was discharged to a DSS building, which is not a discharge location, and was extremely confused and attempted to return to the facility as the resident did not know what to do or where to go but was refused re-entry. The resident is currently living in a homeless shelter and has a friend who helped the resident to apply for temporary assistance. Interviews with the Director of Social Work revealed that the discharge was directed by the facility's Administration. This resulted in Immediate Jeopardy to Residents #1 and 2 with the potential to affect all of the facility's 376 residents. Findings include: The Discharge Planning policy, revised 3/2018, documented discharge planning allows for continuity of care in the community. While discharge planning is interdisciplinary, the social worker is responsible for coordination of facility and community services needed to facilitate the resident's transfer to a lower level of care. Nursing staff is responsible for ensuring all education needs are met prior to discharge, including training of the resident and appropriate family members or responsible party. A discharge can be requested at any time by the resident and/or responsible party. If the facility is unable to provide discharge planning, the resident and/or responsible party will be encouraged to stay at the facility until appropriate arrangements can be made. When it is not advisable for the resident to be discharged , and the resident insists upon discharge, the Against Medical Advice (AMA) form must be completed to remove the facility from any liability that may incur resulting from the discharge. The policy noted to see the AMA policy. On 9/11/2023 at 4:08 PM, the Administrator stated in an interview, there were no other polices related to any aspect of discharges, including discharge planning, notices, or facility-initiated discharges. There was no AMA policy provided when additional discharge-related polices were requested. 1) Resident #1 Resident #1 had diagnoses including dementia, PTSD (post traumatic stress disorder), personal history of self-harm, major depressive disorder, and unspecified psychosis. The 7/15/2023 Minimum Data Set (MDS) assessment documented the Brief Interview for Mental Status (BIMS) was not conducted as the resident rarely/never understood others. A staff assessment of mental status was done and documented the resident had moderate cognitive impairment (made poor decisions and required cues/supervision). The resident required supervision with activities of living (ADL) and exhibited behaviors of rejection of care. The resident had an active discharge plan to return to the community. The 7/18/2020 PASRR (Pre-admission Screening and Resident Review) Level II assessment documented the resident had serious mental illness and recommendations included ongoing psychiatric care and medication management. The 7/12/2023 registered nurse (RN) MDS Coordinator #5's progress note documented they unsuccessfully attempted an interview with Resident #1. They went to the medication nurse who said the resident had paranoia, expressed fear of being poisoned, was afraid people were after them, and appeared to be afraid of their reflection in windows or mirrors and voices on television, computers, or radio. The 7/28/2023 social worker (SW) #3's progress note documented a care plan meeting was held and the resident did not participate. The resident remained appropriate for long term care. The 8/2/2023 and 8/4/2023 SW #2's progress note documented the resident had moderate cognitive impairment and spoke about the food being poisoned and was upset about foreign military action. SW #2 sent a referral to a psychiatric center. The 8/4/2023 SW #3's progress notes documented they contacted 2 local homeless shelters to inquire about placement. SW #3 was advised a temporary assistance (TA) case had to be opened at DSS before the resident could go to a shelter. SW #3 called DSS and left a message to obtain additional information. The 8/4/2023 and 8/5/2023 Director of Social Work's (DSW) progress notes documented they requested referrals to be sent by Medical Records to 11 psychiatric centers and 8 skilled nursing facilities for a transfer. On 8/7/2023, the DSW's progress note documented they spoke to the resident and their relative, who stated they wanted the resident in their county. The relative asked that a referral be sent to a senior living center near them and the DSW sent the referral. The resident and their relative stated they would accept a discharge to a shelter in order to be closer to one another. The Transfer/Discharge Notice dated 8/8/2023, documented the notice was to inform the resident the interdisciplinary team (IDT) determined the resident would be discharged on 8/9/2023. The discharge location documented the address to a DSS building in another county (71 miles from the facility). The reasons for discharge included the resident's health improved sufficiently and the resident no longer needed services provided by the facility; the resident was medically cleared for discharge by occupational and physical therapy (OT, PT) and medical, and the safety of individuals in the facility would be endangered as evidenced by episodes of violence. The resident and DSW signed the form on 8/8/2023. The 8/8/2023 SW #3's progress note documented they called a shelter in another county and was advised a TA case was required before shelter placement. The 8/8/2023 DSW's progress note documented the DSW was notified by Administration the resident was being discharged to another county (71 miles away) on 8/9/2023 at 9:00 AM. The unit SW advised the resident of the move and the DSW called the resident's relative and explained the discharge plan. The 8/9/2023 DSW's progress note documented the resident was discharged and transported by the facility to another county (71 miles away). The resident planned to seek TA from DSS and obtain housing. The 8/9/2023 Discharge Packet documented the discharge address was the DSS office building in another county; a pharmacy name and address were listed; a psychiatric provider's name and phone number were listed with no appointment date noted; the resident had 5 medications, including an antidepressant, and there were no other providers, community contact/agencies, or service providers noted on the discharge packet. The 8/23/2023, New York State (NYS) police report documented they picked up the resident walking on the wrong side of the highway (7 miles from where they were dropped off on 8/9/2023 and 75 miles from the facility). The resident was brought to the DSS office in the city in which they were initially left by the facility transport vehicle. During an interview with SW #2 on 9/5/2023 at 9:46 AM, they stated if a resident had no residential location for a discharge, the facility would provide assistance in establishing the needed community services. If a resident wanted to go to a shelter, SW #2 thought they had to go through DSS first. Resident #1's discharge was handled by the Administrator and Assistant Administrator #7. SW #2 thought the resident was brought to DSS and assisted in getting placed in