**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, interviews, and review of video footage, the facility failed to protect Resident (R)1 from mental and verbal abuse for 1 of 3 residents reviewed for abuse. Specifically, 2 (two) Certified Nursing Assistants (CNA)s video recorded their interaction with R1 and posted the video to social media. On 04/12/24 at 12:45 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 04/09/24. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 04/12/24 at 1:19 PM, the facility provided an acceptable IJ Removal Plan. On 04/12/24, the survey team, validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance. The IJ is considered at Past Non-Compliance as of 04/10/24. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the facility policy titled Dress Code/Phone Policy Updates updated on December 2019, documented, Phones/Social Media/Misc: 1) No using personal mobile phones while in patient care/reception areas 3) No pictures of patients/residents other than as part of activity where legal disclosures are signed. 7) No posting of patient information on social media sites. Review of the facility undated Employee Handbook, documented, Telephone Use Taking photographs or recordings of a resident and/or his/her private space without a resident's or designated representative's written consent is a violation of the resident's right to privacy and confidentiality. Review of the facility policy titled Organizational Ethics Abuse, Neglect, Exploitation, or Mistreatment with an email revision date of 10/23/19, documented, Policy 7. The facility strictly prohibits staff from taking or using photographs or recordings obtained in any manner on any type of device (e.g , camera, smart phone or other electronic device) that would demean or humiliate a patient or resident. Definitions as defined by CMS section 483.5: 1. Instances of abuse of all residents, irrespective of any mental or physical condition, cause harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 5. Mistreatment means inappropriate treatment or exploitation of a resident. Component IV: Identification 2. Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness. Types of abuse include BUT ARE NOT LIMITED TO: B. Mental Abuse: 1) Humiliation 2) Harassment 5) Intentional disrespect or disregard for an individual's right to privacy and dignity as it relates to their person and property. This may include but is not limited to photographing or recording video or audio of a patient/resident or their personal environment or property without consent. D. Verbal abuse includes any use of: 1) Oral language Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: dementia, chronic obstructive pulmonary disease, anxiety disorder, need for assistance with personal care, dysphagia, cognitive communication deficit, and major depressive disorder. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/24, revealed a Brief Interview for Mental Status (BIMS) was not conducted due to R1 being rarely/never understood. Further review of the MDS, under section GG-Functional Abilities and Goals, revealed R1 is dependent on staff (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Review of R1's Care Plan with a problem start date of 08/16/23, documented, [R1] is dependent on staff for meeting emotional, intellectual, physical, and social needs. Further review of the Care Plan revealed a Care Plan with a problem start date of 06/03/22, documented, [R1] requires extensive to total assist with ADL's [activities of daily living] due to confusion and weakness. Another Care Plan with a problem start date of 11/04/21, documented, [R1] is at risk for complications related to impaired communication and cognition. The goal for this Care Plan stated, [R1's] dignity and self-esteem will be preserved and quality of life improved by minimizing risk associated with cognitive and communication impairment . Review of video footage provided by the facility, revealed text at the bottom of the video which read, Southpointe Healthcare and Rehabilitation Greenville, SC. The text at the top of the video revealed a name (later identified as CNA2) and the time of 10:29. Further review of the video footage revealed CNA1 and CNA2 (later verified by the Administrator and Director of Nursing) mocking and laughing at R1. CNA1 could be heard stating, we ain't got no wee wee for you. CNA2 begins to laugh out loud at the remark made by CNA1. R1 could be heard yelling and telling the CNAs to get out. R1 continues to yell unintelligibly through the remainder of the video. At one point, the video shows R1, with a linen covering her upper body and head. R1's legs were visible from the bottom of the linen and were kicking as if R1 was in distress. CNA2 continues to laugh out loud. CNA2 stated, I bought you a fresh blanket. CNA1 responded, . if you yell, I'm going to take it back . CNA2 can be seen exiting R1's room. Review of a Witness Statement dated 04/09/24, written by the Director