**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial needs for 1 of 3 residents (Resident #1) reviewed for care plans as follows: The facility failed to ensure to document Resident #1 was required to wear a fire-resistant apron and receive direct supervision from staff while smoking in the care plan, which resulted in staff not being trained or made aware of how to provide the resident with proper care. Resident #1's smoking assessment reflected she required direct supervision when smoking due shaking while smoking, falling asleep while smoking, past accidents/incidents with smoking materials, having visible burn marks on her clothing and she had finger dexterity problems. An Immediate Jeopardy was identified on 8/23/25 at 4:15 PM. The IJ template was provided to the facility Administrator on 6/12/24 at 4:18 PM. While the immediate jeopardy was lifted on 8/24/24 at 6:00 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent future concerns. This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs which could result in serious harm and injuries. Findings included: Record Review of Resident #1's face sheet dated 8/22/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had a medical history of type 2 diabetes mellitus with diabetic chronic kidney disease (damage to the kidneys caused by high blood sugar and blood pressure), unspecified visual loss (loss of eye sight), hyperlipidemia unspecified (high levels of fats in the blood), schizophrenia unspecified (mental illness that causes hallucinations, delusions, and disorganized thinking), unspecified convulsions (sudden, violent, irregular movement of a limb or the body), dorsalgia unspecified (back pain), and essential (primary) hypertension (high blood pressure). Record review of Resident #1's MDS dated [DATE] revealed, Section C - Cognitive patterns revealed a BIMS score of 7 which indicated Resident #1 had severe cognitive impairment. Record review of Resident #1's care plan dated 7/14/25 revealed focus: Resident #1 was caught smoking in her room was at risk for injury while smoking and required supervised smoking, date initiated 8/14/25, Goals: Resident #1 will be able to smoke without causing injury through the next review date, date initiated 7/14/25, revision date 8/4/25, target date 10/14/25. Interventions: Resident #1 always check to make sure she does not have her cigarettes and lighter on her, remove if found, ensure smoking in designated smoking areas, ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 7/14/25 and 8/14/25. Record review of Resident #1's safe smoking assessment dated [DATE], revealed under Section A Evaluation answered yes to the following questions, 7 resident shakes/has tremors while smoking, 8 resident falls asleep while smoking, 9 had past accidents/incidents with smoking materials, 10 are there any visible burn marks on the resident's clothing or coat, 11 does the resident have finger dexterity problems; and under Section B Summary the following options are checked, 2 This resident requires direct supervision while smoking, 3 this resident requires a fire-resistant smoking apron while smoking, 6 the evaluation has been discussed with the resident. Record review of Resident #2's care plan dated 7/17/25 revealed focus: Resident #2 vapes, date initiated 2/14/25, Goals: Resident #2 will be able to vape without causing injury, date initiated 2/14/2, revision date 2/14/24, target date 10/15/25. Interventions: Ensure smoking occurs in smoking areas, ensure that ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 7/14/25 and 8/14/25, the resident will be supervised by a visitor or facility staff member at all times, date initiated 2/14/25. Record review of Resident #2's safe smoking assessment dated [DATE] revealed under Section A Evaluation answered no to the following questions: 3. Can the resident independently light smoking materials safely, 4. Can the resident extinguish smoking material completely in an appropriate receptacle, 5. Can the resident dispose of ashes or other tobacco-related residue appropriately, 6. Explanation: poor coordination; and under Section B Summary the following option was checked, 2. This resident requires direct supervision while smoking. Record review of Resident #3's care plan dated 6/19/25 revealed focus: Resident #3 had oxygen via a trach collar (surgical opening in the neck to provide an airway into the trachea) secondary to respiratory failure, date initiated 8/15/21. Additionally Resident #3 smokes, dated 5/14/24, Goal: Resident #3 will be able to smoke without causing injury, date initiated 5/14/24, revision date 7/29/25, target date 9/19/25. Interventions: Ensure smoking occurs in smoking areas, ensure that ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 5/14/24, the resident is safe to smoke unsupervised, at this time, date initiated 5/14/2, keep all material at nurse station, date initiated 9/21/21. Record review of Resident #3's safe smoking assessment dated [DATE] revealed under Section B Summary the following option was checked, 2. This resident is safe to smoke unsupervised at this time. Record review of Resident #3's physician orders dated 8/23/25 revealed a prescription for Respiratory care of O2 (oxygen) at night and a trach collar during the day with a start date of 9/5/23. During an observation on 8/22/25 at 11:44 AM, revealed Resident #1 was leaned forward and was asleep. Resident #1 leaned over more and more and sat up when another resident spoke to her. No staff were present in the smoking room. Resident #1 was observed not wearing a smoking apron as she held an unlit cigarette that she stated she would smoke later. During an interview on 8/22/25 at 11:45 AM, Resident #3 said he and Resident #1 often smoked together in the smoking room. He said he helped watch her because she was blind. He said he had never seen Resident #1 wear a smoking apron when she smoked. He said staff brought Resident #1 into the smoking room but they have never stayed to supervise her. During an interview on 8/22/25 at 11:50AM, Resident #1 said staff did not supervise her when she smoked but there were other residents looking out for her in the smoking room. She stated she did not have to wear an apron while smoking. She stated staff or someone with a lighter would light her cigarettes for her. She stated her cigarettes were kept at the nurse's station. She stated she had lived at the facility for about three weeks and she had not burned herself. She stated she did not fall asleep while smoking but sometimes people thought she was because her head was down. She stated she put her head down because she had bulging disks in her neck but she was not asleep. She stated she was completely blind. During an interview on 8/22/25 at 3:36 PM, CNA D said she worked on hall 1. She said she took Resident #1 in the smoke room and lit her cigarette for her. She said she had to keep an eye on her but did not have to supervise her. She said Resident #1 would be okay as long as someone was in there with her. She said she checked on her periodically. She said she had not seen Resident #1 get burned. She said she was not aware of Resident #1 if had to be supervised when she smoked or any other accommodations. During an observation on 8/22/25 at 3:45PM, Resident #1 was observed smoking a cigarette facing the corner in the smoking room. She was not wearing a smoking apron. Cigarette ashes were observed on her lap. Resident #1 was observed hunched over leaning forward and appeared to be asleep. During an interview on 8/22/25 at 3:53PM, Resident #11 said staff brought Resident #1 to the smoke room. She or other staff with lit her cigarettes. Resident #11 said Resident #1 did not wear a smoking apron; staff go back inside; they did not watch her. During an interview on 8/22/25 at 4:01PM, Resident #8 said Resident #1 had fallen asleep while smoking but she had denied it. He said he knew she was asleep because he had seen her burn her purse and he had seen her with a cigarette in her hand that was completely ash. He said he had seen staff push her to the table, give her the ashtray and cigarette, and they left. He said Resident #1 did not wear an apron when smoking. During an interview on 8/22/25 at 4:32 PM, RN A said staff helped Resident #1 to the smoking room. She was initially an independent smoker and kept her cigarettes in her room but then she accused someone of stealing them, and she lit a cigarette in her room and hallway, but said she did not know she was in the building. Resident #1 was now required to keep her cigarettes and lighter stored at the nurse station. However, she was not required to be supervised or wear protective apron when smoking. During an interview on 8/22/25 at 4:50 PM, the Regional Compliance Nurse said currently, staff were required to light the cigarette for Resident #1 but she was able to smoke by herself without supervision or devices/accommodations. During an interview on 8/23/25 at 10:57 AM, LVN B said she did not know who was responsible to update staff on updated smoking assessments. LVN B stated the facility did not have a DON and there had been a lot of changes and staffing. LVN B said changes in smoking assessment should've been updated in the care plan immediately and passed on in report. During an interview on 8/23/25 at 10:56 AM, RT M said an update to a resident's smoking assessment should have been updated on the care plan because staff used that document to refer to when they provided care to the residents. She stated the ADONs and DONs told them when there were changes in a resident's smoke assessment. During an observation and interview on 8/23/25 at 11:16AM, Resident #1 was observed smoking with no apron and sitting at table with an ashtray. No staff were present in the room. During an interview on 8/23/25 at 11:38 am, the SW said she did not think Resident #1 should smoke unsupervised. The SW said she had seen ashes in Resident #1's hair. The SW said Resident #1 would get upset and said they were trying to make her look bad when they tried to address it with her. She said the nurses completed the smoking assessments and were supposed to notify the DON or the ADM who then updated the care plan. The SW stated there was no DON currently. She said the nursing department communicated those changes through report. She was not sure of the policy on how often they updated the smoking assessments but she thought the EHR prompted staff when they were due. During an interview on 8/23/25 at 12:30PM, the MDS Coordinator said she was responsible for completing and updating MDSs and care plans. She said either she, the DON, or the ADONs updated the care plans if there were changes in a resident's smoking assessment. She said someone would let her know to update the care plan. She said she could also check the 24-hour report for changes, and they were also updated during morning meeting discussions, and also the SW would let her know of changes that needed to be updated on the MDS or care plan. She stated the EHR did not alert them of changes in smoking assessments. The MDS Coordinator said she was not sure how often they were updated. She said the person who did the smoking assessment was responsible to communicate any changes to staff, the ADM, and herself. She said changes from a safe to an unsafe smoker should have been updated on the care plan as soon as the change was reported. She said she was not aware Resident #1's care plan was not updated to her being a supervised smoker. She said she was not aware Resident #1 was supposed to wear an apron while smoking. She stated a potential negative outcome of the care plan not being updated was that staff referred to the care plan to know how to provide care for the residents and they would not know Resident #1 was a supervised smoker and should've been wearing apron if the care plan was not updated. She said another potential negative outcome was that residents would not receive the right care and that could be dangerous. During an interview on 8/23/25 at 12:49PM, the ADM stated he worked at the facility since June 30, 2025, and there had been no DON for about a month, but one was starting next week. He said unsafe smokers could burn themselves or start fire if not wearing the smoking apron. He said the care plan should have been updated with the updated smoking assessment results so everyone could know what was going on with resident because that was what staff refer to when they provide care to the residents. He stated not updating care plans could cause residents to be unsafe or a resident could get injured. He said he was not aware Resident #1's care plan was not updated. The ADM said care plans were supposed to be updated immediately with changes. He said changes in care plans were communicated to the DON and the DON should review them on a regular basis. He said currently the Compliance Nurse had been trying to manage it the best she could but she worked at several different facilities. He said smoking assessments were completed monthly if that was what was documented in the care plan. He said not following care plan could result in an injury to a resident. He said the DON and ADONs were responsible to train staff. The ADM said their system to communicate changes needed or updates needed to the MDS and care plan were to discuss them during morning meetings to ensure care plans were being followed. During an interview on 8/23/25 at 7:12 PM, LVN C said he checked the care plan to determine how to care for residents. He said the ADON was responsible to update care plans. Record review of the facility policy titled, Comprehensive Care Planning, undated, revealed in part the following: he facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plans may include but are not limited to resident Kardex records, baseline care plans, and task listings. The comprehensive care plan will describe the following - the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASAR and the resident's representative(s)- The resident's goals for admission and desired outcomes. The resident's preference and potential for future discharge. The facility document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. Discharge plans in the comprehensive care plan, as appropriate. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing, or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. This was determined to be an IJ on 8/23/25 at 4:15PM. The Administrator and Regional Compliance Nurse were notified on 8/23/2024 at 4:18 PM and IJ situation was identified due to the above failure and the IJ Template was provided. The following Plan of Removal submitted by the facility was accepted on 8/23/2025 at 7:50PM. Record review of the facility Plan of Removal reflected the following: [Facility Name] 8/23/20258/23/2025Plan of RemovalProblem: IJ F656 related to care planning called on 8/23/2025Interventions:1. On 8/23/2025, the Regional Compliance Nurse/ Administrator reviewed care plans for all residents who smoke and updated them with correct information related to the safe smoking assessments completed on 8/23/2025. This was to include any special safety equipment or procedures identified in those assessments.2. On 8/23/2025, off cycle QAPI with the medical director was done by the Administrator and Regional Compliance Nurse over the IJ and plan of removal.3. On 8/23/2025 Administrator and MDS case managers were in-serviced over assuring that care plans are reflective of resident conditions and preferences to include safe smoking. Monitoring:1. Beginning 8/25/2025 and 5 times weekly DON/Administrator and MDS case managers will review any changes to resident conditions or preferences to include safe smoking in the morning meeting.2. Weekly the regional compliance nurse will review 5 care plans to assure that care plans are current and reflective of resident conditions and preferences to include safe smoking.3. The Area Director of Operations and Regional MDS support staff will assure that monitoring and updating of care plans is being done according to this plan of correction. On 8/24/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record of facility an in-service dated 8/23/2025 revealed training on the facility will allow smoking only supervised and in designated smoking areas. There will not be any smoking or vaping devices, including cigarette lighters in resident rooms. If a resident seen with a lighter, request if from the resident and notify the Administrator immediately. Residents who wear O2 (oxygen) must leave oxygen tank inside the facility prior to enter smoking area had signatures 32 staff members. Record review of a facility in-service dated 8/23/2025 revealed training on the facility has changed today 8/23/25 to a supervised smoking facility. All smoke breaks are to be supervised, please see attachment for smoking schedule had 29 staff signatures. Record review of the off-cycle Quality Assurance Meeting document, dated 8/23/25, titled: ADHOC QAPI for identification of a system in need of immediate attention by QAPI committee. On 8/23/25 a failure was identified to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 3 residents) reviewed for accidents and supervision while smoking. Residents were identified on 8/23/2025 that the facility failed to ensure Resident #1 wore a fire-resistant apron and received direct supervision from staff on while smoking on 8/22/2025 and 8/23/25. Monitoring will start 8/24/2025. Regional Compliance Nurse/Area Director of Operations will monitor during weekly visits and ask DON and Administrator about status of the smoking changes and any violations identified. Monitoring will start 8/24/2025 and will continue for at least 8 weeks and prn thereafter. The administrator / DON / ADONs will monitor 5 residents' rooms daily, 5 days a week to ensure residents do not have any prohibited smoking paraphernalia in the rooms, was signed by the ADM, Regional Compliance Nurse, and physician. Record review of an in-service training dated 8/23/25 revealed, SUBJECT MATTER: Care Plans Updates. Administrator/ ADONs and MDS case managers will assure the care plans are reflective of resident conditions and preferences to include safe smoking. Once a week during the staff meeting smoking assessments and care plans will be reviewed to reflect any changes, signed by the MDS Coordinator. Record review of an in-service training dated 8/23/25 revealed, SUBJECT MATTER: Care Plans Updates. Administrator/ ADONs and MDS case managers will assure the care plans are reflective of resident conditions and preferences to include safe smoking. Once a week during SOC meeting smoking assessments and care plans will be reviewed to reflect any changes, signed by the ADON. Record review of an in-service training dated 8/23/25 revealed, SUBJECT MATTER: Care Plans Updates. Care Plans Updates. Administrator/ ADONs and MDS case managers will assure the care plans are reflective of resident conditions and preferences to include safe smoking. Once a week during SOC meeting smoking assessments and care plans will be reviewed to reflect any changes, signed by the ADM. Record review of Resident #1's care plan dated 7/14/25 revealed focus: Resident #1 was often caught smoking in her room. Resident #1 was a supervised smoker and needed a smoking blanket or apron when smoking, date initiated 8/23/25, Goals: Resident #1 will be able to smoke without causing injury through the next review date, date initiated 7/14/25, revision date 8/4/25, target date 10/14/25. Interventions: Resident #1 always check to make sure she does not have her cigarettes and lighter on her, if smoking materials are found on her, remove from her and continue to redirect her not to smoke in room, ensure smoking in designated smoking areas, ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, resident was notified via negotiated risk agreement (NRA) on 8/23/25 that smoking is only allowed supervised at designated times in designated areas, she may not store smoking materials in her room and must check these in at the nurse station, this resident requires a fire-resistant smoking apron while smoking, dates initiated 7/14/25, 8/14/25, and 8/23/25. Record review of Resident #1's safe smoking assessment dated [DATE], revealed under Section A Evaluation answered yes to the following questions, 7. Resident shakes/has tremors while smoking, 8. Resident falls asleep while smoking, 9. Had past accidents/incidents with smoking materials, 10. Are there any visible burn marks on the resident's clothing or coat, 11. Does the resident have finger dexterity problems; and under Section B Summary the following options are checked, 2. This resident requires direct supervision while smoking, 3. this resident requires a fire-resistant smoking apron while smoking, 6. The evaluation has been discussed with the resident. Record review of care plans for Residents #2,#3, $4, #5, #6, #7, #8, #9, #10, #11, #12, #13 revealed they were updated with current smoking information on 8/23/25. During an interview on 8/24/25 at 9:55AM, the ADM said they completed in-services to ensure care plans were updated timely and were updated with residents most current information. They would discuss smoking assessments weekly and review care plans. He said they would document their monitoring on logs to ensure they were monitoring according to the plan of removal. During an interview on 8/24/25 at 1:10 PM, with Resident #3, stated he messed up when he took his oxygen tank in the smoking room, he owned it. He stated he was upset about the changes of the supervised smoking schedule and how the code to the front door was changed so they have to be let out by staff. He stated he was upset about the changes and felt like it was prison. During an observation and interview on 8/24/25 at 1:24PM, with HK O, stated staff were in-serviced about having a smoking schedule and the different departments would take turns and monitor the residents when smoking and all of the new smoking procedures and rules. Resident #1 was observed smoking and was wearing an apron. Three HK staff were watching her. Resident #1 was observed to be leaning over. A HK staff asked Resident #1 if she was falling asleep. Resident #1 said she was told she could not smoke when she wanted, it would be a schedule. Resident #1 stated staff come get her for smoke breaks. She said she felt claustrophobic with the apron but she would wear it. Resident #1 was observed dropping ash on herself. During an interview on 8/24/25, at 1:39PM, Resident #2 said he was told about the new rules for smoking. He said his vape was at the nurse station and he would be supervised while vaping. He said he was told about the new smoke schedule and that the front door code was changed. He said he was told staff would let him out after he signed out. He said he had no concerns to report. During an interview on 8/24/25 at 3:45PM, the Regional Compliance stated she provided in-services to staff on care plans. She said the ADON was trained to review care plans in service the ADON, MDS Coordinator, and ADM would review them once a week. She would train the new DON on those updates after they start. She said she would continue to in-service staff of changes in care plans. She said care plans should've been updated immediately because it could cause harm to residents. She said she would come once a week and review care plans to ensure they were updated. She would also train the new DON to check weekly to ensure care plans are updated. On 8/24/2025 between the 3:00 to 5:31PM interviews were conducted with the following staff members: CNAs D, K, L, RN A, LVNs B, C, E, I, MAs F, G, H, SW, DOR, RTs M, N, DS, HKs O, P, Q, AIT, and LS J. All staff members stated they were in-serviced on 8/23/25 and 8/24/25 on smoking policies including scheduled smoking and smoking schedule, and residents were supervised, all cigarettes, vapes, and lighters must stay at the nurse station, no oxygen was allowed in the smoking room, Resident #1 must wear a smoking apron, Resident #2 must be supervised, staff must light the cigarettes and residents were not allowed to share cigarettes were supervised, all cigarettes, vapes, and lighters must stay at the nurse station, no oxygen was allowed in the smoking room, Resident #1 must wear a smoking apron, Resident #2 must be supervised, staff must light the cigarettes and residents were not allowed to share cigarettes.On 8/24/25 at 6:00PM, the ADM was informed the IJ was removed however the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 3 of 3 residents (Resident #1, Resident #2, and Resident #3) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1 wore a fire-resistant apron and received direct supervision from staff on while smoking on 8/22/2025 and 8/23/25. Resident #1's smoking assessment reflected she required direct supervision when smoking due shaking while smoking, falling asleep while smoking, past accidents/incidents with smoking materials, having visible burn marks on her clothing and she had finger dexterity problems. 2. The facility failed to ensure Resident #2 received direct supervision per his smoking assessment from staff while smoking a vape on 8/23/25. 3. The facility failed to ensure Resident #3 did not have his oxygen tank with him while smoking on 8/22/25 and 8/23/25. An Immediate Jeopardy was identified on 8/23/25 at 4:15 PM. The IJ template was provided to the facility Administrator on 8/23/24 at 4:18 PM. While the immediate jeopardy was removed on 8/24/24 at 6:00 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent future concerns. The failures could place residents at risk for serious injury, serious harm, burns, and death. Findings included: Resident #1 Record Review of Resident #1's face sheet dated 8/22/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had a medical history of type 2 diabetes mellitus with diabetic chronic kidney disease (damage to the kidneys caused by high blood sugar and blood pressure), unspecified visual loss (loss of eye sight), hyperlipidemia unspecified (high levels of fats in the blood), schizophrenia unspecified (mental illness that causes hallucinations, delusions, and disorganized thinking), unspecified convulsions (sudden, violent, irregular movement of a limb or the body), dorsalgia unspecified (back pain), and essential (primary) hypertension (high blood pressure). Record review of Resident #1's MDS dated [DATE] revealed, Section C - Cognitive patterns revealed a BIMS score of 7 which indicated Resident #1 had severe cognitive impairment. Record review of Resident #1's care plan dated 7/14/25 revealed focus: Resident #1 was caught smoking in her room, was at risk for injury while smoking and required supervised smoking, date initiated 8/14/25, Goals: Resident #1 will be able to smoke without causing injury through the next review date, date initiated 7/14/25, revision date 8/4/25, target date 10/14/25. Interventions: Resident #1 always check to make sure she does not have her cigarettes and lighter on her, remove if found, ensure smoking in designated smoking areas, ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 7/14/25 and 8/14/25. Record review of Resident #1's safe smoking assessments dated 8/1/25, revealed under Section A Evaluation answered yes to the following questions, 7. resident shakes/has tremors while smoking, 8. resident falls asleep while smoking, 9. had past accidents/incidents with smoking materials, 10. are there any visible burn marks on the resident's clothing or coat, 11. does the resident have finger dexterity problems; and under Section B Summary the following options were checked, 2. This resident requires direct supervision while smoking, 3. This resident requires a fire-resistant smoking apron while smoking, and 6. The evaluation has been discussed with the resident. Record review of progress notes written by SW for Resident #1 dated 7/28/25, revealed staff spoke with the resident regarding the smoking policy and smoking in the hallways. Resident #1 stated she was confused and believed the CNA