**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from of any significant medication errors for 1 of 11 residents (Resident #1) reviewed for medication regimen. The facility did not administer physician ordered medications to Resident #1 that included handheld nebulizer breathing treatments, inhalers, nasal sprays, and tablets for diagnosed respiratory diseases. This resulted in the need for Resident #1 to be transferred to ED on 08/04/2024 at 8:55 PM and admitted to hospital with diagnosis of acute exacerbation of chronic obstructive pulmonary disease (lung disease causing breathing problems) and symptoms of shortness of breath. An Immediate Jeopardy was identified on 08/09/2024. The Immediate Jeopardy Template was provided to the Administrator on 08/09/2024 at 3:40 PM. While the Immediate Jeopardy was removed on 08/10/2024 at 5:41 PM, the facility remained out of compliance at a scope of pattern and severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective actions. This failure placed residents at risk of significant medication errors and a decline in health status, serious injury, and/or death. The findings included: Record review of Resident #1's admission Record, dated 08/08/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE] at 03:38 PM. The resident's diagnoses included chronic obstructive pulmonary disease (lung disease causing breathing problems), anxiety disorder (feelings of worry), essential hypertension (high blood pressure), hypothyroidism (thyroid disorder), type 2 diabetes mellitus (elevated blood sugar), long term (current) use of anticoagulants (use of blood thinner), unspecified asthma (breathing disorder caused by airway restriction), gastro-esophageal reflux disease (stomach digestive disease), pain (discomfort), localized edema (swelling in a specific area), allergic rhinitis (allergic response causing sneezing) and hereditary and idiopathic neuropathy (weakness, numbness, pain from nerve damage). Record review of Resident #1's Medication Administration Record, dated 08/08/2024, revealed in part: Brezti HFA 160-9-4.8ncg 2 puffs inhalation twice a day Dx: COPD, inhaled medication to open airways and decrease breathing difficulties (2 of 2 missed doses) Budesonide 0.5mg/2ml 1 vial twice a day Dx: COPD, (an inhaled medication to open airways and decrease breathing difficulties) (2 of 2 missed doses) Fluticasone 50mcg 1 spray nasal twice a day Dx: Allergic Rhinitis, (a nose spray for nasal allergies). (3 of 3 missed doses) Ipratropium-Albuterol 0.5mg-3mg/3ml 1 vial via HHN twice a day Dx: COPD, (an inhaled medication to open airways and decrease breathing difficulties) (3 of 3 missed doses) montelukast tablet. 10mg. 1 at bedtime Dx: Asthma, (a tablet to decrease allergy symptoms) (2 of 2 missed doses) Losartan 25mg 2 tablets once a day Dx: COPD, HTN, (a tablet to maintain blood pressure and decrease airway difficulties) (1 of 1 missed doses) Prednisone 10mg once a day (AM) Dx: COPD (1 of 1 missed doses) Albuterol Sulfate HFA Inhaler PRN wheezing/SOB (a breathing inhaler medication to decrease airway difficulties) (was not administered) Record review of Resident #1's Nursing Progress Note, dated 08/03/2024 through 08/04/24, revealed: 08/03/2024 at 09:23 PM, LVN A documented resident's arrival to facility on 08/03/2024 at 5:00 PM, admitted from acute care hospital with diagnosis of peripheral vascular disease and transported via facility van. LVN A also documented admission orders entered into matrix care and medication orders sent to pharmacy at 5:00 PM. 08/04/2024 at 03:49 AM, LVN F documented Resident has heart rate of 122, anxiety, problems breathing. (Physician) notified and he ordered one time order of Clonazepam1mg for resident. Administered at this time. Will continue to monitor. 08/04/2024 at 05:46 AM, RN G documented Repeat vitals,BP131/89,SPO2 98,resp26,pulse 92,Temp 97.8. On oxygen 4L/min at this time. pt still having dyspnea. Will continue to monitor. 08/04/2024 at 09:39 PM, LVN B documented transfer resident to Hospital ER. Primary reason for transfer: shortness of breath, anxiety and husband wanted resident transferred. Resident condition upon transfer alert and oriented with oxygen applied at 3liters per minute. Resident left facility at 08/04/2024 at 9:00 PM. Resident did not have medications in facility d/t not received from pharmacy resident admitted after 1600(4:00PM) on 08/03/2024. Record review of Resident #1's hospital medical record ED Provider note, dated 8/4/24 at 2137 (9:37PM), revealed the following [in part]: Chief complaint of shortness of breath. Vital signs: T-98.5, HR 123, R 23, BP 159/104, SpO2 100%. Physical Exam Comments: Abuse. Chronically Ill. On a non-rebreather mask. Diminished in lung bases. Scattered rales. Blood Gas (lab to detect oxygen, acidity, and carbon dioxide in the blood), Venous - Collected 8/4/24 @ 9:30 PM with the following results: Ph Venous - 7.32 (Normal 7.35-7.45), PCO2 Venous 72.0 (Normal 80-100), HCO3 Venous 37.3 (Normal 22-26),CO2- 34 (Normal 23-30). Hospital admitting diagnosis: Acute Exacerbation of Chronic Obstructive Pulmonary Disease. In an interview on 08/08/24 at 10:49 AM with Resident #1's Physician, he stated he was at the facility in Resident #1's room at the time of Resident #1's transfer initiation to the ER. He said the resident complained of difficulty breathing and wanted to be transferred to the ER. He stated, I am sure that the lack of medication could have contributed to exacerbation of COPD. He further said the staff at the nursing home usually notified him if the medications were unavailable so he could Give a new order if needed, he continued to say that the clinical staff was in contact with him regarding Resident #1. In an interview on 08/08/24 at 1:18 PM, LVN A, who was the admitting nurse for Resident #1, stated When I went in to assess (Resident #1), she was fine and not short of breath unless she walked to the restroom. She did have an inhaler that her husband brought from home that she used, but I have no idea what it was, (resident's husband) put it back in his pocket. I think it was blue. I suppose it would be me and (other nurse) that should order medication, I only work a few days, so I am not sure. When I received the order, me and the other nurse put the orders in and as far as I know that is what triggers the pharmacy to deliver the medication. I don't give scheduled medications only controlled medications. I knew (Resident #1) didn't have anything upon arrival for meds, I think they have a thing in the med room that they can pull from. All of the orders were put in, I thought they would be delivered at 12 am. In an interview on 8/08/24 at 1:32 PM, LVN B stated Sometimes admission orders are faxed in advance from the hospital, and sometimes they are sent with the resident in a packet when they arrive at the facility. We cannot enter any orders into the computer until the resident is in the building. We cannot enter orders until the resident is entered in the census to open a chart. When the orders are entered into the chart, they automatically are sent to the pharmacy. As long as orders are entered in the computer before 6:30 PM, they should be delivered that same night, but they're not delivered. The orders aren't received immediately by the pharmacy. If the meds aren't delivered, then the nurse gets them from the emergency box, (EMDS). The medication aide administers new residents' meds, except insulin, breathing treatments of any kind (inhalers, nebulizer treatments, supplemental oxygen), PRN narcotics. Med aides can give routinely scheduled narcotics, just not PRNs. Medication aides reorder routine meds when they get low. There is a column on the right-hand side of each medication on the eMAR that says resupply and the medication aide just clicks on it to reorder. The licensed nurses reorder narcotics because the pharmacy has to be called. LVN B stated she called the doctor to ask if medications have refills or if a prescription could be written to send to the pharmacy. LVN B stated she worked for an agency not the facility, has worked in facility for about 2 weeks averaging 4 days per week and doesn't work weekends. LVN B stated the agency nurse was assigned whatever hall was open, including the Medicare Hall, Hall A. She admitted a resident to the Medicare Hall A, entered meds in the computer, and completed the admission nursing assessment, a standardized form. During the week, the ADONs and the DON would help with the admission process and would sometimes enter the medication orders. In an interview on 08/08/24 at 1:51 PM, ADON H stated the Charge Nurse was responsible for ordering medications and if they could not get the medication after calling the pharmacy, they should have notified administrative staff to give direction on what to do. ADON H stated the failure of Resident #1 not getting her medication could have occurred because of a lack of knowledge maybe. ADON H said the risk of the failure for Resident #1 not receiving her medications was an Exacerbation of her Chronic Diseases. In an interview on 08/08/24 at 2:02 PM, ADON I stated the medication aide should have notified the nurse that Resident #1's medication had not been delivered in the medication cart and the Nurse did not follow through to make sure Resident #1 got her medication. ADON I said she did not realize Resident #1 had not received any of her medications for 08/03/24 or 08/04/24 until the morning of 08/08/24. ADON I said the Charge Nurse and the medication aide lacked initiative to get the medication which caused the failure. She said if it were her, I would have pulled everything possibly from the (EMDS) and then contacted the pharmacy to have the rest delivered from backup. ADON I said that did