of Nursing (DON), revealed at 10:30 PM, I received a phone call from Social Services Director about a possible video that was made by possible staff members. At 10:45 PM, I received a call from Human Resources that the video was received and I needed to call and suspend the staff involved. At 10:50 PM, I called to the facility and spoke with [CNA2], I asked him who was inside the room with him when he made that footage on the self-deleting app. He stated nobody. I then made him aware that he was suspended pending investigation. He hung up the phone. At 10:56 PM, I called back to facility and spoke with [Licensed Practical Nurse], I asked her who was assigned to [R1] she stated [CNA1]. I asked to speak with her. Once on the phone I asked [CNA1] was she inside of the room with [CNA2] when he made the video on the self-deleting app and she stated yes ma ' am. I then made her aware that I was so disappointed in her and that I would have to suspend her at this time pending investigation. She stated ok. Review of a Witness Statement signed on 04/11/24, by the Administrator, revealed, On 04/09/24, I received a call at 10:52 PM from the DON. She explained that she was notified by the Social Worker there was video that had been posted on social media of two employees and the video showed the employees in a resident room and the resident could be seen . Review of [local police department] County Sheriffs Office Victim/Witness Assistance Program dated 04/10/24, revealed the local police department conducted an investigation related to Abuse Vulnerable Adult. Review of a Suspension Form dated 04/09/24, revealed Certified Nursing Assistant (CNA)1 was suspended Due to an allegation of abuse, employee was heard on a video that was posted on social media, the employee could be heard telling the resident we don't have a wee wee for. Employee could also be heard saying stop yelling. DON [Director of Nursing] notified employee by phone that she was being suspended pending an investigation. Review of a Termination Form dated 04/10/24, revealed CNA1 was terminated from employment due to gross misconduct. Further review revealed CNA1 was terminated for Employee Termed for Resident Abuse. Review of a Suspension Form dated 04/09/24, revealed CNA2 was suspended Due to allegation of abuse. Employee was seen in a video while another CNA was providing care. This video was posted on social media. [CNA2] was heard/seen mocking the resident who has diagnosis of dementia. The video had the facility name shown. The employee was notified by the DON that he was being suspended pending an investigation. Review of a Termination Form dated 04/10/24, revealed CNA2 was terminated from employment due to gross misconduct. Further review revealed CNA2 was terminated for Employee Termed for Resident Abuse. Multiple attempts were made to contact CNA2, but were unsuccessful. During an interview on 04/12/24 at 11:58 PM, the DON stated, I got a call Tuesday night from Social Service Director and she said there is possibly a video of a staff of ours. But she did not have the actual footage. Somehow she got the footage and notified HR, and HR called me stating they got the footage and to suspend the CNAs. I came on site and saw the video and identified the male CNA. I questioned the male CNA and he said he was alone, I told him he was suspended and he hung up the phone. I talked to the nurse on duty and she verified [CNA1] was the other CNA. [CNA1] stated she was in the room with [CNA2] when he took the video. I informed her she was suspended. I notified everyone. During an interview on 04/12/24 at 12:28 PM, CNA1 stated, unfortunately I cannot talk about it without my attorney present. During an interview on 04/12/24 at 1:18 PM, Social Services (SS) stated, I got a call from a member stating I need to see something. The member wanted to remain anonymous. She facetimed me and showed me the video that was on Snapchat (a social media platform). After I saw the video, I called the DON and HR. I was able to identify who was in the video and I saw the patient. I knew the staff member by face but not by name. I initially thought it was agency, and I knew he was in the building. On 04/12/24 at 1:19 PM, the facility provided a removal plan of the IJ which included: Alleged perpetrators suspended pending investigation immediately upon discovery. Head to toe completed on identified Resident #1 on 4-9-24 with no negative outcomes. Psychosocial evaluation completed on resident by licensed social worker on 4-10-24. Resident #1 was referred to psychiatry and psychology for follow up. A review of the 24 hour report and facility activity report was completed on 4-10-24 by the Director of Nursing beginning 4-9-24 through 4-10-24 to identify possible allegations of abuse or neglect. No concerns identified at this time. The Administrator and Director of Nursing will be re-educated by the Clinical Consultant on Abuse and Neglect policy including: -Identification of abuse or neglect, by observable and objective evidence, witness reports of unusual occurrence or patterns or trends of potential abuse or neglect -Abuse is the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual of goods or services that are necessary to maintain physical, mental and psychosocial wellbeing. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse -Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish or mental illness -Immediate identification and removal of the alleged perpetrator -Identification and assessment of the alleged victim -Reporting immediately to State Survey and Certification agency -Resident dignity -HIPPA -Cellphone usage in the facility and Social Media usage in the facility. This reeducation was completed on 4-10-2024 Facility Staff were re-educated by the Administrator on 4-9-24 Abuse, Neglect and Misappropriation policy including: -Identification of abuse or neglect, by observable and objective evidence, witness reports of unusual occurrence or patterns or trends of potential abuse or neglect -Abuse is the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual of goods or services that are necessary to maintain physical, mental and psychosocial wellbeing. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse -Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish or mental illness -Immediate identification and removal of the alleged perpetrator -Identification and assessment of the alleged victim -Reporting immediately to Facility Abuse Coordinator, Director of Nursing, and Social worker regardless of time of day Facility Staff were re-educated by the Administrator on 4-9-24 including -Process of reporting -Resident dignity -HIPPA -Cellphone usage in the facility and Social Media usage in the facility. This reeducation began immediately and will be completed by 4-12-24. Any staff not receiving this information prior to this date will receive prior to next scheduled shift. This education will be presented in New Hire and agency staff orientation. Administrator contacted Regional Ombudsman on 4-10-24. Administrator and Director of Nursing will review incident reports and grievance reports daily for identification of possible allegations of abuse. Members of nursing Management will interview 3 random residents daily for one week, then weekly for three months validating residents feel safe and have no care concerns. The results of this monitoring will be presented to the Quality Assurance/Performance Improvement Committee for a period of three months for review and recommendation. Any identified concerns will be addressed at the time of discovery. Human Resources will interview 3 random employees daily for one week, then weekly for three months for compliance with Abuse, Neglect, Misappropriation, resident dignity, process of reporting, resident dignity, HIPPA, cellphone usage in the facility and Social Media usage. Ad Hoc QAPI was held on 4-10-24. The Medical Director was notified of the Immediate Jeopardy on 4-12-24. Allegation of Compliance- 4-10-24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Additional findings include A review of a facility policy titled, Safety and Health Policies and Procedures, dated 11/01/2018, indicated, General Oxygen Safety, 1. Oxygen cylinders shall be stored in racks with chains, sturdy potable carts, or approved stands. 8. Oxygen cylinders shall not be dragged or slid across floors. 10. Oxygen cylinders shall never be left freestanding. Also indicated while at work, use good judgement regarding safety and that all times remember, an accident/injury cannot be undone. A review of the Face Sheet indicated the facility admitted R40 with diagnoses that included sepsis, hypokalemia, peripheral vascular disease (PVD), difficulty walking and lack of coordination. The quarterly MDS with an ARD of 04/12/2023, revealed R40 had a BIMS score of 15, which indicated the resident was cognitively intact. The resident was independent with bed mobility, eating and toileting. On 07/09/2023 at 12:00 PM, R40 was observed in their room with an oxygen cylinder at doorway leaning against the wall without being placed in a stand or secured from tipping over. Oxygen tubing was still attached to the oxygen cylinder and loosely wrapped around the cylinder and concentrator. During a concurrent observation and interview on 07/09/2023 at 12:00 PM, R40 was observed sitting in a wheelchair at bedside with the arm rest on the wheelchair raised up high with resident's arms resting on the arm rest at chest level. R40 stated that the arm rests were loose. R40 showed surveyor how the arm rests were loose and moved back and forth freely. R40's hips were pushing against the arm rests. R40 stated their hips hurt because the wheelchair was too small. During an interview on 07/09/2023 at 1:35 PM, Certified Nursing Assistant (CNA)3, stated that the oxygen cylinder was not supposed to be in the resident's room unsecure and was a hazard. During an interview on 07/09/2023 at 1:45 PM, LPN1, stated