**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** HARM 9. Resident 47 was admitted to the facility on [DATE] with diagnoses that included but not limited to spina bifida, type two diabetes mellitus with hyperglycemia, muscle weakness, bladder disorder, anxiety disorder, chronic pain, essential hypertension and a colostomy. On 2/6/23 at 12:31 PM, an interview was conducted with resident 47. Resident 47 stated he fell from his wheel chair onto his buttocks when he was transported to this doctor's appointment. Resident 47 stated he fell in the van right before his doctor's appointment. Resident 47 stated it happened because his seat belt was not secured properly. Resident 47 stated he had a new driver that day and they were aware on how to secure his wheelchair in the van and tighten his seat belt. Resident 47 stated that on his way to the appointment, he kept slipping out of his wheelchair every time the driver had to brake. Resident 47 stated when they made it to his doctor's appointment, he fell out of his wheelchair and had to have paramedics lift him back into it. Resident 47 stated he received a skin tear on his buttocks from the fall. Resident 47 stated the transport driver only notified the transport company about his fall and did not notify facility staff about the fall. Resident 47 stated he had to tell his nurse what happened to him. Resident 47's medical record was reviewed on 2/7/23 A Quarterly MDS assessment dated [DATE] documented resident 47 was total 2 person physical assist for transfers and bed mobility. Nursing progress notes documented the following: a. Nursing note on 1/24/23 documented that resident 47 was a total dependent 2 person assist with mechanical life transfer and was an extensive 1 person assist with all other activities of daily living (ADLs). b. Nursing note on 2/1/23 stated, Resident states that he was sitting in the van in his wheelchair and the driver pushed on her brakes and he slid out of his chair onto the van floor. Therapist at appointment tried to help him up and ended up having to call EMS [Emergency Medical Services] to get him up and in his chair. He states that he did not hit his head. The transportation company was called and waiting for driver to call and give us report on the fall and what had happened. This was not reported to the facility when he was transported back after appt [appointment]. Resident is the one that told staff he had a fall. Skin check complete. Resident stated that he feel [sic] on his buttocks. Increased blood on bandages from wound. Wound nurse was notified and talked with resident. He denies increased generalized pain. No areas of concerns on complete skin check. Will continue to monitor for bruising or increased pain. Full body assessment completed with no areas of concerns. No abrasions, redness, bruising and/or new open areas noted on assessment. He denies pain at the time of assessment. ROM [range of motion] is baseline for him. Frequent checks initiated. Increased monitoring for 72 hours initiated. Frequent checks and rounds to ensure resident is getting his needs met. MD/NP [medical doctor/nurse practitioner] notified and DON. Resident states that he does not want a phone call to his emergency contact. He states that he will notify her at his convenience. Transportation company called to get statement from driver. [Name of hospital omitted] called to see if they were aware of the fall and did not report. Called and messages left. We will continue to follow up. c. Nursing note on 2/2/23 stated, Fall increased tissue damage to wound on buttocks. Increased size of wound, very red and swollen with new areas of open skin. Wound nurse was notified to ensure proper orders are in place. Will get proper measurements when able to assess. Increased pain to site. PRN [as needed] oxycodone 5mg [milligrams] Q4 hours given with good result. Wound care completed new dressing in place. d. Nursing note on 2/3/23 stated, Transportation company called to get statement from the staff member on the event from 2/1/23 when [resident 47's name omitted] fell from wheelchair due to not being properly strapped in the transportation vehicle. Transportation company states they will have a statement from driver faxed to the facility. Requested that the company also send us proper education with the driver to ensure residents are always properly secured in the vehicle during transport. No incident report regarding resident 47's fall during transport was located. On 2/7/23 at 12:43 PM, an interview was conducted with the Wound Care Nurse (WCN). The WCN stated resident 47's buttocks wound was assessed at the clinic right after he had fallen. The WCN stated that resident 47 had not allowed her to check his wounds when he arrived to the facility after the fall. The WCN stated she assessed his wounds yesterday and they looked better than what was described to her. The WCN stated resident 47 skin was very fragile and due to the trauma