**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and Nurse Practitioner, resident, and staff interviews, the facility failed to provide effective supervision for Resident #3 who had dementia with severe cognitive impairment, hemiparesis (mild or moderate weakness) of the dominant right side due to a stroke, and a history of smoking. A smoking assessent completed on 12/20/24 noted Resident #3 had limited range of motion and unclear speech response but was determined as having no issues with her ability to smoke safely and was determined to be safe to smoke unsupervised. On 3/19/25, Resident #3 was smoking unsupervised in the designated smoking area and caught her hair on fire. Resident #3 patted her hair with her right hand to put out the fire. Resident #3's hair was singed on her right side at least one inch starting from her hairline at her right ear through her hairline to the center part of her hair. Resident #3's right eye lid was blistered, and the palm of her right hand and behind her right ear also received mild burns and all were treated with a topical antibiotic cream. The smoking assessment completed 3/19/25 determined Resident #3 required staff supervision with smoking due to being unable to safely light smoking materials, hold smoking materials safely, and unable to call for emergency assistance. On Sunday 4/20/25 Resident #3 exited the front entrance of the building in her wheelchair and self- propelled herself 151 feet from the entrance of the facility through the parking lot to the parking lot entrance/exit area and was headed toward the main road without staff knowledge. The main road in front of the facility and was four lanes with a speed limit of 35 miles per hour. A facility visitor who was leaving the parking lot telephoned the Weekend Nurse Supervisor around 7:00 PM and stated a resident was in her wheelchair outside at the parking lot entrance/exit and was wheeling herself towards the main road. The Weekend Nurse Supervisor notified Unit Manager #3 and they both responded to the parking lot where Resident #3 was found at the parking lot's entrance/exit area seated in her wheelchair facing the facility with her back towards the main road and self-propelling herself backwards up the exit incline towards the main road. Resident #3 did not have smoking material in her possession but told the staff she was in the parking lot because she wanted to smoke. This deficient practice had a high likelihood of causing serious harm or injury to Resident #3 and affected 1 of 3 residents reviewed for supervision to prevent accidents (Resident #3). Immediate jeopardy began on 3/19/25 when Resident #3 was smoking unsupervised and lit her hair on fire and again on 4/20/25 when Resident #3 exited the facility unsupervised and without staff knowledge. The immediate jeopardy was removed on 5/01/25 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of a D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses that included stroke, expressive aphasia (partial loss of the ability to produce language), and hemiparesis (mild or moderate weakness) of the dominant right side, seizure disorder, and muscle weakness. Resident #3 was also diagnosed with dementia in 2015 and anxiety disorder, depression, and bipolar disease in 2018. Resident #3's quarterly smoking safety assessment completed by the previous Administrator dated 7/15/24 revealed Resident #3 was a smoker with a limited range of motion, weak grasps, diminished reflex response, and unclear speech response. Under the direct smoking observation section, Resident #3 was assessed as being unable to hold smoking materials safely and respond quickly to fallen ashes. Therefore, the smoking requirement for Resident #3's safety was for her to be a supervised smoker, wear a smoking apron, and smoking materials to be stored by the facility. The revised care plan dated 7/15/24 revealed Resident #3 was a smoker with a goal that she would not suffer any injuries from unsafe smoking practices through next review date. Interventions included Resident #3 could utilize cigarettes and smoke supervised, wear a smoking apron to protect her clothing, and had been instructed on smoking risks and hazards. Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. Resident #3 was also assessed for use of tobacco, being ambulatory with assistance of a wheelchair, required substantial assistance for transfers, functional limitation of range of motion with impairments to the upper and lower extremities on one side, and no change in behaviors were noted. Resident #3's quarterly smoking safety assessment completed by the MDS Coordinator #2 dated 12/30/24 revealed Resident #3 was a smoker with limited range of motion and unclear speech response. Under the direct smoking observation section, Resident #3 was assessed as having no issues with her ability to smoke safely. Therefore, the smoking requirement for Resident #3's safety was changed for her to become an unsupervised smoker, no smoking apron required, and smoking materials continued to be stored by the facility. Care Plan updated to show change in smoking status from supervised to unsupervised. An interview with the MDS Coordinator #2 on 4/29/25 at 2:06 PM revealed she was familiar with Resident #3 and had completed her smoking evaluation on 12/30/24. She stated she had completed Resident #3's to the best of her knowledge and understanding of the questions. During her observation of Resident #3 smoking she felt Resident #3 was able to light, smoke, and dispose of her cigarette properly, and that was why she made her an unsupervised smoker. She revealed she was aware of Resident #3 being cognitively impaired and of her limited range of motion but felt that she was able to handle and smoke a cigarette safely. When asked if there had been any improvements or changes with Resident #3's cognition, functional abilities, or diagnosis since her last smoking assessment on 7/15/24, the MDS Coordinator #2 stated no but that she believed that Resident #3 was able to hold a cigarette and smoke it safely. The revised care plan dated 12/30/24 revealed Resident #3 was a smoker with a goal that she would not suffer any injuries from unsafe smoking practices through next review date. Interventions included Resident #3 could utilize cigarettes and smoke unsupervised, observe clothing and skin for signs of cigarette burns, and had been instructed on smoking risks and hazards. Resident #3's annual MDS assessment dated [DATE] revealed she was severely cognitively impaired. Resident #3 was also assessed for use of tobacco, being ambulatory with assistance of a wheelchair, required partial assistance for transfers, functional limitation of range of motion with impairments to the upper and lower extremities on one side, and no change in behaviors were noted. Nursing progress note written by Nurse #3 dated 3/19/25 revealed Resident #3 was outside smoking when her hair caught fire. Hair to the right of her head was