wheeled her into the smoking room. Reminded her that it was unsafe for her and the other residents to smoke inside. She understood and stated it won't happen again. Nurse and I (SW) asked her if we could hold the cigarettes and lighter at the nurses' station. Resident #1 said no, I'm not a child. Spoke with family member in person. Updated her and asked her if she would be willing to speak with the resident about the situation. The family member said yes and was understandable of situation. Record review of nursing progress notes, author unknown, for Resident # 1 dated 8/14/25, revealed Resident #1 was noted to be found smoking in the room. The resident stated she did not know she was in the building and said she thought she was in the smoking area. The resident was educated about fire hazards and a no smoking tolerance in the building. The family member was notified about the incident. Resident #2 Record Review of Resident #2's face sheet dated 8/23/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had a medical history of paraplegia unspecified (paralysis of the legs or lower body), quadriplegia, 5-C7 complete (paralysis of all four limbs, torso, and some organs), unspecified asthma uncomplicated (lung condition that causes trouble breathing), epilepsy unspecified not intractable without status epilepticus (brain disorder causing seizures), unspecified lack of coordination, muscle weakness (generalized), muscle wasting atrophy (loss of muscle tissue), cognitive communication deficit (difficulty with communication due to cognitive impairment), and dysphagia unspecified (difficulty swallowing). Record review of Resident #2's MDS dated [DATE] revealed, Section C - Cognitive patterns revealed a BIMS score of 12 which indicated Resident #2 had moderate cognitive impairment. Record review of Resident #2's care plan dated 7/17/25 revealed focus: Resident #2 vapes, date initiated 2/14/25, Goals: Resident #2 will be able to vape without causing injury, date initiated 2/14/2, revision date 2/14/24, target date 10/15/25. Interventions: Ensure smoking occurs in smoking areas, ensure that ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 7/14/25 and 8/14/25, the resident will be supervised by a visitor or facility staff member at all times, date initiated 2/14/25. Record review of Resident #2's safe smoking assessment dated [DATE] revealed under Section A Evaluation answered no to the following questions: 3. Can the resident independently light smoking materials safely, 4. Can the resident extinguish smoking material completely in an appropriate receptacle, 5. Can the resident dispose of ashes or other tobacco-related residue appropriately, 6. Explanation: poor coordination; and under Section B Summary the following option was checked, 2. This resident requires direct supervision while smoking. Resident #3 Record Review of Resident #3's face sheet dated 8/23/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had a medical history of acute and chronic respiratory failure with hypercapnia (build-up of carbon dioxide in the lungs), type 2 diabetes mellitus with diabetic polyneuropathy (high blood sugar levels that cause nerve damage), obstructive sleep apnea (temporary pauses in breathing during sleep), acute diastolic (congestive ) heart failure with hypoxia (blood backed up in the lungs and insufficient oxygen delivery to the body), unspecified lack of coordination (difficulty controlling muscle movements), muscle weakness (generalized), tracheostomy status (surgical opening in the neck to provide an airway into the trachea), and cognitive communication deficit (difficulty with communication due to cognitive impairment). Record review of Resident #3's MDS dated [DATE] revealed, Section C - Cognitive patterns revealed a BIMS score of 9 which indicated Resident #3 had moderate cognitive impairment. Record review of Resident #3's care plan dated 6/19/25 revealed focus: Resident #3 had oxygen via a trach collar (surgical opening in the neck to provide an airway into the trachea) secondary to respiratory failure, date initiated 8/15/21. Additionally Resident #3 smokes, dated 5/14/24, Goal: Resident #3 will be able to smoke without causing injury, date initiated 5/14/24, revision date 7/29/25, target date 9/19/25. Interventions: Ensure smoking occurs in smoking areas, ensure that ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 5/14/24, the resident is safe to smoke unsupervised, at this time, date initiated 5/14/2, keep all material at nurse station, date initiated 9/21/21. Record review of Resident #3's safe smoking assessment dated [DATE] revealed under Section B Summary the following option was checked, 2. This resident is safe to smoke unsupervised at this time. Record review of Resident #3's physician orders dated 8/23/25 revealed a prescription for Respiratory care of O2 (oxygen) at night and a trach collar during the day with a start date of 9/5/23. Record review of the facility's smokers list dated 8/21/25 revealed Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13 smoked. During an observation on 8/22/25 at 8:54 AM, revealed a sign was observed next to the front door on the outside front porch area that indicated it was a no smoking area. During an observation and interview on 8/22/25 at 11:44 AM revealed there was sign posted on the wall outside of smoking room, that reflected, No oxygen beyond this point. Observed Residents #1 and #3 in the smoking room. Resident #3 was observed smoking a cigarette while sitting in his scooter with an oxygen tank in between his legs. Resident #3 was observed wearing a trach collar on his neck. Resident #1 was within arm's reach distance from Resident #3. Resident #1 was leaned forward and was asleep. Resident #1 leaned over more and more and sat up when someone spoke to her. No staff were present in the smoking room. Resident #1 was observed not wearing a smoking apron while holding an unlit cigarette that she stated she was holding for later. During an interview on 8/22/25 at 11:45 AM, Resident #3 said he used oxygen as needed during the day. He said he and Resident #1 often smoked together in the smoking room. He said he helped watch her because she was blind. He said he had never seen Resident #1 wear a smoking apron when she smoked. He said staff brought Resident #1 into the smoking room, but they never stayed to supervise her. He said staff or himself or other residents would light Resident #1's cigarettes for her. He said he had not seen Resident #1 burn herself while smoking. During an interview on 8/22/25 at 11:50AM, Resident #1 said staff did not supervise her when she smoked but there were other residents looking out for her in the smoking room. She stated she did not have to wear an apron while smoking. She stated staff or someone with a lighter would light her cigarettes for her. She stated her cigarettes were kept at the nurse's station. She stated she had lived at the facility for about three weeks and she had not burned herself. She stated she did not fall asleep while smoking but sometimes people thought she was because her head was down. She stated she put her head down because she had bulging disks in her neck but she was not asleep. During an interview on 8/22/25 at 2:46PM, Resident #9 said she smoked in the smoke room regularly. She had seen Resident #1 in the smoke room and had never seen staff supervise Resident #1 when she smoked. She said she had never seen Resident #1 wear an apron when she smoked. She said Resident #1 had fallen asleep while smoking. She said she had not seen Resident #1 get burned while smoking. During an interview on 8/22/25 at 2:48PM, Resident #12 said he occasionally saw staff bring Resident #1 outside but staff did not stay to supervise her. He said Resident #1 did not wear a smoking apron. During an interview on 8/22/25 at 3:25 PM Resident #4 said he saw Resident #4 smoke, staff brought her in the smoking room, staff did stay to watch her. He said he had never seen her wear a smoking apron. He said he was not aware of her burning herself. He said staff lit her cigarettes or other smokers would. During an observation on 8/22/25 at 3:31 PM, revealed staff CNA D rolled Resident #1 in the smoke room and exited at 3:33PM. Resident #1 stayed in the smoking room. During an interview on 8/22/25 at 3:36 PM, CNA D said she had worked at the facility for 2 weeks and worked 6am to 6pm. She said she worked on hall 1. She said she took Resident #1 in the smoke room and lit her cigarette for her. She said she had to keep an eye on her but did not have to be in the room to supervise her. She said Resident #1 would be okay as long as someone was in there with her. She said she checked on her periodically. She said she had not seen Resident #1 get burned. She said she was not aware if Resident #1 had to be supervised when she smoked or any other accommodations. She said she was not aware of any resident on her hall that had to be supervised while smoking. During an observation on 8/22/25 at 3:45PM, Resident #1 was observed smoking a cigarette facing the corner in the smoking room. She was not wearing a smoking apron. Cigarette ashes were observed on her lap. Resident #1 was observed hunched over leaning forward and appeared to be asleep. CNA D entered the smoking room and asked Resident #1 why she was in the corner. Resident #1 said she did not know where she was in the smoking room. Resident #1 said she was still trying to learn her way around the facility. CNA D moved her to the table and gave her an ashtray. She was observed to use the ashtray properly. Smoking aprons were observed to be hanging in the smoke room and a red container labeled fire blankets was hung up on the wall in the smoke room. During an interview on 8/22/25 at 3:53PM, Resident #11 said staff brought Resident #1 to the smoke room. She or other staff lit her cigarettes. Resident #11 said Resident #1 did not wear a smoking apron; staff went back inside, they did not watch her. She had not seen Resident #1 burn herself. During an interview on 8/22/25 at 4:01PM, Resident #8 said Resident #1 had fallen asleep while smoking but she had denied it. He said he knew she was asleep because he had seen her burn her purse and he had seen her with a cigarette in her hand that was completely ash. He said he had seen staff push her to the table, give her the ashtray and cigarette, and they left. He said Resident #1 did not wear an apron when smoking. During an interview on 8/22/25 at 4:32 PM, RN A said staff helped Resident #1 to the smoking room. She was initially an independent smoker and kept her cigarettes in her room but then she accused someone of stealing them, and she lit a cigarette in her room and hallway, but said she did not know she was in in the building. He said staff were supposed to put Resident #1 in front of the table in the smoking room, she was still able to light her own cigarette, or he would light it for her. Resident #1 was now required to keep her cigarettes and lighter stored at the nurse station. However, she was not required to be supervised or wear a protective apron when smoking. He was not aware of any residents on halls 1 and 2 that were required to be supervised while smoking or wear an apron. They tried to promote independence. He had no concerns of her smoking independently. He said he did not know if she had burned herself at the facility but had seen burn marks on almost all of her clothing. He was not aware if it happened before she moved to the facility. He said the only other cigarettes he kept at the nurse station was for Resident #13 who needed help rationing them. During an interview on 8/22/25 at 4:47PM, Resident #2 said he only smoked a vape in the front, he did not smoke in the smoking room because could not stand the smell. He said staff were not with him when he smoked, and he did not need a smoking apron to smoke a vape. During an interview on 8/22/25 at 4:50 PM, the Regional Compliance Nurse said currently, staff were required to light the cigarette for Resident #1 but she was able to smoke by herself without supervision or devices/accommodations. During an interview on 8/23/25 at 9:13 AM, RN A sated there were no vapes being held at the nurse station for any residents. He said they only held Resident #1's cigarettes due to her smoking in her room and she accused people of stealing her cigarettes. He said he had not been told to supervise any residents while they smoked. He said residents were not supposed to take oxygen tanks in the smoking room. He said there were no residents in the facility they supervised when smoking. He said residents who vaped must still vape in the smoking room. During an observation on 8/23/25 at 9:23 AM, a sign was observed on the wall hanging next to the smoking-room entrance doors that reflected, No oxygen beyond this point. During an interview on 8/23/25 at 10:27 AM, a Family Member said Resident #1 had been blind for 7 years and smoked since she was 7 years old. The family member said Resident #1 caught a pillowcase and blanket on fire in the past, she had burned her fingers, ankle, knee, thighs, and clothing. No medical treatment was needed for any of the burns. The family member said the facility no longer allowed Resident #1 to keep her cigarettes or a lighter in her room. She had to get them from staff now. The staff would light the cigarette for Resident #1. She thought staff watched Resident #1 smoke but was not sure. She said she did not know if Resident #1 was required to wear an apron when smoking. The Family Member said when Resident #1 lived with her, she often fell asleep and the cigarette had fallen out of her hand before. The Family Member said Resident #1 denied being asleep and she would tell Resident #1 to wake up and Resident #1 would not know the cigarette had fallen out of her hand. She said the ADM told her they caught Resident #1 smoking in her room. She told them she would ask Resident #1 to let them hold her cigarettes at the nurse station for safety purposes. She now gave the