of the fall, resident 47 developed a skin tear on his left thigh and buttocks. On 2/8/23 at 1:05 PM, an interview was conducted with the Transportation Driver (TD). The TD stated he was not the driver that day but knew what had happened. The TD stated the driver had noticed that resident 47 had the hoyer sheet underneath and believed that was what made resident slide off of his wheelchair and fall. The TD stated resident 47 was not strong enough to hold himself onto the chair with the hoyer sheet underneath him. The TD stated the facility had forgotten to remove the hoyer sheet from underneath resident 47. The TD stated the facility either applied something in between the hoyer sheet and the wheel chair to provide more traction for the resident or removed the hoyer sheet from underneath the resident. The TD stated that resident 47 slid down his wheelchair with every bump and stop made along the way to his doctor's appointment. The TD stated that resident 47's driver had asked him if he wanted to stop along the way to be repositioned but resident 47 insisted, they continued to drive straight there. The TD stated when the driver arrived to the clinic, they noticed resident 47 was barely holding on to his wheelchair and attempted to reposition him but was unable to. The TD stated they had four buckles that were attached to wheelchair and one buckle that goes across the resident's waist when they were secured in the transportation van. The TD stated resident 47 had all the seat belts secured but he slid off. The TD stated that the waist was not able to be tightened. The TD stated the waist seat belt needed to go in between the wheelchair armrest and with resident 47 there was a gap in between the seat belt and the resident 47's waist. The TD stated the waist seat belt was secured above the armrest and not in between them. The TD stated that was why resident 47 fell out of his wheelchair. The TD stated resident 47 slide out of his chair when his waist seat belt was unbuckled. The TD stated the driver had to unbuckle resident 47 because he was no longer seated upright in the wheelchair and the choking risk the seatbelt presented to resident 47. The TD stated the driver had to call additional people to help put resident 47 back on his wheelchair after he fell on the floor. The TD stated the driver was not aware it was unsafe to transport a resident with just a hoyer sheet on the wheelchair because of the potential sliding hazard it presented to the resident. The TD stated staff should have communicated with the driver to have prevented the incident with resident 47. The TD stated the driver's responsibility was to drive resident 47 to his appointment. The TD stated the facility was responsible for the resident's safety. The TD stated the facility had not kept resident 47 safe since they had not applied a cushion in between the hoyer sheet and the wheel chair. The TD stated that resident 47 scratched his bed sore due to the fall and caused him to bleed. The TD stated he was unsure if the driver had told the facility nurse about resident 47 incident when they arrived back to the facility. On 2/8/23 at 2:52 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated usually the person who had done the transport found the nurse and gave them a packet and reported if anything happened. RN 1 stated that day, the transporter just dropped resident 47 off in his room and had not told staff about what had occurred. RN 1 stated that resident 47 was the one to tell her of his fall. RN 1 stated once she found out, she tried to call the transportation company to obtain a statement from them of what happened to resident 47. RN 1 stated she wanted to make sure the transportation company provided education to their employees so residents were safe for future transports. RN 1 stated that they had used an outside transportation company for resident 47 that day since they were unable to use their own transportation staff member. RN 1 stated that resident 47 obtained a new skin tear from his fall. RN 1 stated when they assessed his buttocks wounds, they had increased bleeding but resident 47 denied any increased pain. RN 1 stated they offered resident 47 pain medications but stated he did not take any. On 2/13/23 at 2:16 PM, an interview was conducted with the ADM and the DON. The ADM and DON stated they were aware that resident 47 had fallen during his transport a couple of weeks ago. The ADM and DON stated they had called the transportation company to provide them education on patient safety throughout the transport process but stated they had not heard anything back from the transportation company. The DON stated they had not done an incident report since resident 47 had not fallen in the facility. The DON stated the transport company needed to do an incident report since the fall happened during the transport. 