not occur because, PRN nurses, either didn't know the process or just didn't follow it. ADON I stated it was the responsibility of the med aide, nurse, nurse on call, DON ADM to order medications for a new admission. ADON I stated the failure could include death for a resident. In an interview on 08/08/24 at 3:50 PM the DON, stated training began on 08/05/24 with the anticipated DON, start date of 08/12/24. The DON further stated Resident #1 did not receive any of her medications for 08/03/24 or 08/04/24, but the facility did not realize Resident #1 did not receive any of her medications until after the State Surveyors began the investigation and the facility began a Chart Audit after 6ish Wednesday (6:00PM 08/07/24). The DON said (Resident #1) should have received her medications and the on-call nurse, DON, MD should have been immediately notified if the medications were not available. The DON stated the failure occurred because, lack of communication, agency LVN, and admission process. The DON stated the ADON and the LVN had access to the EMDS, and (facility) were working on getting all facility employed nurses' access to the system. The DON stated nurses were responsible for providing residents with nebulizers, inhalers and nasal sprays. In an interview on 8/08/24 at 4:10 PM, MA D stated the licensed nurses give the initial dose of medications. If a resident is new to the facility, then all their medications are considered initial doses, and the Med Aide doesn't do it. MA D stated I did not give Resident #1 any medications. Medication Aide D said The nurses put the orders in the computer for the pharmacy and the licensed nurses give the initial doses and all the PRN medications. The nurses can get meds from (EMDS) (EMDS), but the med aides cannot. I did not see LVN A give Resident#1 any medications and I don't know if she (LVN A) gave the resident any medications. MA D stated the resident did not have any medications in the med cart because she didn't come with any. MA D also stated Medication Aides do not do any kind of respiratory care or breathing treatments - no inhalers or nebulizer treatments. The med aides can get the oxygen cylinder, but the nurse sets the liters and applies the oxygen. In an interview on 08/08/24 at 4:27 PM the Clinical Resource Nurse stated the medications were ordered, but the pharmacy should have been called to ensure the orders were filled, the medication should have been obtained from (EMDS) and what isn't obtained from (EMDS) the pharmacy should have been called, the physician should have been called, or you could call the family to see if they have home medications, we could have gotten medication from hospital, we could have notified DON. The Clinical Resource Nurse said the nurse didn't administer Resident #1's medications from the EMDS because, I am not sure why she didn't give them, but there were many opportunities for her to seek the assistance to obtain the medication. The Clinical Resource Nurse stated the failure could have occurred because of a lack of education, further stating the nurses were responsible for initial doses of medications, nebulizers or breathing treatments and inhalers. The Clinical Resource Nurse said the failure could have caused the rehospitalization of Resident #1. In an interview on 8/8/24 at 4:44 PM, the Administrator stated, the facility failure was that they did not check the (EMDS) and did not notify nursing management that they were missing all of those medications, as well as the charge nurse. The Administrator stated I know I got a call Sunday about an uber and picking up medication how to pay an uber, I said no the pharmacy orders thru a local pharmacy they take care of it, at that time I called ADON I, at that time I was aware of the clonazepam only. Otherwise, I didn't know of anything else until yesterday . I was not aware of other medications not given until yesterday evening. Record review of the facility's policies/procedures for Medication Orders revealed [in part]: Non-controlled Medication Orders, 12/12 Procedures - Elements of the Medication Orders 4. The prescriber shall be contacted by nursing for direction when delivery of a medication will be delayed or the medication is not available. Documentation of the Medication Order: a. New orders b. Written transfer orders (sent with a resident from a hospital or other health care facility): Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete or the date signed is different from the date of admission. 4. Scheduling new medications orders on the Medication Administration Record (MAR)/Treatment Administration Record (TAR): a. Non-emergency medication orders: The first dose of medication is scheduled to be given after the next regularly scheduled pharmacy deliver to the nursing home. b. Emergency/STAT medication orders when medication is available in the emergency kit: From the emergency kit, remove the appropriate number of doses to be administered prior to the regularly scheduled pharmacy delivery. Thereafter, does are scheduled according to nursing care center policy on medication administration. c. Emergency/STAT medication order when medication is not available in the emergency kit: An emergency STAT order is placed with the provider pharmacy and the medication is scheduled to be given as soon as received. Subsequent doses are timed according to nursing care center policy on medication administration schedule. This was determined to be an Immediate Jeopardy on 08/09/2024. The Administrator was provided the Immediate Jeopardy Template on 08/09/2024 at 3:49 PM and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 08/10/2024 at 10:17 AM: 1. Immediate Actions Taken for Those Residents Identified: Action: Resident #1 was sent to the hospital on 8/4/2024. Person(s) Responsible: Charge Nurse/The Physician/The Facility Completion Date: 8/4/2024 2. How the Facility Identified Other Possibly Effected Residents: Action: Facility wide MAR to cart audit to ensure medications on the MAR are available on the medication carts, including recent admissions/readmissions. This has been completed on 8/9/2024 with no other discrepancies noted. Person(s) Responsible: Regional Nurse, Director of Nursing, Assistant Director of Nurses and/or Designee Completion Date: 8/9/2024 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Director of Clinical Operations and Clinical Resource Nurse educated Director of Nursing and Assistant Director of Nurses regarding the facility's emergency medication dispenser and ordering medications from the pharmacy. Charge Nurses were educated by the Clinical Resource Nurse, Director of Nursing, and/or Assistant Director of Nurses over the facility's emergency medication dispenser, ordering medications from the pharmacy. Charge Nurses and Certified Medication Aides were educated over their responsibilities in administering medications and initial doses and notifying the physician with any medications that are unavailable through the emergency medication dispenser and/or would be delayed in receiving and following MD orders. If the medication is not available in the Emergency (EMDS) the nurse will notify the Pharmacy On Call that the medication is not available in the Emergency (EMDS) and determine if the provider pharmacy will be filling the medication order or they will be sending the order to a local 24-hour pharmacy for fill and arranging delivery or pick up. The nurse will determine an approximate time of delivery and document this is the progress notes. Charge Nurses/Certified Medication Aides will be educated prior to working their next shift. New and temporary Charge Nurses/Certified Medication Aides will be educated prior to working their first/next shift. Person(s) Responsible: Director of Clinical Operations, Clinical Resource Nurse, Director of Nurses, Assistant Director of Nurses, and/or Designee Completion Date: 8/9/2024 4. How the Corrective Actions Will be Monitored, by whom and for how long: Action: Review all admissions/readmissions to ensure medications are available during clinical meetings, daily. Charge nurses will communicate with the Director of Nursing, Assistant Director of Nursing, and/or Administrator and Doctor if medications are not available immediately from the emergency medication dispenser for the next administration time for all admissions/readmissions regardless of day or time and/or pharmacy is unable to deliver the medications timely/on the next run, immediately through the above education. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Charge Nurses, and/or Designee Completion Date: 8/9/2024 Action: Medication unavailable report to be ran and reviewed during clinical meetings, Monday-Friday, staff will know to communicate unavailable medications with the Director of Nursing, Assistant Director of Nursing, and/or Administrator and notification of the MD through the above education if there is a noted issue with medications being unavailable. Any issues noted with medication unavailable/failure to communicate will result in 1:1 education with the Charge Nurse or Certified Medication Aide responsible. Director of Nursing, Assistant Director of Nursing, Charge Nurses, and/or Designee Completion Date: 8/9/2024 Action: Notify the MD/Ad hoc QAPI regarding the deficient practice and the facility's plan to avoid future noncompliance. Person(s) Responsible: Administrator/Director of Nursing Completion Date: 8/9/2024 Monitoring and Verification of the facility's Plan of Removal began 08/10/2024 at 10:19 AM as follows: In an observation on 08/10/2024 at 1:39 PM, 3 medication carts were inspected and 3 of 3 new admission residents medications were available on the cart and were administered as ordered. In an interview on 08/10/2024 at 11:09 AM, LVN N stated Upon admission orders are brought to facility, put in computer, pharmacy is called, then pull medications from EMDS. The CMA should inform the nurse if there are no medications on the cart to be given to the resident, then the nurse would have gone thru the EMDS, called the pharmacy and then administered. If the CMA does not communicate to the nurse the nurse would not know. LVN N further stated, if an issue with a medication, LVN N immediately calls the pharmacy to get the medication. LVN N stated I received training regarding responsibilities of Charge nurse, I have been here three years, we (nursing staff) got another training yesterday (8/9/24) that was provided by DON. Yesterday we reviewed the EMDS, physician orders, notifying physician regarding medications that are unavailable and get a suitable substitute, nurses providing initial doses. DON reviewed this with me one on one and I felt comfortable asking questions. In an interview on 08/10/2024 at 01:21 PM, MA D stated she was in-serviced by ADON I, face to face on Medication Administration, which included if a new admission comes in the initial dose is to be given by the charge nurse and that the nurses set up all of the oxygen stuff as well. MA D further stated If there is a resident on my cart I tell the nurse they do not have medication and to remind them to pull from EMDS. In an interview on 08/10/2024 at 1:39 PM, MA E stated in-service training provided in the past day regarding medication administration, new admission medication, to notify nurses if missing medications, that only nurses initial dose,the EMDS that nurses could retrieve medications from. MA E stated she received one on one training from the DON and was able to ask questions. MA E further stated if there was a medication ordered, MA E immediately told the nurse it was not available. In an interview on 08/10/2024 at 1:52 PM, LVN K stated an in-service by the DON and the ADON one on one with each regarding EMDS use of and what was available, admissions, medication ordering and physician notification. LVN K stated nurses were responsible for the initial dose. LVN K further stated Medications for new admissions, I would order from pharmacy and use EMDS if I need so that no doses are missed and if it's a resident that is already here I would check to make sure overflow and pull from STAT EMDS box to avoid missing a dose. In an interview on 08/10/2024 at 2:13 PM, MA M stated an in-service was given by ADON I, one on one regarding initial doses, and notification to nurse if medication needed was not available. In an interview on 08/10/2024 at 2:17 PM, LVN L stated an in-service completed by ADON I, one on one, regarding EMDS demonstration, initial dosing, HHN, new admission responsibility of orders and medications, procedure if medications were not available in the EMDS, notify pharmacy, physician and clinical staff. In an interview with Clinical Resource Nurse on 08/10/24 at 4:02 PM revealed Resident #1 was transferred to the hospital on [DATE] from the facility. The CRN stated she did the chart audits on 08/09/24 and any medications that were low were ordered from the pharmacy and/or restock was completed. The CRN explained in-services completed with staff consisted of ordering medications for admissions and readmissions, accessing and use of EMDS with demonstration, and ordering routine medications for all residents in the facility's new and current, reviewed notification of doctor, DON, ADON and ADM if any medications were unable to be obtained, always including weekends and after hours. The information provided to the licensed nursing staff specified if a medication could not be found in the medication cart it could be found in the EMDS. Charge nurses employed by facility may access the EMDS. Agency staff should ask for assistance obtaining medication needed from the EMDS which included tablet, capsule, liquids, HHN and injectables. A copy of the EMDS manufacturer Quick Reference Guide was reviewed with the nurses and gave specific step-by-step instructions on how to operate the medication dispensing machine with pictures of power-point slides. A printed list of the Active Inventory of medications in the EMDS for the facility. The staff did return demonstration of use of the medication dispense machine. She said, facility DON or designee will run a report Monday thru Friday mornings of medications not given. The DON would then bring the report to morning meeting to discuss with the team. The DON or designee would initiate an investigation, speak with the nurse or CMA who was responsible, find out why the medication wasn't administered, educate them, and follow the discipline policy as needed. In an interview on 08/10/24 at 4:37 PM, the DON stated the DON and both ADON's in-serviced all facility charge nurses regarding log in access to EMDS with demonstration regarding how to use system, initial dosing must be completed by license staff only, admission and re-admission medication process, ordering and dispensing, the CMA scope of practice. The DON explained in further detail the DON and the ADON educated clinical staff regarding upon admission that all resident medications should be reviewed for verification that medications were available for supply, the DON or ADON must be notified if not able to supply for next steps such as notifying the discharge provider for alternate or to send with supply, initial doses were only to be given by licensed nursing staff, the CMA expectation was not to administer initial doses and they were to notify the charge nurse of any medications not available to them. The DON further explained above information was given one on one to each facility nurse and facility CMA. The DON also stated the DON was responsible for education regarding the in-services and education given to clinical staff, she, with the help of the ADONs and the Clinical Resource Nurse completed trainings. The DON stated the process to address all new referrals and new medication orders in the morning meetings, as well as the DON or the on call clinical designee would call in on weekends to verify. The DON stated, medication unavailable report will be reviewed daily Monday thru Friday in morning meeting. If anything is flagged, DON will review, investigate, and determine why medication was missed or not given and then take corrective action as appropriate. She said The process to address all new referrals and new medication orders in the morning meetings, as well as DON or the on call clinical designee will call in on weekends to verify. In an interview on 08/10/2024 at 5:00 PM with the DON, she said they had a QAPI meeting and attendance with the medical director via phone. The Medical director was called by the ADM. Interview also revealed that Medical Director was notified by the DON regarding medications not administered to Resident #1 on 08/08/24 at 10:53AM. In an interview with ADM 08/10/2024 at 5:02PM regarding physician notification of Medical Director regarding IJ and SQC, ADM stated that medical was notified by ADM via phone on 08/09/24 at 5:11PM. Record review of Resident #1 hospital record dated 08/04/24 at 9:42 PM, revealed Resident #1 arrival to the emergency department with symptoms of shortness of breath at 9:15 PM on 08/04/2024. In an interview on 08/10/24 at 10:21am, with Resident #1's family, she said Resident #1 discharged from the hospital on [DATE] to a different nursing facility and was feeling much better. Record review of Chart Audit, dated 08/09/24, revealed All Medication Carts were audited and completed as signed by CRN and dated 08/09/24. Record Review of In-services dated, 08/08/24 & 08/09/24, included the following: Initial Dosing-8/9/24Certified Medication Aide (CMA) are not to administer the initial dose of any medication. This includes newly admitted residents and residents who have orders for any new medication. Initial dosing medication is not within the scope of practice of a CMA. This inservice had facility staff signatures and facility staff names and phone numbers indicating nurses and medication aides were inserviced on the information. New Admit Readmit Med Process Med Dispense Machine-Nurse Administrative Staff-8/9/24. 1. New admission Medication 2. Med Dispense 3. Nebulizer Med Administration dated 8/9/24-Admission/readmission Medication Process- Always including nights and afterhours-1. Enter orders for residents hospital discharge medication list. 2.Contact the pharmacy to confirm medication time of arrival 3. Enter pharmacy communication information in a nurse's note. Include name of person that was spoken to at pharmacy. 4.Check the medication dispensing machine for available medications. 5. At this time notify doctor, director of nursing, assistant director of nursing, or administrator of any medication that is unavailable, to obtain a substitute medication or in order to DC the medication until it is available from the pharmacy. And alternate pharmacy may be considered (local pharmacy) 6. Communication with director of marketing, to request discharge medication for medication that is unavailable prior to discharge. 7. In the morning meeting review referral documentation. communicate with the director of marketing to request discharge medication for medication that is unavailable prior to discharge. Consider holding admission if it is foreseen that we will be unable to attain medication including after hours or on weekends. 