a shelter. SW #2 stated DSS was not an appropriate or safe discharge location as it was an office building and not a place to reside. SW #2 stated they did not think Resident #1 was able to live independently due to their history of behaviors, mental illness, and non-compliance with medications. During an interview on 9/6/2023 at 8:46 AM, facility transport person #6 stated they received instructions to take Resident #1 to the DSS office building in another county (71 miles away). The resident had 4 plastic bags and they assisted the resident with the bags. Inside the office building, a security guard was present. They left the resident in the entrance of the office building with their bags. During an interview on 9/6/2023 at 12:00 PM, Adult Protective Services (APS) worker #12 stated on 8/23/2023, the police called APS after picking the resident up on the highway. APS worker #12 suggested they bring the resident to the DSS office building. APS worker #12 stated they did not see the resident that day and there was no record the resident was seen by APS or DSS on 8/23/2023. APS worker #12 reviewed their records and stated the resident arrived to DSS 8/9/2023 for housing assistance. The resident had no identification or Medicaid card and was denied assistance. The resident was advised by DSS to go to the warming shelter in the city. As of 9/6/2023, the resident was listed as homeless in DSS records and had no active case for assistance or housing. During a telephone interview with the resident's relative on 9/6/2023 at 2:05 PM, they stated someone from the facility contacted them at the beginning of 8/2023 to say the resident was being discharged and the relative said they wanted the resident to be near them. The relative was not able to care for the resident and asked the facility to send a referral to an assisted living facility nearby. The facility told the relative they could find a shelter for the resident until they could get into an assisted living. They were told the resident would be brought to the DSS building in their county and would get shelter placement. The relative was not told the resident needed to open a case before getting shelter placement and was not told to meet the resident at DSS to assist with obtaining shelter placement. When the relative called the facility after the resident was discharged , they were unable to tell them where the resident was. The relative called DSS and they did not know anything about the resident so the relative made several posts to social media and located the resident on 9/2/2023. The resident was found very dirty, with no belongings, and no medications. The resident did not know the area or the relative's phone number. The resident's whereabouts was unknown from 8/9/2023 to 9/2/2023. During a telephone interview with Resident #1 on 9/6/2023 at 2:18 PM, they stated they did not know why they left the facility and they were just told they were going. They did not ask to leave and did not want to go to a shelter. They did now know where they were going when they left the facility. They were brought to the DSS building and did not know what to do. They had no identification, money, or telephone and did not know their relative's phone number. From 8/9/2023 through 9/2/2023, they walked around the city, spent time in the bus station, park, and sometimes slept at the shelter or bus station. The shelter opened at 7:00 PM and the resident had to be out by 6:00 AM. The resident was able to have dinner and breakfast at the shelter when they stayed there and had no means to get food otherwise. They did not know what happened to their belongings and they had not taken their medications since they left the facility. During an interview with the DSW on 9/11/2023 at 10:21 AM, they stated a safe discharge included making plans with the resident, family, and IDT to determine what was needed following discharge. Discharge planning included verification of all needed levels of support, including housing, prior to discharge. The DSW stated a DSS case was required before an individual could get into a shelter. Resident #1's discharge was very sudden. The DSW was instructed by Assistant Administrator #7 to see the resident about discharge and they met with the resident for the first time on 8/8/2023 to notify them of the discharge. The DSW called the resident's relative to discuss options and sent a referral to a facility in their county. The DSW asked if the resident was willing to go to a shelter and told them they would have to go through DSS first. The resident and relative agreed. Upon communicating this to Assistant Administrator #7, they instructed the DSW to immediately send the resident to DSS in the relative's county. The DSW did not have an opportunity to verify a TA case could be established with DSS; was unable to verify what the resident needed to do, and was unable to verify what the relative's role would be. The DSW was not aware if the resident had identification or the understanding to establish services with DSS. The resident's relative was informed the resident was going to DSS and was not provided any other information. The DSW did not feel it was a safe discharge, there was no plan for supports in the community, and there was no assessment to determine the resident's ability to live independently. The DSW stated the resident remained appropriate for long term care and should have had time for a lateral move to another facility, or assessed for assisted living. During an interview with Assistant Administrator #7 on 9/11/2023 at 12:04 PM, they stated Resident #1 had been requesting to leave the facility and was agreeable to shelter placement. The discharge occurred rapidly due to the facility having the means to transport the resident to the other county and not wanting to lose a spot at the shelter. Assistant Administrator #7 was unaware of the discharge plan details and stated the DSW handled it. Assistant Administrator #7 stated they did not direct the DSW to initiate Resident #1's discharge and stated it was a team decision. During an interview with the Administrator on 9/11/2023 at 12:41 PM, they stated Resident #1 insisted on discharge and was to obtain shelter placement upon arrival to DSS. The facility was not able to discharge directly to a shelter, individuals must go through DSS in order to obtain shelter placement. The plan was for the resident's family member to meet them at DSS. The Administrator stated they did not have anything to do with the discharges and expected the social worker documented the plan appropriately. The resident insisted on going and the facility did their best to ensure they were discharged with the safest plan, per the resident's wishes. During a telephone interview with nurse practitioner (NP) #8 on 9/12/2023 at 2:12 PM, they stated it was their understanding Resident #1 requested to be discharge to another county to a shelter. The NP was not aware of the details of the discharge or what would make it a safe discharge. The NP stated they would expect the nursing and social work departments to ensure needed areas were addressed. The NP thought the family was involved in the discharge plan and would be available to assist the resident. 