7. Resident 231 was admitted on [DATE] with diagnoses that included sepsis, gangrene, non-pressure chronic ulcer of foot with necrosis, acquired absence of foot right and left, paranoid schizophrenia, anxiety disorder, stimulant abuse, homelessness, protein-calorie malnutrition, alcohol abuse, tobacco use, and major depressive disorder. A Smokerlist [sic] was provided by the facility. Resident 231 was on the list. On 2/8/23 resident 231 refused to be interviewed. Resident 231's medical record was reviewed. An MDS admission assessment dated [DATE] revealed that resident 231 had a BIMS score of 15, which would indicate that the resident was cognitively intact. The assessment also revealed that resident 231 required one person physical assistance when moving to and returning from off-unit locations. A smoking safety evaluation dated 1/28/23 revealed that resident 231 demonstrated one or more of the following cognitive impairments: Poor safety awareness impaired short-term memory, impulsiveness. The evaluation scoring section documented that resident 231 may smoke independently. The evaluation was incomplete and did not confirm that resident 231 had been deemed independent with smoking or safely have smoking paraphernalia on person. Additional documentation stated, Pt unable to care for herself properly prior to admission-infection of post metatarsal amputation bilateral feet. Needs further eval [evaluation] concerning smoking at this time. Resident 231's care plan dated 2/6/23, revealed that [resident's name] uses tobacco smokes: cigarettes. Interventions included: a. Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. b. Notify charge nurse immediately if it is suspected resident has violated smoking policy. c. The resident can smoke UNSUPERVISED. Resident 231 had an updated smoking assessment completed on 2/10/23. The assessment included Resident demonstrates one or more of the following cognitive impairments: Poor safety awareness, impaired short-term memory, and impulsiveness. Also included was Resident has a history of unsafe smoking practices. The evaluation scoring was marked as Resident is unable to smoke independently. Resident requires supervision while smoking. Care plan required. Review for need of behavioral program. Completion of Risk vs. Benefits needed. Provide and document education for identified safety needs. The resident was then evaluated as resident has been deemed independent with smoking and can safely have smoking paraphernalia on person. Additional documentation included, Patient has paranoid schizophrenia with impulsiveness. On assessment patient demonstrates safe smoking practices and the ability to follow smoking rules and be an independent smoker. On 2/8/23 at 2:22 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated when he conducted an admission assessment, he used the standard admission documents to assess a resident. RN 3 stated he did the smoking evaluation and if the resident was a smoker, he would pull up a pre-populated form and ask the residents questions. RN 3 stated based on that smoking assessment, interventions would be added for how the resident could smoke safely or not smoke. RN 3 stated if the assessment, which was based on a point system, had anything above a zero score, the resident required assistance to smoke. RN 3 stated things that would indicate the need for supervision included impaired orientation, neuropathy, cognitive impairment, short term memory loss, and non-compliance. On 2/8/23 at 3:53 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated resident 231 had smoking materials at the nurse's station. LPN 3 stated resident 231 could get cigarettes from other people and she thinks they do that quite a bit. LPN 3 stated staff took residents out sometimes so they could watch residents. LPN 3 stated any staff member could go out with residents to smoke. LPN 3 stated the residents know if they need help, they will ask to go out and smoke. Residents ask all day long if they can go out. LPN 3 stated if she was unable to go out with a resident or it was not a smoking time the resident will have to wait. Regarding how staff knew which resident's needed assistance while smoking, LPN 3 stated the residents know if they need help. On 2/11/23 at 3:48 PM, an interview was conducted with LPN 2. LPN 2 stated a binder had been placed at every nurse's station. LPN 2 stated the residents information in the binder was for residents who were not independent smokers. LPN 2 stated smoking times smoking times remained at 9, 1, 4 and 8. On 2/11/23 at 3:56 PM, an observation was made at the doorway leading to the smoking area. New signage had been posted stated No oxygen outside in smoking area. Another sign stated Do not assist any smokers unless the nurse is notified first. On 2/13/22 at 8:32 AM, an interview was conducted with the Director of Nursing (DON). The DON stated she was unaware that resident 231 had a history of unsafe smoking practices. The DON stated if something specific was noted, it could be added to the resident's care plan. The DON stated she would find out who completed resident 231's most current smoking evaluation and clarify the documentation, but the information was never provided. 