**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 2 of 23 residents reviewed for misappropriation of resident property. (Resident # 9 and Resident #63) The facility failed to protect Resident #9 from misappropriation of his personal funds when CNA D and CNA E attempted an ATM transaction for $200.00 on 2/21/2025 with unauthorized use of Resident #9's debit card. The facility failed to protect Resident #9 from misappropriation when Resident #63 used Resident #9's debit card and gave it to CNA E and CNA D to withdraw money that was not authorized by Resident #9 to allow CNA E and CNA D to use his debit card. The facility failed to prevent unauthorized transactions on Resident #9's debit card account on 1/27/25, 2/6/25, 2/7/25, and 2/10/25. An IJ was identified on 05/09/25. The IJ template was provided to the facility on [DATE] at 06:29 PM. While the IJ was removed on 05/10/25, the facility remained out of compliance at a scope isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for decreased quality of life, misappropriation of property, and financial distress. Findings included: Record review of Resident #9's face sheet dated 05/09/25 indicated he was an [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses dementia and anxiety. Record review of Resident #9's quarterly MDS dated [DATE] indicated he made himself understood and understood others. The MDS also indicated he had a BIMS score of 8 which meant he had moderate cognitive impairment. Record review of Resident #9's care plan revised on 04/07/25 indicated he had impaired cognition and was at risk for further decline with a goal of his needs being met timely, dignity maintained, and current level of functioning maintained. The care plan interventions included keep routine consistent and try to keep caregivers consistent, and monitor/document/report to physician any changes in cognitive function. Record review of the facility associate discplinary memorandum dated 02/24/25 indicated CNA D was suspended pending investigation. Record review of Resident #9's checking account statement dated 01/16/25-02/14/25 indicated there were transactions at the ATM: 1)01/27/25 in the amount of $103.00, $2.00 and $103.00, $2.00 and $203.00, $2.00 and $203.00 2)2/06/2025 in the amount of $103.00, $2.00, $203.00, $2.00 3)2/7/25 in the amount of $103.00; $2.00; $203.00; $2.00 4)2/10/2025 in the amount of $103.00; $2.00, $203.00, $2.00 5) 2/10/2025 Temu charge in the amount of $20.25 and $277.89 During an interview on 05/5/25 at 02:22 PM CNA D stated a lot of staff would go to the store for Resident #63 and purchased things knowing the card did not belong to Resident #63. CNA D stated she never returned back to the facility to work because it's a lot of messy stuff going on and people taking advantage of that man card. During an interview on 05/08/25 at 4:40 p.m., CNA E stated her, and CNA D were leaving for break when Resident #63 asked her if she could go and withdraw $200 from the ATM. CNA E stated Resident #63 handed her a card and gave her the pin number to the card. CNA E stated she did not know at the time the card belonged to Resident #9 until she tried to withdraw the money and suspicious fraud popped up on the screen. CNA E stated she called to the facility and spoke with CNA N and had her to put Resident #63 on the phone. CNA E stated when Resident #63 got on the phone she stated she told him that was not his card and Resident #63 stated yes, I know, go ahead, and bring it back. We have to call his family member to fix the card because the same thing happened yesterday. CNA E stated she brought the card back and gave it to Resident #63 and told him to give it back to Resident #9. CNA E stated she did not report the incident to the Administrator until Monday (02/24/25) when an incident happened between CNA N and another resident. CNA E stated she was suspended that 02/24/25. CNA E stated there had been several occasions she witnessed Resident #63 going to get money from Resident #9 and handing it to Laundry V, CNA N, and Housekeeping C. CNA E stated CNA N's family member charge Resident #9 $1,000 to go to Walmart and CNA N' family member charged him $600 to take him to (city) Texas. CNA E stated Resident #29 family member has charged him $1,000 to go to the bank. CNA E stated Resident #29 and Resident #37 also takes money from Resident #9. CNA E stated she did not report any of these incidents to the ADM because was already aware. CNA E stated she also heard the ADM was taking money from Resident #9. During an interview on 05/06/25 at 1:41 p.m., MA UU stated she has heard about Resident #63 taking money from Resident #9. MA UU stated she had also heard Resident #29's family member coming to take Resident #9 to the bank. MA UU stated she reported what she had heard to the ADM. MA UU stated she could not recall the exact date. During an interview on 05/08/25 05:13 PM The Administrator said she was not aware of any staff members taking Resident #9's money. She said she asked Resident #9 about his money, and he told her he was giving out money to residents if they needed it. The Administrator said she called Resident #9's family member and told them about him giving away his money to residents in the facility. She said the VA came to the facility to assess Resident #9 and what he was doing with his money and the VA said he had the right to give his money away because his BIMS was high. The Administrator said Resident #9 gave Resident #63 his card to use. She said she knew CNA D and CNA E went to the gas station to get some chicken for a red soda. The Administrator said she said she was not aware of the $200 the CNAs attempted to get. She said CNA D and CNA E both were suspended on 02/24/25. She said it was not acceptable for staff to get Resident #9's card. She said she never got any money from that Resident #9. The Administrator said misappropriation was the state guideline but Resident #9 gave Resident #63 his card to use so that made it not misappropriation. She said CNA D and CNA E did not get money. The Administrator said the police said it was not misappropriation if Resident #9 gave it to Resident #63. During an interview on 05/09/25 at 1:41 p.m., Laundry aide V said she did not take any money from Resident #9, and he did not offer her any money. She said she was aware of Resident #63 getting money from Resident #9. She said the Administrator was aware that Resident #63 had taken Resident #9's money, but nothing was done about it. She said she took the Administrator and Resident #9 to the bank several times and once to the funeral home. She said she stayed on the bus, so she was unaware of what occurred while at the bank or the funeral home. During an observation and interview on 05/09/25 at 2:21 PM, Resident #9 said he gave Resident #63 his debit card to use 1 time. He told Resident #63 he could have between 20-30 dollars. He said Resident #63 did pay him back for the money. The surveyor asked if he knew Resident #63 was giving others his debit card, including staff, and Resident #9 said he was unaware and he did not authorize Resident #63 to give his debit card to anyone else. Resident #9 and the surveyor reviewed some of his bank statements. After reviewing the bank statements, he and the surveyor saw some charges on 02/07/25, showing Resident #9 made an ATM withdrawal 3 times for 203 dollars, and 103 dollars, totaling 918 dollars in a day. Resident #9 put his head down and said he did not know about those charges in a shaky voice. Resident #9 became saddened and teary-eyed after discussing the charges on his bank account. The surveyor went to get ADON AA, and she witnessed Resident #9 say he had not given staff permission to use his card, and he authorized Resident #63 to use his card, but not for those amounts. During a telephone interview on 05/09/25 at 2:58 p.m., CNA D stated her, and CNA E was going to lunch and CNA E told her to stop at the store so she could withdraw some money for Resident #63. CNA D stated, I had no dealing with card, I was just the driver. During an interview on 05/09/25 at 4:41 p.m., the ADM stated she had taken Resident #9 to the bank to get his statements so she could see if any money was withdrawn from the account when Resident #63 gave Resident #9 bank card to CNA E and CNA N. The ADM stated the bank was not going to give him another card because of the fraudulent activity. The ADM stated, I agreed with the lady at the bank. The ADM stated on Monday (02/24/25) there was a risk call made that included she, DON, Regional Consultant Nurse and the Regional Operations to discuss the incident about CNA E, CNA D, Residents #63 and #9 and another incident with CNA D. The ADM stated she stated during the call during the investigation her and the DON found out by CNA D that CNA E was given Resident #9 card by Resident #63 and was told to withdraw $200. The ADM stated during the call she told the regional people CNA E attempted to withdraw the money but was unsuccessful. The ADM stated she told them she suspended CNA E and was told by the Regional Operations Manager she should have never suspended her just written her up because there was no money taken. The ADM stated she was told by Resident #9 family member to take Resident #9 to a funeral home to take out a pre-burial policy because Resident #9 would not let his family member take him. The ADM stated she took out $13,034.41 And $500 to start him a trust fund at the facility. The ADM stated her, and Laundry V took him to the funeral home to take out the policy. During an interview on 05/09/25 at 5:45 p.m., the BOM stated the ADM told her when she took Resident #9 to the bank after the incident with CNA E, CNA D and Resident #63 the card was put on hold. The BOM stated the ADM did not elaborate if the bank put the card on hold or if she initiated it. The BOM stated she was told by the ADM she did get bank statements that day. The BOM stated Resident #9 family member had brought statements in before the incident between CNA E, CNA D, and Resident #63 because she wanted to know what all the withdrawals was for. The BOM stated she told her she would look into and that was when the BOM spoke with the ADM about the withdrawals of the bank account. The BOM stated the ADM told her She would look into it. The BOM stated the issue was brought up several times in morning meetings and the ADM stated she was looking into it. The BOM stated it got to a point the ADM stated, were done talking about that. Record review of the facility policy Policy and Procedures: Abuse, Neglect and Exploitation dated 10/24/22 indicated: Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property This was determined to be an Immediate Jeopardy (IJ) on 05/09/2025 at 06:24 PM. Administrator was provided with the IJ template on 05/09/2025. The following Plan of Removals was accepted on 05/12/2025 at 02:57 PM. The plan of removal was accepted on 5/12/2025 at 2:57 p.m., and included: Immediate Action Taken: V. On 5/9/2025 DON completed an assessment on Resident # 9 to determine if resident was having any emotional distress related to this incident. The resident stated he was fine and was attending church services. The assessment was conducted privately prior to church services. W. On 5/9/2025 the DON completed a Comprehensive Trauma screen on the resident, and resident will be referred to Psychology services for further evaluation. On 5/9/2025 The V.A. Social Worker was contacted by the facility regarding the need of the resident needing a Psychology evaluation related to this incident. X. On 5/9/2025 the Regional Director of Operations provided 1:1 in-service with the Regional Nurse Consultant on the facility's abuse, Neglect, and Misappropriations policy. Y. On 5/9/2025 The Regional Nurse Consultant provided 1:1 education to the facility DON on the Abuse, Neglect, and Misappropriations policy. This was completed on 5/9/25. Z. On 5/9/2025 DON started in-service education with all staff on the facility's Abuse, Neglect, Misappropriations policy, including post-test. This was completed at 8:00pm on 5/9/2025, and no staff will be allowed to work until they have completed their education. AA. On 5/8/2025 the Administrator was suspended by the Regional Director of Operations pending investigation. BB. On 5/12/2025 the resident will be taken to his bank by the Maintenance Director and Social Services to obtain a new debit card. Residents' family will be encouraged to go as well. Resident does have an active Trust fund in the facility and has access to immediate funds if he chooses. Residents have made 10 trust fund withdrawals in April 2025, and 4 in May 2025. CC. On 5/8/2025 the Misappropriation incident was reported to HHSC by DON. DD. On 5/8/2025 the Misappropriation incident was also reported to the local law enforcement agency. EE. On 5/9/2025 this incident was reported to HHSC by DON regarding resident # 63 not being authorized to use resident #9 debit card. FF. Resident # 63 was discharged from the facility on 5/7/2025 and does not have access to resident # 9 debit card. GG. On 5/8/2025 the facility started an investigation into the incident, the investigation was completed on 5/10/2025 at 12:00 pm. HH. On 5/9/2025 C.N.A. E was suspended by the DON related to this incident. II. C.N.A. D was suspended on 2/24/2025 and never returned to work. 2. Identification of Residents Affected or Likely to be Affected: A. Starting 5/7/25 the Social Worker/designee will complete alert resident interviews 3 x week for 3 weeks, then weekly x 6 weeks to validate that all residents are allowed to make choices about aspects of his/her life in the facility, including financial choices. This will be reviewed after each interview is completed by the DON and Social Services so any issues, if applicable, can be addressed immediately. B. The Regional Nurse Consultant will oversee this process weekly x 6 weeks. 