singed off. Ear and hand to right side noted red. Provider and Responsible Person was updated. The Medical Director responded with the following feedback: Continue to monitor any changes at this time. Resident #3's quarterly smoking assessment completed by Nurse #3 dated 3/19/25 revealed Resident #3 was a smoker with problematic short- and long-term memory, limited range of motion, and unclear speech. Under the direct smoking observations sections, Resident #3 was assessed as being unable to safely light smoking materials, hold smoking materials safely, and unable to call for emergency assistance. Therefore, the smoking requirement for Resident #3's safety was for her to become a supervised smoker, wear a smoking apron, and smoking materials to be stored by the facility. A telephone interview with Nursing Assistant (NA) #7 on 4/29/25 at 3:11 PM revealed she was familiar with Resident #3. She stated on 3/19/25 she had gone into another resident's room to check on them and was looking out of their window to the smoking area and she observed Resident #3 outside at the smoking area patting on the side of her head. She revealed she left the other resident's room, went over to the door that leads out to the smoking area, and saw Resident #3 trying to open the door to come back inside the facility. NA #7 stated she opened the door for Resident #3 to come in and immediately noticed the smell of something burning and when she looked at Resident #3's hair she could tell it had been singed and the right side of her face at her hairline was red. She revealed she immediately assisted Resident #3 over to the nurse's desk and informed Nurse #3 what happened and then went to get the DON. She revealed Nurse #3, and the DON began treating Resident #3 and she went back to her residents. An interview with Nurse #3 on 4/29/25 at 12:34 PM revealed he was familiar with Resident #3. He stated he was standing at the nurse's desk on 3/19/25 when NA #7 brought Resident #3 over to him stating she believed Resident #3 had burned her hair while smoking. He revealed when he began to assess Resident #3, he observed that she had singed her hair starting from her hairline at her right ear up through the hairline at the center part of her hair. He stated he also observed that she had redness behind her right ear, on her face at her hairline, and to the palm of her right hand. Nurse #3 revealed he asked Resident #3 what happened, and she stated she was smoking and her hair caught fire, and she put it out with her hand. He stated he notified the physician who told him to monitor, made a note for the NP to assess Resident #3 for burns, documented in the medical chart, and completed a new smoking assessment for Resident #3 to be a supervised smoker. He revealed after he finished assessing Resident #3, the Director of Nursing (DON) came and took Resident #3 back to her room. Previous infection control nurse progress note dated 3/19/25 revealed the Nurse Practitioner (NP) notified of blistered area (second-degree burn) to right eyelid. New order to apply [a topical antibiotic cream used to treat and prevent infection of serious burns] to area twice a day and Tylenol 650 milligrams (MG) every 8 hours as needed for pain. Resident #3 to be evaluated by NP upon next round. Resident #3 was made aware. NP order for Resident #3 dated 3/19/25 revealed Tylenol Oral Tablet 325 MG (Acetaminophen) give 2 tablets by mouth every 8 hours as needed for pain for 3 Days and apply [topical antibiotic cream] to right upper eyelid twice a day. An NP progress note dated 3/20/25 revealed nursing staff reported Resident #3 was smoking outside and burned her right hand and behind her right ear. Resident #3 was a [AGE] year-old female seen per nursing request for burns to right hand and behind right ear due to smoking. Nursing staff requested a visit for initial evaluation and treatment of burns. The risk of complication was moderate. Burn of unspecified degree of right hand, unspecified site, initial encounter: right hand burn was mild, only redness, no blistering, will start antibiotic cream to area twice a day. Burn of unspecified degree of head, face, and neck, unspecified site, initial encounter: Burn area behind left ear was mild, only redness noted, no blistering, will start antibiotic cream to area twice a day. NP order for Resident #3 dated 3/20/25 revealed clean areas to right upper and lower eyelids, right ear, right face, right forehead and right hand with normal saline (NS) and apply [topical antibiotic cream] twice a day for burns. Resident #3's March 2025 Medication Administration Record revealed she did not require the use of her as needed pain medication. Resident #3 was observed on 4/29/25 at 10:30 AM outside smoking in the designated smoking area. The designated smoking area was a cemented area located inside the fenced courtyard, had a permanent shade to protect from the weather, tables, chairs, ash trays, and fire extinguisher available, and the area was accessible through a door in the dining room. Resident #3 was seated in her wheelchair wearing her smoking apron and using a smoking device to assist with smoking. The smoking device was an ash tray permanently mounted onto a flat wooden board, a long rubber tubing was attached to the ash tray by an adaptor on one end to hold the cigarette and allow ashes to fall into the ashtray safely, and a mouthpiece was attached at the other end of the tubing for Resident #3 to smoke safely. Hospitality Aide #1 was outside with Resident #3 supervising her while smoking. Resident #3 was observed to be able to smoke safely while using the device. When asked Resident #3 how she liked smoking with the device she kept frowning and shaking her head No. An interview and observation with Resident #3 on 4/29/25 at 11:30 AM revealed she was outside smoking unsupervised in the designated smoking area on 3/19/25 and her hair caught fire. She demonstrated she used the palm of her hand to pat out the fire. Observation of Resident #3's hair showed where at least 1 inch of the hair on the right side of head starting from the ear to the center part of head was singed off and was starting to grow back. Observations of Resident #3's palm of her right hand, behind her right ear, and top of her right eyelid revealed no signs of redness, mild burns, or scarring. An interview with Hospitality Aide #1 on 4/29/25 at 10:40 AM revealed he was responsible for taking supervised smokers outside to smoke during their scheduled smoking times, apply their smoking aprons, provide them with their smoking materials from the locked box that was kept at the nurse's station. He stated there was a list of the supervised and unsupervised smokers kept at each nurse's desk, so he was aware of who smoked and if they were supervised or unsupervised. He revealed all smoking materials were kept inside the locked box located at the nurse's desk and residents who were unsupervised smokers would have to request their smoking