she was called in to work and that she was the one that removed the cylinder from the resident's room. She stated that was a hazard because the oxygen cylinder was not on a stand and was leaning against the wall. During an interview on 07/12/2023 at 12:07 PM, the Social Service Director (SSD) stated that she was not aware of problems with R40's wheelchair and that she would let therapy know so that R40 could be evaluated. During an interview on 07/12/2023 at 12:21 PM, LPN1, stated that she checked the wheelchair and seen the arm rest. She stated the arm rests were too high for R40's stature, and the wheelchair was too tight. She stated that she was going to check to see if they have other arm rest available to fit R40. During an interview on 07/12/2023 at 12:32 PM, the Director of Nursing (DON) stated that she expected oxygen cylinders to be in a holder or secured. She stated that she was not aware of R40's wheelchair and had not evaluated it herself. She stated therapy was responsible for measuring wheelchairs for the resident and expected a resident's wheelchair to fit appropriately and to be in a safe operating manner. During an interview on 07/12/2023 at 1:04 PM, the Administrator (ADM) stated that oxygen cylinders should be secured in a cart or on a stand and not leaning up against the wall unsecured. She stated that when an oxygen cylinder was not being used the oxygen cylinders should be put in the oxygen storage closet. She stated that she did not know about R40's wheelchair. She stated she expected oxygen cylinders to be stored properly. She expected residents' wheelchairs to be maintained safe and fit properly. A review of R71's Face sheet revealed the facility admitted the resident with diagnoses which included, myasthenia gravis, insomnia, opioid use, recurrent depressive disorders, supraventricular tachycardia, gastro-esophageal reflux disease without esophagitis, fusion of spine cervical region, and mixed hyperlipidemia. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/19/2023, revealed R71 had a Brief Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A review of R71's comprehensive care plan initiated 04/19/2023 revealed there was no care plan to address the resident leaving the facility to go smoke off the property. A review of R71's progress note on 06/15/2023 at 11:50 AM written by the social worker (SW) stated, SW and Assistant Director of Nursing (ADON) educated resident about signing in and out, also about not having paraphernalia on campus. Also not allowing other residents to hold on to his chair to go up the road. A review of R71's progress note dated 06/19/2023 at 05:55 AM written by Licensed Practical Nurse (LPN)4 revealed, Resident's room had strong odor of cigarette smoke. When questioned, resident admitted to 'burning something'. When asked about smoking a cigarette he stated, that's what I burned. Resident refused to give Nurse his lighter. Informed resident that I would have to report the incident to management. A review of R71's progress note dated 06/19/2023 at 09:04 AM written by the SW revealed, Staff contacted SW about resident smoking in room and would not give cigarette and lighter to the staff. SW will talk with administrator about plan. A review of R71's progress note dated 06/19/2023 at 03:16 PM written by the SW revealed, Administrator met with resident to educate that facility is smoke/vape free. Went over that resident has to sign in and sign out. No paraphernalia allowed on campus including alcohol. Resident was also explained that a warning letter and 30-day dc notice will be given if not in compliance. Review of R71's Release of Responsibility for leave of absence Signing Out revealed the following: 5/26/23 1:43 PM 5/30/23 3:21 PM 6/2/23 (no time written by date) 6/3/23 2:33 PM 6/4/23 3:24 PM 6/7/23 1:56 PM 6/8/23 2:27 PM 6/9/23 2:43 PM 6/15/23 2:23 PM 6/16/23 2:18 PM 6/20/23 2:44 PM 6/21/23: 4:57 PM 6/22/23 12:27 PM 6/23/23 3:45 PM 6/28/23 3:30 PM 6/30/23 2:44 PM 7/1/23 5:23 PM 7/3/23 11:47 AM 7/7/23 2:40 PM The Signing IN revealed dates and times of: 5/6/23 3:25 PM 5/26/23 2:30 PM was struck out. 6/25/23 2:30 PM 6/1/23 9:21 PM An interview with R71 on 07/10/2023 at 9:43 AM revealed the resident left the facility a few times a day, unsupervised. R71 stated, I go outside and ride around. I sign in and out at the front desk. I don't smoke cigarettes; I only smoke black and mild. I don't buy packs of anything; I only buy one and I smoke them before I come back to the facility. I'm usually back by dinnertime. An interview with the SW on 07/10/2023 at 10:53 AM revealed the SW worked at the facility since 2014. The SW stated R71 was one of the smokers in the facility. She also stated, The smokers have been educated to sign themselves in and out and not have lighters or paraphernalia on their person. We are a smoke free facility, and we have residents who are non-compliant. The resident had a lighter and refused to give it to a staff member. Resident was