cigarettes to nurse for them to hold and Resident #1 was okay with it. The Family Member said Resident #1 smoked 12 to 15 cigarettes a day. The Family Member said Resident #1 did not have neck muscles and held her neck down. She's had several falls over the years, she was never trained to walk with a walking stick, and she did not know how to do anything while being blind. During an observation and interview on 8/23/25 at 10:53AM, Resident #2 was observed sitting on the front porch smoking his vape. No staff were observed to be present. Resident #2 said he kept his vape in his room. During an interview on 8/23/25 at 10:57 AM, LVN B said she was the charge nurse on hall 2. She said Resident #3 was the only smoker on this hall and he was an independent smoker. LVN B said Resident #2 used an oxygen concentrator at night and used a portable oxygen tank as needed during the day. She said Resident #3 was not supposed to take the oxygen tank into the smoke room because it could start a fire and burn himself or others. She said the oxygen tank could ignite. LVN B said everyone was responsible to make sure he did not take it in there. LVN B said she had been asking for scheduled smoke breaks so they could check everyone on their way to the smoke room. She said no one vaped on hall 2. She said she was not sure if Resident #3 kept his cigarettes in his room because they held cigarettes for everyone at the nurse station on hall 1. She said she was not aware if residents were allowed to keep cigarettes and lighters in their rooms. She said there was no system in place to track when residents smoked. She said she did not know who was responsible to update staff on updated smoking assessments. LVN B stated the facility did not have a DON and there had been a lot of changes and staffing. LVN B said changes in smoking assessment should've been updated in the care plan immediately and hopefully passed on in report. During an interview on 8/23/25 at 10:56 AM, RT M said Resident #3 went to dialysis on Tuesday, Thursday, Saturday, and took a portable oxygen tank with him. RT M said Resident #3 used the concentrator at night and as needed during the day and during the day he used room air and could use oxygen as needed when out of breath. RT M said Resident #3 knew he was not supposed to take the oxygen tank into the smoking room. RT M said the oxygen tank was flammable and could ignite and burn a resident or start a fire. She said no one on hall 2 vaped. She stated there was no system in place to track when Resident #3 went to smoke because there was no smoking schedule. RT M said an update to a resident's smoking assessment should have been updated on the care plan because staff used that document to refer to when they provided care to the residents. She stated the ADONs and DONs told them when there were changes on a resident's smoke assessment. During an observation and interview on 8/23/25 at 11:16AM, Resident #1 was observed at the nurse station and asked for a cigarette. RN A was observed getting a cigarette out of a lock box and he gave it to Resident #1. RN A then rolled Resident #1 into smoking room, lit the cigarette, and exited room at 11:19AM. Resident #1 was observed smoking with no apron and sitting at table with an ashtray. She was observed to use the ashtray. She said she had never burned herself but had burned her clothes when she lived with her one of her family members. She said she had never started a fire with a cigarette. During an observation on 8/23/25 at 11:31 AM, Residents #3 and #8 were observed smoking outside on the front porch within arm's reach of each other. Resident #3 had a portable oxygen tank in between his legs on his scooter. During an interview on 8/23/25 at 11:38 am, the SW said she did not think Resident #1 should smoke unsupervised. The SW said she had seen ashes in Resident #1's hair. SW said Resident #1 got upset and said they were trying to make her look bad when they tried to address it with her. The SW stated staff held Resident #1's cigarettes at the nurse station because she was an unsafe smoker, she had ashes in her hair, and she missed the ashtray. The SW stated Resident #1 had not burned herself while at the facility, but all of her clothing had burn holes, but Resident #1 reported they were from before she lived at the facility The SW said Resident #1 was lethargic and was hunched over and she looked like she fell asleep when she was smoking, but there was no confirmation of that. She said the nurses completed the smoking assessments and were supposed to notify the DON or the ADM who then updated the care plan. The SW stated there was no DON currently. She said the nursing department communicated those changes through report. She was not sure of the policy on how often they updated the smoking assessments, but she thought the EHR prompted staff when they were due. The SW said per policy, residents were not supposed to keep cigarettes in their room, nurses were supposed to keep them. The SW said Resident #1 went on a pass with her family member and could bring cigarettes in without them knowing. The SW said she was not aware of residents that kept cigarettes in their rooms. She said she did not think residents were supposed to take oxygen tanks in the smoking room because residents could get burned or catch on fire, the oxygen tanks could explode, and it was a safety concerns. The SW said there was a fire blanket in the smoking room. She said they had not had anyone report burning themselves or their clothing. The SW said it wouldn't hurt for Resident #1 to wear an apron even if she denied getting the burn holes while at the facility, but she did not think Resident #1 would agree. Resident #1 said she did not want to be treated like a child. The SW said a potential negative outcome of not supervising resident were that they could get burned, ashes in their clothing, cigarettes may not be put out properly, and there would be cigarette butts everywhere. During an interview on 8/23/25 at 12:30PM, the MDS Coordinator said she was responsible for completing and updating MDSs and care plans, she helped with therapies, PASRR, and helped on the floor if needed. She said either she, the DON, or the ADONs updated the care plans if there were changes in a resident's smoking assessment. She said someone would let her know to update the care plan. She said she could also check the 24-hour report for changes, and they were also updated during morning meeting discussions, and also the SW would let her know of changes that needed to be updated on the MDS or care plan. She stated the EHR did not alert them of changes in smoking assessments. The MDS Coordinator said she was not sure how often they were updated. She said the person who did the smoking assessment was responsible to communicate any changes to staff, the ADM, and herself. She said there had been meetings with staff, resident council meetings, and with the ombudsman about smoking issues at the facility. The MDS Coordinator said residents go to the grocery store and could bring smoking materials in without them knowing. She said residents were not supposed to keep cigarettes or lighters in their rooms, they were kept at the nurse desk. She said she was not sure about vapes but she thought they would be treated like cigarettes. She said resident were not supposed to vape in their room or keep vapes in their rooms. She said there was a sign outside the smoking room that reflected, no oxygen beyond this point. She said she did not think residents could take oxygen tanks in the smoking room. She said residents were not allowed to smoke on the front porch and were not supposed to smoke outside next to someone with an oxygen tank. The MDS Coordinator said she saw Resident #3 smoking with another resident on the front porch this morning and she told them they were not allowed to smoke there; however, she did not notice Resident #3 had an oxygen tank between his legs. The MDS Coordinator said she was not sure if a person that vaped had to be supervised since there was no fire involved. She said she was not sure if there was a system in place to ensure staff were communicating changes in smoking restrictions. She said staff monitored the facility to see if they saw residents with cigarettes in their hands, but they could not do anything about the ones that hid them and took them into their rooms. She said all residents who smoked and used oxygen knew they could not take oxygen in the smoking room. She said there was no system to check resident's with oxygen before they enter the smoking room, there was not smoking schedule as resident's smoked whenever they wanted. The MDS Coordinator said a potential negative outcome could be that the oxygen tank could explode and cause a fire, that happened at the facility about 14 years ago. She said that was even possible even if they were smoking outside in close proximity to an oxygen tank. She said residents could burn themselves and they could catch themselves on fire if not supervised and not wearing an apron. She said changes from a safe to an unsafe smoker should have been updated on the care plan as soon as the change was reported. She said she was not aware Resident #1's care plan was not updated to her being a supervised smoker. She said she was not aware Resident #1 was supposed to wear an apron while smoking. She stated a potential negative outcome of the care plan not being updated was that staff referred to the care plan to know how to provide care for the residents and they would not know Resident #1 was a supervised smoker and should've been wearing apron if the care plan was not updated. She said another potential negative outcome was that residents would not receive the right care and that could be dangerous. She said she was not aware Resident #3 took his oxygen tank into the smoke room and outside while sitting with other people smoking. During an interview on 8/23/25 at 12:49PM, the ADM stated he worked at the facility since June 30, 2025, and there had been no DON for about a month, but one was starting next . He said residents who used oxygen should've left the oxygen in their room or somewhere safe, they were not allowed to take oxygen in the smoke room. He said the system to monitor that was the residents should tell staff they wanted to smoke and staff were supposed to remove the oxygen tank from their chairs. He said residents were not supposed to keep cigarettes and lighters in their rooms. He said residents were not supposed to smoke vapes or keep vapes in their room. They must vape in the designated smoking areas. He said the SW was responsible for completing smoking assessments. He said there was no policy on how often smoking assessments were completed and updated. He said an initial smoking assessment was completed during admission, and they would go from there to determine when to complete the next one. He stated himself and the DON were responsible to communicate changes in smoking assessments to staff. He said changes were currently communicated during morning meetings. The ADM said he believed a person that was an unsafe smoker and vaped should be supervised as well. He said unsafe smokers could burn themselves or start fire if not wearing the smoking apron. The ADM said oxygen was combustible and could start a fire and burn residents. He said he was not aware a resident took an oxygen tank in the smoking room or that a resident was outside with an oxygen tank smoking with other resident. He said he was not aware of a resident that vaped that was not being supervised that should be supervised. He said he did not know any of the residents that vaped. He said he was aware there was a resident that should be wearing an apron and should be supervised but he was not aware that was not occurring. He said regardless of the age of documentation it should be followed until otherwise updated. He said care plans should have been updated with the updated smoking assessment results so everyone could know what was going on with residents because that was what staff referred to when they provided care to the residents. He said the DON and ADONs were responsible to train staff. The ADM said their system to communicate changes needed or updates need to the MDS and care plan were to discuss them during morning meetings to ensure care plans were being followed. During an interview on 8/23/25 at 7:12 PM, LVN C said he completed the smoking assessment on Resident #1 because he observed her two or three times and observed her to be asleep with a cigarette in her hand, on her lap, in the smoking room. He said it was not a scheduled assessment. He said Resident #1 got mad and denied falling asleep. He said some of her clothes had burn marks on them and he did not believe her clothes had burn marks on them when she moved in. He said Resident #1 wanted to smoke as soon as she woke up. He said he did not believe she was fully awake but they could not tell her anything because she would holler and curse people out. He said she smoked every 30 minutes. He said last night she called her family member at 4:00AM to bring her cigarettes because she ran out. LVN C said Resident #1 accused him of stealing her cigarettes. He said he forwarded the smoking assessment to the ADON and he went and told the ADON that night he did it, as well. He said he did not know what the ADON was supposed to do with the assessment next. He said he would tell his aides of the changes and he would verbally pass it on to the nurse on the next shift. He said the aides he told no longer worked at the facility, but he told the new aide last night. He said he told RN A about it as well. He said RN A told him last night that the SW told him Resident #1 was to b

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an effective Infection Control Program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections for 1 of 28 residents (Resident #1) and 1 staff (SW) reviewed for infection control. The SW failed to wear appropriate PPE and