7. On 5/9/25the facility's DON notified the Medical Director regarding the Immediate Jeopardy the facility received related to failure to implement the abuse policy 8. On 5/9/25 the facility conducted an Ad Hoc QAPI meeting to discuss Misappropriation, and implementation of the abuse policy and sustaining compliance. The surveyor confirmed the following actions had been implemented sufficiently to remove the immediacy by: Record review of Resident #9's emotional assessment was completed by the DON on 5/09/2025. Record review of Resident #9's Comprehensive Trauma assessment was completed by the DON on 5/09/2025. Record review of a referral dated 5/09/2025 to the VA Social Worker for psychological services. Record review of the Administrator's suspension form dated 5/08/2025 indicated she was suspended pending investigation. Record review of the DON's in-service on the facilities Resident Rights policy dated 5/09/2025. Record review of the Regional Nurse Consultant's 1:1 in-service with the DON on the Abuse, Neglect, and Misappropriation policy. Record review of the Regional Director of Operation's 1:1 in-service with the Regional Nurse Consultant on the Abuse, Neglect, and Misappropriation policy. Record review of the in-service on the facility's Abuse, Neglect, Misappropriation policy dated 5/09/2025 conducted by the DON. The in-service also included a post test. During an observation on 5/12/2025 Resident #9 was driven to his financial institution where he was able to obtain a new debit card to his personal account. During an interview on 5/12/2025 at 11:54 AM Resident #9 said he had obtained a working debit card to his personal account. Record review of the reportable incident on 5/08/2025 to HHSC with intake #1008525 regarding Resident #9's misappropriation. Record review of the policy report # dated 5/08/2025 indicated the local authority was notified of the unauthorized use of Resident #9's debit card. Record review of the reportable incident on 5/09/2025 to HHSC with intake #1008767 indicated the reporting of Resident #63's unauthorized use of Resident #9's debit card. Record review of Resident #63's electronic record indicated he had discharged from the facility on 5/07/2025. Record review of the facility's investigation regarding the incident #--- with the completion date of 5/10/2025. Record review of CNA E's personnel record indicated she had been suspended pending investigation. Record review of CNA D's personnel record indicated she was suspended on 2/24/2025 and never returned to work. During an interview on 5/10/2025 the Medical Director indicated he was made aware by the DON of the facility's immediate jeopardy regarding failure to implement the abuse policy regarding misappropriation. During interviews conducted on 5/10/2025 - 5/12/2025 the Administrator, DON, ADON AA, ADON XX, MDS Nurse, CNA F, CNA G, CNA L, CNA N, CNA O, MA T, MA T,CNA B, CNA D, CNA E, RN H, MA K, LVN M, CNA P, CNA Q, CNA R, CNA S, CNA U, Van Driver V, MA W, CNA X, MA Y, CNA Z, MA BB, LVN CC, LVN DD, CNA EE, LVN FF, MA GG, RN HH, Dishwasher KK, Dietary Aide LL, [NAME] MM, LVN OO, LVN PP, CNA QQ, CNA RR, CNA SS, LVN TT, MA UU, CNA VV, and RNC WW indicated they had been in-serviced on the facilities abuse and neglect policy. The staff indicated a resident had the right to be free from abuse including misappropriation of property, and allegations should be reported immediately to the abuse coordinator. The Administrator was informed the Immediate Jeopardy was removed on 05/12/2025 at 11:54 AM. The facility remained out of compliance at a severity level of potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to follow their policy on abuse for 1 of 23 residents (Resident #9) reviewed for abuse. The facility failed to implement their abuse policy and failed to protect Resident #9 from misappropriation of his personal funds when CNA D and CNA E attempted an ATM transaction on 02/21/25 using Resident #9's debit card associated with his personal bank account. The facility failed to implement their policy when they failed to conduct an investigation of misappropriation of Resident #9's monies and unauthorized transactions. An IJ was identified on 05/09/25. The IJ template was provided to the facility on [DATE] at 06:29 PM. While the IJ was removed on 05/12/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could cause residents to have misappropriation of their property and financial distress. Findings included: Record review of the facility policy Policy and Procedures: Abuse, Neglect and Exploitation dated 10/24/22 indicated: Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Record review of Resident #9's face sheet dated 05/09/25 indicated he was an [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses dementia, anxiety, hear failure, high blood pressure, and lack of coordination. Record review of Resident #9's quarterly MDS dated [DATE] indicated he made himself understood and understood others. The MDS also indicated he had a BIMS score of 8 which meant he had moderate cognitive impairment. Record review of Resident #9's care plan revised on 04/07/25 indicated he had impaired cognition and was at risk for further decline with a goal of his needs being met timely, dignity maintained, and current level of functioning maintained. During an interview on 05/08/25 at 4:40 p.m., CNA E stated she and CNA D were leaving for break on 02/23/25 when Resident #63 asked her if she could go and withdraw $200 from the ATM. CNA E stated Resident #63 handed her a card and gave her the pin number to the card. CNA E stated she did not know at the time the card belonged to Resident #9 until she tried to withdraw the money and suspicious fraud popped up on the screen. CNA E stated she called the facility and spoke with CNA N and had her to put Resident #63 on the phone. CNA E stated when Resident #63 got on the phone she stated she told him that was not his card and Resident #63 stated Yes, I know, go ahead, and bring it back. We have to call Resident #9's family member to fix the card because the same thing happened yesterday. CNA E stated she brought the card back and gave it to Resident #63 and told him to give it back to Resident #9. She said she gave it back to Resident #63 instead of Resident #9 because that was who she got the card from. CNA E stated she did not report the incident to the Administrator until Monday 02/24/25 when an incident happened between CNA N and another resident. CNA E stated she was suspended that 02/24/25. CNA E stated there had been several occasions she witnessed Resident #63 going to get money from Resident #9 and handing it to Laundry V, CNA N, and Housekeeping C. CNA E stated CNA N's aunt charged Resident #9 $1,000 to take him to Walmart and CNA N's cousin charged Resident #9 $600 to take him to another city. CNA E stated Resident #29's family member has charged Resident #9 $1,000 to go to the bank. CNA E stated Resident #29 and Resident #37 also took money from Resident #9. CNA E stated she did not report any of those incidents to the ADM because the ADM was already aware. CNA E stated she also heard the ADM was taking money from Resident #9. During an interview on 05/06/25 at 1:41 p.m., MA UU stated she heard about Resident #63 taking money from Resident #9. MA UU stated she had also heard Resident #29's family member taking Resident #9 to the bank. MA UU stated she reported what she had heard to the ADM. MA UU stated she could not recall the exact date. During an interview on 05/08/25 05:13 PM the Administrator said she was not aware of any staff members taking Resident #9's money. She said she asked Resident #9 about his money on several occasions, and he told her he was giving out money to residents if they needed it. The Administrator said she called Resident #9's family member and told them about him giving away his money to residents in the facility. She said the VA came to the facility to assess Resident #9 and what he was doing with his money and the VA said he had the right to give his money away because his BIMS was high. The Administrator said Resident #9 gave Resident #63 his card to use. She said she knew CNA D and CNA E went to the gas station to get some chicken and for a red soda. The Administrator said she was not aware of the $200 the CNAs attempted to get. She said CNA D and CNA E both were suspended on 02/24/25. She said it was not acceptable for staff to get Resident #9's card. She said she never got any money from Resident #9. The Administrator said misappropriation was the state guideline but Resident #9 gave Resident #63 his card to use so that made it not misappropriation. She said CNA D and CNA E did not get money. The Administrator said the police said it was not misappropriation if Resident #9 gave it to Resident #63. During an observation and interview on 05/09/25 at 2:21 PM, Resident #9 said he gave Resident #63 his debit card to use 1 time on an unrecalled date. He told Resident #63 he could have between $20-$30. He said Resident #63 did pay him back for the money. The surveyor asked if he knew Resident #63 was giving others his debit card, including staff, and Resident #9 said he was unaware and he did not authorize Resident #63 to give his debit card to anyone else. Resident #9 and the surveyor reviewed some of his bank statements. After reviewing the bank statements dated 1/16/25-2/14/25, he and the surveyor saw some charges on 02/07/25 that reflected Resident #9 made an ATM withdrawal 3 times for $203, and $103, totaling $918in a day. Resident #9 put his head down and said he did not know about those charges in a shaky voice. Resident #9 became saddened and teary-eyed after discussing the charges on his bank account. The surveyor went to get ADON AA, and she witnessed Resident #9 say he had not given staff permission to use his card, and he authorized Resident #63 to use his card, but not for those amounts and he had not been to an ATM. During a telephone interview on 05/09/25 at 2:58 p.m., CNA D stated she, and CNA E were going to lunch on 02/23/25 and CNA E told her to stop at the store so she could withdraw some money for Resident #63. CNA D stated, I had no dealing with card, I was just the driver. During an interview on 05/09/25 at 4:41 p.m., the ADM stated she had taken Resident #9 to the bank to get his statements so she could see if any money was withdrawn from the account when Resident #63 gave Resident #9 bank card to CNA E and CNA N. The ADM stated the bank was not going to give him another card because of the fraudulent activity. The ADM stated, I agreed with the lady at the bank. The ADM stated on Monday (02/24/25) there was a risk call made that included herself, the DON, the Regional Consultant Nurse and the Regional Operations to discuss the incident about CNA E, CNA D, Residents #63 and #9 and another incident with CNA D. The ADM stated she stated during the call during the investigation her and the DON found out by CNA D that CNA E was given Resident #9 card by Resident #63 and was told to withdraw $200. The ADM stated during the call she told the regional people CNA E attempted to withdraw the money but was unsuccessful. The ADM stated she told them she suspended CNA E and was told by the Regional Operations Manger she should have never suspended her just written her up because there was no money taken. The ADM stated she was told by Resident #9 sister to take Resident #9 to a funeral home to take out a pre-burial policy because Resident #9 would not let the sister take him. The ADM stated she took out #13,034.41 and $500 to start him a trust fund at the facility. The ADM stated she and Laundry V took him to the funeral home to take out the policy. During an interview on 05/09/25 at 5:45 p.m., the BOM stated the ADM told her when she took Resident #9 to the bank after the incident with CNA E, CNA N and Resident #63 the card was put on hold. The BOM stated the ADM did not elaborate if the bank put the card on hold or if she initiated it. The BOM stated she was told by the ADM she did get bank statements that day (02/24/25). The BOM stated Resident #9's family member had brought statements in (on an unknown date) before the incident between CNA E, CNA N, and Resident #63 because she wanted to know what all the withdrawals were for. The BOM stated she told her she would look into it and that was when the BOM spoke with the ADM about the withdrawals of the bank acct. The BOM stated the ADM told her she would look into it. The BOM stated the issue was brought up several times in morning meetings and the ADM stated she was looking into it. The BOM stated it got to a point the ADM stated, We're done talking about that. This was determined to be an Immediate Jeopardy (IJ) on 05/09/2025 at 06:24 PM. The Administrator was provided with the IJ template on 05/09/2025. The following Plan of Removals was accepted on 05/12/2025 at 02:57 PM. The plan of removal was accepted on 5/12/2025 at 2:57 p.m., and included: Immediate Action Taken: H. On 5/9/2025 the DON completed an assessment on Resident #9 to determine if resident was having any emotional distress related to this incident. The resident stated he was fine and was attending church services. The assessment was conducted privately prior to church services. I. On 5/9/2025 the DON completed a Comprehensive Trauma screen on the resident, and resident will be referred to psychology services for further evaluation. On 5/9/2025 The V.A. Social Worker was contacted by the facility regarding the need of the resident needing a psychology evaluation related to this incident. J. On 5/9/2025 the Regional Director of Operations provided 1:1 in-service with the Regional Nurse Consultant on the facility's abuse, Neglect, and Misappropriations policy. K. On 5/9/2025 the Regional Nurse Consultant provided 1:1 education to the facility DON on the Abuse, Neglect, and Misappropriations policy. This was completed on 5/9/25. L. On 5/9/2025 the DON started in-service education with all staff on the facility's Abuse, Neglect, Misappropriations policy, including post-test. This was completed at 8:00pm on 5/9/2025, and no staff will be allowed to work until they have completed their education. M. On 5/8/2025 the Administrator was suspended by the Regional Director of Operations pending investigation. N. On 5/12/2025 the resident will be taken to his bank by the Maintenance Director and Social Services to obtain a new debit card. Residents' family will be encouraged to go as well. Resident does have an active Trust fund in the facility and has access to immediate funds if he chooses. Residents have made 10 trust fund withdrawals in April 2025, and 4 in May 2025. O. On 5/8/2025 the Misappropriation incident was reported to HHSC by the DON. P. On 5/8/2025 the Misappropriation incident was also reported to the local law enforcement agency. Q. On 5/9/2025 the incident was reported to HHSC by the DON regarding Resident #63 not being authorized to use Resident #9's debit card. R. Resident #63 was discharged from the facility on 5/7/2025 and did not have access to resident # 9's debit card. S. On 5/8/2025 the facility started an investigation into the incident; the investigation was completed on 5/10/2025 at 12:00 pm. T. On 5/9/2025 C.N.A. E was suspended by the DON related to the incident. U. C.N.A. D was suspended on 2/24/2025 and never returned to work. 2. Identification of Residents Affected or Likely to be Affected: A. Starting 5/7/25 the Social Worker/designee will complete alert resident interviews 3 x week for 3 weeks, then weekly x 6 weeks to validate that all residents are allowed to make choices about aspects of his/her life in the facility, including financial choices. This will be reviewed after each interview is completed by the DON and Social Services so any issues, if applicable, can be addressed immediately. B. The Regional Nurse Consultant will oversee this process weekly x 6 weeks. 