educated on the fact that he could have smoking paraphernalia on them, and they would be given a 30 day notice if behavior persisted. The resident was re-educated on 7/10/23. During an interview on 07/10/2023 at 11:02 AM, Licensed Practical Nurse (LPN)4 stated, I was doing a med pass and I went passed the residents' room and I smelled the cigarette smoke. When I walked into R71's room I smelled the smoke. I asked the resident were they smoking, and they stated they had just lit something. I asked was it a cigarette and they stated yes, but I wasn't smoking. I asked for their lighter and cigarette and they refused to give them to me. I informed them I would let the administrator know and they didn't care. I made the facility aware, and the resident still refused to give them to anyone. This was only incident I've had with this resident with smoking. It's hard to keep up with the residents who smoke. They will come in and leave back out. It's hard to keep up with the smoking resident's when doing a medication pass. I have come to work and they're on the corner of the street. They could easily get hurt with the traffic on the roads. During an interview with the Administrator on 07/10/23 at 3:30 PM, the Administrator stated that the facility is a non-smoking facility and therefore the facility does not complete smoking assessments. The Administrator also stated that the facility does not care plan for smoking because residents can have therapeutic leave. The facility only has 3 resident that sign themselves out and the residents have decisional capacity. Decisional capacity was what the facility used to determine if a resident can make decisions. The Administrator further revealed that when residents are going out to smoke, the staff try to confiscate any cigarettes or lighters the residents may have. The residents are not always cooperative, and the facility can't search the residents or force the residents because the residents have rights. During an interview on 07/12/2023 at 07:49 AM, the Medical Director (MD) stated the smoking residents have the decisional capacity to sign themselves in and out of the facility. We advise the residents against drinking, smoking, and using illegal substances. We can't chain the residents to the bed. The nurses have been telling me about everything involving the residents smoking. R71 stated we can't stop R71 from going out and smoking. The MD stated R71 stated they don't care what the facility says. The facility has offered smoking cessation and nicotine patches and that doesn't help. The Medical Director states she fears if the facility does not let the smokers sign themselves out, smokers will smoke in their rooms. During an interview on 07/12/2023 at 08:21 AM, the Director of Nursing (DON) stated the facility was a non-smoking facility. The residents who smoked reviewed the smoking policy and know that smoking materials are prohibited in the facility. When we screen residents for smoking history prior to admission. We offer cessation. Because the facility is a non-smoking facility, the facility doesn't complete smoking assessments. The facility can't deem the smokers safe to smoke because that would be violate the facility's policy. The policy says you can't smoke in or around the facility. Residents can sign themselves out if they are decisional. The residents can go off the property. The staff have completed smoking cessation more than once with the smoking residents. The facility can't stop them from smoking when the residents leave the property, but the facility can try to keep them safe when they leave off the property. Social services, the Administrator and the DON have met with the smokers to let them know when they do not comply with the non-smoking rules, they would be given discharge notices. The residents are required to sign in and out of the facility. The facility has asked the residents to check in with the nurse when they come back in the facility and to hand over their smoking material. Although, the facility was a non-smoking facility, the staff should not be the gate keepers for smoking material. Technically, the residents should be taken off the property to smoke and not bring those materials into the facility. Based on interview, observations, record review and review of facility policies the facility failed to protect 3 of 4 sampled residents from accidents and/or accident hazards, Residents (R)99, R70 and R71. On 07/10/23 at 1:25 PM, the Administrator was notified that the facility's failure to protect residents from accidents and/or accident hazards by allowing R99, R70 and R71 to sign out of the facility to smoke and not signing back in the allowing the facility to not having the knowledge of knowing were the residents are located. Furthermore, a vaporizer (inhalation device) was discovered in the possession of R99. Administrator was notified that the allegations constituted Immediate Jeopardy (IJ) at F689, with an effective date of 06/14/23 and the