Health inspection·March 21, 2024

F689 (Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) §483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. § 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: A)Identification of care needs based upon initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patientcare plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 2/14/24 at 9:30 AM the Department of Public Health conducted an unannounced visit at the facility, to investigate a complaint regarding allegations of quality of care and accidents. The facility failed to ensure that a system was in place to provide a safe patient environment for patients who smoke and for patients who do not smoke. The facility failed to identify smoking hazards for Patients 1, 2, 3, 4, 5, and 6 who use a non-smoking designated area at the facility’s courtyard patio to smoke and failed to ensure Patients 7 and 8 who do not smoke and are continuous oxygen use were kept safe, comfortable and free from the hazards of second hand smoke, as indicated in the patient’s written plans of care and the facility’s policy and procedure on “Smoking.” As a result, Patients 1, 2, 3, 4, 5, 6, 7, and 8 were at risk for unexpected burns, fire hazards, and/ or injuries caused by unsafe smoking, while exposing non -smoking patients and visitor to secondhand smoke. During an interview on 2/14/2024 at 11:04 AM, the facility’s Activity Director (AD) was interviewed regarding the facility’s Smoking policy and procedure. The AD stated the facility has a designated Smoking Area located in the facility’s parking lot. The AD stated the facility does not use the Smoking Area located at the parking lot because the facility was waiting for a city permit to approve smoking in the parking lot. The AD stated that currently, the patients who smoke would smoke outside by the facility’s patio (courtyard patio) next to a sign indicating “No Smoking,” that is located next to Patient 7’s room. The AD stated the facility’s (courtyard) patio should not be the designated Smoking Area since patients’ rooms sliding doors were in close proximity to the courtyard patio. The AD stated smoking was a potential fire hazard. The AD stated the facility’s (courtyard) patio was the designated Smoking Area at this time, for patients who smoke in the facility. During an interview on 2/14/2024 at 11:09 AM, Patient 2 stated he smokes in the (courtyard) patio because facility staff told him not to use the Smoking Area located in the facility’s parking lot. During an interview on 2/14/2024 at 11:14 AM, Patient 1 stated he smokes in the facility’s (courtyard) patio in the presence of Activity Assistant (AA) 1. Patient 1 stated he was aware of the “No Smoking” posted in the courtyard patio, but the facility staff told him to smoke in the courtyard patio. During an interview on 2/14/2024 at 11:18 AM, Patient 3 stated he smokes in the facility’s (courtyard) patio because the facility staff told him not to use the facility’s Smoking Area by the parking lot. During an observation on 2/14/2024 at 11:39 AM, while in the facility’s courtyard patio, the facility’s courtyard patio, the “No Smoking” sign was observed at the corner end, approximately 2 feet from Patient 7 and Patient 8’s room and sliding door. Patient 7 and 8’s sliding door facing the courtyard patio open with curtains, covering the room for privacy. During an observation, a round metal open top trash can with no lid (cover) was observed adjacent to the “No Smoking” signage. The open top trash contained multiple cigarette butts. During a review of patients 1, 2, 3, 4, 5, 6, 7, and 8’s medical records, the following information were obtained: 1. A review of Patient 1’s Admission Record indicated the facility admitted a 79 year old male patient to the facility on 6/21/2023, with the diagnoses including unspecified psychosis (a mental disorder characterized by a disconnection from reality), depression (constant feeling of sadness), and cardiomyopathy (diseases of the heart muscle, where the walls of the heart chambers have become stretched, thickened, or stiff. This affects the heart's ability to pump blood around the body). A review of Patient 1’s History and Physical dated 6/06/2023, indicated the patient had mild dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Patient 1’s Minimum Data Set (MDS – a standardize assessment and care screening tool) dated 12/27/2023, indicated the patient had moderately impaired cognition (the ability or mental action or process of acquiring knowledge and understanding). A review of Patient 1’s Care Plan dated 12/12/2023, indicated Patient 1 smokes. The care plan approaches included to explain to the patient that smoking is allowed only in designated areas, monitoring by staff to ensure compliance of safety rules for smoking in the facility, and regularly remind patient of safety rules. 