8. The morning following admission the DON or designee will verify the medications were obtained. - Nursing staff signatures reflected they reviewed and acknowledged the information. Accessing medication from med dispense located in the med room at the nurses station medication that cannot be found in the medication cart can be found in the Med dispense. Charge nurses employed by (facility) may access the Med dispense machine agency staff should ask for assistance obtaining medication needed from the medication dispense machine including tablet, capsules, liquids, HHN, injectables. Nursing staff signatures reflected they reviewed and acknowledged the information. 1 ·The Director of Nursing/designee will review referrals preadmission specifically those that may be admitting after hours/weekends and request potential discharge date and time and discharge orders if these are available.2· The Director of Nursing/designee will determine what medications are needed and specifically note if any medications will not be available in the facility's emergency medication dispenser (review the referral prior to admission, communicate with the discharging entity on potential discharge date (s), proactively request discharge orders from the discharging entity).3. If the Director of Nurses/designee identifies medications that are not in the Emergency medication dispenser and if this medication will be needed prior to the next Pharmacy delivery the Director of Nurse/designee will request the discharging entity to provide medications until the facility can obtain the medications. If the discharging entity is unable to supply the medication{s) the facility will notify the physician and determine further actions or delay the admission until the medication can be obtained.- Nursing staff signatures reflected, they reviewed and acknowledged the information. Medication unavailable report to be ran and reviewed during clinical meetings, Monday-Friday, staff will know to communicate unavailable medications with the Director of Nursing, Assistant Director of Nursing, and/or Administrator and notification of the MD through the above education if there is a noted issue with medications being unavailable. Nursing staff signatures reflected, they review[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure the environment remained free of accidents hazards and provided adequate supervision to prevent accidents for 5 of 9 (Resident #1, #8, #9, #10 and #11) residents reviewed. 1. The facility failed to ensure Resident #1, #8, #9, and #10 were provided direct supervision of staff when smoking. Residents #1, #8, #9, and #10 were allowed to sign out and go outside to smoke in an undesignated smoking area unsupervised in an area with flammable objects of dry grass and dry wood. Residents #1 and #8 were observed to cross the street in front of the facility to the picnic table at the park and smoke in their wheelchairs unsupervised near a creek with an 8-foot drop off. 2. The facility failed to ensure Resident #1 was safe when smoking with no supervision as evidence by a burn on his clothing, fanny pack and blanket. 3. The facility failed to ensure Residents #1,#8, #9, and #10 complied with the facility's smoking policy that required all smoking paraphernalia to be checked in and out by the nursing staff and stored in a secure location upon return from pass. 4. The facility failed to follow their Nursing Guideline: Out on Pass/Leave Procedure Policy, dated 03/2024, by failing to abide by: - ensure smoking actions were implemented in Residents #1 and #8's Care Plan per policy to correctly identify the residents' smoking safety needs. - obtain physician orders prior to Residents #1, #8, #9, and #10 physically signing out of the facility on pass to smoke. - ensure proper documentation on the Out of Pass Release of Responsibility Form for Resident #1, #8, and #10 was completed accurately and entirely, to include what time the residents left the building, and what time the residents planned to return. - ensure Resident #1, #8, #9, and #10 were assessed by a nurse prior to signing out and leaving the facility and upon return to the facility from pass. 5. The facility failed to ensure a smoking assessment was conducted for Resident #9's to determine his smoking risk when admitted on [DATE]. 6. The facility failed to ensure Resident #11's cigarettes were not stored on his person and kept in a secure area during other times than scheduled, supervised smoking breaks. An IJ was identified on 03/28/2024. The IJ template was provided to the facility on [DATE] at 1:15 p.m. While the IJ was removed on 03/29/2024, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm, severe injury, and possible death to residents who require supervision while smoking. Findings included: Resident #1 Record review on 03/07/2024 at 11:30 a.m. of Resident #1's Face Sheet, dated 03/07/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Unspecified sequelae (consequence of a previous disease) of cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area), Hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant side, Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) Mellitus (the response to insulin was diminished and defined as insulin resistance), and surgical amputation of both legs below the knees. Record review on 03/07/2024 at 11:31 a.m. of Resident #1's Doctor's Orders, dated 01/24/2024, revealed Resident #1 had a general order of Nasal Cannula (prn for comfort): o2@ (2-4) L/Min, Every shift - PRN Shift, Shift1, Shift2, Shift3. Record review on 03/07/2024 at 11:32 a.m. of Resident #1's Doctor's Orders, dated 03/07/2024, revealed Resident #1 did not have physician orders that identified Resident #1 was able to leave the facility, to include the reason, medical or social, and the circumstances (i.e. alone or with family/friends). Record review on 03/07/2024 at 11:33 a.m. of Resident #1's Quarterly MDS Assessment, dated 01/26/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 14, which identified an intact cognitive response. Section GG0115 - Functional Limitation in Range of Motion revealed Resident #1 had impairment on both sides of his lower extremity and Section GG0120 revealed Resident #1 ambulated by use of a wheelchair. Review of Section E - Behavior, E0800 revealed Resident #1 had no behaviors or refusals of care. Record review on 03/07/2024 at 11:34 a.m. of Resident #1's Smoking Risk Assessment, dated 09/29/2023, revealed Resident #1 scored high and was deemed an unsafe smoker. The assessment revealed Resident #1 was assessed as a chain smoker, severe problem with smoking in unauthorized area, severe problem with careless with smoking materials, such as drops cigarette on floor or burns fingertips, severe problem smoking used cigarettes butts from ash trays, severe problem giving cigarettes to others, and severe problem with begging or stealing cigarettes. The assessment recommended Resident #1 continue current plan of care and follow facility policy. Record review on 03/07/2024 at 11:36 a.m. of Resident #1's SLP Smoking Risk Assessment, dated 02/13/2024, revealed a paper copy of an Observation Detail List Report with the identifying information marked out with a black marker. Under the Section - Smoking, Assessment - Observation Information, Resident #1's name was hand-written in. Review revealed the questions on the assessment were blank and the form was unsigned and not dated. The summary and rating of Resident #1's smoking ability was blank and undetermined. Record review on 03/07/2024 at 11:38 a.m. of Resident #1's Care Plan, dated 12/18/2023, revealed Resident #1 had a Problem/Category area of - Smoking: I am a smoker. I am not always compliant with the smoking policies. I have been found smoking outside of the designated smoking area and I have been known for not returning all of my smoking materials. Review revealed Resident #1's goal was to comply with smoking policies and would smoke in designated area(s) at scheduled times through the next review period. Record review on 03/07/2024 at 11:39 a.m. of Resident #1's Progress Note, dated 2/08/2024 at 8:07 a.m., revealed Resident #1 was observed smoking outside in the smoking area even though he was reminded not to go. Resident #1 said to the staff, stay out of my business and I am not a f__cking child. Resident #1 remained outside and refused to extinguish his cigarette. Record review on 03/07/2024 at 11:40 a.m. of Resident #1's Progress Note, dated 2/10/2024 at 12:35 a.m., revealed Resident #1 was observed going outside with another male resident who pushed Resident #1 in his wheelchair to the smoking area even though he was reminded not to go but he went anyway and smoked. During an observation on 03/07/2024 at 8:30 a.m., Resident #1 was observed outside sitting in his wheelchair and smoking on the east side of the facility unsupervised in an undesignated smoking area. Observed the area where Resident #1 was smoking was located by a side street that intersected with the road that ran in front of the facility. Resident #1 was observed as he smoked by a telephone phone surrounded by yellow, dried weeds approximately two (2) feet in height and a grey wooden pallet, or a flat wooden platform on which goods are stored so that they can be lifted and moved using a forklift truck, was observed lying flat on top of the weeds. During an interview on 03/07/2024 at 9:32 a.m., LVN L said he had observed Resident #1 exit the facility through the front entrance and go to the east side of the facility and smoke unsupervised on multiple occasions. LVN L said he did not know which residents who smoked were assessed as safe or unsafe. LVN L said he had observed Resident #1 across the street at the park at the picnic table smoking on several occasions. LVN L said Resident #1 was independent and he assumed Resident #1 could smoke as long as he was off the property. On 03/27/2024 @8:33 a.m., Resident #1 was observed with a small hole in his fanny packet he wore around his waist, approximately ¼ inch