IJ template was presented. On 07/11/23 at 10:38 AM the Administrator provided an acceptable IJ removal plan for F689, the immediacy of the IJ was removed and the IJ was lowered to the scope and severity of E, no actual harm with the potential for more than mini al harm that is not IJ. In addition, the facility failed to ensure a resident's room and wheelchair were free of potential accidents and hazards for R40. Specifically, R40 was observed with an unsecured oxygen cylinder in their room, and a wheelchair that did not fit properly and had unsecured wheelchair arms. Findings Include: Review of policy titled Leaving the Facility in the facility's admission Handbook, revised on 02/2022, revealed that Residents may leave the facility at any time with written permission from their physician. It is essential that you sign-out with the charge nurse or supervisor when you leave the facility and that you check-in with them upon your return. Review of policy titled Smoking Policy in the facility's admission Handbook, revised on 02/2022, revealed that All residents are prohibited from keeping any type of smoking materials in their rooms or on their person. Violations of this policy endanger the health and safety of others at the facility. Review of facility policy titled, Day Outings/Therapeutic Leave of Absences, with a revision date of 10/01/20 states .The LOA must be consistent with the resident's goals for care which are evaluated by means of the Comprehensive Assessment and incorporated into the Comprehensive Plan of Care. Facility staff will document Voluntary Leave Notification and Release of Liability information in the patient's/resident's medical record for use in coordinating day outings/LOAs. Alternatively, the facility may use a log with individual Voluntary Leave Notification and Release of Liability forms for signature that are added to the electronic medical record . Review of R99's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/19/23 revealed a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating the resident was moderately, cognitively impaired. Review of R99's care plan revealed that R99 was not care planned to smoke nor for leave of absences as stated in the facility policy. Review of R99's Progress Notes revealed the following : On 06/15/23 SW and ADON educated resident about signing in and out, also about not having paraphernalia on campus. On 06/20/23 3:25 PM Administrator met with resident to educate that facility is smoke/vape free. Went over that resident has to sign in and sign out. No paraphernalia allowed on campus including alcohol. Resident was also explained that a warning letter and 30 day dc notice will be given if not in compliance. On 06/22/23 at 4:08 PM staff reported resident up at store with sign asking for money. resident was educated about riding up the road and other activities. resident continued to go further up road On 07/06/23 at 4:43 PM Resident went LOA after lunch . resident refused to get out of electric chair & stated I need to get my book & find some where else to stay resident went outside without signing himself out On 07/06/23 5:34 PM Resident left building without signing out, resident remained in electric chair. Resident had his walker [NAME] to back of electric chair when he went out the door. On 07/06/23 at 6:12 PM Resident requested PRN oxycodone, given as ordered. Resident was instructed to stay inside for a while after taking to that staff could monitor for safety, resident said he was going to eat food & go out to smoke. On 07/08/23 1:12 AM This resident has been in and out of facility this shift. Staff member located this resident outside in driveway earlier and requested for resident to sign himself out when leaving property, Resident stated that he is looking for another facility to go to because this one is too strict. This writer attempted to reorient resident to safety precautions. Resident resting in bed at this time. Call light in reach. On 07/10/23 . administrator went over sign in and out , not to have lighters, cigarettes/vapes, alcohol, and resident has the right to go to a facility that allows smoking. Resident was also given a warning violation letter with required signature. During an observation of R99's room on 07/10/23 at 9:02 AM revealed R99 lying in bed and a pink vaporizer was lying on the residents bedside table, LPN1 was then notified and confiscated it. During an interview with Licensed Practical Nurse (LPN)1 on 07/10/23 at 9:06 AM, LPN1 stated that she has a bag of confiscated items that they have taken from residents after they had signed themselves out and left the premises. LPN1 then confirmed that residents should be checking with staff before signing themselves in and out. LPN1 stated that R99 is known to leave the facility multiple times per day and that the staff does not always know if he is in or out of the building. During an interview with the Administrator on 07/10/23 at 3:30 PM, she stated that they are a