2) Resident #2 Resident #2 had diagnoses including unspecified dementia with behavioral disturbance, unsteadiness on feet, contracture of unspecified joint, and type 2 diabetes. The 7/7/2023 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and exhibited physical behaviors directed toward others 1 to 3 day of the assessment period. The resident required supervision with their activities of daily living (ADL). The resident took antipsychotic, antianxiety, and antidepressant medication daily during the last 7 days of the assessment period and took opioids 2 days of the assessment period. The resident did not have an active discharge plan. Social worker (SW) #3's progress notes documented on 11/16/2022, the resident's friend called and reported the resident wanted to be discharged ; on 11/20/2022, an application for the resident to go to a local shelter was submitted, and on 12/23/2022, the shelter application was denied due to the resident's dementia diagnosis. SW #3's progress notes documented on 1/3/2023, an application was submitted to another shelter; on 1/19/2023, a care plan meeting was held, the resident had severe cognitive impairment, and on 3/23/2023, the shelter declined the resident's application due to the resident not being fully independent with cooking, bathing, and medication management. SW #3's progress notes documented on 7/18/2023, SW #3 discussed a third smoking warning with the resident and a 30-day discharge notice was given. The resident refused to sign the notice. A referral was sent to a skilled nursing facility (SNF) in another county and on 7/20/2023, lateral transfer referrals were sent to 6 SNFs in the same county as the facility. SW #3's progress note documented on 7/20/2023, the care plan meeting was held, the resident had severe cognitive impairment and their cognition fluctuated due to dementia. The resident had a 30-day discharge notice and referrals were sent to multiple SNFs. Two shelters in the area declined the resident due to dementia, behaviors, and age. SW # 3's progress notes documented on 8/3/2023 and 8/4/2023, the SW contacted multiple adult homes and skilled nursing facilities for possible transfers. The Director of Social Work's (DSW) progress notes documented: - On 8/5/2023, a call was placed to the resident's relative to inquire if any family members were able to have the resident live with them. - On 8/8/2023, the resident's relative stated there were no family members who could take the resident. The DSW was directed by Administration to set up a discharge for 8/9/2023 to the Department of Social Services (DSS). - On 8/8/2023, the resident's relative called and stated the resident notified them they were being shipped off to a shelter. The relative voiced their frustration and stated they thought they had another week to make a plan. The DSW reminded the relative that no one in their family wanted to take the resident and the relative stated they were still working on some things. - On 8/8/2023, a Medicaid cab was set up for the resident with a 10:00 AM pick up time on 8/9/2023. The Transfer/Discharge Notice dated 8/8/2023, documented the notice was to inform the resident the interdisciplinary team (IDT) determined the resident will be discharged on 8/9/2023. The discharge location documented the address of the DSS building in the facility's county. The reasons for the discharge included the resident's health improved sufficiently and the resident no longer needed services provided by the facility; the resident was medically cleared for discharge by occupational and physical therapy (OT, PT) and medical; the safety of individuals in the facility would be endangered as evidenced by episodes of violence, and the health of individuals in the facility would be endangered as evidenced by episodes of smoking. The resident and DSW signed the form on 8/8/2023. The DSW's 8/9/2023 progress note documented they spoke to the resident on 8/7/2023 and 8/8/2023 regarding discharge. They discussed issues with smoking and episodes of violent behavior toward staff. The resident stated they wanted to leave due to being followed by staff (1:1 supervision). The DSW explained to the resident and their friend, and the resident's relative in a separate call, that the resident would be able to obtain Temporary Assistance (TA) from the county, who will find the resident temporary housing. They expressed understanding, the resident was discharged from the facility, and transported via taxi to the DSS office building. The 8/9/2023 Discharge Packet documented the resident was discharged to the address of the county DSS office building; a pharmacy name and address were listed; a community health center was listed as the medical provider with no appointment date noted, and 13 medications were listed, including: Buspirone (anti-anxiety), Depakote Sprinkles (seizure medication), Lorazepam (anti-anxiety, controlled substance), Norco (narcotic pain reliever), Quetiapine fumarate (antipsychotic), and Trazadone (sedative). There were no providers, community contacts/agencies, or service providers noted on the discharge packet. During a telephone interview with the resident's relative on 9/8/2023 at 9:45 AM, they stated they knew the facility was discharging the resident due to behaviors. They were told by the DSW the resident had a shelter set up and would have a case manager who would help find more suitable housing. The relative did not agree to shelter placement but felt they had no choice due to the resident being discharged the next day. When the resident was dropped off at DSS, the resident did not know what to do. They had no identification or phone and was not able to receive assistance. The resident went back to the facility that night (8/9/2023) and was told to leave. The resident's friend picked them up and the fried helped the resident get into a homeless shelter. The relative had had to pick the resident up at times to assist them with bathing and other tasks as the resident had contractures in their hands limiting their mobility. At times, the resident called them because they got lost walking the streets during the day. The resident wandered all day until it was time to go to the shelter in the evening. The resident had not lived on their own since going to the facility in 2018 and was not able to safely care for themselves. During a telephone interview with the resident's friend on 9/8/2023 at 10:40 AM, they stated they were told when the resident was discharged that someone would be at DSS waiting to take them to the shelter. Later that evening (8/9/2023), after 9:00 PM, the facility called and told them the resident returned to the facility and if they did not leave, they would call the police. The friend picked up the resident who had a plastic bag full of medications with them. The resident did not know how to take their medications and could not manipulate the packages as their hands were contracted. They brought the resident to a hotel for the night and then assisted the resident in getting into the shelter. The resident