in diameter, singed and melted around the edges. Observed two small black spots on the blanket Resident #1 had draped over his lap. Resident #1 said he was sitting outside smoking a week prior and the wind blew his blanket up and knock his cigarette out of his hand. Resident #8 Record review on 03/07/2024 at 6:45 p.m. of Resident #8's Face Sheet, dated 03/07/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses of Atherosclerotic (thickening or hardening of the arteries) heart disease of native coronary artery with unspecified angina pectoris (occurs when arteries that carry blood to your heart become narrowed and blocked because of thickening or hardening of the arteries or a blood clot); Alcohol dependence; History of methamphetamine dependence, Chronic obstructive pulmonary disease, and Acquired absence of other specified parts of digestive tract-Partial colectomy (surgeon removes the diseased portion of the colon and a small portion of surrounding of heathy tissue). Record review on 03/07/2024 at 6:46 p.m. of Resident #8's Doctor's Orders, dated 09/23/2023, revealed Resident #8 had a general order of Oxygen 2-4 L/Minute PRN As Needed, PRN1, PRN2, PRN3. Record review on 03/07/2024 at 6:47 p.m. of Resident #8's Doctor's Orders, dated 03/07/2024, revealed Resident #8 did not have physician orders that identified Resident #8 was able to leave the facility, to include the reason, medical or social, and the circumstances (i.e. alone or with family/friends). Record review on 03/07/2024 at 6:48 p.m. of Resident #8's MDS Quarterly Assessment, dated 02/22/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 12, which indicates moderate impairment. Section - GG0120 - Mobility Devices, revealed Resident #8 ambulated with the use of a wheelchair. Review of Section E - Behavior, E0800 revealed Resident #1 had no behaviors or refusals of care. Record review on 03/07/2024 at 6:49 p.m. of Resident #8's SLP Smoking Risk Assessment, dated 02/13/2024, revealed a paper copy of an Observation Detail List Report with the identifying information marked out with a black marker. Under the Section - Smoking Assessment - Observation Information, Resident #8's name was hand-written in. Under the Section - Observation Detail List Report - the question, Is the resident physically capable of smoking? was blank as well as Section - Evaluation, Smoking Risk, Referral, and Plan of Care. Review revealed the assessment was not signed or dated and was incomplete. The summary and rating of Resident #8's smoking ability was blank and undetermined. Record review on 03/07/2024 at 6:51 p.m. of Resident #8's Smoking Risk Assessment, dated 09/28/2023, revealed Resident #8 had a score that identified her as Potentially Unsafe Smoker and deemed Resident #8 with the need for care plan intervention. The assessment revealed Resident #8 was assessed as a chain smoker, minimum problem with smoking in unauthorized area, moderate problem with careless with smoking materials, such as drops cigarette on floor or burns fingertips, moderate giving cigarettes to others, and moderate problem with begging or stealing cigarettes. The assessment recommended Resident #8continue current plan of care and follow facility policy. Record review on 03/07/2024 at 6:54 p.m. of Resident #8's Care Plan, dated 01/08/2024, revealed Resident #8 had a Problem area of - Res is a smoker; Review revealed Resident #8's goal was to maintain safety while smoking, which included nursing staff to assist and assure Resident #8 removed oxygen before smoking and reviewed/discussed the facility's smoking policy with Resident #8 quarterly. Resident #9 Record review on 03/08/2024 at 9:25 a.m. of Resident #9's Face Sheet, dated 03/08/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Other psychoactive (affecting the mind) substance abuse with substance-induced persisting dementia (loss of cognitive functioning - thinking, remembering, and reasoning- to such an extent that it interferes with a person's daily life and activities), Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) Mellitus (the response to insulin was diminished and defined as insulin resistance) with hyperglycemia (high blood glucose), Osteomyelitis (infection in the bone) of vertebra (spine), thoracic region (middle of spine), and Paraplegia, incomplete (the injury has not completely severed the spinal cord and some degree of sensation and movement control would be present). Record review on 03/08/2024 at 9:26 a.m. of Resident #9's Doctor's Orders, dated 03/08/2024, revealed Resident #9 did not have physician orders that identified Resident #9 was able to leave the facility, to include the reason, medical or social, and the circumstances (i.e. alone or with family/friends). Record review on 03/08/2024 at 9:27 a.m. of Resident #9's Other Payment MDS Assessment, dated 12/06/2023, Section C- Cognitive Response Patterns revealed a BIMS score of 14, which identified an intact cognitive response. Section G revealed Resident #9 required extensive assistance with two or more persons with toileting and transferring to his wheelchair. Review of Section E - Behavior, E0800 revealed Resident #9 had no behaviors of rejection of care to meet his goals for health and well-being. Record review on 03/08/2024 at 9:30 a.m. of Resident #9's clinical record progress notes, dated 09/18/2023 through 02/13/2024 revealed Resident #9 did not have a Smoking Risk Assessment. Record review on 03/08/2024 at 9:33 a.m. of Resident #9's SLP Smoking Risk Assessment, dated 02/13/2024, revealed a paper copy of an Observation Detail List Report with the identifying information marked out with a black marker. Under the Section - Smoking Assessment - Observation Information, Resident #9's name was hand-written in. Under the Section - Observation Detail List Report - the question, Is the resident physically capable of smoking? was blank as well as Section - Evaluation, Smoking Risk, Referral, and Plan of Care. Review revealed the assessment was not signed or dated and was incomplete. The summary and rating of Resident #9's smoking ability was blank and undetermined. Resident #10 Record review on 03/08/2024 at 10:20 a.m. of Resident #10's Face Sheet, dated 03/08/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Osteomyelitis (serious infection of the bone) of vertebra (spine), thoracic (middle section of your spine) region, End stage renal (kidney) disease, Unspecified dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to an extent that it interferes with a person's daily life and activities) , Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) Mellitus (the response to insulin was diminished and defined as insulin resistance), Dependence on renal dialysis (treatment for people whose kidneys are failing), and Chronic kidney disease, Stage 5 (last stage). Record review on 03/07/2024 at 10:22 a.m. of Resident #10's Doctor's Orders, dated 02/16/2023, revealed Resident #10 had a general order of Nasal Cannula (PRN): O2@ 2L/Min, As Needed, PRN 1, PRN 2, PRN 3. Record review on 03/08/2024 at 10:24 a.m. of Resident #10's Doctor's Orders, dated 03/08/2024, revealed Resident #10 did not have physician orders that identified Resident #10 was able to leave the facility, to include the reason, medical or social, and the circumstances (i.e. alone or with family/friends). Record review on 03/08/2024 at 10:25 a.m. of Resident #10's Quarterly MDS Assessment, dated 12/10/2023, Section C- Cognitive Response Patterns revealed a BIMS score of 08, which identified moderate impairment. Section I - Active Diagnoses revealed in I8000 Resident #10 had the diagnosis of Dependence on renal dialysis. Section O - Special Treatments revealed in Section O0110 J1, Resident #10 received the treatment of Dialysis upon admission and while a resident. Section E - Behavior, E0800 revealed Resident #10 had no behaviors of rejection of care. Record review on 03/08/2024 at 10:28 a.m. of Resident 10's Smoking Assessment, dated 12/20/2023, was incomplete as the questions were not answered and the assessment was not dated and signed. Review of the Resident #10's Smoking Assessment, dated 10/06/2023, revealed Resident #10 had a minimal problem of understanding the facility policy and a minimal problem of general behavior and interpersonal interaction. Resident #10's score was a 5, which in the middle of the range of the safe smoker category. Review revealed Plan of Care section recommended to continue current care plan. Record review of Resident 10's Care Plan dated 02/02/2024, revealed the plan did not include a goal or interventions to address smoking. Resident #11 Record review on 03/14/2024 at 5:50 p.m. of Resident #11's Face Sheet, dated 03/14/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] , with diagnoses of Cerebral infarction, unspecified (stroke or not enough blood was getting through certain blood vessels in your brain and the tissue had not received enough blood causing damage); Bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Gout (happens when urate, a substance in your body, builds up and forms needle-shaped crystals in your joints), Morbid obesity (have a high body mass index and experience negative health effects due to excessive body weight), and Hypertension (when the pressure in your blood vessels is too high). Record review on 03/14/2024 at 5:53 p.m. of Resident #11's MDS Optional State Assessment, dated 12/06/2023, Section C- Cognitive Response Patterns revealed a BIMs score 15, which identified an intact cognitive response. Review of Section E - Behavior, E0800 revealed Resident #11 had no behaviors or refusals of care. Record review on 03/14/2024 at 5:55 p.m. of Resident #11's Smoking Risk Assessment, dated 09/29/2023, revealed Resident #11 had a score that