practice hand hygiene before entering or exiting room [ROOM NUMBER] for Resident #1 who was on contact isolation for Carbapenem Resistant Pseudomonas Aeruginosa (bacteria resistant to certain classes of antibiotics). The SW removed a reusable cup from room [ROOM NUMBER] and carried it to the community water station at the nurse's station, refilled the cup and returned the cup to room [ROOM NUMBER]. The SW entered three additional residents' rooms with signed posted enhanced barrier precaution after exiting room [ROOM NUMBER]. An Immediate Jeopardy was identified on 6/12/24/at 4:35 PM. The IJ template was provided to the facility Administrator on 6/12/24 at 4:50 PM. While the immediate jeopardy was lifted on 6/13/24 at 4:15 PM, the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent future concerns. These failures could place residents at risk for infection and cross contamination of pathogens and illness, which could lead to worsening of their condition, hospitalization, or death. Finding include: Record review of Resident #1's undated face sheet revealed a [AGE] year-old female with an initial admission date of 10/06/2023 and a readmission date of 02/22/2024 with the following diagnoses: acute and chronic respiratory failure with hypoxia (lack of oxygen in the blood), chronic obstructive pulmonary disease (airflow blockage and breathing-related problems), tracheostomy status (surgically created hole in the windpipe for breathing), dependence on respirator [ventilator status], and hypothyroidism (thyroid condition). Record review of Resident #1's Quarterly MDS dated [DATE] revealed resident #1 had a BIMS of 08, which indicated the resident's cognitive status was moderately impaired. Additionally, section H - Bladder and Bowel revealed Resident #1 had an indwelling catheter, section M - Skin Conditions revealed Resident #1 had a pressure ulcer, and section O - Special Treatments, Procedures and Programs revealed Resident #1 received tracheostomy care and uses an invasive mechanical ventilator. Record Review of Resident #1's Care Plan, dated 02/22/2024, revealed Resident #1 was on contact precautions related to Pseudomonas Aeruginosa in sputum (bacterial organism in lung secretions). Interventions were to have PPE readily outside of the resident's room, place sign in the resident's door to check with nurse prior to entering put gown, gloves, and to sanitize hands prior to entering and exiting the room. The Care Plan also revealed Resident #1 has Chronic Obstructive Pulmonary Disease (COPD), a tracheostomy related to respiratory failure, a Foley catheter, had oxygen therapy via trach collar secondary to respiratory failure, and was ventilator dependent related to respiratory failure. Record Review of Resident #1's Physician's Orders dated 06/12/2024 revealed an order dated 02/23/2021 for isolation protocol for Carbapenem Resistant Pseudomonas Aeruginosa - Staff will require gown and gloves while giving care. The physician's orders further revealed an order dated 10/06/2023 for Trach care, an order dated 04/27/2024 for Foley catheter care, and an order dated 01/30/2024 for a vent setting: AC/VT = 450, Rate = 18, Peep = 8 8/liters every shift. Record Review of Resident #1's Discharge Instructions Record dated 02/22/2024 revealed CRPA infections can occur in a wound or surgical incision. It can also occur in other areas of the body, such as the urinary system, blood stream, lungs, and abdomen. CRPA infections may cause severe illnesses such as: Gastrointestinal illness, Pneumonia, bone or joint infections, bloodstream infections, and invasive infections in other body organs. CRPA bacteria may colonize wounds, the respiratory tract of some patients, and medical devices that are in place for a long time. Healthcare facilities may utilize isolation precautions to prevent the spread of the bacteria to other patients. The most effective way to prevent the spread of bacteria is to wash your hands often. This condition is caused by Pseudomonas aeruginosa bacteria that no longer responds to carbapenem antibiotic medicines. This bacterium can be spread by: direct contact of an open wound of an infected person, having contact with a medical device that has the bacteria on it (is contaminated), and touching surfaces or items that have been in contact with an infected person. Those most at risk include patients in hospitals, especially if: you had a long-term hospital stay, especially in an intensive care or burn unit, you have been on antibiotics for the treatment of other conditions, you use a breathing machine (ventilator), you use urinary (bladder) catheters, or are on kidney dialysis, you have a short-term or long-term vascular access device, such as a catheter or IV, you have wounds from surgery or burns, or you have a weakened defense system (immune system). Pseudomonas aeruginosa infections are generally treated with antibiotics. Unfortunately, people in exposed to healthcare settings like hospitals or nursing homes, Pseudomonas aeruginosa infections are becoming more difficult to treat because of increasing antibiotic resistance. To identify the best antibiotic to treat a specific infection, healthcare providers will send a specimen (often called a culture) to the laboratory and test any bacteria that grow against a set of antibiotics to determine which are active against the germ. The provider will then select an antibiotic based on the activity of the antibiotic and other factors, like potential side effects or interactions with other drugs. For some multidrug-resistant types of Pseudomonas Aeruginosa, treatment options might be limited. During an observation on 6/12/24 at 10:43 AM, the SW was observed in the 200 hall, entering room [ROOM NUMBER], which had a sign posted outside of the door for Contact Precautions, and a clear three drawer cart with PPE in the cart. The SW entered room [ROOM NUMBER] without any PPE on and did not practice hand hygiene. SW walked to the bedside near Resident #1 and spoke with Resident #1. SW picked up the re-useable drinking cup for Resident #1 and exited the room. SW walked down the hall to the nurse's station and used the community water station to refill the cup for Resident #1. SW touched the spout for the community water pitcher to refill the cup. SW placed the cup on the counter at the nurse's station and walked over to talk with another staff. SW walked back to the nurse's station and picked up the re-usable cup and walked back down the hall to room [ROOM NUMBER] and entered the room. SW placed the re-usable cup on the BST and exited the room. SW did not Donn (put on correctly)PPE either time she entered the room, and she did not practice hand hygiene any time she entered or exited the room. SW entered three additional resident rooms after exiting room [ROOM NUMBER]. SW entered room [ROOM NUMBER], 205 and 204. SW was observed knocking on the doors and pushing the doors open with her hands. There was signed posted on the outside of the door for room [ROOM NUMBER], 205 and 204 for Enhanced Barrier Precautions. The SW did not practice hand hygiene prior to entering or exiting rooms [ROOM NUMBER]. During an observation on 6/12/24 at 10:43 AM of a facility sign posted outside of room [ROOM NUMBER] titled Contact Precautions reflected (Contact Precautions are in addition to Standard Precautions. See Standard Precautions for questions) Attention! Visitors must report to the nurse station before entering. Patient Placement: Private room, if possible. Ensure that patients are physically separated (i.e.,>3 feet apart) from each other. Draw the privacy curtain between beds to minimize opportunities for direct contact. Personal Protective Equipment (PPE) Don gown and gloves outside of the resident's room. Remove gown and gloves and observe hand hygiene before leaving the patient-care environment. Hand Hygiene (according to Standard Precautions) Avoid unnecessary touching of surfaces in close proximity to the patient. When hands are visibly dirty, contaminated with proteinaceous material, visibly soiled with blood or body fluids, wash hands with soap and water. If hands are not visibly soiled, or after removing visible material with soap and water, decontaminate hands with alcohol-based hand rub. Alternatively, hands may be washed with an antimicrobial soap and water. Preform Hand Hygiene: Before having direct contact with patients After contact with blood, body fluids, or excretions, mucous membranes, non-intact skin, or wound dressings. After contact with a patient's intact skin (e.g. when taking a pulse or blood pressure or lifting a patient) If hands will be moving from a contaminated body site to a clean body site during patient care After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient After removing gloves Patient Transport When transporting or movement in any healthcare setting is necessary, ensure that infected or colonized areas of the patient's body are contaminated and covered. Remove and dispose of contaminated PPE and preform hand hygiene before and after transporting patients on Contact Precautions. Patient-Care Equipment and Instruments/Devices If common use of equipment for multiple patient's is unavoidable, clean and disinfect such equipment before use on another patient. During an observation on 6/12/24 at 10:50 AM of facility sign posted outside of rooms 204, 205, 208 for Enhanced Barrier Precautions reflected: Stop Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following: High-Contact Resident Care Activities. Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. During an interview on 6/12/24 at 10:54 AM, the SW stated she did not see the Contact Precaution sign posted outside the door for Resident #1 in room [ROOM NUMBER]. She stated she did not practice hand hygiene or Donn PPE before she entered room [ROOM NUMBER]. She stated she did not practice hand hygiene before she entered or exited rooms 208, 205 and 204. She stated the Enhanced Barrier Precaution sign posted outside of rooms [ROOM NUMBER] were posted so staff would know what to do when entering those rooms. She stated that Resident #1 had asked for more water, so she carried the re-usable cup down the hall to get more water and took it back. She stated that she had been trained and in-serviced on PPE and infection control and if the sign was posted staff should follow the instructions posted. During an interview on 6/12/24 at 11:57 AM, the Corporate RN stated that if the sign was posted for Contact Isolation, then staff should observe the proper PPE prior to entering the room. She stated even if a staff entered the room to talk with the resident, they would need to observe the proper PPE per the sign posted. During an interview on 6/12/24 at 2:35 PM, the DON stated the facility had trained and in-serviced staff over Infection Control, Enhanced Barrier Precaution, that the SW and other non-nursing staff would need additional education on infection control. She stated all staff should read the signs posted before they enter a room. She stated the SW should not have brought the re-usable cup out of the room, and the SW should get a foam cup and take the refill in the throw away cup in the room. The DON stated staff should not take personal belongings of a resident out of a room that is on isolation. She stated that SW did not follow the facility policy for contact precautions when she entered the room without PPE and took the resident's cup out of the room to refill it. She stated that SW placed other residents at risk for infection. During an interview on 6/13/24 at 11:52 AM, the Administrator stated the SW should have worn PPE and practiced hand hygiene before she entered Resident #1's room. She stated she expected staff to preform hand hygiene when they entered or exited a room, put on all needed PPE before they entered a room with contact isolation precaution, and equipment should be disposable. She stated the SW should not have carried the re-usable cup out of the room and down the hall to the community water station. She stated staff could have spread the bacteria to other residents, or staff. She stated that the DON would monitor staff and randomly pick staff to complete competency check offs on hand hygiene. She stated the DON had completed hand washing competency check offs and donning and doffing (take off correctly) PPE on all staff that had clocked in for work on 6/13/24. She stated the facility would discuss any area of concerns in the QA meeting. During an interview on 6/13/24 at 9:20 AM, the Corporate RN stated the facility knew they did not follow what was posted about contact isolation on 6/12/24. During an interview on 6/13/2024 at 1:31 PM with the NP whose office saw Resident #1, she stated she was familiar with Resident #1 as well as the resident's diagnosis of CRPA. She stated she was aware that Resident #1 was on contact precautions at the facility. The NP stated that in her professional opinion, a staff member removing a cup from the isolation room, carrying it down the hallway and using a community water station to refill it, then returning the cup to the isolation room, would place other residents on the hall at a huge risk for infection and/or cross contamination with CRPA. Record review of facility's resident roster for hall 200 dated 6/12/24 reflected 28 residents lived on that hall, 11 residents had active wounds, 12 residents received tube feeding, 22 residents had tracheostomies and 11 of those were ventilator dependent and 14 residents had catheters. Record review of facility provided policy titled, Fundamentals of Infection Control Precautions dated 2019, revealed: A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. 1. Hand Hygiene Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: o Before and after entering isolation precaution settings; o After handling soiled equipment or utensils; Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections. 