remained at the homeless shelter without their medications or a permanent plan for housing. During an interview with the DSW on 9/11/2023 at 10:21 AM, they stated a safe discharge included making plans with the resident, family, and the IDT to determine what they will need following discharge. Facility-initiated discharges should include a safe plan. When Resident #2 was discharged , it was driven by Administration in order to get the residents who smoked out of the facility. There was no time for the resident to be fully assessed for their ability to live independently or to find appropriate placement. The resident was previously declined for the shelters due to their inability to manage their medications and was not fully independent in their ADLs. The discharge to DSS was not safe, it was not a residential location and the resident was not able to obtain their own services needed for placement. During an interview with the Administrator on 9/11/2023 at 12:41 PM, they stated Resident #2 initiated their own discharge, it was not a facility-initiated discharge. The Administrator was unaware of the reasons the Discharge Notices noted otherwise. The resident was medically cleared and had capacity to make their own decisions and they insisted on leaving. The facility could not discharge directly to a homeless shelter and the resident had to go through DSS in order to obtain assistance. The Administrator expected the SW to ensure the resident had the needed documentation and was set up for a case at DSS. The Administrator stated they felt this was a safe discharge since the facility set up transportation, ensured the resident had their medications, gave instructions for applying for assistance at DSS, and notified their family. During a telephone interview with nurse practitioner (NP) #8 on 9/12/2023 at 2:12 PM, they stated it was their understanding Resident #2 requested to be discharged to a shelter. The NP was not aware of the details of the discharge or what would make it a safe discharge. The NP stated they would expect the nursing and social work departments to ensure needed areas were addressed. The NP thought the resident was going to have a SW or case manager assigned upon arrival to DSS to assist them in obtaining shelter placement. 10NYCRR415.11(d)(3) ______________________________________________________________________________ Immediate Jeopardy was identified, and the facility Administrator was notified on 9/11/2023 at 4:42 PM. Immediate Jeopardy was removed on 9/12/2022 at 1:00 PM prior to survey exit based on the following corrective actions taken: - All discharges planned for 9/11/2023 -9/12/2023 were postponed pending verification of post-discharge services, receiving locations, and approval of the correction plan for future discharges. - SW and Assistant Administrators educated on discharge planning process to include verification of safety. - SW and Assistant Administrators were educated on discharges to shelters, proper steps, criteria, needed materials, appointments, and safety assessment. - The DSW was educated and will document review all discharges for needs and safety verification. - All Unit Managers, SWs, Director of Nursing (DON), Assistant Director of Nursing (ADONs), Therapy Director, and Assistant Administrators were educated on the updated discharge policy. - The policy update and education included education on facility-initiated and AMA discharges. - All staff identified for education received education on 9/11/2023 and 9/12/2023, with the exception of 3 staff members who were not available. The individuals who did not received education will complete education upon their return, prior to the start of their shift. - Interviews were completed on 9/12/2023 to determine compliance with staff training and education including the DSW, 1 SW, 1 Assistant Administrator, 1 Unit Manager, and 1 ADON.

Based on observation, record review, and interview during the recertification, abbreviated (NY00317278), and extended surveys conducted from 7/17/23- 7/28/23, the facility failed to ensure each resident received adequate supervision for 3 of 3 residents (Residents #42, 198, 204) reviewed for smoking. Specifically, from 9/22/22-7/24/23 Resident #42 had 15 documented occurrences when they were discovered by staff smoking in the facility. Adequate supervisory interventions were not put into place to prevent additional occurrences. Observation on 7/24/23 revealed cigarette smoke odor near a common bathroom, licensed practical nurse (LPN) #1 was notified, and Resident # 42 was discovered in a bathroom with a strong smell of cigarette smoke and immediately admitted to smoking and flushing the cigarette in the toilet. Resident #198 was a known smoker and was found smoking in the facility and in the possession of smoking materials; and Resident #204 was witnessed by staff smoking in the facility. The facility staff and administration were aware of Residents #42's, 198's, and 204's smoking behaviors and there were no plans in place to supervise the residents. Subsequently, the failure to provide adequate supervision for Resident #42 resulted in Immediate Jeopardy and Substandard Quality of Care with the likelihood for serious harm to Resident #42 and the other 106 residents residing on Resident #42's nursing unit. The facility also failed to ensure each resident received adequate supervision for 1 of 2 residents (Resident #763) reviewed for elopement. Specifically, Resident #763 was left unsupervised while waiting for a wander alert device replacement. Subsequently, Resident #763 exited the facility undetected. Findings include: SMOKING The facility policy titled (Resident) No Smoking revised on 1/16/19 documented the facility promoted a smoke-free facility and grounds for their residents and provided a smoke-free community to maintain the health and welfare of the resident's residing at the facility. Prior to offering a bed, the Screener and/or Director of admission would discuss the no smoking policy with the individual. Upon admission, the social worker would ensure that that resident or designated representative would sign the admission agreement indicating that they understood there was a no smoking policy at the facility. Smoking materials, including tobacco cigarettes, matches, lighters, e-cigarettes would not be allowed in the possession of the residents at the facility. Security may conduct a physical inspection of the resident room and possessions to locate smoking materials. If at any time during the course of the stay the resident is found to be in violation of this policy, the following actions will be taken: 1st Offense: The Social Worker will review no smoking policy and the resident will sign the NO SMOKING NOTICE which states that they agree to follow the smoking policies of the facility. The form will be kept in the resident's Social Services file. Documentation and narrative note by the social worker will be completed at that time. The social worker will review with the resident that continued violation of this policy may/can result in a 30-day discharge letter and transfer to the first appropriate available bed. Physician services will offer smoking cessation again (if not already completed pre-admission by the hospital). 