identified him as Potentially Unsafe Smoker and deemed Resident #11 had the need for care plan intervention. The assessment revealed Resident #11 was assessed as a chain smoker, severe problem with providing smoking material to other residents, severe problems with begging and stealing smoking materials from other residents, and severe problem with behavior and interpersonal interaction. The assessment revealed Resident #11 continue current plan of care and follow facility policy. Record review on 03/14/2024 at 5:58 p.m. Resident #11's Care Plan, dated 03/11/2024, revealed a Problem Area included in Resident #11's Care Plan in the category of smoking, which was started 09/18/2023. The Care Plan revealed under the Category: Smoking: I am a smoker, and I am not always compliant with smoking policies. I have been found smoking in areas that are not designated smoking areas and I do not always comply with returning smoking materials. Review revealed the goal was to comply with smoking policies through the next review period. During an interview on 03/06/2024 at 6:45 p.m., Resident #1 said he could not go more than 30 minutes without smoking a cigarette. Resident #1 said the facility's smoking policy was unfair and he did not agree with the policy that he could not smoke without being supervised. Resident #1 said he signed himself out at the nurses' station, signed his name on the sign book and smoked on the east side of the building. Resident #1 said the staff that was at the nurses' station at the time he signed out would hand him a bag that contained his cigarettes and lighter and he went outside without staff to smoke. During an interview on 03/06/2024 at 7:31 p.m., Administrator F said the nursing home followed facility policy and provided supervision to the residents who were assessed as unsafe smokers. Administrator F said if a resident had a high BIMS score and was assessed as a safe smoker, the resident could sign-out on pass at the nurses' station and smoke outside unsupervised. Administrator F said the facility did not have policy that covered when residents signed out on pass to specifically smoke. During an observation on 03/07/2024 at 11:45 a.m., observed the smoking schedule posted on the door that exited out into the designated smoking area revealed smoking breaks were scheduled for 6:30 a.m., 8:30 a.m., 11:00 a.m., 1:00 p.m., 4:00 p.m., and 7:00 p.m., and were 15 minutes in length or two (2) cigarettes each time. Observed the facility's designated smoking area was located outside a door accessible from the dining room. Observed the door had opened into a secure gated area that contained a table, chairs, ashtrays, and smoking vests that hung on the wall. During an interview on 03/07/2024 at 12:05 p.m., ADON B said the facility had one designated smoking area and the designated smoking space was the area located off the dining room through a non-exit door into the secure fenced area. ADON B said the residents did not smoke outside the facility and there was not a designated smoking area on the East side of the building on the outside of the fenced in location. ADON B said the residents were provided cigarettes during designated smoking times from the staff who provided supervision and when the break was over, the residents returned the cigarettes and lighters to the staff to be secured in a plastic tote that was stored under the nurses' station. ADON B said residents who were assessed as safe smokers signed out on pass and requested cigarettes from the nurses who would get them from the plastic storage box located under the desk area in the nurses' station. ADON B said the nurse would give the resident what the resident had in the box even if it was 2 cigarettes or a pack of cigarettes. During an observation on 03/07/2024 at 12:47 p.m., observed a clear plastic storage tote under the nurses' station that was not locked or secure. Observed the storage tote was under the desk area at the front of nurses' station where the sign out book was located. Observed ADON B open the tote and remove a small tackle box that contained a vape device with three (3) bottles labeled nicotine. Observed approximately 30 large zip lock bags with residents' name written on the side that contained lighters and cigarettes or cigarette packs. During an interview on 03/07/2024 at 12:50 p.m., ADON B said the employee of the facility or person who let the resident in the door was responsible to ensure he/she returned his/her plastic bag including the lighter. ADON B said the reason Resident #1 could sign out and smoke was because Resident #1 had a high BIMS Score and was his own responsible party. During an observation on 03/07/2024 at 12:53 p.m., observed Resident #8 at the front desk, sign out on the facility sign out book, and take her cigarette and lighter from the staff behind the counter. Observed Resident #8 exit the facility and ambulate by use of her wheelchair to the east side of the facility and light her cigarette and smoke unsupervised by the telephone phone and side street. During an interview on 03/07/2024 at 1:15 p.m., DON D said the residents had a right to sign out if they had a high BIMS score and a safe smoking assessment. DON D said once a resident signed out, the facility could not stop them from smoking on the east side of the building unsupervised. DON D said the east side of the building was not a designated smoking area and was not set up to meet the facility's policy as a designated smoking area During an interview on 03/07/2024 at 1:30 p.m., Resident #8 said she knew the facility had a designated smoking area by the dining room and designated smoking break times, but she would rather sign herself out on pass and smoke. Resident #8 said she could not wait for each facility break time to smoke because she needed to smoke more often. During an interview on 03/07/2024 at 1:37 p.m., Resident #9 said he would sign himself out on pass and smoke outside the facility. Resident #9 said he did not need supervision and could push himself outside to the side of the facility because he needed to smoke several cigarettes at a time during his smoke break. During an interview on 03/07/2024 at 1:41 p.m., Hospitality Aide E said the residents that were able to independently sign out would sign out on pass and she would give them their cigarettes and lighters that were stored in a zip lock bag inside the plastic tote container. Hospitality Aide E said the residents would go outside to the east side of the building by the telephone pole and side road curb and smoke. Hospitality Aide E said the residents had to have a high BIMS score and be assessed as a safe smoker. Hospitality Aide E said she did not have a list of which residents were safe smokers and were able to sign out on pass independently. Hospitality Aide E said she had not read the smoking policy or out on pass/leave policy. During an observation on 03/07/2024 beginning at 1:48 p.m., observed Resident #1 and Resident #8 sign out on pass, receive their cigarettes from staff at nurses' station, exit the facility, and go outside to the east side of the building to smoke unsupervised in an undesignated smoking area. Observed Resident #1 was in an electric wheelchair and Resident #8 was in a manual. After smoking, observed both cross the parking lot and observed Resident #1 as he rode his chair on the side of the road next to the sidewalk and Resident #8 as she went up on the sidewalk and enter the handicap low curb. Resident #1 and Resident #8 were observed crossing the road to the sidewalk on the other side of the road at the park. Observed Resident #8 take several minutes to maneuver her wheelchair down the sidewalk as there was a sharp slope down to the picnic table. Observed Resident #9 with his family member sitting at the picnic table ahead of Resident #1 and Resident #8. Resident #9's family member was observed walking up the hill and pushed Resident #8 down to the picnic table. Observed the picnic table was approximately 30 yards from the river that had an 8 foot drop off to the water below. During a group interview on 03/07/2024 at 1:59 a.m., at the picnic table at the park across from the facility, Resident #9's family member said Residents #1, #8, and #9 came to the park just about every day. Resident #1 said prior to the first of February, Residents #1, #8, and #9 smoked whenever they wanted to in the designated facility smoking area. Resident #1 said he was assessed by the fact that if he could get out the door, he did not need supervision. Resident #9 said he had never been assessed for smoking. Resident #1 said prior to the first of February, the group could smoke whenever they wanted to in the facility's designated smoking area unsupervised. Resident #9 said he came to park when his family member could push him over because Resident #9 said he was not strong enough to push himself in his wheelchair by himself all the way across the street, down the hill, and to the picnic tables. Resident #9 said he would sign himself out on pass and smoke on the side of the facility when his family member was not at the facility. Resident #1 said prior to first of February, he kept his cigarettes and lighter with him in his room. Resident #8 said she kept her cigarettes and lighter in her room as well and no one asked Resident #8 to turn her lighter in when Resident #8 came in from pass. Resident #8 said she could not go two (2) or three (3) hours without smoking a cigarette and Resident #8 said the smoking policy should only apply to residents who were unsafe smokers. During an interview on 03/07/2024 at 3:27 p.m., Administrator F said residents were deemed able to sign out of the facility and smoke based on a high BIMs score and if a smoking assessment