non-smoking facility and therefore they do not do smoking assessments. She also stated that they do not care plan for smoking because residents can have therapeutic leave. The facility only has 3 residents that sign themselves out and they have decisional capacity, which is what the facility uses to determine if a resident has the ability to do so. The Administrator further revealed that when residents are going out to smoke, they try to confiscate any cigarettes or lighters they may have, but the residents are not always cooperative and they can't search them or force them because they have rights. During an interview on 07/12/23 at 07:49 AM, the Medical Director (MD) stated these smoking patients have the decisional capacity to sign themselves in and out of the facility. We advise the residents against drinking, smoking, and using illegal substances. We can't chain the residents to the bed. The nurses have been telling me about everything involving the residents smoking. The resident stated we can't stop him from going out and smoking. He stated he doesn't care what we say. We have offered smoking cessation and we offer nicotine patches and that doesn't help. I fear if they do, we do not let them sign themselves out, they will smoke in their rooms. During an interview on 07/12/23 at 8:21 AM, the Director of Nursing (DON) stated We are a non-smoking facility. The local hospitals know we are a non-smoking facility. Our admission packets have a non-smoking clause in them. The residents review the smoking policy and smoking materials are prohibited in the facility. When we screen residents for smoking history, we offer cessation. Because we are a non-smoking facility, we don't do smoking assessments. We can't deem them safe to smoke because that would be violating our own policy. The policy says you can't smoke in or around the facility. Residents can sign themselves out if they are decisional. They can go off the property and they are aware that they have to go off the property Realistically, there's one way in and one way out. We have completed smoking cessation more than once. We put yellow flags on their chairs for safety, so that cars can see them. The residents take them off. We can't stop them from smoking when they leave the property, but we can try to keep them safe when they leave off the property. They have been given discharge notices. Social services, the Administrator and I have met with them in the facility to let them know if they did not comply with the non-smoking rules, they would be given discharge notices. The residents are supposed to sign in and out. We ask the residents to check in with the nurse when they come back in to hand over your smoking material. Because we are a non-smoking facility, we should not be the gate keeper for smoking material. Technically, the residents should be taken off the property to smoke and not bring those materials into the facility. In the past, family members would take residents out to smoke. The facility admitted R70 on 05/23/2023 with diagnoses including, but not limited to, physical debility, muscle weakness, alcoholic cirrhosis of the liver, muscle wasting and atrophy of the left and right hand, chronic pain, alcohol abuse and nicotine dependence. Review on 07/10/2023 at 12:10 PM of the medical record for R70, revealed sign out sheets for leave of absence starting on 06/14/2023 through 07/09/2023. R70 went out to smoke, signing a leave of absence 40 times during that period of time. He only signed back in 16 times. There is no documentation to ensure the smoking supplies were taken from the resident and secured in a locked area or compartment any of the 40 days. On 06/16/2023, R70 signed out, leave of absence at 9:23 AM to smoke and signed back in on 06/16/2023 at 8:20 PM. On 06/19/2023, R70 signed out, leave of absence to smoke and signed back in at 8:00 PM. Review on 07/10/2023 at 1:25 PM of a form titled, Authorizations, Consents, & Acknowledgements, revealed, Policies. The policies include: Admission, Discharge and readmission Policies. Smoking Policies. Rules and regulations governing resident conduct. Policies/procedures for bringing personal items into the facility and securing personal belongings, valuables and money. Policies and procedures for filing grievances. These are all signed by the resident. Further review of the forms revealed a form titled, Addressing Decisional Capacity, The form is signed by the physician on 04/05/2023 and states, This patient DOES possess the decisional capacity to make healthcare decisions for self. R70 has a BIMS score on a a MDS assessment dated [DATE] of 14 out of 15. Review of R70's medical record revealed no physicians order for R70 to sign out as a leave of absence and smoke. Review on 07/10/2023 at 2:20 PM of the progress notes revealed: Progress note dated: 6/23/23 5:50 AM -Nurse from the Blue Hall Unit brought resident back to the Pink Hall Unit stating that resident had been outside with another resident