2nd Offense: The social worker will reiterate with the resident that this is a non-smoking facility and will offer transfer to another facility that permits smoking. Document and care plan. 3rd Offense: The social worker will present the resident and first contact with a 30-day letter of discharge/transfer. Document and care plan. The undated facility Resident Orientation Handbook documented residents and visitors were not permitted to smoke in the building or on the grounds of the health care center. On 7/17/23 at 10:07 AM, during the entrance conference meeting with the facility Administrator, they stated the current census was 358 residents and there were no residents in the building who smoked. On 7/23/23 a request for Resident #42's smoking/non-smoking agreement or any resident no smoking notices were requested. The facility did not provide any such documentation. 1) Resident #42 was admitted to the facility with diagnoses including nicotine dependence and hemiplegia (paralysis on one side) following a cerebral infarction (stroke). The 7/3/23 Minimum Data Set (MDS) assessment documented the resident had intact cognition, did not exhibit behavioral symptoms, required supervision with assistance of 1 for locomotion on the unit, extensive assistance of 1 for toileting and personal hygiene, had functional limitation in range of motion in one arm, and used a wheelchair for mobility. The 1/17/23 annual MDS assessment documented the resident did not use tobacco. The admission comprehensive care plan did not include the resident's history of smoking. The 9/22/22 registered nurse (RN) #74's progress note documented the resident's bathroom smelled of cigarette smoke and the resident denied smoking. Security was called to search the room but did not find any cigarettes. The 10/31/22 licensed practical nurse (LPN) #73's progress note documented there was a strong odor of cigarette smoke noted when walking by the resident's room. The resident was observed sitting in their wheelchair in front of the open window. The resident denied smoking and said they did not know why the room smelled like cigarette smoke. When the resident was asked to hand over their lighter and cigarettes, they stated No. I don't have any. The incident was reported to the RN supervisor (RNS). The 10/31/22 social worker #2's progress note documented the resident was found smoking and they reiterated to the resident the facility's non-smoking policy and smoking was dangerous due to oxygen use. (There were no documented orders for the resident to receive oxygen). The 11/1/22 RN #4's progress note documented the resident was smoking in their room again. The social worker was notified. The resident was reminded of the non-smoking policy and offered a nicotine patch. The resident denied smoking but stated they would like a nicotine patch. The room had obvious smoke and a strong odor of cigarettes. The 11/1/22 social worker #2's progress note documented they visited the resident in their room due to being caught smoking again. Upon entering the room, it clearly smelled of smoke. The resident was seen in the hallway and was re-educated about not smoking. The resident responded, Well I can't go outside to do it. The resident was told smoking was not allowed inside or outside the facility. The 11/1/22 nurse practitioner (NP) #21's progress note documented the resident was seen at the request of nursing due to smoking in their room. The resident was found smoking in their room. The plan included to start a 7 milligram (mg) nicotine patch for nicotine withdrawal and dependence. A 11/1/22 physician order documented nicotine transdermal patch 7 milligram (mg)/24 hours, one patch as needed for nicotine dependence. The 11/26/22 RN #4's progress note documented there was a strong odor of cigarette smoke emanating from the resident's room/bathroom. The resident denied smoking and was reminded of the facility smoking policy. The resident was not receptive to the reminder. The 11/30/22 LPN #72's progress note documented a strong odor of cigarettes was smelled within the resident's room. Upon entering the resident room, the resident was sitting on the edge of the bed facing the open window. The resident stated they were not smoking and did not have any cigarettes. The resident was re-educated the facility was a non-smoking facility. The 12/8/22 LPN #72's progress note documented the smell of smoke was noted outside of the resident's room. The staff member heard a spray sound within the room. The resident said they were not smoking and was reminded the facility was a nonsmoking facility. There were no documented Incident/Accident reports for the 9/22/22, 10/31/22, 11/1/22, 11/26/22, 11/30/22, and 12/8/22 incidents; and no documentation the CCP was revised to reflect the resident's history of smoking in the facility. A 1/10/23 at 9:00 PM Incident/Accident Report completed by RN #41 documented upon exiting the elevator the smell of smoke was present in the core (the central area dividing the north and south ends of the unit) and Resident #42 was the only one present. The resident denied smoking and NP #46 was notified. The section care planning interventions currently in place and any changes implemented to care plans had a line drawn through them. The 1/11/23 NP #46's progress note documented the resident was caught smoking again and frequently refused the nicotine patch as they felt it was ineffective. Nicotine lozenges were prescribed to aid the resident in quitting smoking. The 3/13/23 LPN #1's progress note documented the resident was witnessed smoking in the bathroom in the 5 South core bathroom. LPN #1 explained to the resident that smoking was prohibited in the building and the resident began to yell, I cannot go outside to smoke. The social worker and the Unit Manager were notified. A 3/13/23 at 1:44 PM Incident/Accident Report completed by RN Unit Manager #4 documented they were notified by LPN #1 that Resident #42 was found smoking in the core bathroom on the 5th Floor. The resident was re-educated on the no smoking policy and NP #46 was notified. The resident stated they smoked in there because I can't smoke outside. The care plan was reviewed. The section care plan interventions currently in place had N/A written in. Corrective actions included issuance of a smoking violation, education on the policy, and nicotine replacement was ordered. The report was signed by the Administrator with no date. The 3/13/23 RN Unit Manager #4's progress noted documented the resident was found smoking in the core bathroom (the common area between the north and south ends of the units was referred to as the core) against policy. The resident was assessed and did not sustain any injuries or burns. The resident was re-educated on the smoking policy of the facility. Smoking cessation assistance was offered and declined by the resident. The resident had been issued a smoking violation in the past and was issued an additional violation statement which they refused to sign. The incident was reported