8. Resident 77 was admitted to the facility on [DATE] with diagnoses that included but not limited to aftercare following joint replacement surgery, unspecified fracture of right femur, age-related osteoporosis with current pathological fracture, presence of right artificial hip joint, chronic obstructive pulmonary disease, difficulty in walking, muscle weakness and history of falling. On 2/8/23 at 2:35 PM, an interview was conducted with resident 77. Resident 77 stated since he had been here, he had only smoked twice. Resident 77 stated the he had not smoked because of his throat problems. Resident 77 stated he has tried to quit smoking for 35 years. Resident 77 stated he kept his smoking supplies with him and had a couple of cigarettes in his pocket. Resident 77 stated staff only helped him light his cigarettes. Resident 77 stated when he did smoke, he turned his oxygen off and stated that the designated smoking times did not apply to him. Resident 77 stated this was a rehab and not a jail and he did not want to be controlled. Resident 77 stated a lot of residents were going to be pissed off if the smoking policy was changed. A Smokerlist [sic] was provided by the facility. Resident 77 was on the list. Resident 77's medical records were reviewed on 2/22/23 A smoking care plan was not located for resident 77. An admission MDS assessment dated [DATE] documented that resident 77 was a one person limited assist. A smoking safety evaluation dated 2/1/23 documented resident 77 as a smoker and had scored a 0 which deemed he was safe to smoke independently. The smoking safety evaluation stated that resident 77 was safe to smoke unsupervised and was allowed to keep his smoking paraphernalia with him. An updated smoking safety evaluation dated 2/9/23 documented resident 77 needed assistance coming in and out of the building for smoking with staff assistance. In the smoking safety assessment section documented that resident 77 had a diagnosis of neuropathy or other neurological impairment. That documented diagnosis gave resident 77 a score of 1 point. The evaluation section which added up the scoring documented that resident 77 had scored 0 points which stated a resident can smoke independently. On 2/9/23 at 8:47 AM, an interview was conducted with CNA 5. CNA 5 stated that resident 77 required stand by or limited assistance depending on his strength when he walked. CNA 5 stated they had to watch resident 77 transfer because he was shaky at times. CNA 5 stated they were not aware that resident 77 was a smoker. A form titled Assisted Smoking Times: was observed throughout the facility and was provided upon entrance. The times were listed as 9:00 AM, 1300 with hand written 1:00 PM, 1600 with hand written 4:00 PM, and 2000 with hand written 9:00 PM. It should be noted that 2000 was 8:00 PM. The facility Policy/Procedure - Nursing Administration for smoking adopted 10/2017 revealed the following: Purpose: To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. It is also the objective of this policy to communicate to each resident/POA (Power of Attorney) that they are responsible for following each rule and on-going compliance with the Resident Smoking Policy. Policy: It is the policy of this facility to ensure smoking policies and procedures have not been established to restrict any residents' right to smoke. Our policies have been developed as a matter of health and safety to all our residents, staff and visitors. All smoking will occur in a designated smoking area at designated times. All resident who desire to smoke will be evaluated to see if they can do so safely. A Smoking Behavior Contract must be completed, signed and followed by each resident/POA who smokes. Noncompliance with the Smoking Behavior Contract and this Resident Smoking Policy will be taken seriously with appropriate facility response to violation of this policy up to including involuntary discharge of the individual violating the terms and conditions of the Resident Smoking Policy and Smoking Behavior Contract. Notice of Smoking Policy 1. At the time of admission each resident and legal representative shall be informed of and receive a written copy of the facility's Resident Smoking Policy. 2. Each resident who desires to smoke shall receive and have explained the Smoking Behavior Contract. The resident/POA is required to complete, sign and follow the Smoking Behavior Contract. Smoking safety - Resident Assessment 1. Resident who desire to smoke will be assessed using a smoking risk assessment (see separate document) for their ability to smoke safely at the time of admission, quarterly and at the time any condition or behavioral change impacts their ability to smoke safely. 