and that it was after 10:00 PM and that it was time to come in and go to rooms. Resident on Blue Hall Unit came in and went to room. This resident came in but did not come back to the unit. When the nurse brought resident to this unit he was sitting in wheelchair with his head laid over to the side. Resident was unable to hold eyes open. Resident did slightly open eyes when touched on the shoulder with calling out his name. Resident did respond that he had been drinking when asked by co nurse on Pink Hall Unit. Resident urinated on himself when in wheelchair at desk. This is not normal for this resident as he normally uses a urinal. VS taken, DON called and was made aware of situation. On call Nurse Practitioner (NP) called with vital signs given and recount of the situation. NP stated to let resident sleep and monitor resident through the shift. Resident's contact called and made aware of situation. Resident is currently up yelling out this morning. Resident does not remember the events of earlier in shift. Progress note dated: 6/14/23 3:58 AM-Second shift CNA went out to her car and heard someone hollering help at the cul-de-sac in front of facility. CNA told nurse on the other unit and that nurse called this nurse. Walked to cul-de-sac and found resident sitting in his wheelchair. Liquor bottles and beer cans found laying on ground at curb. This nurse asked resident if he had been drinking and resident stated yes. Resident smelled of alcohol. Resident was unable to wheel himself back to facility. Resident had hard time holding eyes open and speech was slurred. Resident normally is able to propel self in wheelchair. Called Nurse Practitioner (NP) on call to notify of resident. Called Assistant Director of Nursing and Director of Nursing and made aware. Vital signs taken and vitals were stable. All bedtime medications held. Resident is currently resting in bed with no further distress noted at this time. Progress note dated: 6/23/2023 06:39 PM-Resident continues with PT/OT, resident has displayed verbal aggressiveness towards staff for unknown cause/reason. Resident currently out of facility. There is no documentation on the form titled, Release of Responsibility for Leave of Absence, that R70 even left the building that day in the afternoon. The removal plan for F689 included: R99, R70 and R71 are currently in the building. R99's vaporizer was removed from his possession with their consent by the Unit Manager and stored in Unit Manager's office. Resident's family notified to obtain vaporizer from the facility. A Review of the Release of Responsibility for leave of absence forms was completed by the Director of Nursing. Residents who are currently signed out were located in the facility and reeducation was provided to residents who sign themselves out regarding signing back in upon return and notifying nurse they have returned on 7/10/23 at approximately 2:30 PM. On 7/10/23 at 11:30 AM, Administrator has spoken with residents who sign themselves in and out and requested any smoking materials be turned into the nurse for secured storage in locked medication areas. Staff- both licensed and non-licensed staff and residents who sign themselves out via leave of absence form will be reeducated by Director of Nursing /Designee on 7/10/23 on the following: o Residents will sign in and sign out with the nurse or facility representative at the nurse's station when they leave the building. o Residents check in with charge nurse or facility representative upon return-facility representative will sign next to resident signature to validate. o Residents are prohibited from keeping any type of smoking materials in their rooms or on their persons. If residents do not surrender smoking materials upon reentry, appropriate discharge planning by Social Services will occur if smoking materials are identified. Any staff not receiving this education on 7/10/23 will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation and for agency staff. The Director of Nursing will randomly interview a minimum of 2 staff and 2 interview residents weekly times 4 weeks then monthly for 2 additional months to validate understanding and compliance with leave of absence sign in/out process. Director of Nursing/designee will review sign out logs twice a shift for 5 days then daily for 3 additional weeks, then monthly for 2 additional months to validate residents remain compliant with signing in and out of the facility. Administrator/designee will round in resident rooms 2 times per day for 5 days, then daily for 3 additional weeks then monthly for 2 additional months to validate there are no smoking materials in residents' rooms or on their persons. Any concerns will be addressed at time of discovery. The Medical Director was notified on 7/10/23 of the Immediate Jeopardy. Ad Hoc Quality Assurance Performance Improvement Meeting was held on 7/10/23 to discuss contents of this plan. Administrator will oversee compliance of this plan for three months.