to the attending nurse practitioner. A 3/17/23 at 9:30 AM Incident/Accident Report completed by RN Unit Manager #4 documented they were notified by staff that Resident #42 was again smoking in the core bathroom. RN Unit Manager #4 knocked on the door and the resident denied smoking. When exiting the room smoke was present and a cigarette butt was found in the toilet. The resident denied smoking. The care plan was reviewed. The sections care plan interventions currently in place and corrective actions were blank. The report was signed by the Director of Nursing (DON) on 3/21/23 and by the Administrator with no date. The 3/17/23 RN Unit Manager #4's progress note documented the resident was found smoking in the 5th Floor core bathroom. RN #4 knocked on the door of the bathroom asking if the resident was smoking in the room and the resident denied smoking. When the resident exited the bathroom, there was an odor of smoke, and smoke vapor was visible. There was a cigarette in the toilet. The resident was educated again about the no-smoking policy, and smoking cessation assistance could be provided. The resident continued to deny they were smoking. The attending NP, administration, and social work were informed of the incident. The 3/20/23 NP #46's progress note documented the resident was caught smoking again in a bathroom and had been caught multiple times for smoking in the facility. The resident was extremely anxious during the bedside evaluation and reported the smoking cessation aids had not worked. They had tried Wellbutrin (antidepressant used as a smoking cessation aid) in the past and that did not work. The resident stated the reason for smoking was anxiety. The resident was started on alprazolam (sedative) 0.25 mg twice a day and was told it was not a long-term solution and the resident would be referred to psychiatry for pain and anxiety. A 3/23/23 at 9:32 AM Incident/Accident Report completed by LPN Assistant Unit Manager #25 documented the resident was caught smoking in the common restroom on the 5th Floor at the end of the hall near the core area. The resident denied they were smoking and refused the offer of smoking cessation. The resident's room was searched, and no smoking materials were found. NP #46 was notified. The Incident/Accident form did include the care plan sections. The report was signed by the DON on 3/24/23 and by the Administrator with no date. There was no documented evidence of a CCP to address the resident's continued incidents of smoking in the facility or interventions to ensure safety from 9/22/22-4/13/23. The CCP initiated 4/13/23 documented smoking as a problem area. The resident had a history of smoking in the community prior to admission. The resident was found smoking in their room and in the bathroom. Goals included the resident would follow the facility No Smoking rules and policy. Interventions included sign smoking contract, monitor compliance with smoking contract, social worker counseling as necessary regarding accepting smoking material from peers, visitors and/or outside contractors, offer nicotine replacement treated, praise all positive efforts to quit smoking. A 4/16/23 at 8:20 PM Incident/Accident Report completed by RN #26 documented the resident fell in the bathroom near the core. The resident stated they were washing their hands and slipped from their electric wheelchair. The resident was smoking in the bathroom, the cigarette had been extinguished upon staff entry. The care plan was reviewed. The section for care plan interventions currently in place documented requested resident to refrain from smoking in building. Security met with the resident. Corrective action documented the resident's cigarettes and lighter were requested and the resident stated they threw them in the garbage can and RN #26 was unable to locate the items. The report was signed by the DON on 4/17/23 and by the Administrator with no date. The CCP was updated on 4/17/23 at 12:22 PM and included the resident was found smoking in the core bathroom and had a fall at that time The 5/12/23 social worker #3 progress note documented they witnessed the resident coming out of the bathroom with an overwhelming smell of cigarette smoke. The social worker educated the resident that there was no smoking allowed in the building and why. The resident refused to sign the smoking agreement. Numerous referrals to other facilities were made and the resident could not be safely discharged to the community. The Unit Manager and the Director of Social Services were made aware. On 6/29/23 at 12:22 PM, the CCP for smoking was reviewed and updated. There were no additional interventions documented. During an observation on 7/24/23 at 2:15 PM, there was a smell of cigarette smoke in the hallway on the 5th Floor North end D side. The surveyor and LPN #1 knocked on the bathroom door and Resident #42 was in the bathroom. There was a very strong smell of cigarette smoke present. The resident stated they were smoking in the bathroom because they were tired of being lied to and wanted to leave the facility against medical advice. The resident stated they found the cigarette on the floor of the elevator, and the lighter was in the bathroom. The resident stated they put the cigarette butt in the toilet. No lighter was observed in the bathroom. The 7/24/23 at 2:20 PM LPN #1's progress noted documented they smelled cigarette smoke when they walked into the core. They searched the area and opened and closed all the doors. When they attempted to open the bathroom door near the core, the door was locked, and the smell was stronger. They knocked on the door and the door was opened by Resident #42. When asked if they were smoking, the resident said yes. Social worker #3 and the RN were made aware. The resident stated the lighter was in the bathroom, but there was no lighter found in the bathroom. The resident stated they flushed the cigarette down the toilet. During an observation and interview on 7/25/23 at 11:04 AM, Resident #42 stated they were aware it was a non-smoking facility. They obtained cigarettes from a resident on the 4th Floor, and they got one cigarette at a time. They stated they had smoked every day for 46 years and since being admitted to the facility they only smoked occasionally. They stated they flushed the lighter down the toilet. They had been offered nicotine gum and patches, but they did not work. During an interview on 7/25/23 at 11:27 AM, RN Unit Manager #4 stated that any residents that were caught smoking were given 30-day notice and were now on 1:1 supervision with a staff member. They stated if a staff member was aware of a resident smoking, they should report it to the Unit Manager or the RN supervisor during an off shift. They had never seen Resident #42 actually smoking but there was evidence of smoking, such as the smell of smoke and a cigarette in the toilet. During an interview on 7/26/23 at 12:47 PM RN #41 stated they remembered doing an Accident/Incident report regarding smelling cigarette smoke for Resident #42. They were aware Resident #42 was suspected of smoking in the past. They stated a more thorough investigation