5. On 5/9/25 the facility's DON notified the Medical Director regarding the Immediate Jeopardy the facility received related to failure to implement the abuse policy 6. On 5/9/25 the facility conducted an Ad Hoc QAPI meeting to discuss Misappropriation, and implementation of the abuse policy and sustaining compliance. The surveyor confirmed the following actions had been implemented sufficiently to remove the immediacy by: Record review of Resident #9's emotional assessment was completed by the DON on 5/09/2025 with no issues noted. Record review of Resident #9's Comprehensive Trauma assessment was completed by the DON on 5/09/2025 with no trauma found. Record review of a referral for Resident #9 dated 5/09/2025 to the VA Social Worker for psychological services. Record review of the Administrator's suspension form dated 5/08/2025 indicated she was suspended pending investigation. Record review of the DON's in-service on the facilities Resident Rights policy dated 5/09/2025. Record review of the Regional Nurse Consultant's 1:1 in-service with the DON on the Abuse, Neglect, and Misappropriation policy which indicated it was the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Record review of the Regional Director of Operation's 1:1 in-service with the Regional Nurse Consultant on the Abuse, Neglect, and Misappropriation policy indicated it was the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Record review of the in-service provided to all disciplines across all shifts on the facility's Abuse, Neglect, Misappropriation policy dated 5/09/2025 conducted by the DON. The in-service also included a post test. During an observation on 5/12/2025 at 09:45 AM Resident #9 was driven to his financial institution where he was able to obtain a new debit card to his personal account. During an interview on 5/12/2025 at 11:54 AM Resident #9 said he had obtained a working debit card to his personal account. Record review of the reportable incident on 5/08/2025 to HHSC regarding Resident #9's misappropriation. Record review of the police report #25-313884 dated 5/08/2025 indicated the local authority was notified of the unauthorized use of Resident #9's debit card. Record review of the reportable incident on 5/09/2025 to HHSC indicated the reporting of Resident #63's unauthorized use of Resident #9's debit card. Record review of Resident #63's electronic record indicated he had discharged from the facility on 5/07/2025. Record review of the facility's investigation regarding the incident #1008525 determined to be reported on 05/08/25 and the investigation was ongoing. Record review of CNA E's personnel record indicated she had been suspended on 02/24/25 pending investigation. Record review of CNA D's personnel record indicated she was suspended on 2/24/2025 and never returned to work. During an interview on 5/10/2025 at 06:11 PM the Medical Director indicated he was made aware by the DON of the facility's immediate jeopardy regarding failure to implement the abuse policy regarding misappropriation. During interviews conducted on 5/10/2025 at 04:22 PM - 5/10/2025 06:04 PM the Administrator, DON, ADON AA, ADON XX, MDS Nurse, CNA F, CNA G, CNA L, CNA N, CNA O, MA T, MA T,CNA B, CNA D, CNA E, RN H, MA K, LVN M, CNA P, CNA Q, CNA R, CNA S, CNA U, Van Driver V, MA W, CNA X, MA Y, CNA Z, MA BB, LVN CC, LVN DD, CNA EE, LVN FF, MA GG, RN HH, Dishwasher KK, Dietary Aide LL, [NAME] MM, LVN OO, LVN PP, CNA QQ, CNA RR, CNA SS, LVN TT, MA UU, CNA VV, and RNC WW indicated they had been in-serviced on the facilities abuse and neglect policy. The staff indicated a resident had the right to be free from abuse including misappropriation of property, and allegations should be reported immediately to the abuse coordinator. The Administrator was informed the Immediate Jeopardy was removed on 05/12/2025 at 11:54 AM. The facility remained out of compliance at a severity level of potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24-hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (which included the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law through established procedures for 3 of 23 residents (Resident #'s 9, Resident #126, and Resident #54) reviewed for abuse and neglect. The facility failed to report timely to HHSC when CNA D and CNA E attempted an ATM transaction on 02/21/25 using Resident #9's debit card associated with his personal bank account. The facility failed to ensure that CNA E, LVN FF, and LVN YY reported the resident-to-resident altercation between Residents #126 and Resident #54 to the Administrator, who was the abuse coordinator, immediately on 02/22/25, which resulted in the Administrator not learning of the altercation until 02/25/25. The non-compliance was identified as PNC. The IJ began on 02/21/25 and ended on 02/25/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for further potential neglect due to unreported and uninvestigated allegations of abuse and neglect. Findings included: 1)Record review of Resident #9's face sheet dated 05/09/25 indicated he was an [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses dementia, anxiety, hear failure, high blood pressure, and lack of coordination. Record review of Resident #9's quarterly MDS dated [DATE] indicated he made himself understood and understood others. The MDS also indicated he had a BIMS score of 8 which meant he had moderate cognitive impairment. Record review of Resident #9's care plan revised on 04/07/25 indicated he had impaired cognition and was at risk for further decline with a goal of his needs being met timely, dignity maintained, and current level of functioning maintained. During an interview on 05/08/25 at 4:40 p.m., CNA E stated she and CNA D were leaving for break on 02/23/25 when Resident #63 asked her if she could go and withdraw $200 from the ATM. CNA E stated Resident #63 handed her a card and gave her the pin number to the card. CNA E stated she did not know at the time the card belonged to Resident #9 until she tried to withdraw the money and suspicious fraud popped up on the screen. CNA E stated she called the facility and spoke with CNA N and had her to put Resident #63 on the phone. CNA E stated when Resident #63 got on the phone she stated she told him that was not his card and Resident #63 stated Yes, I know, go ahead, and bring it back. We have to call Resident #9's family member to fix the card because the same thing happened yesterday. CNA E stated she brought the card back and gave it to Resident #63 and told him to give it back to Resident #9. She said she gave it back to Resident #63 instead of Resident #9 because that was who she got the card from. CNA E stated she did not report the incident to the Administrator until Monday 02/24/25 when an incident happened between CNA N and another resident. CNA E stated she was suspended that 02/24/25. CNA E stated there had been several occasions she witnessed Resident #63 going to get money from Resident #9 and handing it to Laundry V, CNA N, and Housekeeping C. CNA E stated CNA N's aunt charged Resident #9 $1,000 to take him to Walmart and CNA N's cousin charged Resident #9 $600 to take him to another city. CNA E stated Resident #29's family member has charged Resident #9 $1,000 to go to the bank. CNA E stated Resident #29 and Resident #37 also took money from Resident #9. CNA E stated she did not report any of those incidents to the ADM because the ADM was already aware. CNA E stated she also heard the ADM was taking money from Resident #9. During an interview on 05/06/25 at 1:41 p.m., MA UU stated she heard about Resident #63 taking money from Resident #9. MA UU stated she had also heard Resident #29's family member taking Resident #9 to the bank. MA UU stated she reported what she had heard to the ADM. MA UU stated she could not recall the exact date. During an interview on 05/08/25 05:13 PM the Administrator said she was not aware of any staff members taking Resident #9's money. She said she asked Resident #9 about his money on several occasions, and he told her he was giving out money to residents if they needed it. The Administrator said she called Resident #9's family member and told them about him giving away his money to residents in the facility. She said the VA came to the facility to assess Resident #9 and what he was doing with his money and the VA said he had the right to give his money away because his BIMS was high. The Administrator said Resident #9 gave Resident #63 his card to use. She said she knew CNA D and CNA E went to the gas station to get some chicken and for a red soda. The Administrator said she was not aware of the $200 the CNAs attempted to get. She said CNA D and CNA E both were suspended on 02/24/25. She said it was not acceptable for staff to get Resident #9's card. She said she never got any money from Resident #9. The Administrator said misappropriation was the state guideline but Resident #9 gave Resident #63 his card to use so that made it not misappropriation. She said CNA D and CNA E did not get money. The Administrator said the police said it was not misappropriation if Resident #9 gave it to Resident #63. During an observation and interview on 05/09/25 at 2:21 PM, Resident #9 said he gave Resident #63 his debit card to use 1 time on an unrecalled date. He told Resident #63 he could have between $20-$30. He said Resident #63 did pay him back for the money. The surveyor asked if he knew Resident #63 was giving others his debit card, including staff, and Resident #9 said he was unaware and he did not authorize Resident #63 to give his debit card to anyone else. Resident #9 and the surveyor reviewed some of his bank statements. After reviewing the bank statements dated 1/16/25-2/14/25, he and the surveyor saw some charges on 02/07/25 that reflected Resident #9 made an ATM withdrawal 3 times for $203, and $103, totaling $918in a day. Resident #9 put his head down and said he did not know about those charges in a shaky voice. Resident #9 became saddened and teary-eyed after discussing the charges on his bank account. The surveyor went to get ADON AA, and she witnessed Resident #9 say he had not given staff permission to use his card, and he authorized Resident #63 to use his card, but not for those amounts and he had not been to an ATM. During a telephone interview on 05/09/25 at 2:58 p.m., CNA D stated she, and CNA E were going to lunch on 02/23/25 and CNA E told her to stop at the store so she could withdraw some money for Resident #63. CNA D stated, I had no dealing with card, I was just the driver. During an interview on 05/09/25 at 4:41 p.m., the ADM stated she had taken Resident #9 to the bank to get his statements so she could see if any money was withdrawn from the account when Resident #63 gave Resident #9 bank card to CNA E and CNA N. The ADM stated the bank was not going to give him another card because of the fraudulent activity. The ADM stated, I agreed with the lady at the bank. The ADM stated on Monday (02/24/25) there was a risk call made that included herself, the DON, the Regional Consultant Nurse and the Regional Operations to discuss the incident about CNA E, CNA D, Residents #63 and #9 and another incident with CNA D. The ADM stated she stated during the call during the investigation her and the DON found out by CNA D that CNA E was given Resident #9 card by Resident #63 and was told to withdraw $200. The ADM stated during the call she told the regional people CNA E attempted to withdraw the money but was unsuccessful. The ADM stated she told them she suspended CNA E and was told by the Regional Operations Manger she should have never suspended her just written her up because there was no money taken. The ADM stated she was told by Resident #9 sister to take Resident #9 to a funeral home to take out a pre-burial policy because Resident #9 would not let the sister take him. The ADM stated she took out #13,034.41 and $500 to start him a trust fund at the facility. The ADM stated she and Laundry V took him to the funeral home to take out the policy. During an interview on 05/09/25 at 5:45 p.m., the BOM stated the ADM told her when she took Resident #9 to the bank after the incident with CNA E, CNA N and Resident #63 the card was put on hold. The BOM stated the ADM did not elaborate if the bank put the card on hold or if she initiated it. The BOM stated she was told by the ADM she did get bank statements that day (02/24/25). The BOM stated Resident #9's family member had brought statements in (on an unknown date) before the incident between CNA E, CNA N, and Resident #63 because she wanted to know what all the withdrawals were for. The BOM stated she told her she would look into it and that was when the BOM spoke with the ADM about the withdrawals of the bank acct. The BOM stated the ADM told her she would look into it. The BOM stated the issue was brought up several times in morning meetings and the ADM stated she was looking into it. The BOM stated it got to a point the ADM stated, We're done talking about that. Record review of the facility patient questionnaires for 4 other residents dated 02/24/25 completed by the Social Worker indicated no other residents had any concerns with abuse. Record review of the facility in-service for Allegations of Abuse and the abuse coordinator dated 02/24/25 indicated staff members across all shifts had been in-serviced over the abuse and neglect