5. Gowns and protective apparel 2. Gowns are also worn by personnel during the care of patients infected with epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens from residents or items in their environment to other residents or environments; when gowns are worn for this purpose, they are removed before the personnel leave the resident's environment. Record review of facility provided policy titled, Transmission-based Precautions dated 2010, revealed: Transmission-based precautions are used for residents who are known to be, or suspected of being infected or colonized with infectious agents, including pathogens that require additional control measures to prevent transmission. It is essential both to communicate transmission-based precautions to all health care personnel, and for personnel to comply with requirements. A sign will be placed at the resident's room entrance to See Nurse Before Entering so to communicate to staff and visitors so that the nurse can communicate any precautions; in addition, it will be communicated to staff via verbal report what type of precautions are required to care for the resident. It is important to use the standard approaches, as defined by the CDC for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precaution determines the type of PPE to be used. Communication (e.g., verbal reports, signage) regarding the particular type of precaution to be utilized is important. When transmission-based precautions are in place, PPE should be readily available. Proper hand washing remains a key preventive measure, regardless of the type of transmission-based precaution employed. Contact Precautions Contact transmission risk requires the use of contact precautions to prevent infections that are spread by person-to-person contact. Contact precautions require the use of appropriate PPE, including a gown and gloves upon entering the contact precaution room. Prior to leaving the contact precaution room the PPE is removed and hand hygiene is performed. Depending on the situation, options for residents on contact precautions may include the following: a private room, cohorting, or sharing a room with a roommate with limited risk factors (e.g., without indwelling devices, without pressure ulcers and not immunocompromised). Implementation of Transmission-Based Precautions The Personal Protection Equipment (PPE) will be readily available near the entrance to the resident's room. Signage will be posted on the resident's door instructing visitors to see the nurse before entering. Record review of facility provided policy titled, Hand Washing dated 2012, revealed: We will ensure proper hand washing procedures are utilized. Employees are to frequently perform hand washing as outlined below. Procedure: 1. Hand washing occurs in sinks provided for that purpose; sink areas provide hot/cold running water, soap in dispensers, and paper towels, and should have a sign posted conspicuously near or above wash basin. 2. The hand washing technique is as follows: a. Remove ring and watch if they cannot be sanitized during the hand washing process. b. Turn on water, adjusting to warm temperature and forceful flow. c. Wet hands. d. Deliver soap in palm. e. Lather up soap. f. Cup the fingertips within the palms of the hands and rub vigorously. g. Interlock fingers and work them back and forth and side to side. h. Scrub back of hands, wrists and lower arms. i. Rinse hands, wrists, and lower arms thoroughly 3. Dry hands and arms with paper towel, then turn off the faucets with the paper towel. 4. Discard used paper towels in trash receptacle. 5. Food preparation sinks are not to be used for hand washing. This was determined to be an Immediate Jeopardy (IJ) on 06/12/2024 at 4:35PM. The Administrator, DON, and Corporate Nurse were notified. The Administrator was provided with the IJ Template on 06/12/2024 at 4:58 PM. The following Plan of Removal submitted by the facility was accepted on 06/13/2023 at 10:15 AM Record review of the facility Plan of Removal reflected the following: (Facility Name) Plan of Removal 06/12/2024 F880 ALLEGED ALLEGATION: Infection Control Staff did not wear correct PPE while entering the room of a resident on isolation Staff did not sanitize when entering and exiting the isolation resident room Staff removed a non-disposable beverage cup from the infected resident room and filled from the community water station and used hand to operate the spout. Staff placed infected resident cup on the nursing station contaminating the desk and placing immunocompromised residents at risk due to cross contamination. Interventions: The following in-services were initiated by the DON, ADON and regional nurse on 6/12/2024: Any staff member not present or in-serviced on 6/12/2024, will not be allowed to assume their duties until in-serviced. o Staff will be Inservice on the following: In-service staff on Infection Control Overview In-service staff on proper PPE use for MDRO isolation and Enhanced Barrier Precautions In-service staff with return demonstration related to hand hygiene and donning and doffing PPE. In-service staff on management of multi- use or non-disposable items leaving isolation rooms In-service staff on Carbapenem-resistant pseudomonas aeruginosa (CRPA) In-service staff over management of all dietary items including beverage cups using disposable items only. o Community water station was removed from service and sanitized prior to continued use. o Nursing station was immediately sanitized to prevent cross contamination. o Disposable cups will be placed behind the nursing station for use with MDRO isolation residents. o All non-disposable cups were removed from the resident room. o Disposable blood pressure cuffs, thermometer, stethoscope to be kept in room to prevent cross contamination. o MDRO isolation signs will be printed in bright orange color to attract staff attention prior to entering resident rooms. The medical director was notified of the immediate jeopardy situation on 6/12/2024 at 1745. Monitoring The DON / designee will observe PPE use by randomly selecting 10 staff members weekly on various shifts. The DON/designee will observe all MDRO resident rooms 3 times weekly to assure that non-disposable dietary items are not in resident room. The QA committee will review findings and makes changes as needed. During an observation on 6/13/24 at 10:25 AM revealed there was a bright orange contact precaution sign posted outside of room [ROOM NUMBER]. Staff observed donning PPE prior to entering the room. Disposable foam cups were observed in room [ROOM NUMBER]. The re-useable drinking cup was no longer in room [ROOM NUMBER]. During an observation on 6/13/24 at 10:30 AM revealed foam cups were at the nurse's station at the community water station for use. During an observation on 6/13/24 at 11:24 AM revealed disposable equipment was observed in room [ROOM NUMBER] for staff use. Record review of the facility in-service dated 6/12/24 titled Meal Service to isolated residents revealed: Absolutely no trays may enter isolation residents' rooms. One staff member may don gown, mask, gloves and enter the resident room. A second staff member is to hand the disposable containers with resident meals to the staff member in PPE to give to resident. (76 staff had signed). Record review of the facility in-serviced dated 6/12/24 titled Transfer Devices with Isolation Residents revealed: Multi use, non-Disposable patient care devices must be sanitized upon completion of use. (i.e. Hoyer Lifts, Geri chairs). *K-Quat is to be used on non-disposable items. Other multi use patient care devices must remain in the resident's room and be sanitized upon completion of use. (i.e. BP cuff, stethoscope, pulse oximeter, glucometer). *Sani wipes to be used on these items. (71 staff signed). Record review of the facility in-serviced dated 6/12/24 titled Hand Hygiene and policy revealed: Hand Hygiene, you may use alcohol-based hand cleaner or soap / water for the following: and examples of when to use. You must use soap/water for the following (alcohol-based hand cleaner is not recommended) examples given. (77 staff signed). Record review of the facility in-serviced dated 6/12/24 titled Enhanced Barrier Precautions and policy revealed: EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. (71 staff signed). Record review of the facility in-serviced dated 6/12/24 titled MDRO Isolation revealed: Carbapenem Resistant Pseudomonas aeruginosa/Carbapenem resistant Acinetobacter baumannii. Residents are on contact isolation. Disposable medical equipment is required (stethoscope, blood pressure cuff, pulse oximeter, etc.). disposable cups for hydration (water is carried into the room in disposable cups). Donning and doffing PPE is required (Gown, mask and gloves). Rooms are clearly marked with bright isolation signage. Any staff attempting to enter these rooms must perform hand hygiene, and don masks, gloves, gowns. Prior to exiting the room masks, gloves, gowns are removed and disposed of, and hand hygiene preformed. All staff are required to follow all infection control policies. (74 staff signed). Record review of the facility in-service dated 6/12/24 titled Refilling isolation beverages revealed: Residents on contact isolation are served meals on Styrofoam plates and disposable utensils to prevent cross contamination to the dietary department or staff picking up trays. When managing a non-disposable drinking cups for these residents, they may not leave the room to be refilled. We may bring in a disposable cup with ice and water to refill the container. Those are disposed of inside of the resident room. If the non-disposable drink receptacle needs to be washed, and cannot be washed in the room, we will throw it away and get a new one. (71 staff signed). Record review of competency test dated 6/13/24 and titled Putting on and Removing Personal Protective Equipment (PPE) revealed 45 tests were completed for staff. Record review of competency test dated 6/13/24 and titled Hand Hygiene revealed 48 tests were completed for staff. During an observation interview on 6/13/2024 at 11:24 AM with Resident #1 and family member who was present in the room, revealed the resident was connected to a ventilator via her tracheostomy and was able to answer questions with a head shake or nod. When asked if all staff donned PPE prior to entering her room, Resident #1 nodded her head yes. When asked if staff were friendly with her while performing care, Resident #1 nodded her head yes. The family member also stated staff are very pleasant with the resident always. The family member stated prior to the foam cups being brought to the resident's room yesterday, the staff would bring drinks to the room in a disposable, clear cup. During an interview on 6/13/24 at 1:05 PM, the Dietary Aide stated she received in-serve on contact isolation precaution and the process that must be done before entering a resident room on those precautions. She stated she received in-service on EBP and when PPE would be needed. She stated there were signs posted outside the doors for EBP and bright orange signs posted for Contact precaution. She stated she was in-serviced on infection control and CRPA. She stated she was in-serviced on hand hygiene, and it must be performed prior to entering and exiting rooms; and how to preform hand hygiene, and staff completed competency check off for hand hygiene. She stated she was in-serviced on disposable containers used for residents on contact precautions, and that nothing could be removed from the room, as well as how a meal would be served, and that any items used that are not disposable must be cleaned and sanitized with K-quat sanitizer solution. She stated if she had any questions or concerns, she would ask staff before for assistance before she entered a room. During an interview on 6/13/24 at 1:36 PM, the MD Assistant stated the facility notified her of the IJ for infection control on 6/12/24 and the POR. She stated she informed the Medical Director and they agreed with the POR. She stated they followed up with the facility on 6/13/24. During an interview on 6/13/24 at 2:40 PM, the Activity Director stated she went in resident's rooms to provide activities. She stated there are signs posted outside of resident rooms when on isolation or EBP. She stated the facility in-serviced her on infection control, CRPA, donning and doffing PPE, hand hygiene, when to wash hands and when to use hand sanitizer, the bright orange sign posted for contact precaution, the PPE used for isolation and when to use it She stated the facility provided an in-service about staff using disposable cups for containers for residents that are on contact isolation precautions. That staff cannot remove items for the resident rooms if on isolation, staff needs to use foam cups to take water or ice in rooms and throw away in rooms. That staff should not bring items out of rooms for residents on isolation. That any non-disposable items that were used in an isolation room would need to be cleaned and sanitized with k-quat. During an interview on 6/13/24 at 2:45 PM, LVN A stated the facility provided in-service over contact isolation, infection control, EBP, equipment used in isolation rooms, cleaning and disinfecting those items before use in another room or with resident, disposable drinking cups, and meal containers, how to serve a meal to a resident on isolation, PPE used for isolation verses EBP and when to use PPE, hand hygiene, when to wash hands, when staff can use hand sanitizer, and to practice hand hygiene before entering rooms and exiting rooms. LVN A stated staff should use foam cups when refilling water for residents on isolation, to take the refill in the room and dispose of the foam cup, not bring items out of the room. The facility will use orange sign posted outside of resident rooms for contact isolation and signs for EBP will be posted outside of resident rooms. During an interview on 6/13/24 at 2:53 PM, the SW stated the facility provided an in-service on EBP and there were signs posted outside of the door and staff were to sanitize their hands before they