materials prior to smoking and return their materials when they are finished. Hospitality Aide #1 stated supervised smokers were not allowed to have access to their smoking materials, staff provided them with their smoking materials, light their cigarettes for them, and then place their materials back into the locked box. He revealed supervised smokers have designated smoking times at 10:30 AM, 1:30 PM, and 6:30 PM. An interview with the Nurse Practitioner (NP) on 4/29/25 at 11:00 AM revealed she was familiar with Resident #3. She stated she was notified by telephone on 3/19/25 of Resident #3's smoking incident where her hair caught fire causing some redness to the palm of her right hand and behind her right ear and a blister to her right eyelid. She revealed she ordered on 3/19/25 for a medicated cream to be applied to her right eyelid and an order for as needed pain medication. The NP stated she assessed Resident #3 in person on 3/20/25 and noted mild second-degree burns like a bad sunburn to the palm of her right hand and behind her left ear and continued the order for the medicated cream to the right eyelid to include the right hand and behind the right ear. She revealed she did not recall Resident #3 complaining of any pain from those areas, but she did have as needed pain medications ordered just in case. She stated she was not familiar with Resident #3's smoking abilities but would assume that based on her diagnosis and the fact that she does have some good and some bad days would most likely contribute to her inability to complete certain tasks such as smoking safely. An interview with the Administrator and DON on 4/29/25 at 2:40 PM revealed they were familiar with Resident #3. The Administrator stated she was on leave when the smoking incident with Resident #3 occurred and was notified of the incident when she returned. The DON stated she was working at the facility on 3/19/25 when the smoking incident with Resident #3 occurred, she was notified by NA #7 that Resident #3 had caught her hair on fire while outside smoking. She revealed she went to the nurse station where Nurse #3 was assessing Resident #3 for injuries and observed the hair next to her hairline on the right side had been singed off and she did have some redness on her face, behind her ear, and to the palm of her right hand. The DON stated that after Nurse #3 completed his assessment, she assisted Resident #3 back to her room and asked her what happened, and Resident #3 stated that she was outside smoking, caught her hair on fire and put it out with her hand. She revealed Resident #3 did have right sided weakness with limited range of motion and because of that would sometimes lean more to her right side. The DON stated she had assumed that what caused the incident was Resident #3 had her hand that was holding her cigarette up and as she leaned, she caught her hair on fire. She revealed Resident #3 was an unsupervised smoker prior to the incident. The DON stated an updated smoking assessment was completed on 3/19/25 and Resident #3 was now a supervised smoker, wore a smoking apron, and used a smoking device. Resident #3's wandering assessment dated [DATE] revealed no history of wandering or exit seeking behaviors and no interventions needed. Resident #3's quarterly MDS assessment dated [DATE] revealed she was severely cognitively impaired. Resident #34 was also assessed as being ambulatory with assistance of a wheelchair, functional limitation of range of motion with impairments to the upper and lower extremities on one side, with no history of wandering or exit seeking behaviors. Nursing progress note written by Unit Manager #3 dated 4/20/25 revealed Resident #3 went outside into the front parking lot because She wanted to go smoke, and believed if she went out of the front door staff would come quicker. Resident #3 stated she was not trying to leave the building. A telephone interview with the Weekend Nurse Supervisor on 4/29/25 at 1:19 PM revealed she was familiar with Resident #3. She stated she was working on the evening of 4/20/25 and sometime between 7:00 PM and 7:15 PM she received a telephone call from a visitor who was leaving the facility parking lot (she could not recall the visitor's name) that a resident was out in the parking lot at the entrance/exit area and headed towards the road. She revealed she immediately went to get Unit Manager #3 and when they went outside to the parking lot, they found Resident #3 seated in her wheelchair at the entrance and exit area of the parking lot. Resident #3 was inside her wheelchair facing the facility with her back facing the road and was trying to wheel herself backwards up the entrance/exit incline towards the main road. The Weekend Nurse Supervisor stated she and Unit Manager #3 asked Resident #3 what she was doing out in the parking lot, and she stated she was going to smoke. She revealed she checked, and Resident #3 did not have any smoking materials on her and when asked if she was trying to leave the facility, Resident #3 kept saying she just wanted to go smoke. Weekend Nurse Supervisor stated Resident #3 was a supervised smoker and she had just taken her out to smoke in the designated smoking area for the last scheduled smoking time around 6:30 PM. She revealed after Resident #3 smoked her normal two cigarettes; she assisted Resident #3 back inside the facility which was probably around 6:45 PM and she went back to the hall she was assigned, and Resident #3 was wheeling herself down the hall back towards her room. Weekend Nurse Supervisor stated she was not aware of Resident #3 asking any staff between the time she came back inside from smoking at 6:30 PM and the time she was found outside to go smoke. She stated Unit Manager #3 called the Administrator who advised to take Resident #3 back inside the facility, assess her for any injuries, and then take her to smoke. The Weekend Nurse Supervisor revealed Unit Manager #3 assessed Resident #3 with no injuries noted and then she took her out to smoke with no further issues. She stated to her knowledge Resident #3 had never displayed any wandering or exit-seeking behaviors and she felt this was an isolated incident where Resident #3 wanted to go back out to smoke and that was her way of getting staff's attention so they would take her to go smoke. An interview with Unit Manager #3 on 4/29/25 at 11:42 AM revealed she was familiar with Resident #3. She stated she was working on the evening of 4/20/25 and sometime between 7:00 PM and 7:15 PM the Weekend Nurse Supervisor came to her stating Resident #3 was in the parking lot unattended. She revealed she and the Weekend Nurse Supervisor went outside to the parking lot and found Resident #3 in the parking lot at the bottom of the entrance and exit incline. Resident #3 was seated inside her wheelchair, the wheelchair was turned backwards with her back towards to road, and she was attempting to wheel herself up the incline towards the road. Unit Manager #3 stated she and the Weekend Nurse Supervisor asked Resident #3 why she was outside in the parking lot and where she was going and Resident #3 stated that she was going to smoke. She revealed Resident #3 continued to say that she was going to smoke and when asked if she was trying to leave the facility, Resident #3 shook her head No and said she was not leaving she just wanted to go smoke. The Unit Manager stated she called the Administrator and informed her of Resident #3 being out in the parking lot and the Administrator instructed her and the Weekend Nurse Supervisor to take Resident #3 back inside the facility, assess her for any injuries, and then take her out to smoke. Unit Manager #3 revealed she completed Resident #3's assessment with no injuries noted, the Weekend Nurse Supervisor took Resident #3 out to smoke, and there were no further issues the rest of the evening. She stated to her knowledge Resident #3 had never had any wandering behaviors before and she truly felt that she was just trying to get nursing staff's attention so they would take her out to smoke. An interview with Resident #3 on 4/29/25 at 11:30 AM revealed on the evening of 4/20/25 she exited the facility to the parking lot and was heading towards the road to smoke when staff came and stopped her. She stated she did not have any smoking materials on her, she wanted to go smoke. When asked where she was going to get the smoking materials needed to smoke, Resident #3 stated she would get them at the road. When asked if she was trying to leave the facility, Resident #3 stated, No that she just wanted to go outside and smoke. When asked if she had gone outside to smoke during the last smoking time at 6:30 PM, Resident #3 stated Yes but she just wanted to go smoke. When asked if she had told staff she wanted to go back outside to smoke again, Resident #3 shook her head No. When asked if she was aware of the concerns with her going outside in the parking lot towards the road in her wheelchair by herself, Resident #3 shook her head No and stated again that she was just trying to go smoke. Attempted contact with NA #8 who was scheduled with Resident #3 on the evening of 4/20/25 was unsuccessful. Attempted contact with NA #9 who was scheduled with Resident #3 on the evening of 4/20/25 was unsuccessful. Observation of the facility and route taken by Resident #3 on 4/29/25 at 3:15 PM revealed the facility was a single-story building facing a main four lane road with a speed limit of 35 miles per hour, surrounded by multiple businesses, and within one mile of a hospital. The entrance to the facility was covered, open, with no sidewalks, and accessible from the front parking lot off from the main road. The route taken by Resident #3 as described by Unit Manager #3 and the Weekend Nurse Supervisor revealed Resident #3 was seated in her wheelchair and wheeled herself outside through the unlocked doors located at the front entrance of the facility, went into the front parking lot, took a right towards the parking lot entrance, and was found at the bottom of the incline at the parking lot entrance with her wheelchair turned backwards and wheeling herself towards the road. The estimated length from the front door entrance to the incline at the entrance parking lot was 151 feet, the incline at entrance of the parking lot was a slope of 10 inches, and starting from the bottom of the incline to the top of the incline located at the main road was 56 feet. Per weather.com the weather at the facility on 4/20/25 was sunny and clear, temperature was 78 degrees, and sunset was at 7:50 PM. An interview was conducted with the NP on 4/29/25 at 11:00 AM revealed she was familiar with Resident #3. She stated she was not aware of the incident on 4/20/25 with Resident #3 leaving out of the facility and attempting to go towards the road. She revealed to her knowledge Resident #3 did not have a history of wandering but she still would have liked to have been informed of the incident so she could have assessed if this was an isolated incident related to wanting to go smoke, or a new behavior brought on by a change with her medical conditions. She stated Resident #3 does require a wheelchair for mobility, had right sided weakness with limited range of motion, and diagnosis of dementia, seizures, and expressive aphasia which could put her at risk of accidents in general. The NP revealed Resident #3, being out in the parking lot and attempting to ambulate herself towards the main road could certainly have put her at more of a risk of having a fall or being hit by a car. An interview with the Administrator on 4/29/25 at 2:40 PM revealed she was familiar with Resident #3. The Administrator stated on the evening of 4/20/25 sometime after 7:00 PM she received a telephone call from Unit Manager #3 stating that Resident #3 was found outside the facility, on the sidewalk not far from the front porch. She stated Unit Manager #3 reported that when they found Resident #3 and asked her what she was doing outside that she told them that she was not trying to leave the facility, that she just wanted to go smoke. The Administrator revealed that she instructed Unit Manager #3 to take Resident #3 back inside and assess her for any injuries and then assist Resident #3 with going to smoke. She stated they did not implement any 15-minute checks just continued normal rounds because at that time they did not feel Resident #3 had tried to elope or that she was an elopement risk, she was just trying to get the staff's attention to go smoke. The Administrator revealed to her knowledge Resident #3 had never had any history with wandering or displayed any exit seeking behaviors and prior to this incident had gone out to the front porch to sit with no issues. She stated although she was never told Resident #3 was further out into the parking lot headed towards the road, she did not believe Resident #3 was ever trying to leave the facility, this was an isolated incident, and did not feel Resident #3 was ever an elopement risk. She revealed Resident #3 had been taken out to smoke during the designated smoking time at 6:30 PM, and she was not aware of her asking staff to go back outside again to smoke prior to exiting out of the front of the facility. The Administrator stated she was not aware of Resident #3 not liking the assigned smoking device and they would be reassessing Resident #3's smoking ability to see if there was another option for her to be able to smoke safely without using the smoking device. The Administrator was notified of immediate jeopardy on 4/30/25 at 5:20 PM. The facility provided the following plan for immediate jeopardy (IJ) removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Facility failed to have effective systems in place to ensure all residents are being appropriately assessed for the correct level of supervision required for smoking to prevent accidents. Facility failed to have effective systems in place to ensure severely