policy, contacting the Administrator immediately, to speak directly with the Administrator to report allegations, not to text allegations, and to call the DON as the second choice if the Administrator was not available. Record review of the facility associate disciplinary memorandum dated 02/24/25 indicated CNA D was suspended pending investigation. Record review of the facility associate disciplinary memorandum dated 02/24/25 indicated CNA E was suspended pending investigation. Record review of the time sheet for CNA D dated 02/20/25-02/27/25 indicated the last time CNA D clocked in the facility on 02/24/25 at 06:14 AM and clocked out of the facility on 02/24/25 at 09:48 AM and her status was now terminated. Record review of the time sheet for CNA E dated 02/20/25-02/27/25 indicated the last time CNA D clocked in the facility on 02/24/25 at 06:14 AM and clocked out of the facility on 02/24/25 at 10:01 AM and returned to work on 02/26/25 at 01:27 PM. 2.Record review of Resident #126's face sheet, dated 05/12/25, indicated a [AGE] year-old male who was re-admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, also known as COPD (a long-term lung disease that makes breathing difficult), stroke and dementia (diseases that affect memory, thinking, and the ability to perform daily activities). Record review of Resident #126's quarterly MDS assessment, dated 01/26/25, indicated Resident #126 usually understood and was usually understood by others. Resident #126's BIMS score was 03, which meant he was severely cognitively impaired. The MDS indicated Resident #126 required total assistance with toileting, bed mobility, dressing, transfers, personal hygiene, and eating. The MDS did not indicate any behaviors. A record review of Resident #126's care plan, revised on 03/30/25, indicated Resident #126 had an alteration in musculoskeletal status related to contracture of bilateral (both) upper extremities. The intervention was for staff to anticipate and meet his needs. Record review of Resident #126's nurses' notes dated 02/25/25, written by ADON XX revealed she was notified by CNA VV about an incident that occurred in the television room on 02/22/25 after lunch. CNA VV said she was informed by Resident #37 that Resident #54 hit Resident #126 in the head three times. ADON XX assessed Resident #126 from head to toe with no skin issues noted. ADON XX then notified the abuse coordinator and the DON. Resident #126 was unable to give any details related to the incident due to his cognitive impairment. Record review of Resident #126's skin assessment dated [DATE] did not indicate any skin issues. 3. Record review of Resident #54's face sheet, dated 05/07/25, indicated a [AGE] year-old male who was re-admitted to the facility on [DATE] with diagnoses which included depression (sadness), anxiety (characterized by excessive and persistent worry, fear, and nervousness) and dementia (diseases that affect memory, thinking, and the ability to perform daily activities). Record review of Resident #54's quarterly MDS assessment, dated 03/28/25, indicated Resident #54 understood and was understood by others. Resident 54 BIMS score was 05, which meant his cognition was severely impaired. The MDS indicated Resident #54 required help with toileting, bed mobility, dressing, transfers, personal hygiene, and was independent with eating. The MDS indicated Resident #54 has verbal and physical behavior. Record review of Resident #54's care plan, revised on 10/14/24, indicated Resident #54 had a Behavioral Problem as evidenced by aggressive behaviors. The interventions were for staff to assist the resident to a calm, quiet area if he starts to become agitated. Record review of Resident #54's skin assessment dated [DATE] did not indicate any skin issues. During a phone interview on 05/09/25 at 8:50 a.m., CNA E said she was walking down the hall towards the lounge area when she saw Resident #54 hit Resident #126 in the head three times. She said she removed Resident #126 to safety and then reported to LVN FF and LVN YY. She said Resident #54 had a history of hitting others. She said Resident #54 said Resident #126 was talking about him. She said Resident #126 does not talk. During a phone interview on 05/09/25 at 9:47 a.m., LVN YY said he was Resident #126 and Resident #54's nurse. He said he vaguely remembered them. He said he did not recall a resident-to-resident altercation. He said he was newly hired at the facility and did not know all the steps he needed to take to complete an incident or skin assessment. He said as he continued to work at the facility, he became aware of filling out an incident report, skin assessment, and reporting to the Administrator. He said if a resident-to-resident altercation occurred, he should have reported it to the Administrator. During an interview on 05/09/25 at 11:45 a.m., LVN FF said she was a nurse on duty when Resident #126 and Resident #54 had the altercation on 02/22/25. She said CNA E told her she was walking down the hall toward the lounge area when she saw Resident #54 hit Resident #126 on the top of his head. She said as she was about to assess the situation, the charge nurse (LVN YY) for Resident #126 and Resident #54 came out from the medication room, and she reported the incident to him. She said she was not aware LVN YY did not report the incident to the Administrator or DON until a few days later, when she was questioned by the Administrator. She said she knew the incident should have been reported to the Administrator as soon as it happened but thought LVN YY reported since he was their charge nurse. During an interview on 05/09/25 at 4:47 p.m., the DON said she expected staff to report any abuse to the Administrator when they were made aware. She said they were not aware of Resident #54 hitting Resident #126 in the head until CNA VV heard it from Resident #37 on 02/25/25. She said that upon their investigation, CNA E said she saw Resident #54 hit Resident #126 in the head three times and separated them. She said CNA E reported the altercation to her charge nurse, LVN YY. She said they spoke with LVN YY, but he did not remember why he did not report it to the Administrator. She said then she spoke to LVN FF, who said she was on duty when the incident occurred between Resident #54 and Resident #126. LVN FF said CNA E reported it to her, and then she reported to their nurse, LVN YY. She said LVN FF thought LVN YY had reported the incident to the Administrator and did the assessment and incident report. She said both residents were assessed on 02/25/25 with no injuries noted. She said they did an in-service on reporting abuse. The DON said it was important to report and investigate abuse/neglect to prevent further abuse/neglect from occurring. During a phone interview on 05/09/25 at 6:03 p.m., the Administrator said she was unaware of Resident #126 and Resident #54's altercation that occurred on 02/22/25 until 02/25/25. She said once she became aware, the nurses assessed both residents, and the investigation process began. She said she then reported to HHSC. She said the resident-to-resident altercation should have been reported to her, and her responsibility was to protect the residents and report to HHSC within 2 hours of the incident. She said the staff was aware that she was the abuse coordinator and should have reported the allegation of abuse to her. She said they did an in-service with staff on reporting. The Administrator said when allegations were not reported promptly, abuse could continue to occur, and residents could be in danger if the abuse/neglect was continuing. Record review of the facility's in-service on reporting dated 02/25/25, revealed an in-service on resident-to-resident altercations.1.Immediately separate residents, 2. Place aggressor on 1:1 supervision and document, 3. Contact Administrator immediately, 4. License nurses will complete a head-to-toe assessment on both residents and document, 5. Notify family and doctor, 6.License nurse will complete an incident report, 7.Refer resident to psych services for clearance, 8.Update care plan for behaviors, 9.Educate staff on abuse/neglect and resident to resident altercations. Record review of the facility's in-service on abuse dated 02/25/25, revealed an in-service on reporting to the abuse coordinator. 1 contact the Administrator, 2. Notify Immediately and do not wait, 3. Do not text, you must call the Administrator, if no answer then keep calling, 4.The DON is second choice to call if administrator is out or does not return your call after several attempts. Record review of the Texas Unified Licensure Information Portal, also noted as TULIP (an online system for submitting long-term care licensure applications), indicated the facility reported the intake regarding the resident-to-resident altercation involving Resident #126 and Resident #54 on 02/25/25. During interviews conducted on 5/10/2025 at 04:22PM - 5/10/2025 at 06:04 PM the Administrator, DON, ADON AA, ADON XX, MDS Nurse, CNA F, CNA G, CNA L, CNA N, CNA O, MA T, MA T,CNA B, CNA D, CNA E, RN H, MA K, LVN M, CNA P, CNA Q, CNA R, CNA S, CNA U, Van Driver V, MA W, CNA X, MA Y, CNA Z, MA BB, LVN CC, LVN DD, CNA EE, LVN FF, MA GG, RN HH, Dishwasher KK, Dietary Aide LL, [NAME] MM, LVN OO, LVN PP, CNA QQ, CNA RR, CNA SS, LVN TT, MA UU, CNA VV, and RNC WW indicated they had been in-serviced on the facilities abuse and neglect policy. The staff indicated a resident had the right to be free from abuse including misappropriation of property, and allegations should be reported immediately to the abuse coordinator. Record review of the facility policy titled Abuse, Neglect, Exploitation, revised 10/24/22, indicated, policy: it is the policy of this facility to provide protection for the health, wealth, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury. II.Employee Training: A. New employees will be educated on abuse, neglect, exploitation, and misappropriation of resident property during initial orientation. B. Existing staff will receive annual education through planned In-services and as needed. C. Training topics will include: 1. Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. 2. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property. 3. Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, such as physical or psychoactive indicators. 4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources IV. Identification of Abuse, Neglect, and Exploitation A. The facility assists staff to understand the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff-to-resident abuse and certain resident-to-resident altercations Reporting: A. The facility reports abuse and abuse allegations that include: I. Reporting allegations involving staff-to-resident abuse, resident-to-resident altercations, injuries of unknown source, misappropriation of resident property/exploitation, and mistreatment. 2. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified timelines: A. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or B. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The non-compliance was identified as PNC. The IJ began on 02/21/25 and ended on 02/25/25. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as possible and each resident receives adequate supervision to prevent accidents for 14 of 87 (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) residents reviewed for accidents/hazards. The facility failed to provide adequate supervision for Resident #1 when she left the facility with a stranger on 7/4/23. Resident #1 was taken approximately 25 miles away from the facility to her former residence, where the stranger dropped her off. Resident #1 was gone from the facility for approximately 1 and ½ hours. The facility was not aware she had left the facility. The facility failed to complete an updated elopement assessment when Resident #1 displayed wandering/elopement behaviors. The facility failed to complete a quarterly elopement assessment for Resident #1 #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 #13, and #14. These failures resulted in Resident #1's elopement from the facility and placed her and other residents at risk for serious injury, serious harm, serious impairment or death. An Immediate Jeopardy (IJ) was identified on 8/15/23 at 9:45 a.m. The IJ template was provided to the facility on [DATE] at 10:14 a.m. While the IJ was removed on 8/18/23 at 3:24 p.m., the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate due to the facility's need to complete in-services and evaluate the effectiveness of the corrective systems. These failures could place residents with exit seeking behaviors at risk for injury or death. Findings included: 1.Record review of Resident #1's face sheet indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses including, dementia, anxiety, depression, heart disease, type II diabetes, high blood pressure, muscle weakness and lack of coordination. Record review of the MDS dated [DATE] indicated Resident #1 had the behavior of wandering that occurred 1 to 3 days during the 7 days look back period. Record review of the MDS dated [DATE] indicated Resident #1 usually made herself understood and usually understood others. The MDS indicated she had severe cognitive impairment (BIMS of 5). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #1 had exhibited no behavior of wandering during the 7 days look back. The MDS indicated Resident #1 required extensive assistance with mobility and bathing. The MDS indicated Resident #1 required limited assistance with toilet use. The MDS indicated she required supervision with all other ADLs. The MDS indicated Resident #1 was not steady and was only able to stabilize with staff assistance when walking (with assistive device), turning around, and moving on and off the toilet. The MDS indicated she was frequently incontinent of bowel and bladder. Record review of Resident #1's care plan dated 2/3/23 indicated Resident #1 wandered related to cognitive impairment and was at [NAME] for injury. The care plan interventions were, attempt to determine any isolated or cause of wandering; weigh monthly; redirect resident if resident entered a restricted area; encourage social and activity attendance; use verbal clues for redirection to dissuade exit seeking behaviors; distract resident from wandering by offering pleasant diversions, structured activities, food, television, book, etc . There were no updated care plan interventions after the elopement incident on 7/4/23. Record review of Resident #1's admission elopement assessment dated [DATE] indicated Resident #1 scored her as zero and stated, Not at risk to elope at this time . The elopement assessment stated, a combined score of 6 or more triggers possible elopement risk. The elopement assessment indicated the assessment was to be completed on initial (admission), re admit, quarterly, or significant change. The score of zero resulted from the following behavioral observation questions/responses: *Spends time on the first floor or wanders between floors or units? -Response: no; *Hangs around facility exits and/or stairways? -Response: no; *Verbalizes a serious/strong intent to leave the facility in the absence of an appropriate discharge plan? -Response: no; *Responds poorly to staff re-direction when roaming into areas that are off limits or unauthorized. -Response: no *Has the physical ability to leave the building? -Response: no *Becomes agitated, confused and/or disoriented or displays consistently poor judgement (i.e., would not be able to safely care for him/herself outside of the facility)? -Response: no; and *Engages in theme behavior(i.e., leaving for work, seeking his/her car, searching for children, seeking people/places from days/years gone by)? -Response: no This assessment was completed by LVN A. Record review of the nursing note for Resident #1 dated 1/24/23 at 10:49 p.m., Res. (Resident #1) up ambulating the facility with walker without distress or pain noted. Confused and forgetful. Wanders hallway without attempt to leave facility. Redirected easily . This note was written by LVN C. Record review of the nursing note for Resident #1 dated 1/25/23 at 9:40 p.m., stated Res. (Resident #1) up ambulating facility without distress or pain. Alert and responsive. Disoriented and wandering facility. Redirected easily . This note was written by LVN C. Record review of the nursing note for Resident #1 dated 7/4/23 at 2:00 p.m. stated Left facility with other family and did not sign out, family brought (Resident #1) back safely. This note was written by LVN A. Record review of the nursing notes for Resident #1 from 1/20/23 to 7/4/23 found no additional notes which referenced wandering or elopement behaviors. Record review of Resident #1's elopement assessment dated [DATE] indicated Resident #1 scored her as an 8 and stated, At risk for elopement . The elopement assessment stated, a combined score of 6 or more triggers possible elopement risk. The elopement assessment indicated the assessment was to be completed on initial (admission), re admit, quarterly, or significant change. The score of eight resulted from the following behavioral observation questions/responses: *Spends time on the first floor or wanders between floors or units? -Response: no; *Hangs around facility exits and/or stairways? -Response: no; *Verbalizes a serious/strong intent to leave the facility in the absence of an appropriate discharge plan? -Response: yes; *Responds poorly to staff re-direction when roaming into areas that are off limits or unauthorized. -Response: no *Has the physical ability to leave the building? -Response: yes *Becomes agitated, confused and/or disoriented or displays consistently poor judgement (i.e., would not be able to safely care for him/herself outside of the facility)? -Response: yes; and *Engages in theme behavior (i.e., leaving for work, seeking his/her car, searching for children, seeking people/places from days/years gone by)? -Response: Yes This assessment was completed by RN B. Record review of the elopement assessments completed for Resident #1 since her admission on [DATE] to 7/6/23 revealed Resident #1 had an elopement assessment completed upon her admission to the facility (1/20/23) and after her elopement incident (7/6/23). The elopement assessments revealed there were no additional elopement assessments between 1/20/23 and 7/6/23. During an interview on 8/10/23 at 10:18 a.m., Resident #1's visitor said 7/5/23 she was at home with her family. Resident #1's visitor said a family member noticed a car pull up to Resident #1's former residence. Resident #1's visitor explained her home was adjacent to Resident #1's previous residence. Resident #1 said no one lived in Resident #1's previous home and they (Resident #1's visitor and family) maintained the property. Resident #1'svisitor said they (Resident #1's visitor and family) watched as car pulled up an older gentleman got out of the car and assisted an older woman out of the car (she explained the distance from which she was observing impeded her ability to initially identify the woman). Resident #1's visitor said they (Resident #1's visitor and family) watched as the car drove off. Resident #1's visitor said approximately 10 minutes or so had passed and they (Resident #1's visitor and family) decided to walk down and check on Resident #1's previous residence. Resident #1's visitor said as they (Resident #1's visitor and family) approached the home they found Resident #1 sitting in her carport. Resident #1's visitor said Resident #1 was confused and was looking for her house keys to get into the home to start laundry and cook dinner for her (Resident #1's) husband. Resident #1's visitor explained Resident #1's husband had been deceased for over a year. Resident #1's visitor said she asked Resident #1 who the man was that had brought her to the home, and she said she did not know him. Resident #1's visitor said they (Resident #1's visitor and family) then returned Resident #1 to the facility. Resident #1's visitor said the home was approximately 25 miles from the facility and estimated Resident #1 had been gone from the facility for 1-1 ½ hours. Resident #1's visitor said when they (Resident #1's visitor and family) returned to the facility with Resident #1 the facility was not aware she had left. Resident #1's visitor said she was very concerned over the incident. She said the family was thinking about leaving for the day and was so thankful they had not. She said Resident #1 would have been outside without water in the heat for who knows how long had they left the house. During an interview on 8/10/23 at 10:50 a.m., the Administrator said the front door was staffed by a receptionist on the day (7/4/23) Resident #1 left the facility with another resident's family member. The Administrator said she had spoken with the resident's family member that took Resident #1 from the facility on 7/4/23. The Administrator said he (the resident's family member that took Resident #1 from the facility ) was very upset and felt awful, she explained he thought Resident #1 was a visitor who simply needed a ride home. The Administrator said it was possible Resident #1 left with the man while the receptionist had went to bathroom. The Administrator the facility receptionists were all in-serviced after the elopement and instructed that if they needed to leave the desk, even to use the restroom they were to notify/obtain supervision for the front door. The Administrator said the door was secured with an exit code at the time of the elopement, but the facility now ensured the code for exit was changed daily and only the receptionist and department heads knew the code. The Administrator said Resident #1's admission elopement assessment was negative. The Administrator said elopement assessments were to be completed upon admission and quarterly. The Administrator said she in-serviced staff to complete elopement assessments if residents displayed elopement behaviors even if it was not time for the quarterly elopement assessment. The Administrator said Resident #1 now has a wander guard device (bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time. When a resident with a bracelet approaches a monitored door, the system alarms and alerts caregivers) in place. During an interview and observation on 8/10/23 at 10:55 a.m., Resident #1 sat in a chair in the social area adjacent to the nurses' station. Resident #1 said I need to go home. Can you take me home? Resident #1 had a wander guard device on her left ankle. During an observation on 8/10/23 at 10:58 a.m., LVN A walked with Resident #1 to the front entrance of the building. When Resident #1 was within a few feet of the door, the wander guard system began to alarm. During an interview on 8/10/23 at 11:05 a.m., LVN A said she regularly took care of Resident #1 on the 6:00 a.m. to 6:00 p.m. shift. LVN A said Resident #1 wandered in the facility but had never been exit seeking before 7/4/23. LVN A said Resident #1 would always approach staff and make statements like, 'I need to go home', 'Where is my son?', Do you know where (city of former residence) Texas is?'. LVN A said wandering and making those statements/asking those questions ('I need to go home', 'Where is my son?', Do you know where (city of former residence) Texas is?') were not new behaviors for Resident #1 and said she those behaviors were present since her admission. LVN A said Resident #1 was always easily redirected and reorientated. LVN A said she took care of Resident #1 on 7/4/23 and served he lunch in the dining room that day. LVN A said she had no idea that Resident #1 had left the facility until her (Resident #1's) family brought her back to the facility. LVN A said she would have to look at her nursing documentation to know what time Resident #1 had returned to the facility. LVN A said she believed Resident #1 was gone from the facility for approximately an hour. LVN A said elopement assessments should be completed on admission, readmission, quarterly and with any change of condition. During an interview on 8/10/23 at 11:15 a.m., CNA M said she regularly took care of Resident #1. said Resident #1 wandered in the facility but had never been exit seeking before 7/4/23. CNA M said LVN A said Resident #1 would always approach staff and say things like, 'Where am I?', 'Where is my son?', 'I need to go home to my husband'. During an interview on 8/10/23 at 2:55 p.m., CNA N said she regularly took care of Resident #1. CNA N said she regularly took care of Resident #1. She said Resident #1 wandered in the facility but typically approached staff and say things like, 'Where am I?', 'I need to go home', 'Do you know where (city of former residence) Texas is?' CNA N said Resident #1 was not exit seeking before the 7/4/23. During an interview on 8/10/23 at 3:00 p.m., LVN C said she regularly took care of Resident #1 on the 6:00 p.m.- to 6:00 a.m. shift. LVN C said elopement assessments should be completed on admission, readmission, quarterly and with any change of condition. LVN C regularly wandered the facility but not aimlessly. LVN C said she would sometimes be tearful and say she (Resident #1) needed to go home. LVN C said Resident #1 was always easily reoriented and reassured that she (Resident #1) lived in the facility. LVN C said elopement assessments should be completed on admission, readmission, quarterly and with any change of condition. During an interview on 8/10/23 at 3:14 p.m., LVN L said elopement assessments should be completed on admission, readmission, quarterly and with any change of condition. LVN L said she did not regularly care for Resident #1 as her primary nurse but was familiar with her. LVN L said Resident #1 wandered the facility in the area in front of the nurses station. LVN L said she would approach staff and say things like 'Where am I?', 'I need to go home', 'Do you know where (city of former residence) Texas is?' 'Do you know where my son is?'. LVN L said Resident #1 was not exit seeking and was easily reoriented. During an interview on 8/10/23 at 3:23 p.m., RN D said she regularly cared for Resident #1 on 6:00 a.m. to 6:00 p.m. shift. RN D said Resident #1 would always approach staff and make statements like, 'I need to go home', 'Where is my son?', and 'Do you know where (city of former residence) Texas is?' Rn D said Resident #1 was easily reoriented. RN D said Resident #1 was not exit seeking but always wandered the facility. RN D said elopement assessments should be completed on admission, readmission, quarterly and with any change of condition. During an interview on 8/14/23 at 10:20 a.m., LVN A said when she completed the admission elopement assessment on 1/20/23 for Resident #1, she (Resident #1) had been in the facility a few hours. LVN A said she based her answers on the observations she had at that time (1/20/23) and from speaking with the family. LVN A said Resident #1 did not receive another elopement assessment until after she left the faciity on 7/4/23. LVN A said elopement assessments should be completed on admission, readmission, quarterly and with any change of condition. LVN A said nurses are alerted by the EMR system what assessments are due and when they need to be completed. LVN A said if the assessment does not appear on the work list, the nurse is not aware the assessment needs to be completed. LVN A said had she completed an assessment on Resident #1 at the end of April or beginning of May 2023 she would have answered the elopement assessment questions in the following manner: *Spends time on the first floor or wanders between floors or units? -Response: yes *Hangs around facility exits and/or stairways? -Response: no; *Verbalizes a serious/strong intent to leave the facility in the absence of an appropriate discharge plan? -Response: no; *Responds poorly to staff re-direction when roaming into areas that are off limits or unauthorized. -Response: no *Has the physical ability to leave the building? -Response: yes *Becomes agitated, confused and/or disoriented or displays consistently poor judgement (i.e., would not be able to safely care for him/herself outside of the facility)? -Response: yes; and *Engages in theme behavior (i.e., leaving for work, seeking his/her car, searching for children, seeking people/places from days/years gone by)? -Response: yes LVN A said her responses would have scored Resident #1 as a 6 and triggered her as a risk for elopement. During an interview on 8/14/23 at 11:41 receptionist F said she worked at the facility supervising the front entrance on 7/4/23from 12:00 p.m., to 2:00 p.m. Receptionist F said she saw the family visitor Resident #1 was said to have left with. Receptionist F said she did not see Resident #1 leave the building with the family visitor. Receptionist