may have been needed due to the resident's history of smoking. A prevention plan included offering cessation several times, and violations and 30 day notices were given to the resident. The process for Accident/Incidents was to determine a root cause and try to prevent recurrence. They stated if someone smoked in the facility it could put all residents and staff in danger. During an interview on 7/26/23 at 2:02 PM LPN Supervisor #25 stated they previously worked on the 5th Floor. Their duties included reviewing 24 hour report and filling out Accident/Incident paperwork. The RN was responsible for the actual assessment. An Accident/Incident was used to document an occurrence and identify ways to prevent it from happening again. They stated they caught Resident #42 smoking in April 2023, they completed an Accident/Incident report, and spoke to the resident about smoking. The social worker and security were called, and there was a possibility of the resident having to leave if they were caught again. Smoking in the building presented a danger of starting a fire. There was oxygen in use throughout the building which would put both residents and staff at risk. During a follow-up interview on 7/26/23 at 2:07 PM, RN Unit Manager #4 stated they wrote progress notes on 3/13/23 and 3/17/23 about the resident smoking in the bathroom. They stated they did not witness the resident actively smoking, but the area around the resident looked smoky and they saw a cigarette butt in the toilet. They stated they reported it to the social worker. They did not complete the accident and incident report, and they reported it to the social worker, DON, and the Administrator. RN Unit Manager #4 stated when a staff member observed a resident smoking, they should notify security, the DON, a medical provider, administration, and the family. They thought verbally reporting the smoking incidents to the appropriate staff was the start of the investigation but stated they should have started a written accident and incident report. The resident care plan should be updated, and a referral should be made for discharge. They stated the resident care plan was updated on 4/17/23 with a smoking care plan. During an interview on 7/26/23 at 2:28 PM social worker #3 stated they had not witnessed the resident smoking. They stated no one had actually caught the resident smoking but staff had suspicions the resident was smoking because of smelling cigarette smoke. No smoking materials had ever been found on the resident. The resident had been educated on not smoking. They stated they were not involved with completing Accident/Incident reports and nursing was responsible for care plans. They stated they informed their supervisor of the resident potentially smoking in the facility. Security was also made aware so they could perform a search for smoking materials. The resident was offered smoking cessation and the facility looked into discharge planning and had sent referrals. During an interview on 7/26/23 at 3:37 PM, NP #46 stated Resident #42 had been seen on many occasions for witnessed smoking in the facility. The facility should complete investigations for the smoking, and they were not involved in that. The resident was accepting of treatment for anxiety but would not accept any smoking cessation aides. During an interview on 7/26/23 at 3:51 PM, the Medical Director stated the facility was a non-smoking facility. All residents should have received an admission packet that stated the facility was a non-smoking facility. The residents would also be told by the hospital that discharged them to the facility, that the facility was a non-smoking facility. They stated it was the facility's job to do their best to keep all residents safe. Smoking in the facility could potentially cause an unsafe situation as there were several residents that utilized oxygen. During an interview on 7/26/23 at 4:29 PM, the facility Administrator stated that if residents were smoking in in the building, they wanted to be made aware. They stated when there was an incident, an investigation must be completed. The purpose of an investigation was to determine a root cause of the incident and information should be obtained from all parties involved. The Administrator stated they were not sure if they were made aware of all the smoking incidents with Resident #42 since September 2022, but the facility dealt with each issue daily. They stated when there was an odor of cigarette smoke, they could not accuse a resident, because they worked with a very dynamic patient population. They stated they did not want their staff to be accusatory toward the residents. They should investigate right away and do whatever was needed to keep the resident safe. They stated the resident would be at risk for being burned if they had a physical disability. The resident was aware they were not supposed to smoke in the facility and was able to make their needs known. They stated they thought the front-line staff did what they should do when they observed a resident smoking. 2) Resident #204 had diagnoses including nicotine dependence with withdrawal, schizophrenia, and chronic obstructive pulmonary disease (COPD, restricted airway). The 9/21/22 admission Minimum Data Set (MDS) assessment documented the resident currently used tobacco. The 4/5/23 MDS documented the resident was cognitively intact and required supervision with setup for most activities of daily living (ADLs) The 9/14/22 admission assessment did not document a history of smoking. The 10/6/22 at 6:53 AM, licensed practical nurse (LPN) #23 progress note documented the resident attempted to go outside to smoke. A staff member brought the resident back to the unit, informed the LPN, and handed the LPN two cigarettes wrapped in a paper towel. The resident refused to tell the LPN where the cigarettes were obtained from. The supervisor was made aware. The 10/14/22 at 8:27 PM, registered nurse (RN) #24 progress note documented a cigarette smell was evident when the RN exited the 7-South elevator. There were 2 residents observed in the unit TV area corner. The residents were sitting in wheelchairs smoking cigarettes. Both residents were educated on the safety aspect of not smoking in the building and were encouraged to try nicotine replacement programs. Education had been provided previously. The residents were told the incident would be reported to medical, social services and nursing administration. The 10/14/22 at 8:27 PM unsigned Incident/Accident Report documented Resident #204 was found by the RN Supervisor (RNS) smoking in their wheelchair in the 7th Floor dining room. The resident was counseled and told How would you feel if you hurt someone by causing a fire? The section for care plan interventions currently in place was not completed. Corrective action included verbal education and nicotine replacement treatment. The medical provider was notified on 10/14/22 at 8:50 PM. The incident report was signed by the Director of Nursing (DON) on 10/19/22 and signed by the Administrator with no date. The 10/14/22 social worker #3's progress note documented the resident was spoken to