cognitively impaired residents are not leaving the building unsupervised to prevent accidents. On 12/30/24 a smoking assessment was completed for resident by MDS. The smoking assessment found resident able to smoke unsupervised. Resident had been previously assessed as requiring supervision while smoking due to being unable to hold smoking materials safely or respond to fallen ashes quickly. On 3/19/25 Resident was assessed by licensed nurse with injuries noted to the right forehead, right ear, and right hand pursuant to a smoking incident. The Medical Director was notified by the Director of Nursing with treatment orders obtained. The facility initiated a therapy referral for positioning while in wheelchair on 3/19/25. Therapy followed resident with plan of treatment. The Responsible Person was notified of incident, follow up treatment plan and change in supervision with smoking with resident's consent. Resident's smoking assessment was re-evaluated by charge nurse on 3/19/25 and resident was notified that she was now a supervised smoker, resident verbalized understanding and in agreement. Despite some cognitive impairment she is oriented and conversant. Resident has expressive aphasia and able to communicate needs with some delayed verbalization. Staff notified of change in supervision with smoking and residents' apparatus by the Director of Nursing. Director of Nursing updated smoking binder that is in nurse's stations, front office and therapy department. On 3/19/25 the facility ordered resident #3 a smoking adaptive apparatus to hold her cigarette. Being a supervised smoker, staff will light her cigarettes. Resident's care plan/ kardex updated to reflect that her hair is pulled back per resident acceptance. Smoking apron available per residents' acceptance. Resident has dementia and expressive aphasia and has ability to communicate needs and preferences, and facility will honor that per her rights while providing supervision to promote safety. On 4/20/25 resident was witnessed by a family member in the parking lot approximately 20 feet from the road. The family stayed with the resident and notified the facility that resident was outside and safe as staff were not aware. The resident was witnessed less than 15 minutes prior to at the nurse's station. On 4/20/25 the Unit Manager assessed resident and there was no physical injuries and resident was not in any mental distress. Resident expressed she was not leaving and only wanted a cigarette. The Unit Manager assessed resident for wandering tendencies and resident did not present as a risk as she wanted to go outside and have a cigarette. Resident was provided with a cigarette in designated smoking area. Residents' preference for smoking times to be honored per request with staff supervision. On 4/29/25 facility made aware that resident did not prefer the smoking apparatus and discontinued the apparatus on 4/30/25. Resident can safely hold a cigarette with supervision. Residents that smoke may have potential of being affected by deficient practice, therefore skin assessments were completed on all residents who smoke to ensure no burns identified from smoking. Assessments were completed by licensed nurses on 3/19/25. No areas of burns were identified. The Director of Nursing and licensed nurses re-assessed all residents who wish to smoke for need of supervision and/or adaptive equipment, no additional residents were noted. Assessments were completed on 3/19/25. On 3/19/25 The Director of nursing and licensed nurses reviewed care plans and Kardex's for all supervised and unsupervised smokers to ensure up to date and accurate with no additional concerns noted. On 4/20/25 the charge nurse completed a resident headcount to ensure that all residents were accounted for. There were no concerns with any other res[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, family, Hospice Nurse, Hospice Medical Director, and Nurse Practitioner (NP) interviews, the facility failed to manage the pain of 1 of 1 resident (Resident #1) who complained of pain and exhibited non-verbal cues of pain that included moaning, groaning, and grimacing as staff moved or touched her after returning to the facility from Emergency Department (ED) following a fall that resulted in a cervical one (C-1 - upper vertebrae in the neck) fracture in her neck and left humerus (upper arm) fracture on [DATE]. There was no pain treatment from the time Resident #1 returned from the ED until she was transferred to an inpatient hospice facility approximately 28 hours later. Immediate Jeopardy began on [DATE] when Resident #1 complained of pain and exhibited nonverbal signs of pain and no pain management was offered or administered. Immediate Jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D (no actual harm with more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of staff education. The findings included: Resident #1 was admitted to the facility from a hospital on [DATE] with diagnoses that included rheumatoid polyneuropathy (disease affecting multiple nerves of the body causing pain) with rheumatoid arthritis of multiple sites and chronic pain. Review of Resident #1's most current care plan dated [DATE] read, resident was at risk for uncontrolled pain because of the physical effects of aging, and history of chronic pain. Resident had diagnoses of rheumatoid arthritis, cervical spondylosis (deterioration of the spinal vertebrae), and acute pain related to fall with fracture to left lower leg. The goal read: The resident's pain would be managed to the greatest extent possible, so it did not affect day-to-day activities. Interventions included: evaluate the effectiveness of pain interventions every shift and as needed, to be gentle with care as movements could be very painful, give pain medications as needed within doctor's order guidelines, offer/provide non-medication interventions such as heat or cold, exercise, rest, guided imagery, repositioning. An additional intervention dated [DATE] was added: monitor for non-verbal expression of pain such as agitation, facial expression such as wincing, holding a body part, change in posture, refusing to eat, decreased level of activity, increased heart rate/rate of breathing, dilated pupils, sweating, anxiety, restlessness, difficulty sleeping, irritability or depression). Note vocalization such as moaning, crying, or screaming. Review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE] revealed Resident #1 was severely cognitively impaired, was not on a schedule pain medication regime, had not received any opioid's during the seven day look back period, and received Hospice services. Review of the physician orders revealed: [DATE] -Tylenol Tablet 325 milligram (mg) Give two 325 mg tablets by mouth every 6 hours as needed for fever/pain. [DATE] - Oxycodone HCL Tablet, give one 20 mg tablet by mouth every 6 hours as needed for pain. [DATE] - Hospice to provide care and services as appropriate. Resident #1's