2. The smoking risk assessment score serves as guideline to the interdisciplinary team who are responsible for using this information, as well as other information, to make a recommendation regarding the amount of assistance that a resident requires to smoke safely. A plan of care shall be developed consistent with the resident's smoking risk assessment. 3. Residents who are determined by the interdisciplinary team as safe for independent smoking will request smoking materials when desiring to smoke and are required to return them upon completion of the smoking session. Residents assessed as independent smokers may only smoke in designated smoking areas when choosing to smoke on facility premises. 4. Residents who are determined by the interdisciplinary team as needing supervision will be within eyesight of facility staff, family, or other resident representative during the time of the smoking session. 5. Residents who are determined by the interdisciplinary team as needing assistance with smoking will receive assistance from facility staff, family or other resident representative. Smoking Safety - General Guidelines 1. Smoking is only allowed in designated area(s) established by management. The facility's designated smoking area is: ___________________________________. 2. The designated smoking area shall be maintained with appropriate safety devices including, but no limited to, available smoking aprons, extinguishing blanket or fire extinguisher, and ashtrays made of noncombustible material and safe design. Metal containers with self-closing covers into which ashtrays can be emptied shall be readily available. 3. Oxygen use is prohibited in smoking areas for the safety of all parties at smoking times. No resident may smoke near/around oxygen. 4. Smoking for residents assessed as unsafe for independent smoking is only allowed during designated times in the designated smoking area(s). The facility's designated smoking times shall be posted in public view. Residents will be informed of any changes in regularly scheduled smoking times through the Resident Council. 5. Residents assessed as independent smokers may only smoke in designated smoking area(s) when choosing to smoke on facility premises. 6. Residents assessed as independent smokers, who choose to leave the facility premises to smoke, must sign themselves out. 7. Facility staff will be present in the designated smoking area during designated smoking times to supervise and assist those residents requiring this according to their plan of care. 8. Facility staff is prohibited from smoking when assigned to be present for a designated smoking time for the residents. 9. Reasonable accommodations for residents who wish to smoke and who require supervision and/or assistance will be made based on available resources and, in no case, will resident care be jeopardized in order to provide supervised smoking. 10. Residents who desire to smoke may not keep smoking related materials (i.e., cigarettes, cigars, pipes, tobacco, lighter, lighter fluid, matches, etc) in their possession. Smoking materials must be given to the nurse for safekeeping and stored by staff at the time of admission, when purchased by the resident, and/or received from family or other visitors. 11. Residents should not give away, sell, share or trade smoking materials due to resident safety concerns. 12. 13. The facility staff has the right to temporarily suspend all residents' smoking privileges if there are unsafe weather conditions. 14 . Smoking Safety - Resident Noncompliance/Unsafe Conditions Individuals who are noncompliant, potentially dangerous, exercise poor judgement and show a lack of concern for the welfare of others will be counseled according to the Smoking Behavior Contract. Smoking privileges will be suspended or revoked if there is a pattern of persistent, hazardous behavior. The following behaviors and/or conditions may restrict, suspend, cause revocation of resident's smoking privileges (1st and 2nd offenses) and/or results in an Involuntary discharge: 1. Smoking in an non-designated area, such as resident rooms, bathrooms, hallways, elevators, stairways and/or smoke-free courtyard. 2. Cognitive impairment, poor judgement, compromised manual dexterity and/or mobility. 3. Self-harmful behaviors, such as burning clothing, hands, fingers, face or lips. This category including residents who are generally 'careless' while smoking and may present a significant risk of fire setting. If needed, a risk vs. benefits will be done. 4. Short attention span, poor safety awareness, wandering/pacing and becoming easily distracted making smoking dangerous for the individual and those are him/her. 5. Inconsiderate behaviors such as not respecting the right of others while smoking. 6. Engaging in any type of trading/bartering/begging/panhandling or other behaviors deemed unsafe by facility staff. Consequences/ corrective action for noncompliance and/or unsafe conditions: 1. Residents/POA will be instructed and educated in regards to the facility Resident Smoking Policy via the Smoking Behavior Contract. 