enter the room and when they exit the room and if any care is provided PPE must be worn; contact isolation and an orange sign would be posted outside of the resident room, staff would have to perform hand hygiene then put on PPE, gown, gloves and a mask before they entered the room, remove the PPE before they exit the room and preform hand hygiene. If a resident was on contact isolation precautions staff cannot remove anything from the room like a cup. If the resident requested a refill or a drink staff would need to use a disposable foam cup and take the drink or refill to the resident in the room and throw away the cup in the room. The SW stated that the facility provided in-service over hand hygiene when to was hands and when sanitizer can be used and how to wash hands. The SW stated the facility provided in-service over infection control and CRPA and to follow the policy. She stated that any reusable item that had to be used in a resident room on isolation would need to be[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident's right to be free from abuse for 5 (Confidential Resident #1, #2, #3, #4, & #5) of 28 residents reviewed for abuse in that: After Confidential Resident #1 reported to the Administrator (ADM) Resident #57 was bullying them, (yelling at them and grabbing their wheelchair). The Administrator failed ensure Confidential Resident #1, was free from abuse and failed to follow through with investigating the incident. After Confidential Resident #2 reported to the ADM Resident #57 was pulling their hair and calling them names, the Administrator failed ensure Confidential Resident #2, was free from abuse and failed to follow through with investigating the incident. The Facility Staff failed to ensure Confidential Resident #3 was free from unwanted contact (physical/ coming into their room without permission and verbally bothering them) with Resident #57. The facility Staff failed to report it to the abuse preventionist, grievance official and failed to ensure the resident was protected from Resident #57. After Confidential Resident #4 reported to the ADM Resident #57 was coming in their room repeatedly and having unwanted verbal contact with them, the Administrator failed ensure Confidential Resident #4 was free of unwanted verbal contact and failed to follow through with investigating the incident. After Confidential Resident #5 reported to the ADM Resident #57 was verbally bothering them and coming into their room repeatedly the Administrator failed to ensure Confidential Resident #5 was free from abuse and failed to follow through with investigating the incident. On 1/19/23 at 1:10 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 1/20/23 at 10:45 AM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures placed Resident #1, #2, #3, #4, #5 & #6 at risk to further verbal and physical abuse by Resident #57 and placed the remaining 74 residents at risk of abuse (verbal, physical and emotional) by Resident #57. Findings Included: Record review of Resident #57's face sheet, dated 1/18/23, revealed a [AGE] year-old-male was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of alcohol dependence with withdrawal, and abnormality of gait. Record review of Resident #57's Quarterly Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section E: Behavior E0200. Behavioral Symptom- Presence & Frequency: No physical, verbal or other behaviors towards anyone. Record review of Resident #57's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section E: Behavior E0200. Behavioral Symptom- Presence & Frequency: No physical, verbal or other behaviors towards anyone. E0600. Impact on Others: No identified symptoms of putting others at risk for physical injury, intruding on the privacy or activity of others, and no significant disruption of care or living environment. Record review of Resident #57's Care Plan dated 01/04/23 revealed the resident did not have a care plan for any documented behaviors. A confidential interview was conducted with Confidential Resident #4 who reported that Resident #57 came into their room, and they did not want him in their room . They said he flipped on her light and yelled I'm back! They said this has been ongoing and they did not like it. They stated she had reported this to the ADM and was told that this would be addressed . They said they reported this verbally at least two weeks before the date of the interview but did not know the exact date. They stated that Resident #57 was with another resident all the time and does not mind that resident coming into their room but does not want Resident #57 in their room. They stated he comes early in the morning and flips on their light, yelling, I am back. They said if they had the ability, they would hit him. They said he makes her uncomfortable, but they cannot do anything alone because they cannot get out of bed. Since they reported this to the ADM, they said no one has come to them and asked if this situation was resolved. They said they had not received any documentation from anyone about the situation. They said it makes them angry when Resident #57 comes to their room and wakes them up early. When they heard him on the hall, they tried to have the staff close her door, but sometimes this did not keep him out, and he will still open her door and look in their room, and this made them uncomfortable. A confidential interview was conducted with Confidential Resident #1, who initially did not want to talk. They stated that nothing would be done. They said that they was being bullied and that nothing had been done about it. They stated 3 or 4 days ago, when they was in the hallway, they was approached by Resident #57. They said Resident #57 was coming down the hall. They said Resident #57 yelled for him to get out of the way. They said they figured they did not get out of the way fast enough because Resident #57 cussed them out and grabbed their wheelchair. They said staff were there and told Resident #57 to return to his hall. Confidential Resident #1 said that they told the ADM about this 3-5 days before the interview, and the ADM said he would take care of it, and nothing has happened . They said when he goes to smoke, if Resident #57 goes to the room, they hurry and get out of the room because they was scared. He said they was afraid and did not feel they could defend themself if ever alone with Resident #57 because they had a stroke and could not do much for themself. They said he had witnessed Resident #57 bother not only them but also bother Confidential Resident #4. They said that Confidential Resident #4 would yell for him to get out of their room, and he would come down the hall yelling, I am back, taunting all of the residents on the hall. He said that even though residents have complained, Resident #57 can go all over the facility, telling everyone what to do. They said that they understood that Resident #57 had rights, but they had rights too, and they felt that their rights were being violated because they cannot feel safe anywhere but in their room. Confidential Resident #1 began to cry and explained that they was scared and did not want to move because this was the only place that fits their needs as far as the smoking schedule but that they did not want to be afraid to leave their room. He said other residents were afraid but won't say anything because nothing was being done about Resident #57. They stated that Resident #57 helps take care of another resident, which was why they believed Resident #57 was allowed to say anything to staff and other residents. Confidential Resident #1 stated since they reported this to the Administrator, no one has come to them and talked to him about the incident. They said they had not received anything in writing stating that this had been resolved. They stated they was scared not to be in their room because they did not know what Resident #57 will do to them. They said they has been called names and threatened by Resident #57. A confidential interview was conducted with Confidential Staff A said that they had observed Resident #57 negative interactions with other residents. They stated no resident has specifically come to them and complained about Resident #57 but that just from observations, they can tell that his behavior bothers other residents. They stated specifically Confidential Resident #3 had told Resident #57 to get out of their room and to leave them alone and they had heard this. They also stated they heard Confidential Resident #4 yell at Resident #57 to get out of their room. Confidential Staff A said they told Resident #57 to get out of Confidential Resident #4 room. They said Resident #57 said he was only playing with Confidential Resident #4. Confidential Staff A stated they did not report this to anyone and this was because she had addressed Resident #57. Confidential Staff A said they also heard negative interactions with Confidential Resident #2. For example, they said they heard Confidential Resident #2 tell Resident #57 to leave them alone. Confidential Staff A said that they had not reported this to the Administrator but had reported it to nurses but could not remember them specifically by name and did not want to say the wrong name. In addition, they said that they had not been trained in what to do about Resident #57 behavior. A confidential interview was conducted with Confidential Staff B. They stated no residents had come to them specifically to complain about Resident #57 but that they had observed behavior that bothered the other residents. They said Resident #57 would come down the halls at 6:00 AM, yelling for the other residents to get up. They said that the residents on Hall 300 preferred to sleep in and that they can tell that it bothered the other residents. They said you hear the residents talking about it. They mainly said the women resident complained the most. When asked for specific residents they knew that Resident #57 had bothered, they could name Confidential Resident #2, Confidential Resident #4, and Confidential Resident #6 . They said they knew those residents did not like how Resident #57 interacted with them because they constantly said that he bothered them, and staff heard them consistently telling him to leave them alone. They said she did not report this specifically to the Administrator or anyone because it happens all the time, and everyone sees it. They said the staff would eventually get tired of it and tell him to stop, but that was it. They said they had not been trained on what to do specifically for Resident #57 behaviors. A confidential interview was conducted with Confidential Resident #3 who reported that Resident #57 bothers them. She said Resident #57 had come into their room , and they had to yell at him to get out multiple times. They said they told him that he was not allowed in the room unless they were invited. They stated they had never invited Resident #57 in his room. They said Resident #57 responded that he would come in anyway, and if they were not in the room, he would come in and take what he wanted. They said that they had not reported anything to anyone because the staff saw it , people know that Resident #57 bothers everyone, and they felt like he does it to her the most. They said that they did not know if he was drunk or high but that he seemed to go to the extreme to bother others. They said some staff would tell Resident #57 to stop, but there were times when staff will just ignore it. They said Resident #57 would make sexual comments toward them. When asked what specifically they said, Resident #57 would say things that included statements about lubricant and if they wanted to do something. They said it makes them uncomfortable and sometimes scared, especially when he blocks them in the hall. They said when he blocks them in the hall, they say whatever he wants to hear so that he will move. A confidential interview was conducted with Confidential Resident #5, who stated that Resident #57 bothers them but that they yells at him to leave them alone . They said that Resident #57 will come in their room and yell at them and turn on her light in the morning. They said that they told the ADM and was told not to talk with him and that even if you do not speak to him, he would come to their room. They said it makes them angry at him when he comes by heir room. They said they did not want him in their room. A confidential interview was conducted with Confidential Staff C who said that they was aware that Resident #57 bothers some residents. They said they had observed him bothering other residents but could not specifically think of others by name. They said that Resident #57 picked on multiple residents. They said this was an ongoing issue and reported this to the Social Worker . They was unable to narrow down a specific date but said it was recent. They said the Social worker would just respond, ok. They said they noticed that Resident #57 would pick on residents that could not defend themselves. They said other staff would ignore Resident #57 because this was the norm for Resident #57. They said rather than correct Resident #57, they would try to distract him by asking if he needed something. They said they had been instructed not to argue with residents, and Resident #57 would argue with you if you entertained him. They said in the daily stand-up meetings that Resident #57's behavior had been discussed, but nothing has ever been done about it. Confidential Staff C said they had observed the resident going into other's rooms but had not observed the resident becoming upset. They said they had discussed with the ADM what they needed to do and said the ADM said all that they needed to do was document Resident #57 behaviors. They could not provide a specific date for this conversation but said this had happened in the past prior to the interview with the surveyor. They said Resident #57 has said ugly things to them, but they ignore it because they were a staff and he was a resident. They expressed