admission diagnosis was polyneuropathy of rheumatoid arthritis of multiple sites with a life expectancy of 6 months or less. Review of the [DATE] Medication Administration Record (MAR) from [DATE] through [DATE] revealed zero (no pain) was documented as Resident #1's pain level every shift. The MAR further revealed no pain medications were administered to Resident #1 during this time period. A nursing progress note written by Nurse #4 dated [DATE] at 1:12 PM indicated the resident was observed sitting on floor and Nurse #4 and a Nurse Aide (NA) assisted Resident #1 into the bed. Resident #1 was assessed, and vital signs were taken. The Nurse Practitioner (NP) came to observe Resident #1 and gave an order to send Resident #1 to Emergency Department (ED). Resident #1 was given her ordered PRN (as needed) pain medication and Emergency Medical Services (EMS) was called. Multiple attempts were made to contact Nurse #4 with no success. The March MAR on [DATE] indicated a score of ten (worst possible pain) on [DATE] immediately after she fell from her wheelchair and Resident #1 received a 20-milligram tablet of Oxycodone at 1:09PM which was administered by Medication Aide (MA) #2. In an interview on [DATE] at 11:41 AM with MA #2, she revealed she came into Resident #1's room on [DATE] when she heard a commotion and saw staff helping Resident #1 back to bed after she fell out of her wheelchair in her room. She stated she medicated Resident #1 with an Oxycodone 20mg tablet at 1:09 PM for pain just before Resident #1 went to the hospital. An ED physician progress note dated [DATE], revealed a computerized tomography scan (CT scan - technique used to obtain detailed internal images of the body) of the cervical spine revealed a cervical one (C-1 - upper vertebrae in the neck) fracture in her neck and an x-ray of the left shoulder/arm confirmed a left humerus (upper arm) fracture. The ED physician documented Resident #1 was medicated with 15 mg of Ketorolac Tromethamine (non-steroidal anti-inflammatory pain medication) for pain on [DATE] at 2:31PM. Additionally, he documented that Resident #1 already had pain medication ordered for her at the facility, so no additional pain medication orders were written. A nursing progress note written by Nurse #2 on [DATE] at 6:00 PM, read, resident was assisted into the bed by two EMS staff. Resident has a splint on her left arm. Elbow placed on pillow for comfort. Resident is arousable but sleepy. During an interview on [DATE] at 1:10 PM with Nurse #2, she stated she cared for Resident #1 after EMS brought her back to the facility on [DATE] from the ED. Nurse #2 stated Resident #1 was calm and sleepy and was put directly in bed upon re-admission. Nurse #2 stated Resident #1 was confused but did not require any extra care more the normal level of care that shift. Nurse #2 stated she gave Resident #1 her regular medications but did not give any pain medications because she did not feel Resident #1 was in any pain as she did not ask for pain medicine. In an interview on [DATE] at 3:24 PM with Nurse Aide (NA) #8, she stated she was not assigned to Resident #1 on [DATE] but assisted with Resident #1's transfer from the EMS stretcher back to bed when she returned from the ED on [DATE] at approximately 5:45 PM. She stated she could tell Resident #1 was in pain because she was moaning, groaning, her face was curled up, and she grimaced as they moved her. She stated she informed the nurse of Resident #1's pain but unsure if Resident #1 received any pain medication. She stated she could not recall who the nurse was to whom she reported the pain concerns. The MAR for [DATE] for the night shift revealed Nurse #3 documented a pain level of 10 and no pain medication was administered. In a phone interview with Nurse #3 on [DATE] at 10:10 AM, he stated he cared for Resident #1 on the night shift that began on [DATE] and ended on [DATE] when Resident #1 returned from the ED. He stated she was confused and not communicative or verbal, had an uneventful shift and was in bed all night. He stated she could not vocalize her needs, but he looked for non-verbal cues of pain such as clenching her teeth or grimacing and did not recall any. He stated he did not recall that he documented Resident #1 had a pain level of 10 on the [DATE] night shift pain scale. He stated her pain level might have been a 1-2, but not a 10. He stated he had never scored anyone's pain as a 10. Nurse #3 stated if Resident #1's pain had been a 10, he would have medicated her for pain and called the physician. He stated he would not let a resident be in that kind of pain. He stated he did not administer any pain medication to Resident #1. Nurse #3 indicated he was unable to recall which NA worked with him and/or cared for Resident #1. The [DATE] MAR revealed only one pain level was recorded by Nurse #6. On [DATE] during the day shift, Resident #1's pain score was recorded as zero. The MAR further revealed Resident #1 had not been administered pain medication at the facility. In an interview on [DATE] at 11:07 AM with Nurse Aide #7 he stated he cared for Resident #1 on [DATE], the day shift after her fall. He stated Resident #1 had arm pain that afternoon and she asked for pain medicine. He stated she was often confused but that day she could tell him that she was in pain. He stated Resident #1 showed signs of pain such as she grimaced when she moved and wouldn't eat since the fall. He stated he reported Resident #1's pain and request for pain medicine to the MA working the 100 hallways, but he could not recall the MA's name or if she ever medicated Resident #1. He stated she stayed in bed all day on his shift. In a phone interview [DATE] at 2:30 PM with Nurse #6, she stated she worked the day shift on [DATE] on the 100 hallway. She stated she was supposed to still be in her training period but had to work a cart until 3:00 PM because a MA did not show up for work. She stated she did not receive any report and did not know anything about Resident #1. She stated she recalled when she first saw Resident #1 on [DATE] she was covered in bruises. She stated no one could tell her what happened to Resident #1, and she did not know how to navigate the electronic medical record well enough to look at her history. She explained that she had received very little training on the electronic medical record system prior to working on the floor on [DATE]. She did not recall that Resident #1 was in any pain, so she didn't offer pain medications. She stated when she gave Resident #1 her other scheduled medications, she spit them out. She stated at 3:00 PM, a MA came to take over the cart, but she did not know the name of the MA. She stated Resident #1's Family Member #2 came to see her in the afternoon and asked her what exactly had happened, and she had to tell the family member she did not know. Nurse #6 stated the family member did not tell her Resident #1 was in pain. An interview was conducted on [DATE] at 10:10 