about their first smoking violation. The social worker clearly outlined the policy and reviewed the rules. The social worker made the resident aware they would receive a 30-day letter of discharge if smoking in the building. The resident signed the smoking agreement. The resident apologized and stated they would not smoke in the facility again. The 10/14/22 Resident No Smoking Notice, signed by the resident, documented the social worker reviewed the Smoking Contract and Rules with the resident. The resident agreed to abide by the terms and a violation could result in a 30-day discharge letter and transfer to the first appropriate available bed at another facility. There was no documented evidence of a CCP to address the resident's continued incidents of smoking in the facility or interventions to ensure safety. The 4/17/23 at 4:29 AM RN #26 progress note documented security addressed the resident that evening due to the resident being found smoking in the building. The 4/17/23 at 4:29 AM, Incident/Accident Report completed by RN #26 documented the resident was found by security smoking in the building. The report did not document where in the building the resident was found. Verbal education was provided, and the resident apologized. The resident refused to sign a statement and nicotine was offered to the resident. The section for care plan interventions currently in place was not completed. Corrective action included social worker counseling as needed and nicotine was offered. The on-call provider was notified on 4/17/23 at 4:29 AM. The report was signed by the DON on 4/19/23 and by the Administrator with no date. The 4/17/23 comprehensive care plan (CCP) documented the resident had a long history of smoking and was found smoking in the facility. Interventions included offering nicotine replacement treatment, all lighting materials would be removed and maintained by the facility, social work counseling as necessary about accepting smoking materials from peers/visitors/outside contractors, praise positive efforts, social work/Activity Director would review smoking policy with resident and issue violations as needed. When interviewed on 7/25/23 at 11:06 AM, certified nurse aide (CNA) #27 stated the facility was a non-smoking facility and staff were to immediately inform the charge nurse if a resident was caught smoking. Security then came to the resident's room and searched for smoking materials. The CNA was not aware if Resident #204 had been caught smoking in the past. The resident had not smelled like smoke, and they had not noticed burn marks on their clothes. The resident was usually not in their room during the day but downstairs or out on the unit. When interviewed on 7/25/23 at 11:17 AM, LPN Assistant Unit Manager #25 stated there was to be no smoking on the premises and signs were posted everywhere. They thought there was a section on the admission assessment for the resident's smoking history. LPN Assistant Unit Manager #25 stated the resident had not been caught smoking recently. Social services and the NP became involved if a resident was caught smoking and a warning was issued to the resident and smoking cessation was offered. The LPN accessed the resident's records and stated the resident was caught smoking on 4/17/23. The RN was responsible for initiating care plans, but the LPNs were able to add to any topic initiated by the RN. The resident had a care plan for smoking that was initiated on 4/17/23. 3) Resident #198 was admitted to the facility with diagnoses including nicotine dependence and dementia with behavioral disturbances. The 7/7/23 MDS assessment documented the resident had severely impaired cognition, required supervision of 1 for most activities of daily living (ADL), and used a wheelchair. The 1/20/23 NP #46's progress noted documented the resident was seen for medication management and documented the resident was a long-term resident of the facility and had no alcohol or tobacco use. The 5/18/23 social worker #3's progress note documented they were made aware the resident was caught smoking in the clinic (health clinic on the 2nd floor) on 5/15/23 at around 10:05 PM. The resident became hostile with security staff. The resident was issued a smoking warning but refused to sign it. The resident denied smoking and stated they did not smoke. They state they were closing the clinic door and the smoke smell was not from them. The 6/13/23 social worker #3's progress note documented the resident was caught smoking in the bathroom last evening on 6/12/23. The social worker met with the resident to review the smoking policy. The resident denied smoking and refused to sign the smoking notice. The undated resident care instructions documented the resident was ambulatory and had behaviors, and staff should redirect, avoid over stimulation, and offer to take the resident outside for walks. There was no documentation the resident had history of smoking and was caught smoking in the building. The 7/18/23 social worker #2's progress note documented they met with the resident to issue a third smoking warning. The resident stated, I was not caught smoking. Social worker #2 explained to the resident cigarettes were found in their room. The resident nodded and said, Yeah, I smoke them when I walk outside. Why can't I have them? I don't smoke in the building. Social worker #2 tried to explain why the resident could not have cigarettes and the resident walked away. Resident #198 declined to sign the smoking notice. This was the resident's 3rd offense. The resident was given a 30-day notice, which the resident did not sign. A referral was sent to another facility. The 7/18/23 transfer/discharge notice documented the resident was informed they would be discharged on 8/10/23 because the safety of individuals in the facility would be endangered, as evidence by continued smoking. The facility documented the resident refused to sign the notice. The form was not signed by a facility representative. The 7/20/23 social worker #2 progress note documented the resident was resident given a 30 day notice recently due to the continued smoking. Lateral transfers to various skill nursing facility were sent. During the meeting, the resident became upset when confronted about smoking and said, I am going to keep doing it. Social worker #2 stated to the resident it was a non-smoking facility. During an observation and interview on 7/24/23 at 4:55 PM, Resident #198 was sitting in the lobby and stated, I got smokes on the outside and I sell them to the residents on the 4th floor, 3 cigarettes for $20, but I don't smoke. Resident #198 stated they did not have a lighter on them. The resident smelled of cigarette smoke. During an interview on 7/24/23 at 12:28 PM social worker #3 stated they were familiar with Resident #198, and they were a smoker. The resident was not supposed to smoke, had been caught smoking in the facility, and would always deny they smoked. During an interview on 7/25/23 at 11:23 AM, CNA #75 stated Resident #198 had been caught smoking in the past. They stated they did not confront them because some of the residents were violent. They