concerns that Resident #57 was allowed to take care of another resident with lower functioning. They said he does not provide nursing services but Resident #57 follows the resident around guiding him and playing music. They had observed him become upset with the resident that he looks after and makes the resident go wherever he wants. They said they had observed Resident #57 stop staff from assisting and providing care to the resident that he follows around. When asked if what they observed could be considered verbal abuse, they stated that this, in their opinion, could be verbal abuse. They said no one wants to be told to shut up. They said no one should be talked to that way. They said when Resident #57 acts this way, it causes tension in the environment, and they observe other residents become uncomfortable and avoid him. A confidential interview was conducted with Confidential Resident #2 who said Resident #57 always bothered them. They said they reported their issues to the ADM, and the only thing that has stopped was Resident #57 had not pulled their hair in a while. They said they had told the ADM multiple times as incidents happen but unable to specifically tell the surveyor an exact date. They said the resident continued to call them names. They said he called them and their friends witches. They said they believed he wanted to call them bitches. They said he would yell at them on their hall to get out of the way because he takes care of another resident. They said he would sometimes push the other resident in front of them and block them. They said it was not the other resident's fault because he did not know any better. They said Resident #57 would come to their room early in the morning, as early as 6:30 AM, and flip on their light and yell, wake up, witch!. They said Resident #57 would tell the other residents not to look at them or their friends, or they would turn into frogs. They said this made them feel really down and bad about themselves. An observation on 1/18/23 at 3:30 PM of Resident #57 in his wheelchair on Hall 300 was made and he did not have any interaction with other residents. He was in his wheelchair listening to music and self-propelling behind another resident. An interview was conducted on 01/18/23 at 4:45 PM with the Social Worker , and she said that she has had many conversations with residents about Resident #57. She said that residents would say he was disturbing them. She said that she had never received a grievance from any residents, yet she considered the concerns from residents as conversations. She said she deciphers the difference between a conversation and an actual grievance when the resident uses the term grievance She said sometimes she would ask residents if they would like to file a grievance. She said no one has asked to file a grievance. She said some of the concerns that she would receive would be that he yells coming down the hall saying, I'm back!. She said there is a fine line between joking and bothering the other residents, and sometimes he may go a little far. She said residents might not like it when he jokes with them, which is when it is too far. She said she is responsible for grievances. She said grievances are more formal and come from staff and the resident council. She said all staff was trained to come to her as the grievance official. Record review the facility's policy titled: Abuse/Neglect, Revised 03/29/18 , revealed the following documentation: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. C. Prevention (3) All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator and per policy. (4) The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse. All occurrences of potential abuse or criminal behavior will be investigated by the Abuse Preventionist and/or designee. (6) The facility will designate an Abuse Preventionist to monitor tracking and trending data and completion of investigations as needed. D. Identification The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly. E. Reporting (1) Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons. (2) When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. (3) Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. F. Investigation Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. G. Protection The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property investigation. Resident to Resident The above policy will apply to potential resident-to-resident abuse. Provider letter 19-17 will be reviewed to determine if resident-to-resident abuse occurred. An interview was conducted on 01/19/23 at 09:21 AM, and the Administrator said that he was the grievance official and that the Social Worker was his backup. He said other staff outside of the Social Worker and himself could also take grievances. When asked what the grievance process was, the Administrator obtained the grievance policy and read the grievance policy. He said the process was as follows: Include the part read. The grievance official will: Oversee the grievance process Receive and track grievances to their conclusion Lead any necessary investigations by the facility Maintain the confidentiality of all information associated with grievances Issue written grievance decisions to the resident Coordinate with state and federal agencies as necessary When asked how he determines the difference between a grievance and a conversation, he said that it is difficult to decipher between the two and that it is his expectation for all grievances to be logged. When asked about reported behavior concerns with Resident #57, he stated that people have come to him about Resident #57 attitude and behavior towards other residents and some toward staff, but nothing physical has been reported or observed by the Administrator. He said people would just say he is mean or that they did not like the way Resident #57 joked. He said that no specifics outside of Resident #57 being mean were reported when this was reported. He said this statement was a matter of onion, not a statement of fact. He stated that everyone was entitled to their opinion. The Administrator stated that he did not log any grievances when it was brought to his attention that Resident #57 was mean because he attributed it to Resident #57 personality. He said there were no instances that amounted to grievance level. When asked how he would determine what a grievance was and if he had a tool that he used, he stated he did not. He described Resident #57 as having an A-type personality. He read from his computer and said an A-type personality refers to a particular behavior for a person with high achievement, competitiveness, and tend to be impatient. He said staff had reported to him that Resident #57 had been mean to them, but nothing more than that. He stated nothing specific had been said. He stated if anyone had reported physical abuse, he would have reported it. He said that he was aware that there were more types of abuse than physical but that nothing has been reported to him that rises to the level of abuse in his opinion as the abuse prevention and grievance official and in his experience as an administrator. He said no residents have come to him and reported any issues regarding Resident #57 pulling anyone's hair, threatening them, grabbing their wheelchair, or name-calling. He said he spoke with Resident #57 on the morning of the interview (01/19/23) because he was loud and yelling in the hallways. He stated that Resident #57 was not yelling about anything specific, but it was 6:30 AM, and he asked him to keep it down. He stated that Resident #57 may rub some people the wrong way. He said that anytime anything was brought to his attention, he evaluated the situation to see if it was a grievance or if it was Resident #57's personality. He said he had evaluated anything brought to his attention and stated that the resident who said Resident #57 was mean did not like him. When asked about Resident #57's behavior, he reported that since the resident's admission, there has been no major shift and that he has had the following behaviors: yelling, cussing, evading care, and yelling for people to get out of the way. He stated that there had not been a specific training or in-service addressing the resident's behavior. He stated that no additional interventions were taken outside of monitoring and reporting the resident's behavior. He said Resident #57 does use profanity. A confidential interview was conducted with Confidential Staff B, when asked if she considered the interaction with the residents and Resident #57 as abuse, she stated that Confidential Resident #3 and #4 might consider it abuse because they keep asking him to stop, and he does not. She said Confidential Resident #4 might consider it abuse when he pulls her hair. When asked if she had observed this hair-pulling behavior, she stated she had. She said it had not been recent, but it had occurred two or three months ago. She said she did not report it but told Confidential Resident #4 to report it. When asked why she did not report it she stated she did not report it because she had instructed Confidential Resident #4 to report it. When asked if there were concerns with Resident #57 she said no. She said Resident #57 She stated she had never seen him be rude to that resident. She stated she had never witnessed any sexual inappropriateness. A confidential interview was conducted with Confidential Resident #3 who confirmed that no sexual contact had occurred and that it had only been verbal. She said Resident #57 had touched them like a pat on the back, but that was it. They stated she was not comfortable with any contact with Resident #57. They stated that Resident #57 would block them in the hallway where they felt they could not get away. They said they had not reported it because the staff was around and did not think about it. They stated that they had never been talked to by staff about the actions of Resident #57. A confidential interview was conducted with Confidential Resident #4 who stated that all interactions with Resident #57 have been verbal and never physical. A confidential interview was conducted with Confidential Resident #2 who said Resident #57 always bothered them. They said they reported their issues to the ADM, and the only thing that has stopped was Resident #57 had not pulled their hair in a while. They said they had told the ADM multiple times as incidents happen but unable to specifically tell the surveyor an exact date. They said the resident continued to call them names. They said he called them and their friends witches. They said they believed he wanted to call them bitches. They said he would yell at them in the hall to get out of the way. They said he would block them in the hallway. They said Resident #57 would come to their room early in the morning, as early as 6:30 AM, and flip on their light and yell, wake up, witch!. They said Resident #57 would tell the other residents not to look at them or their friends, or they would turn into frogs. They said this made them feel really down and bad about themselves. They stated Resident #57 had not said anything sexual, and the only thing he had done was call them names. An observation on 1/19/23 at 12:00 PM of Resident #57 in his wheelchair in the dining room entry talking with staff. Resident #57 was not interacting with any of the confidential residents. He reported to staff that he had lost his phone and that he may have left it in another resident room when he was visiting other residents. On 1/19/23 at 1:10 PM the Administrator, Regional Nurse, and ADON were notified that the facility would be placed in immediate jeopardy status due to failure to keep the resident safe from abuse. The following Plan of Removal submitted by the facility was accepted on 1/20/23 at 08:47AM: Plan of Removal Problem: Abuse allegation Interventions: Alleged perpetrator interviewed and placed in 1:1 observation 1/19/23 at 1330 One on One in-service on grievances and abuse reporting completed with the Administrator/DON /Social Services 1/19/2023 by the Regional Compliance Nurse. Safe surveys conducted on interviewable residents by social services 1/19/2023 Immediate psychiatric services on call for identified residents in need 1/19/2023 1438 Psychiatric services referral ordered and initiated for alleged perpetrator at 1433. Visit completed 1/19/2023 at 1530. MD contacted on 1/19/23 at 1433. Discharge placement ordered for alleged perpetrator. Staff working with alleged perpetrator have been interviewed by regional compliance nurse. Resident safe surveys have been completed by social services. All cognitive residents will be interviewed by corporate staff. Grievance reporting posting was placed on each nursing unit. The following in-services were initiated on 1/19/23: Any staff member not present or in-serviced on 1/19/2023, will not be allowed to assume their duties until in-serviced. o All Staff Abuse/Neglect Abuse/Neglect Reporting Who to Report Abuse/Neglect to Management of aggressive behavior Grievance reporting Monitoring Administrator to Investigate and submit findings of grievances to ADO and Risk Management for review Administrator will submit documentation of investigation with Resident and Staff interviews, as well as weekly follow up interviews with staff and residents x 4 weeks to ensure resident safety/satisfaction with outcome of investigation ADO will monitor weekly x 4 weeks follow up on grievances and monitoring of quality of life rounds and resident and staff interviews. Quality of life rounds on a sample of at least 25% of the residents will be made by Administrator/ Regional compliance nurse weekly x 4 weeks. The QA committee will review findings monthly for no less than 60 days and makes changes as needed On 1/20/23 at 08:47AM the Final Plan of Removal was approved. On 01/20/23 the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: A confidential interview was conducted with Confidential Resident #2 who reported that staff had spoken to her