AM with Family Member #1. The Family Member #1 stated Resident #1 fell out of her wheelchair in her room and was sent to the ED and she was diagnosed with a fractured left arm and a neck fracture. Family Member #1 stated Resident #1 was always in a lot of pain from her rheumatoid arthritis and other medical issues. Family Member #1 stated they knew the facility could only give a certain amount of pain medication, and Hospice could give more pain medication and had heard Hospice was much better at pain control, so the family placed her in Hospice care. Family Member #1 stated the day after Resident #1 fell ([DATE]), Family Member #2 was with her during the day and called him and stated Resident #1 had been sitting up all day in her wheelchair and was in excruciating pain and did not get any pain medicine all day. Family Member #1 stated after he heard from Family Member #2, he immediately called the Hospice Nurse and asked her to come relieve Resident #1's pain because he knew she could do more for her than the facility staff, and he wanted Hospice to take her out of the facility and transfer her to an inpatient hospice facility. In a phone interview on [DATE] at 1:50 PM with the Hospice Nurse who was on-call the weekend of the fall ([DATE]), she stated she received a voicemail from the facility on Friday night, [DATE], and was told that Resident #1 had fallen but they did not mention that they had sent her to the hospital. She explained that she was the on-call nurse for hospice and was not familiar with Resident #1. The Hospice Nurse stated she tried to call the facility several times on Friday night ([DATE]), but the phone was never answered. She stated she called the facility on Saturday, [DATE] around noon, and was told that Resident #1 was fine so she assumed the resident was not sent to the hospital. She stated Resident #1's Family Member #1 called her on [DATE] at 6:28 PM and told her Resident #1 had fallen the day before and was sent out to the hospital and sustained fractures in her neck and left arm. The Hospice Nurse stated Family Member #1 told her Resident #1 was in excruciating pain and had been up in a wheelchair all day. The Hospice Nurse stated Family Member #1 asked the Hospice Nurse for help with Resident #1's pain and told her the family wanted their mother transferred to an inpatient facility for Hospice services. The Hospice Nurse stated she called the Hospice Medical Director who was on-call for the weekend and received new pain medication orders for liquid morphine (pain medicine) and Ativan (anti-anxiety medication). She stated she again tried to call the facility and former Director of Nursing (DON) #1 (DON at the time of the incident on [DATE] - [DATE]) regarding the new pain medication orders without success. The Hospice Nurse arrived at the facility on [DATE] at 8:10 PM and was directed by staff to several incorrect hallways but finally located Resident #1 on the 100 hallway. She stated Resident #1 was confused and grimaced when she moved and was guarded and did not want the Hospice Nurse to touch her left arm. The Hospice Nurse stated Resident #1 was grinding her teeth while trying to breathe and her respirations were 28-30 a minute. The Hospice Nurse stated she spoke with a facility nurse whose name she could not remember and told the facility nurse she had new pain medication orders for Resident #1. The facility nurse stated she did not know if they had any liquid morphine or Ativan in the facility. The facility nurse stated former DON #2 was coming in at 11:00 PM (the nursing supervisor at the time of the incident on [DATE] - [DATE]) and she would know if they had the medications. The facility nurse stated she didn't want to call former DON #2 because she was working that night and she didn't want to wake her up. In a second phone interview with the Hospice Nurse on [DATE] at 3:46 PM, she stated when she spoke with the MA on the 100 hallway, the MA stated she did not know Resident #1 and she had not gotten to her room yet to see her. The Hospice Nurse then tried to find someone in charge to help her with getting the new pain medication orders faxed to the pharmacy. The Hospice Nurse stated she ended up on the 500 hallway and a nurse whose name she did not recall, and she was also unsure about what medications were on hand in the facility. An unknown facility nurse finally called former DON #2 who told the Hospice Nurse she would be there at 11:00 PM and she would then check on what medications they had on hand. The Hospice Nurse stated she asked the former DON #2 if they transferred out Resident #1 for immediate pain management, would Resident #1 still have a bed available when she was ready to return to the facility. The Hospice Nurse indicated former DON #2 stated she thought the bed would be held for 30 days. The Hospice Nurse stated originally they planned to move Resident #1 the next day on [DATE], but once it was clear Resident #1 would have to wait until at least 11:00 PM for pain medication, and because the level of Resident #1's pain, she called her Hospice Medical Director and the Hospice Administrator and they all felt it was unsafe to leave Resident #1 in the facility until the next day and decided to immediately transfer Resident #1 to an inpatient hospice facility for pain management. Resident #1 was transferred to an inpatient hospice facility by EMS on [DATE] at 10:15 PM. In a phone interview with MA #3 on [DATE] at 3:22 PM, he stated he worked on [DATE] the day after Resident #1 fell. He stated he took over a medication cart at 3:00 PM from Nurse #6, but soon was pulled to another hall and could not remember who took over for him or where he was pulled to work. He stated he never saw Resident #1 that shift and denied that he spoke to a Hospice Nurse regarding Resident #1. He confirmed that anyone assigned to a cart, nurse, or MA, had keys to the narcotic box and could obtain and administer narcotics. He further stated liquid morphine was kept in narcotic cart. In an interview on [DATE] at 5:19 PM with NA #9, she stated she worked the 100 hallway for the 3:00 PM-11:00 PM shift on [DATE] and stated she recalled Resident #1 and did care for her on that shift. She stated she was the only NA on the 100 hallway that shift. She stated Resident #1 was calm and hard to wake up, but she would open eyes and mumbled. She stated she informed a nurse that Resident #1 was not communicating or showed any kind of reaction to anything. NA #9 could not recall which nurse she spoke with about Resident #1. She stated later in her shift a nurse, or a doctor came to check on Resident #1 and then someone called EMS and an ambulance came and took Resident #1 away. She stated she did not know who called EMS or where Resident #1 was going. In a phone interview with former DON #2 on [DATE] at 2:20 PM, she stated that nobody ever called her about liquid morphine or Ativan or any other pain medication on [DATE], for Resident #1. She stated if they