F insisted she left her desk at no time between 12:00 p.m. to 2:00 p.m. An interview with the male visitor that took Resident #1 from the facility on 7/4/23 was attempted on 8/10/23 and 8/14/23 but was not completed. During an interview on 8/14/23 at 11:44 p.m., RN B said she was familiar with Resident #1. RN B said elopement assessments should be completed on admission, readmission, quarterly and with any change of condition. RN B said nurses know what residents need an elopement assessment because the EMR system would populate the assessments due to be completed. RN B said there was in issue when the EMR updated a few months ago that seemed to have affected the generation of the assessment lists due for residents. RN B said they discovered the issue because the EMR system was saying residents had assessments due that had already been completed. RN B said she believed this EMR issue was why Resident #1 did not trigger for a quarterly elopement assessment. RN B said had she completed an elopement assessment on Resident #1 at the end of April or beginning of May 2023 she would have answered the elopement assessment questions in the following manner: *Spends time on the first floor or wanders between floors or units? -Response: yes *Hangs around facility exits and/or stairways? -Response: no; *Verbalizes a serious/strong intent to leave the facility in the absence of an appropriate discharge plan? -Response: no; *Responds poorly to staff re-direction when roaming into areas that are off limits or unauthorized. -Response: no *Has the physical ability to leave the building? -Response: yes *Becomes agitated, confused and/or disoriented or displays consistently poor judgement (i.e., would not be able to safely care for him/herself outside of the facility)? -Response: yes; and *Engages in theme behavior (i.e., leaving for work, seeking his/her car, searching for children, seeking people/places from days/years gone by)? -Response: yes RN B said her responses would have scored Resident #1 as a 6 and triggered her as a risk for elopement risk. RN B said had the quarterly assessment been performed and triggered Resident #1 as an elopement risk, we (facility staff) would have spoke to the family and placed a wander guard system at that time. During an interview on 8/14/23 at 12:00 p.m., the Corporate RNC stated she was familiar with Resident #1. The Corporate RNC said had she completed an elopement assessment on Resident #1 at the end of April or beginning of May 2023 she would have answered the elopement assessment questions in the following manner: *Spends time on the first floor or wanders between floors or units? -Response: yes but she was always easily redirected.; *Hangs around facility exits and/or stairways? -Response: no; *Verbalizes a serious/strong intent to leave the facility in the absence of an appropriate discharge plan? -Response: no; *Responds poorly to staff re-direction when roaming into areas that are off limits or unauthorized. -Response: no; *Has the physical ability to leave the building? -Response: yes; *Becomes agitated, confused and/or disoriented or displays consistently poor judgement (i.e., would not be able to safely care for him/herself outside of the facility)? -Response: yes; and *Engages in theme behavior (i.e., leaving for work, seeking his/her car, searching for children, seeking people/places from days/years gone by)? -Response: yes The Corporate RNC said her responses would have scored Resident #1 as a 6 and triggered her as a risk for elopement risk. The Corporate RNC said had the quarterly assessment been performed and triggered Resident #1 as an elopement risk, she would have relied on the judgement of the nursing staff. The Corporate RNC said there was updated to the EMR system that effected the generation of the list of assessments nurses would be prompted to complete. The Corporate RNC said this EMR issue is what cause Resident #1 to miss her quarterly elopement assessment. The Corporate Nurse said the problem was recognized sometime in April 2023. The Corporate RNC said she was working in her buildings to come up with a solution in May/June of 2023 and it was decide all assessments would be started on the next MDS that was due for each resident -instead of a needle in the haystack approach. 2.Record review of Resident #2's face sheet indicated she was [AGE] years old and readmitted to the facility on [DATE] with diagnoses including, dementia, history of right femur fracture, osteoporosis atrial fibrillation, heart failure, muscle weakness, repeated falls, and the presence of right artificial hip joint. Record review of the MDS dated [DATE] indicated Resident #2 made herself understood and understood others. The MDS indicated she had moderate cognitive impairment (BIMS of 11). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #2 had exhibited no behavior of wandering during the 7 days look back. The MDS indicated Resident #2 required extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The MDS indicated she required supervision with locomotion in her wheelchair and eating. The care plan revised on 10/5/22 indicated Resident #2 had impaired cognition and was at risk for further cognitive decline due to dementia. The care plan interventions included, monitor/document report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes. Record review of the elopement assessments on 8/14/23 completed for Resident #2 since 1/20/23 revealed Resident #2 had a quarterly elopement assessment completed 1/20/23 and no additional elopement assessments had been completed. 3.Record review of Resident #3's face sheet indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses including, dementia, history of stroke, hemiplegia and hemiparesis affecting the right dominant side, heart disease, and heart failure. Record review of the MDS dated [DATE] indicated Resident #3 sometimes made herself understood and sometimes understood others. The MDS indicated she had severe cognitive impairment (BIMS of 1). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #3 had exhibited no behavior of wandering during the 7 days look back. The MDS indicated Resident #3 required extensive assistance with bed mobility, transfers, locomotion in her wheelchair on the unit, dressing, and personal hygiene. The MDS indicated she required limited assistance with locomotion off the unit in her wheelchair. The MDS indicated she required supervision with locomotion in her wheelchair and eating. The MDS indicated walking had not occurred during the 7 day look back period. The MDS indicated she was totally dependent on staff for toileting and bathing. The care plan revised on 7/21/23 indicated Resident #3 had impaired cognition and was at risk for further cognitive decline due to dementia. The care plan interventions included, provide a homelike environment, visible clocks, a calendar, low glare light, consistent care routines, and familiar objects. Record review of the elopement assessments on 8/14/23 completed for Resident #3 since 3/15/23 revealed Resident #3 had an admission elopement assessment completed 3/15/23 and no additional elopement assessments had been completed. 4. Record review of Resident #4's face sheet indicated she was [AGE] years old and readmitted to the facility on [DATE] with diagnoses including, dementia, Type II diabetes, heart disease, heart failure and COPD (chronic obstructive pulmonary disease). Record review of the MDS dated [DATE] indicated Resident #4 made herself understood and understood others. The MDS indicated she had intact cognition (BIMS of 13). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #4 had exhibited no behavior of wandering during the 7 days look back. The MDS indicated Resident #4 required supervision only with ADLS. The care plan revised on 6/15/22 indicated Resident #4 had impaired cognition and was at risk for further cognitive decline due to dementia. The care plan interventions included monitor/document report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes. Record review of the elopement assessments on 8/14/23 completed for Resident #4 since 1/13/23 revealed Resident #4 had an admission elopement assessment completed 1/13/23 and no additional elopement assessments had been completed. 5.Record review of Resident #5's face sheet indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses including, history of hydrocephalus, high blood pressure, Type II diabetes, chronic migraine, seizures, muscle weakness and lack of coordination. Record review of the MDS dated [DATE] indicated Resident #5 made herself understood and understood others. The MDS indicated she had moderate cognitive impairment (BIMS of 11). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #5 had exhibited no behavior of wandering during the 7 days look back. The MDS indicated Resident #5 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS indicated she required supervision with eating and locomotion in her wheelchair. The MDS indicated walking had not occurred during the 7 day look back period. The care plan revised on 5/24/23 indicated Resident #5 had impaired cognition and was at risk for further cognitive decline due to confused and forgetful at times. The care plan interventions included, monitor/document report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes. Record review of the elopement assessments on 8/14/23 completed for Resident #5 since 2/15/23 revealed Resident #5 had a quarterly elopement assessment completed 2/15/23 and no additional elopement assessments had been completed. 6. Record review of Resident #6's face sheet indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses including, dementia, high blood pressure COPD, history of stroke, muscle weakness, lack of coordination and severe glaucoma. Record review of the MDS dated [DATE] indicated Resident #6 made herself understood and understood others. The MDS indicated she had moderate cognitive impairment (BIMS of 12). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #6 had exhibited no behavior of wandering during the 7 days look back. The MDS indicated Resident #6 required supervision only with ADLS. The care plan revised on 2/23/23 indicated Resident #6 had impaired cognition and was at risk for further cognitive decline related to dementia. The care plan interventions included, provide a homelike environment, visible clocks, a calendar, low glare light, consistent care routines, and familiar objects. Record review of the elopement assessments on 8/14/23 completed for Resident #6 since 2/16/23 revealed Resident #6 had an admission elopement assessment completed 2/16/23 and no additional elopement assessments had been completed. 7. Record review of Resident #7's face sheet indicated she was [AGE] years old and re-admitted to the facility on [DATE] with diagnoses including, history of strokes, hemiplegia hemiparesis affecting the right dominant side, muscle weakness, lack of coordination, depression, anxiety and polyosteoarthritis (term used when at least five joints are affected with arthritis). Record review of the MDS dated [DATE] indicated Resident #7 made herself understood and understood others. The MDS indicated she had intact cognition (BIMS of 15). The MDS indicated she had no behavior of rejecting care. The MDS indicated Resident #7 had exhibited no behavior of wandering during the 7 days look back. The MDS indicated Resident #7 was totally dependent on staff for transfers, dressing, and bathing. The MDS indicated she required extensive assistance with bed mobility, locomotion in her wheelchair, toilet use and personal hygiene. The MDS indicated she required supervision only with eating. The care plan revised on 8/4/22 indicated Resident #7 had impaired cognition and was at risk for further cognitive decline related to history of stroke, depression and anxiety. The care plan interventions included, the care plan interventions included, monitor/document report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes. Record review of the elopement assessments on 8/14/23 completed for Resident #7 since 3/4/23 revealed Resident #7 had a re-entry elopement assessment completed 3/4/23 and no additional elopement assessments had been completed. 8.Record review of Resident #8's face sheet indicated he was [AGE] years old and admitted to the facility on [DATE] with diagnoses including, Parkinson's disease, mild intellectual disabilities, high blood pressure, unsteadiness on feet, and muscle weakness. Record review of the MDS dated [DATE] indicated

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 2 of 12 (Resident #1 and Resident #2) residents reviewed for safe smoking. 1. The facility failed to have a system in place to ensure resident safety while residents were signed out of the facility when smoking and traveling by themselves. 2. The facility failed to provide supervision for Resident #1, who was allowed to sign herself out and self-propel in a wheelchair to a local convenience store down the street (0.2 miles from facility), loiter in a neighboring medical parking lot, and smoked at the entrance of the facility's parking lot near a two-lane street with a posted speed limit of 30 mph. 3. The facility failed to follow their smoking policy by allowing multiple residents to sign themselves out and smoke and allowing Resident #1 and Resident #2 who required supervision while smoking to smoke unsupervised. There was no designated smoking area in the front of the facility where residents go smoke. 