2. Incidents of noncompliance will follow the Smoking Behavior contract (see separate document). 3. Behavior determined to be potentially harmful may jeopardize the person's ability to remain in health care facility. The facilty may exercise its right to involuntarily discharge such individuals. 4. The facility recognizes the potential harm that may result from careless, hazardous smoking and has implemented this policy to maintain a safe living environment. Violation of this policy will be taken seriously and appropriate action will be forthcoming from facility management. Smoking Safety - Periodic checks for smoking articles 1. The facility shall have the authority to make periodic checks to determine if residents who smoke have any smoking articles that are in violation of the Resident Smoking Policy. 2. Articles found should be given to the on-duty nurse who in turn will store them for the resident and shall make appropriate documentation in the resident's medical record of such articles found. Based on observation, interview, and record review it was determined, for 9 out of 41 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident received second degree burns to the face, scapula area, and thigh when his oxygen cannula ignited while smoking a cigarette unsupervised. Additionally, multiple residents who were identified as requiring staff supervision while smoking were observed smoking without staff present, and residents were not assessed for their smoking assistance/supervision needs. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Another resident sustained a skin tear when he was not secured in the transportation van. This example was cited at a harm level. Resident identifiers: 4, 17, 18, 47, 56, 77, 134, 181, and 231. NOTICE On 2/9/23 at 2:00 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s); evaluate and analyze the hazard(s) and risk(s); implement interventions to reduce hazard(s) and risk(s); and monitor for effectiveness and modify the interventions when necessary. Specifically, the facility failed to ensure that residents were evaluated for smoking safety, that interventions were identified, and that monitoring for safe smoking was implemented. Notice of the IJ was given verbally to the facility Administrator (ADM), Director of Nursing (DON), and the Corporate Resource Nurse (CRN), and they were informed of the findings of IJ pertaining to F689 for residents 4, 17, 56 and 134. On 2/13/23, the facility provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 2/13/23 at 6:15 PM: The facility seeks to ensure that each resident is free from accidents hazards and that each resident receives adequate supervision and assistive devices to prevent accidents. Immediate Interventions: Resident 17: Resident was assessed and found to require full assistance with smoking. He was placed on supervised smoking program where staff will assist him out to the smoking area (without his oxygen) and the staff will light his cigarette, stay and supervise him, extinguish cigarette and assist him back into the facility. If Resident 17 is observed asking for smoking materials from others, nursing staff will redirect him. A Smoking Assistance Form will be initiated by the Licensed Nursing Staff on 2/10/23 to provide guidance for staff to ensure they provide the appropriate level of assistance when he wishes to smoke. This form will be stored in the Smoking Binder at the Nurses Station for CNA's [Certified Nurse Assistants] and other staff to know what level of assistance to provide. The Care Plan will be updated on 2/10/23 to match the interventions contained on the Smoking Assistance Form. Resident 56 Resident will be assessed quarterly and as needed to ensure his smoking plan meets his cognitive/physical level. He currently has been assessed as needing supervision with smoking. Resident 56 chews tobacco most of time. The IDT [Interdisciplinary Team] will review the resident's condition by 2/10/2023 to ensure Resident 56 is safe to have his own smoking materials and has an appropriate place to secure the materials. A Smoking Assistance Form will be initiated by the Licensed Nursing Staff on 2/10/23 to provide guidance for staff to ensure they provide the appropriate level of assistance when he wishes to smoke. This form will be stored in the Smoking Binder at the Nurses Station for CNA's [sic] and other staff to know what level of assistance to provide. When the resident expresses desire to smoke, monitoring will be provided based on the level of assistance indicated on the Smoking Assistance Form. Resident 4 A new smoking evaluation was completed using the Smoking Safety Evaluation in Point Click Care, and Resident 4 was found to require supervision while smoking. The staff will assist the resident outside without oxygen, staff will light cigarette, stay and supervise them, extinguish cigarette, and [TRUNCATED]