revealed the resident was a safe smoker. Administrator F said the east side of the building was not a designated smoking area, but the residents smoked in the space when signed out on pass from the facility. During an interview on 03/07/2024 at 4:06 p.m., Social Worker I said she attempted to complete a smoking assessment with Resident #1 on 02/13/20/24. Social Worker I said Resident #1 told her he did not smoke so she did not complete the assessment. Social Worker I said she had not assessed or attempted to assess Resident #9 after learning he was a smoker. During an observation on 03/08/2024 at 8:55 a.m., observed Resident #1 and Resident #10 outside smoking on the east side of the facility unsupervised in an undesignated smoking area. Observed Resident #1 and #10 ambulated by wheelchairs and sat next to a side street by a telephone pole. During an observation on 03/13/2024 at 8:29 a.m., Resident #1 was observed outside sitting in his wheelchair and smoking on the east side of the facility unsupervised in an undesignated smoking area. Observed Resident #1 sitting by a telephone pole and dry grass next to the pole. No ashtrays present. During an observation on 03/13/2024 at 9:15 a.m., observed Resident #11 walk by the nurses' station with the assistance of a rolling walker with a cigarette tucked behind his left ear. During an interview and observation on 03/13/2024 at 9:52 a.m., Resident #11 said he was a smoker and smoked outside in the designated smoking area. Resident #11 said he would rather not answer the question of where he kept his cigarettes or where he was supposed to keep his smoking supplies. Observed a cigarette behind his left ear. During an interview on 03/13/2024 at 10:10 a.m., Administrator F said all resident smoking materials had to be kept stored in a central place and none was allowed in the residents' rooms or on their person. Administrator F said she was not sure why Resident #11 had cigarettes in his room, but she went down and talked to Resident #11, and he gave her three (3) cigarettes he had in his room. Observed Administrator F with three (3) cigarettes in her hand. During an interview and observation on 03/13/2024 at 2:15 p.m., observed Resident #1 and Resident #9 outside sitting in their wheelchairs and smoking on the east side of the facility unsupervised in an undesignated smoking area. During an interview on 03/15/2024 at 12:57 p.m., Administrator F said the facility smoking policy was necessary and should be enforced for the residents' safety. Administrator F said she realized changes to the process were needed in the smoking assessments and how they were completed did not meet her expectations. During an interview on 03/25/2024 at 8:02 a.m., DON D said the residents who were smokers and who checked out on pass to smoke at the side of the building were violating the facility smoking policy. DON D said the residents were at risk smoking near the building if the cigarette was not extinguished properly. DON D said the residents who smoke had be in-serviced and educated on 03/14/2024 on the dos and don'ts of the smoking policy and had been informed that the only designated area for smoking was the facility patio. During an observation on 03/25/2024 at 10:42 p.m., revealed Resident #1 smoking outside unsupervised approximately 10 feet from a parked car. Resident #1 turned his wheelchair with his back facing the building near the exit of Hall A and was observed with a lit cigarette in his hand. Observed Residents #8 and #9 come out of the facility and join Resident #1 to form a circle and smoke. On 03/27/2024 @8:33 a.m., Resident #1 was [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to provide basic life support, including CPR to a resident requiring such emergency care and subject to related physician orders and the resident's advance directives for 1 (Resident #1) of 9 residents reviewed for CPR, in that; The facility failed to ensure Resident #1 received life saving measures including CPR (Cardiopulmonary Resuscitation) when she was found unresponsive on [DATE]. The non-compliance was identified as past non-compliance. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began. This failure could place residents at risk of not receiving life saving measures including CPR and could lead to death. The findings included: Record review of Resident #1's face sheet dated [DATE] revealed an admission date of [DATE] with diagnoses which included: unspecified dementia, psychotic disturbance, multiple rib fractures, unspecified side, chronic pain syndrome, weakness, chronic kidney disease, stage 3b, and congestive heart failure. Record review of Resident #1's physician orders revealed an order for Code status: Full Code dated [DATE] placed into the electronic medical record and signed by facility Medical Director. Record review of Resident #1's care plan dated [DATE] revealed The Resident and/or Responsible Party will communicate their wishes regarding Advanced Directives/Advance Care Planning and facility staff will honor their stated preferences with interventions which included: Full Code. Record review of Resident #1's progress note dated [DATE] written by LVN A revealed: Resident #1 was climbing out of bed, pulling off O2 tubing, restless and anxious. LVN A documented administration of Ativan and Lortab at 06:30 a.m. LVN A documented at 0730 a.m., Resident #1 was found deceased . Record review of Resident #1's progress note dated [DATE] at 9:15 a.m., revealed: RN C documented end of life care for Resident #1 provided by hospice and staff. Attempts were made to contact family but no answer. During an interview on [DATE] at 8:00 a.m., the Interim Administrator stated he had only been working at the facility since [DATE] (3 days). During an interview on [DATE] at 9:40 a.m., CNA A stated she was working on the day Resident #1 expired. CNA A stated when she was completing her rounds around 6:00 a.m. Resident #1 was lying peacefully then a little bit later, she noticed Resident #1's feet were off of the bed, and she was touching her face. CNA A asked Resident #1 if she was hurting and she nodded her head, so she went to get the nurse. CNA A reports the night nurse (RN A) stated Resident #1 slept well during the night. CNA A reports she went back to the room later and gave Resident #1 her breakfast and a drink of water. CNA A returned a little later and changed Resident #1's top as her back was sweaty. CNA A reports that she was documenting in Point of Care when she heard the nurse say Resident #1 expired. During an interview on [DATE] at 11:07 a.m., CMA A stated she was working on halls D, C and ½ of B the day Resident #1 expired. CMA A stated, LVN A went to see Resident #1 upon notification and that she was her patient in the past. CMA A stated CNA B informed both she and LVN A she was unresponsive around 7:30 a.m. CMA A was able to identify the process for checking a resident's code status by looking in the Kiosk and the crash cart list. During an interview on [DATE] at 11:30 a.m., CNA B stated she was working with Resident #1 on [DATE] and went into her room and saw her leaning on the right side of her pillow looking up toward the light. CNA B stated she did not see Resident #1's chest move with breathing, and she did not respond to CNA B. CNA B was unable to report an approximate time of her observation. CNA B stated she immediately reported this to LVN A. CNA B was able to state to surveyor how to find a resident's code status by looking in the Kiosk. CNA B stated the nurses and the DON will tell you who has a DNR versus who is a full code. During a phone interview on [DATE] at 12:12 p.m., LVN A stated she was working with Resident #1 on [DATE]. LVN A stated she thought because Resident #1 was on Hospice, she had an Out of Hospice Do Not Resuscitate Order. LVN A stated when she reported for duty on [DATE] at 06:00 a.m., the report she received from RN A was Resident #1 was calm and slept well. LVN A stated about 15 minutes later CNA A reported Resident #1 was restless and taking off her oxygen. LVN A stated she administered Ativan and Lortab for pain at 06:30 a.m. as ordered and a little later (7:25 a.m.), administered Morphine Sulfate sublingual as ordered because her assessment reflected, she was still hurting. LVN A reported she notified Hospice (unsure of time) because Resident #1 was not doing good and getting worse. LVN A reported going back into Resident #1's room after being informed by CNA B that she was unresponsive. LVN A reported she went into Resident #1's room observed she had expired around 07:30 a.m. prior to Hospice arrival. LVN A stated she did not take any vital signs or document any assessment including ones prior to finding the resident unresponsive. LVN A stated she was in a hurry. LVN A stated she was not trained on Hospice protocols. LVN A stated when the Hospice nurse came to the facility after 08:00 a.m., she told me Resident #1 was a full code. A review of LVN A's CPR certification revealed she had Basic Life Provider Certification in accordance with the cirriculum of the American Heart Association and did not expire until [DATE]. During an interview on [DATE] at 12:56 a.m., ADON stated she worked the 2 p.m. to 10 p.m. shift on the day Resident #1 expired. The ADON stated she was aware Resident #1 had an order for a full code even though she was receiving services from a local hospice. The ADON stated the residents code status is on the MAR and also posted on the dashboard. The ADON stated you can confirm a resident's code status by checking the dashboard which is uploaded by the DON. During an interview on [DATE] at 1:29 p.m., the DON stated on [DATE], the Regional Nurse Consultant called her and said Resident #1 had passed (expired). The DON