had called her, she only lived three minutes away from the facility and would have immediately gone to the facility and assisted with Resident #1's pain management issues. In a phone interview on [DATE] at 3:18 PM with Nurse #5, she stated she was not assigned to Resident #1, but did go see her sometime on [DATE] on the 3-11 PM shift because she just wanted to see her. She stated Resident #1 was able to tell her she was in pain, and she was grimacing when she tried to move and was making facial grimaces. She stated she didn't tell anyone because she knew Resident #1 was already on daily pain medication. She stated she recalled that a Hospice Nurse came and asked for help with gathering the paperwork for Resident #1's transfer to an inpatient hospice facility. Nurse #5 denied that she had any discussion with the Hospice Nurse about pain medication for Resident #1. In an interview with the Unit Manager on [DATE] at 10:26 AM, she stated the facility had a safe for narcotics for emergencies and they had liquid morphine and Ativan. She stated all the nurses and MAs had the code and access to the safe. In an interview on [DATE] at 12:00 PM with the Nurse Practitioner (NP), she stated Resident #1 was usually in a confused state. She saw the resident after the fall on [DATE] and sent her to the ED for evaluation. She stated Resident #1 had severe rheumatoid arthritis, but she hadn't heard any complaints of pain lately. She stated when she was alert and oriented, she was very vocal about getting her pain medication, but as she declined, she had stopped asking for pain medication. The NP stated she didn't see Resident #1 after she went to the hospital. A phone interview was conducted on [DATE] at 5:15 PM with the Hospice Medical Director and she stated she was contacted by the Hospice Nurse on [DATE] to discuss Resident #1's lack of pain management after a fall where she sustained serious injuries. The Hospice Medical Director stated she gave the Hospice Nurse new pain medication orders, but the Hospice Nurse ran into many barriers in the facility as she tried to get Resident #1 adequately medicated for pain. She stated the Hospice Nurse, the Hospice Administrator and herself made the decision to have Resident #1 transferred to an inpatient hospice facility that evening for pain management. She stated that Hospice inpatient called her when Resident #1 arrived and told her Resident #1 was in intense pain, yelling and moaning in pain when touched or with any gentle movement, and had bruises on her hands, face, and legs. She stated once they stabilized her neck, medicated her for pain, she was calm and comfortable. The Hospice Medical Director stated they gave her pain medications around the clock to keep her comfortable. The Hospice Medical Director stated it was never their first choice to put a resident through the pain and stress of a transfer out of their home, but in this case, Resident #1 was not receiving appropriate pain management so for her well-being an intervention was required. She stated it would have been much easier on Resident #1 if she could have stayed in the facility and had her pain managed appropriately. She stated the staff were clearly not reading or responding to Resident #1's non-verbal pain cues. The Medical Director stated Resident #1 died on [DATE]. In an interview with the Interim DON, on [DATE] at 4:30 PM, she stated Resident #1's pain should have been handled better. She stated the staff should have completed more pain assessments and looked more carefully for non-verbal pain cues such as guarding, moaning, grinding teeth, and have medicated Resident #1 and called the provider. On [DATE] at 1:52 PM, the Interim Director of Nursing and the Regional [NAME] President of Operations were notified via phone of immediate jeopardy. The facility provided the IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Based on record review and staff interviews, the facility failed to manage the pain of Resident #1. Resident #1 had complained of pain and exhibited non-verbal cues of pain which included moaning, groaning, and grimacing. Resident #1 had returned from the Emergency Department on [DATE] at 5:45 PM following a fall with serious injuries. Resident had an order for PRN (as necessary) pain medication upon readmission. Resident received routine medication of Ativan at 10:00 PM and had no documentation of pain after the 10:00 PM medication administration. Resident #1 received no PRN pain medication after her return from the Emergency Department, although medication was available if needed. Resident #1 expressed pain at the facility to a non-facility staff person (Hospice Nurse) which precipitated transfer to an inpatient hospice for pain management. Current facility residents are at risk of being affected by the alleged deficient practice of not managing pain despite non-verbal cues observed by staff. The Director of Nursing and nurse supervisors completed an audit of facility residents on [DATE] to include a pain assessment to ensure no other residents were affected by the deficient practice. There were no adverse effects or other residents identified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The Director of Nursing and Nurse supervisors completed education to nurses, medication aides, and nursing assistants on [DATE], regarding non-verbal cues of pain. Nurses, medication aides and nursing assistants not working on [DATE] received education prior to starting shift, including Agency staff. New nursing staff will receive education regarding non-verbal cues of pain and medication for pain management by the Director of Nursing or nurse supervisors. The Director of Nursing or nursing supervisor will be responsible for ensuring that this education is provided prior to the start of any assignment in which they are working. On [DATE] licensed nursing staff were educated by the Director of Nursing and nurse supervisors to ensure appropriate documentation was completed on residents with pain. Nurses and medication aides not working on [DATE] received education prior to starting shift, including agency staff for substantial compliance. The facility alleges the removal of the immediate jeopardy on [DATE]. Validation of the immediate jeopardy removal plan was conducted in the facility on [DATE]. The facility's initial audit was verified and signature sheet for education reviewed with no concerns. Facility nurses were interviewed and were aware of the pain management protocol, how and when to assess pain and how to appropriately respond to a resident's request or nonverbal signs of pain. Facility Medication Aides were also aware of the pain protocol and how to observe for nonverbal signs of pain and how to respond. Facility Nurse Aides were also interviewed and were able to verbalize how to respond to resident complaint of pain and recognize nonverbal signs of pain and who to report them to. The facility's immediate jeopardy removal date of [DATE] was validated.