4. The facility had no policy to address resident signing themselves out. 5. The facility did not have a covered area or approved ash trays to fire extinguisher. An Immediate Jeopardy (IJ) situation was identified on 07/08/2023 at 5:00 p.m. The IJ template was provided to the facility on [DATE] at 5:00 p.m. While the IJ was removed on 07/11/2023 at 12:58 p.m., the facility remained out of compliance at a scope of pattern and severity level of no actual harm with the potential for more than minimal harm because all staff had not been trained on the smoking policy, sign out on pass, and incident/accident reporting. Theses failures could place residents at risk for harm, serious injuries, and death. Findings included: 1. Record review of a face sheet dated 07/08/23 indicated Resident #1 was a [AGE] year-old female, admitted on [DATE] with diagnoses including Parkinson's disease (is a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), heart failure (the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), cerebral infarction (stroke), contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) to right hand, contracture of muscle, right upper arm, neuropathy (develops when nerves in the body's extremities - such as the hands, feet and arms - are damaged) and hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction affecting right dominant side. The face sheet indicated Resident #1 was her financial contact and a family member was an emergency contact. Unable to determine Resident #1's legal representative. Record review of an annual MDS assessment dated [DATE] indicated Resident #1 was understood and understood others. Resident #1 had minimal difficulty hearing (difficulty in some environment) with no hearing aid, clear speech, and impaired vision (sees large print, but not regular print in newspapers/books) with corrective lenses. Resident #1 had a BIMS score of 13 which indicated intact cognition and required limited assistance for bed mobility, dressing, toilet use, personal hygiene, and bathing but supervision for transfer. Resident #1 had functional limitation in range of motion (interfered with daily functions or placed resident at risk of injury) with impairment on one side, upper and lower extremities. Resident #1 used a walker and manual wheelchair for a mobility device. Resident #1 used tobacco. Resident #1 was administered an opioid (powerful pain-reducing medications). Record review of a care plan dated 10/22/2022 indicated Resident #1 was a smoker and was at risk for injury. Resident #1 was a safe smoker and did not require an apron. Intervention included educate resident on smoking policy, explain, and show resident and family where designated smoking areas are and repeat as necessary, and assist resident to and from smoking area as needed. Record review of a care plan dated 10/20/22 indicated Resident #1 had impaired visual function and was at risk for falls, injury, and a decline in functional ability. Intervention included involve in activities which do not require vision to participate. Record review of a care plan dated 10/20/22 indicated Resident #1 was in the facility for long-term care placement as a result of a continued need for the services of skilled nursing staff as evidence by an inability to provide self-care. Record review of a care plan dated 05/25/22 indicated Resident #1 had the potential for falls related to stroke/hemiplegia, meds, weakness, unsteady/poor balance, neuropathy, right ankle pain, contractures, and osteoporosis (is a disease that thins and weakens the bones). Intervention included wheelchair operation. Record review of a care plan dated 05/05/23 indicated Resident #1 had communication problems related to stroke, decreased hearing, and does not wear hearing aid. Intervention included anticipate and meet needs. Record review of a progress note for Resident #1, dated 06/15/23 at 4:27 p.m., completed by the ADM, indicated Discussed with Resident #1 today our smoking policy. Resident #1 was found in facility smoking area unsupervised actively smoking. When asked how Resident #1 got cigarette she said out of the smoke box, but nursing staff says they didn't provide the cigarettes or the box to her. Resident #1 was educated on smoking policy and need to turn in cigarettes and lighter to nurse's station. Record review of a progress note for Resident #1, dated 06/27/23 at 8:25 p.m., completed by LVN E, indicated up in wheelchair at nurse's station after sitting outside for hours . Record review of a smoking assessment dated [DATE], completed by RN A, indicated Resident #1 had visual deficit and needed supervision for adaptive equipment. Record review of a smoking assessment dated [DATE], completed by RN B, indicated Resident #1 had dexterity problem and needed supervision for adaptive equipment. Record review of a smoking assessment dated [DATE], completed by SW C, indicated Resident #1 had dexterity problem and needed supervision for adaptive equipment. Record review of a fall risk assessment dated [DATE], completed by LVN C, indicated Resident #1 was a moderate risk for falls. Record review of Release of Responsibility for Leave of Absence form of Resident #1, at the reception desk, dated 03/12/23-7/7/23 indicated, I, the undersigned, hereby accept complete responsibility for Resident #1 while away from the facility and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away .Authorization must be signed by the resident/patient . date .time signing out .signature of person accepting responsibility for Resident/Patient . signing in .date .time . signature of facility representative .: *276 out of 279 entries (107 days) Resident #1 did not sign her own signature. *241 out of 279 entries (107 days) Resident #1's destination was not noted. *17 out of 279 entries (107 days) Resident #1 did not have a sign in signature after signing out. *3 out of 107 days Resident #1's sign in was noted 2 hours or more from when she signed out, with outside as the destination. * 18 out of 107 days Resident #1's sign in was noted 2 hours or more from when she signed, with no destination noted. * 3 of the 18 days Resident #1's sign in was noted 2 hours or more from when she signed, with no destination noted, a comment was noted wasn't here when I left. (5/25/23 signed out at 8:30 p.m., 6/19/23 signed out at 8:50 p.m., 6/22/23 signed out at 5:15 p.m., 7/7/23 signed out at 3:11 p.m.). Record review of Release of Responsibility for Leave of Absence form for Resident #1, at the nurse's station, dated 05/17/23- 07/08/23 indicated, I, the undersigned, hereby accept complete responsibility for Resident #1 while away from the facility and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away .Authorization must be signed by the resident/patient . signing out .date .time . signature of person accepting responsibility for resident/patient .signing in . date .time .signature of facility representative .: * 7 out of 12 entries (9 days) Resident #1 did not sign her own signature. * 12 out of 12 entries (9 days) Resident #1's destination was not noted. * 11 out of 12 entries (9days) Resident #1 did not have a sign in signature after signing out. During an interview and observation on 07/08/23 at 2:45 p.m., Resident #1 was sitting in the front lobby in her wheelchair. Resident #1's right arm was contracted. She said she wanted to be interviewed in the front lobby. Resident #1 aggressively said, Are you here about smoking? Resident #1 said she did not keep her cigarettes on herself, but nursing staff gave her cigarettes from a lock box. She said she had not seen any other residents that smoked, with lighters or cigarettes on them while not on smoke break. Resident #1 said she had not seen other residents smoking in the front parking lot. Resident #1 said she was allowed to smoke at scheduled smoke breaks times but could also smoke alone at other times too. She said she had to sign out to smoke at nonscheduled times and had to go far away from the facility to smoke. Resident #1 said she liked to smoke at the end of the parking lot near the entrance and sometimes she went to the store at the corner. She said she had to wheel herself in the street because there was no sidewalk. Resident #1 said she could barely hold the things she bought at store to bring them back. 2. Record review of a face sheet dated 07/08/23 indicated Resident #2 was a [AGE] year-old female, admitted on [DATE] with diagnoses including dementia (is the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), congestive heart failure (is a serious condition in which the heart doesn't pump blood as efficiently as it should), nicotine dependence (involves physical and psychological factors that make it difficult to stop using tobacco, even if the person wants to quit), cigarettes, long term current use of anticoagulants (are medications that help stop your blood from thickening or clotting.) and chronic obstructive pulmonary disease (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). The face sheet indicated Resident #2 was her financial contact and a family member was an emergency contact. Unable to determine Resident #2s legal representative. Record review of an admission MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. Resident #2 had minimal difficulty hearing and no hearing aid. Resident #2 had clear speech and moderately impaired vision (limited vision) used corrective lenses. Resident #2 had a BIMS score of 08 which indicated moderate cognition impairment and required limited assistance for toilet use, extensive assistance for bed mobility, transfer, dressing, personal hygiene, and bathing. Resident #2 was not steady, only able to stabilize with staff assistance for walking and turning around and facing the opposite direction while walking. Resident #2 used a walker and wheelchair for mobility devices. The MDS indicated Resident #2 was not a current tobacco use. Resident #2 had a fall in the last 2-6 months prior to admission. Record review of a care plan dated 03/24/23 indicated Resident #2 had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to confusion, forgetfulness, and age-related decline. Resident #2 takes an anticoagulant and was at risk for bleeding. Resident #2 had impaired visual function and was at risk for falls, injury, and decline in functional ability. Resident #2 had a communication problem related to impaired hearing/vision/cognition. Intervention ensure/provide a safe environment. Resident #2 had the potential for falls related to status post-surgery, weakness, decreased mobility, pain, meds, impaired cognition/vision, and history of falls. Resident #2 was a smoker and was at risk for injury. Resident is a smoker and does not require an apron. Interventions included educate on smoking policy and explain and show resident and family where designated smoking areas are and repeat as necessary and assist resident to and from smoking area as needed. Record review of a smoking assessment dated [DATE], completed by RN B, indicated Resident #2 needed supervision for adaptive equipment and supervised with each smoke break. Record review of a smoking assessment dated [DATE], completed by LVN D, indicated Resident #2 needed supervision for adaptive equipment. Record review of Release of Responsibility for Leave of Absence form for Resident #2, at the reception desk, dated 05/16/23-7/7/23 indicated, I, the undersigned, hereby accept complete responsibility for Resident #2 while away from the facility and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away .Authorization must be signed by the resident/patient . signing out .date .time . signature of person accepting responsibility for resident/patient .signing in . date .time .signature of facility representative .: *32 out of 265 entries Resident #2 did not sign her own signature. *263 out of 265 entries Resident #2's destination was not noted. *9 out of 265 entries Resident #2 did not have a sign in signature after signing out. Record review of Release of Responsibility for Leave of Absence form for Resident #2, at the nurse's station, dated 05/16/23- 07/07/23 indicated, I, the undersigned, hereby accept complete responsibility for Resident #2 while away from the facility and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away .Authorization must be signed by the resident/patient . signing out .date .time . signature of person accepting responsibility for resident/patient .signing in . date .time .signature of facility representative .: * 14 out of 14 entries Resident #2's destination was not noted. * 4 out of 14 entries Resident #2 did not have a sign in signature after signing out. During an observation on 07/07/23 at 3:35 p.m., Resident #2 was observed smoking in the designated smoking area of the facility with no safety concerns. Resident #2 was supervised by the Maintenance Supervisor. During an observation on 07/08/23 at 9:09 a.m., Resident #2 was observed smoking in the designated smoking area of the facility with no safety concerns. Resident #2 was supervised by the Maintenance Supervisor. During an interview on 07/08/23 at 3:00 p.m., Resident #2 said a couple months ago the facility started letting her check in and out to smoke unsupervised. She said she had to sign out at the nurse's station to get her cigarette and lighter and sign out at the receptionist desk. Resident #2 said she had to smoke 50 feet away from the building but still on the facility's premise. She said when she came back from smoking, she had to turn the cigarettes and lighters back to the nurse. Resident #2 said she put her cigarettes out then rolled it up in napkin or Kleenex in her hand the threw it away in a trash can when she got in the facility. She said she did not throw her cigarettes butts in the ground. Resident #2 said Resident #1 did not sign in or out nor return her cigarettes and lighter to the nurse. Resident #2 said the facility instructed her when she smoked in front of the building to wear hat, sunscreen and sit in the shade. Record review of the average weather conditions for 04/23, according to the National Weather Service, indicated the high average monthly temperature was 75.3 degrees and 52.9 degrees as the lowest. Record review of the average weather conditions for 05/23, according to the National Weather Service, indicated the high average monthly temperature was 81.7degrees and 60.7 degrees as the lowest. Record review of the average weather conditions for 06/23, according to the National Weather Service, indicated the high average monthly temperature was 89.6 degrees and 70.4 degrees as the lowest. Record review of the average crime rate on 07/13/23, according to the City-Data., indicated the city's crime rate was higher than in 68.2% of U.S. cities. Record review of a list of In-Services in April, May, June 2023, indicated the following .April topics .Life Safety, Abuse/Neglect, Reporting .May topic . who to contact, how to deal with aggressive behaviors .Abuse/ Neglect .June topics .Customer Service, Dining room service, Wasteful with supplies, Abuse/neglect . Record review of In-services in April 2023 indicated no topics on Smoking policy. Record review an undated facility Smoke Breaks list indicated the following, .Times .9:00 AM, 11:00 AM, 1:00 PM, 3:30 PM, 7:00 PM, 9 PM .Primary .Restorative (9:00 AM) .Receptionist (11:00 AM) . Medical Record (1:00 PM) . Maintenance (3:30 PM) . Hall 3 and 4 (7:00 PM) .Hall 1 and 2 (9:00 PM) . During an interview on 07/07/23 at 5:48 p.m., MA O said residents were not supposed to keep cigarettes and lighters on them. During an interview on 07/07/23 at 6:00 p.m., LVN P said residents who smoked in the front were supposed to be 50 ft away from the building and able to get themselves in and out of the building. She said there was no way for the front desk to know if the resident signed out with the nurse. She said unless a nurse was at the nurse's station, they could miss the resident coming back and some might leave the smoking material at the nurse's station when no staff were there. She said she told the ADM and DON, she did not think it was safe to allow residents to smoke in the front. She said the nursing staff cannot be around to make sure residents signed out and in or if the residents were smoking 50 ft away from the building. She said staff did not know if residents were keeping cigarettes and lighters in their pockets and were not allowed to search them. She said it was important for them to know if resident had smoking items because they did not want the residents to light something with a lot of oxygen in the building. She said there was also a risk of the residents giving their lighter to someone else. During an observation on 07/08/23 at 8:23 a.m., the facility's front entrance was perpendicular to a two lane, side street with a posted speed limit of 30 mph. On the left side of the street, when facing the main street, the facility was near, a building of medical offices was noted and a convenience store. On the right side of the street, was a local hospital. The side street did not have a sidewalk of either side. The facility's entrance driveway was narrow and was cut off by a metal fence. Near the metal fence, parallel parking spots were noted and regular parking spaces on the other side. The front door entrance was on slight incline with a circular driveway. The maintenance supervisor was picking up trash and used cigarettes. During an interview on 07/08/23 at 9:19 a.m., Receptionist F said she worked the front desk on the weekends, either 8am-5pm or 8am-8pm. She said residents could go to the front of the building to smoke. She said residents had to sign in and out in binder when they went out front. She said Resident #1 and Resident #2 were the main residents who smoked out front. She said she had not been in-serviced on the updated Smoking Policy revised in April 2023. She said she had to sign the resident's name sometimes because they would not do it. She said she did not realize the signing out portion on the Release of Responsibility for Leave of Absence was only the signature of the person accepting responsibility for the resident. She said residents had to be 50 ft away from the front door to smoke in the front. She said sometimes the residents were not compliant. She said she would instruct the residents to go smoke in the area with the bench behind the therapy building. She said residents who smoked in the front, left cigarettes butts everywhere. She said there was a trash can by the door but not 50 ft away from the entrance door and no ashtrays. During an interview on 07/08/23 at 11:00 a.m., the payroll coordinator said she had been employed at the facility for 7 years. She said on the weekends she occasionally worked as a CNA. She said since she started 7 years ago, smokers smoked in the back of the facility and at the schedule smoke break times. She said about 90-120 days ago when the new administrator started, smokers were allowed to request their smoking box which held cigarettes and lighter, sign out and in at nurse's station then sign out and in at the receptionist desk and smoke wherever per the administrator. She said the residents did have to smoke at least 50 ft away from the entrance door. She said the residents were supposed to be cognitive enough to sign out and in and return smoking items to the nurse. She said the nurses were supposed to keep up with which resident was smoking out front and if they had turned in their smoking items or not. She said the problem with that situation was that they had to take care of other residents and were not stationed at the nurse's station and different residents were asking for their smoking items at different times. She said she did not know the facility had a revision to the smoking policy in April 2023. She said Resident #1 and Resident #2 did not follow the rules. She said half the time the residents did not sign out and already had their smoking items because they did not turn them in from the previous smoke break. She said she normally arrived to work around 3 a.m.- 6a.m., and residents were outside smoking in the dark parking lot. She said the residents in the front smoked at the front door, in between cars near the metal fence, and at the entrance of the facility parking lot near the hospital. She said she did not think any of the residents who were allowed to smoke in the front were cognitive enough to be outside unsupervised. She said all of residents discarded their used cigarettes on the ground. She said staff from the nearby medical buildings had expressed concerns about the resident being in the front alone. She said the front area where the residents were allowed to smoke did not have ashtrays or metal receptacles. She said she did not feel like the front parking lot was a safe area to smoke in because it was a high traffic area and tight parking spaces. During an interview on 07/08/23 at 11:22 a.m., SW C said she had been employed for the facility for 2 weeks. She said she would be responsible of care plans and initial assessment. She said she was not fully oriented to the facility. She said she had not received training or in-service of the smoking policy. She said she only knew the resident's smoking material was stored behind the nurse's station. She said she knew all smokers had to be supervised and there was scheduled smoke breaks. She said she knew resident could not smoke within 50 feet of the building, in the front. She said if residents were non-compliant with the smoking policy, counseling was provided. She said she had seen ashtrays and metal receptacles in the back smoking area but not the front. She said she felt there was a gray area if the residents were safe smoking in the front. She said it depended on the resident cognition and physical ability. She said she did not know the residents well enough to determine which residents were safe and unsafe in the front smoking unsupervised. During an interview and observation on 07/08/23 at 11: 30 a.m., the staffing coordinator said she had been employed at the facility for 11 years. She said she did fill in and work the floor as a CNA when they were short staffed. She said she thought the ADON had given an in-service on the updated smoking policy but after looking thru in-service binder, she realized they had not done one. She said the smoking area was in the back of the facility and all the residents had to be supervised. She said about 3 weeks ago she noticed residents smoking in the front parking lot of the facility. She said the residents who smoked in the front were usually by the metal fence or by the benches behind the therapy office. She said the front area where the residents smoked did not have metal ashtrays or receptacles. She said she came to work normally at 5am and would occasionally see Resident #2 out front smoking. She said she did not think the front parking lot was a safe area for residents to smoke because visitors and staff members did not know how to drive, and it was a highly trafficked area. During an interview on 07/08/23 at 11:50 a.m., MDS coordinator J said she had been employed at the facility for 6 years and was responsible for care plans and MDS's. She said she had not received an in service on the new smoking policy and did not know what it said. She said she knew the residents had to check out their smoking items from the nursing station, then they could go to the front parking lot to smoke. She said other residents' smoking items were kept in metal boxes and had to be supervised in the back area of the facility. She said residents being required to start signing in and out at the reception desk and nurse's station just started. She said the facility started requiring residents to sign in and out because residents were not turning in their smoking material after smoking breaks. She said Resident #1 smoked in the front and did not follow the rules. She said Resident #1 did not sign in and out and kept their smoking items instead of turning them in. She said the area in front where the residents smoked did not have metal ashtrays or trash cans. She said that the facility had a lot of cigarette butts on the ground since the facility allowed the residents to start smoking in the front. She said she got to the facility around 7 am and residents were already outside smoking. She said the residents were normally at the metal fence in the parking lot and sometimes at the front door smoking. She said she did not think the parking lot was a safe place for the residents to smoke because some of residents were in wheelchairs and may not be seen by drivers. She said the facility had elderly visitors who may not see very well and could hit the residents. She said she had not been instructed to update any residents' care plans who were not following the smoking policy. She said normally if it was an acute problem the ADON updated care plans and she did comprehensive updates. During an interview on 07/08/23 at 12:08 p.m., the BOM said she had been employed at the facility since November 2022. She said she was responsible for the finances and trust funds of the residents, and admissions. She said she normally worked Monday thru Friday 8-5. She said the facility did not provide a safe environment for residents to smoke when they went out front which was what the admission agreement stated. She said that the facility started letting residents smoke out front about 3 to 4 months ago. She said the main residents that smoked out front were Resident #1 and Resident #2. She said Resident #1 was in a wheelchair and Resident #2 used a rollator. She said the residents had to smoke at least 50 feet from the front door. She said the residents normally smoked at the fence line but Resident #1 liked to smoke at the end of the driveway near the side street. She said the facility had a lot of cigarette butts on the ground since the residents were allowed to smoke in the front. She said there was no fire safety stuff in the front where the residents smoked. She said she did not know where the residents disposed of their cigarettes after they smoked because there was no trash can in the front. She said she did not think the front parking lot was a safe area for the residents to smoke due to the facility having elderly visitors who probably could not see well. She said she had not received an in service on the updated smoking policy. She said she did not know who was responsible for ensuring the residents turned in their smoking items or signed in and out in the binders. She said she had heard of some of the residents had their smoking items with them instead of being locked at the nurse's station. She said she thought the residents who smoked out front were cognitive enough to be out front, but the driveway was not safe. During an interview on 07/08/23 at 12:06 p.m., the dietary manager said she had been employed by the facility for 4 years. She said until about 2-3 weeks ago, she supervised the smokers in the designated smoking area. She said she really did not know the smoking policy. She said she did not know a smoking monitor was supposed to be in serviced of the smoking policy. She said until about 30 days ago, resident could only smoke in the designated smoking area in the back of the facility. She said she did not know which residents were allowed to smoke out front. She said she routinely saw Resident #1 and Resident #2 out front smoking. She said Resident #2 was normally by the metal fence in the parking lot, but she had seen Resident #1 at the end of the driveway near the side street. She said Resident #1 and Resident #2 did not have a metal box for their smoking items. She said some residents smoked at the designated smoke times then immediately go smoke in the front parking lot. She said there was no fire safety stuff in front in case a fire started, or a resident got burned. She said the front parking lot was not safe because the driveway slopped and people drove too fast, and the residents were not supervised. She said she had not confiscated any resident's smoking items but heard Resident #1 had smoking items after smoke breaks. She said she had noticed the maintenance supervisor picking up discarded cigarettes butts. During an interview on 07/08/23 at 12:34 p.m., MDS coordinator K said she had been employed at the facility for 2 years but worked in 2010-2019 as the ADON and treatment nurse. She said she had not been in serviced on the updated smoking policy. She said her understanding of the smoking policy was only a resident who was able to sign themselves out were allowed to smoke in the front. She said the resident had to sign out at the nurse's station and front desk and sign back in then returned smoking items to the nurse. She said the residents who smoked in the front were normally in gravel area of the parking lot but Resident #1 was by side street but sometimes not smoking. She said the front parking lot was not safe because of the high traffic and hilly, bumpy driveway. She said the front parking lot did not have fire safety equipment. She said she did not know where the residents were discarding their used cigarettes. During an interview on 07/08/23 at 12:43 p.m., the Business Development Specialist said she had worked for the company for 15 years. She said she was at the facility 3-4 times a week. She said she had not been in serviced on the updated smoking policy from April 2023. She said smoking in the front of the facility was not safe, but the residents had been instructed to put on a hat and sunblock plus bring a water bottle outside. She said the residents who smoked out front had been asked to not smoke when it was dark outside. She s[TRUNCATED]