started working at the facility [DATE]. The DON stated she was not aware of Resident #1's code status prior to her passing but she knows now. The DON stated she arrived at the facility on [DATE] after notification and began training on facility policy and procedures including a mock CPR drill. The DON stated she would be responsible for notifying staff of code status including who has a DNR. She stated a resident's code status is placed on the 24-hour report, crash cart list and by each nurse's station. She stated she uploads the information into the electronic health record (Matrix) and staff have easy access to Matrix. During an interview on [DATE] at 2:26 p.m., LVN B stated she received a call from the triage nurse who reported Resident #1 expired on [DATE] at 7:20 a.m. LVN B stated she arrived at the facility at 8:08 a.m. and asked LVN A if she initiated CPR as Resident #1 was a full code. LVN A informed LVN B she did not realize Resident #1 was a full code. LVN B notified the Hospice Medical Director at 8:09 a.m. Resident #1 was pronounced expired at 8:11 a.m. by the Hospice Medical Director. At the direction of the Regional Nurse Consultant, LVN B reported she called a local funeral home to pick up Resident #1 at 8:16 a.m. Resident #1 was taken by funeral home at approximately 9:13 a.m. During an interview on [DATE] at 4:08 p.m., the Lead [NAME] President of Operations (who acquired facility [DATE]) stated there is a code status present for each resident in Matrix (electronic health record) and also present on a list attached to the Crash Cart. She said she was notified on [DATE] along with the Clinical Resource Nurse regarding Resident #1 expiring without CPR and having a full code status. She stated the facility corrective actions on [DATE] included LVN A was placed on administrative leave pending investigation, a mock CPR drill conducted on [DATE], training on Abuse, Neglect, Exploitation, Emergency Management Code Procedure, a DNR audit reviewing the physician orders for DNR/Full code status to ensure it was set up correctly in Matrix, Crash Cart notebook with resident names who have a DNR versus those who are full codes, and audit of orders to care plans to face sheets for code status and lastly an ad hoc QAPI meeting including the Medical Director with regards to the deficient practice. During an interview on [DATE] at 5:16 p.m., RN A stated Resident #1 slept well the night of [DATE]. RN A stated one of the aides asked them to check on Resident #1 while they were conducting shift counts as she was hurting and needing pain medication. RN A stated LVN A went to check on Resident #1. RN A stated that she knew Resident #1 was a full code before hospice but not after until she received the training. RN A stated she knew to look on the MAR and in the record for code status. RN A could confirm the process of a resident's code status during an emergency. RN A stated there was also a code status list on the crash cart. During an interview on [DATE] at 9:40 a.m., RN B stated she admitted Resident #1 to a local hospice on [DATE], with a diagnosis of heart failure and chronic kidney disease. RN B stated Resident #1 did not have any family involvement. RN B stated when residents get placed on services, they are asked if they would like a DNR and Resident #1 chose to remain a full code. RN B stated when nurses go in for routine visits, residents are asked if they would like to remain a full code status. This continued to be Resident #1's choice and was documented with each hospice visit. During an interview on [DATE] at 10:20 a.m., the Medical Director for a local hospice stated he did receive a call from a staff member about Resident #1 expiring. He stated he was aware Resident #1 was a full code and the facility should have called 911. During an interview on [DATE] at 11:54 a.m., the facility Medical Director stated he had been notified of the incident involving Resident #1. He stated he attended the ad hoc QA meeting held by the facility addressing this issue. Others in attendance included the DON, ADON, and Regional Nurse Consultant. The Medical Director stated he recommends starting CPR and calling 911 on residents who are designated as a full code. During an interview on [DATE] at 1:26 p.m., the Regional Nurse Consultant stated the facility requires 2 or more staff to be certified in CPR per shift. On [DATE] there were over 4 CPR certified staff including 3 licensed staff. During interviews on [DATE] from 8:46 a.m. to 5:45 p.m. of licensed staff including 2 RN's and 2 LVN's (DON, RN A, ADON, LVN C) verified they had received in-service training in cardiopulmonary resuscitation, location of DNR and code status, and abuse/neglect. Record review of an Ad Hoc QAPI Code Status document dated [DATE] revealed: Problem Area Identified: Emergency procedures for Cardiopulmonary resuscitation. CPR Baseline: The facility audited for all Code status of current residents. Allowable deviation: There will not be an allowable deviation. Changes Implemented to reach Baseline: Lack of education, training, and leadership. In-services are being completed to obtain a baseline. Impact of change: Successful implementation of changes noted above. Baseline attained on (Date): [DATE] Implementation change did not reach baseline. Continue change for 30 more days to allow additional time for staff to comply with new system. New changes or modifications will be implemented and tested for 30 days to bring measured activity to baseline. Subcommittee will report to QAPI every month regarding movement toward baseline. Record review and observation of Code Status lists by all 3 nurses station computers and at the crash cart revealed all lists were current and reflecting accurate advance directives (Full Code versus Do Not Resuscitate) associated with each resident name. Record review and observation on [DATE], of an in-service training, titled Emergency Procedure-CPR dated [DATE] with attached Emergency Procedures Cardiopulmonary Resuscitation policy revealed 16 licensed staff had signed the training document. Record review of an in-service training, titled Code Blue/Medical Emergency Practice Drill dated [DATE] with attached Code Blue/Medical Emergency Practice Drill checklist revealed 4 licensed staff had participated in the mock drill on A Hall and at the Nurses' Station. Record review of an in-service training, titled Emergency Management Code Procedure dated [DATE] with attached Emergency Management Codes and Procedures policy revealed 16 licensed staff had signed the training document. Record review of an in-service training, titled Abuse Neglect and Exploitation dated [DATE] with attachment Abuse Neglect and Exploitation policy revealed 16 licensed staff had received training and signed the training document. Record review of a facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation revised [DATE] revealed: 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis). 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or physician's order not to administer CPR. Record review of a facility policy titled Patient Advanced Directives (undated) revealed: The facility will be compliant with the Patient Self-Determination Act (PSDA). We will encourage all patients to make choices and decisions about types and extent of medical care they want to accept, or refuse should they become unable to make decisions due to illness. Staff responsible for patients' care should be made familiar with the contents and requirements of a patients' advance directive. The provision of this information on advance directives, and any provider-patient discussion concerning advance directives, also should be documented in the medical record. The Administrator was notified of the IT on [DATE] at 4:12 pm. The IT Template was provided at that time. Record review of Plan of Removal provided by Regional Nurse Consultant revealed: 1. Immediate Action: LVN was suspended pending investigation. MD and RP of Resident #6858-01 notified. Person Responsible: Director Of Nursing Date: [DATE] @ or by 12 noon 2. Identification Action: All residents received an order, to care plan, to face sheet audit of their Code Status. No discrepancies noted. Person Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: [DATE] @ or by 6 p.m. 3. Identification Action: Audited the DNR Book (Do Not Resuscitate) to ensure it is current with the upmost updated status of our resident population. (Crash Cart and Nurses Station) Person Responsible: Director Of Nursing, Assistant Director of Nursing, and/or Designee Date: [DATE] @ or by 6 p.m. 4. Preventative Action: Audited employee CPR cards to ensure an adequate number of certified employees each shift Person Responsible: Human Resources, Director Of Nursing, and/or Designee Date: [DATE] @ or by 6 p.m. 5. Preventative Action: Education provided to nursing staff related to Code Status, Initiating CPR for Full-Codes, and Location of the DNRs/Code Statuses. Person Responsible: Human Resources, Director Of Nursing, and/or Designee Date: [DATE] @ or by 6 p.m. 6. Systematic Change Action: New admission and residents with a change in code status will be reviewed in daily meeting/clinical meeting to ensure the chart reflects the appropriate code status. Person Responsible: Director Of Nursing, and/or Assistant Director of Nursing Date: [DATE] @ or by 10 a.m. 7. QA Action: Ad hoc AQPI performed with Medical Director reviewing the deficient practice/template and the plan to correct. Person Responsible: Administrator Date: [DATE] 10:00 a.m. On [DATE] at 4:12 p.m. the Administrator, DON, and Regional Nurse Consultant were informed of the IJ. The non-compliance was identified as past non-compliance. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began.