2. A review of Patient 2’s Admission Record indicated the facility admitted a 63 year old male on 10/17/2023, with the diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), unspecified arterial fibrillation(abnormal heartbeat, extremely fast and irregular beats from the upper chambers of the heart (usually more than 400 beats per minute) , and hypothyroidism(the thyroid gland can't make enough thyroid hormone to keep the body running normally). A review of Patient 2’s History and Physical dated 10/19/2023, indicated the patient had the capacity to understand and make decision. A review of Patient 2’s MDS dated 1/23/2024, indicated the patient had intact cognition (the ability or mental action or process of acquiring knowledge and understanding). A review of Patient 2’s Care Plan dated 12/12/2023, indicated Patient 2 smokes. The care plan approaches indicated explaining to the patient that smoking is allowed only in designated areas, show the patient the designated smoking areas, monitoring by staff to ensure compliance of safety rules for smoking in the facility, and regularly remind patient of the smoking safety rules. 3. A review of Patient 3’s Admission Record indicated the facility admitted a 73 year old male on 6/1/2022, with the diagnoses of chronic obstructive pulmonary disease (chronic lung diseases that block airflow and make it difficult to breathe), atherosclerotic hearth disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery), and supraventricular tachycardia (abnormally fast heart rhythm). A review of Patient 3’s History and Physical dated 11/10/2023 indicated that the patient had the capacity to understand and make decision. A review of Patient 3’s MDS dated 1/18/2024, indicated the patient had intact cognition. A review of Patient 3’s Care Plan dated 12/12/2023, indicated Patient 3 smokes. The care plan approaches included explaining to the patient that smoking is allowed only in designated areas, showing patient the designated smoking areas, monitoring by staff to ensure compliance of safety rules for smoking in the facility, and regularly remind the patient of the smoking safety rules. 4. A review of Patient 4’s Admission Record indicated the facility admitted a 65 year old male on 1/17/2024 with the diagnosis of nonrheumatic aortic stenosis (a thickening and narrowing of the valve between the heart's main pumping chamber and the body's main artery), and muscle wasting and atrophy (the decrease in size and wasting of muscle tissue). A review of Patient 4’s History and Physical dated 2/2/2024 indicated that the patient has the capacity to understand and make decision. A review of Patient 4’s Minimum Data Set (MDS – a standardize assessment and care screening tool) dated 1/22/2024 indicated that the patient had intact cognition (the ability or mental action or process of acquiring knowledge and understanding). A review of Patient 4’s Care Plan dated 1/20/2024 indicated the Patient 4 is a smoker. The care plan approaches included to instruct the patient about the facility policy on smoking with regards to location, times, safety concerns and notify the charge nurse immediately if it is suspected that the patient has violated the facility smoking policy. 5. A review of Patient 5’s Admission Record indicated the facility admitted a 56 year old male on 1/23/2024, with the diagnoses including chronic obstructive pulmonary disease(chronic lung diseases that block airflow and make it difficult to breathe ),hearth failure ( a condition that develops when your heart doesn't pump enough blood for your body's needs), and cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). A review of Patient 5’s History and Physical dated 1/30/2024, indicated the patient had the capacity to understand and make decision. A review of Patient 5’s MDS dated 2/2/2024, indicated that the patient had intact cognition. A review of Patient 5’s Care Plan dated 1/24/2024, indicated Patient 5 is a smoker. The care plan approaches included instructing the patient about the facility policy on smoking with regards to location, times, safety concerns, and notify the charge nurse immediately if it is suspected that patient had violated the facility smoking policy. 6. A review of Patient 6’s Admission Record indicated the facility admitted a 64 year old male on 1/11/2024, with the diagnoses of chronic obstructive pulmonary disease (chronic lung diseases that block airflow and make it difficult to breathe, epilepsy (a disorder of the brain characterized by repeated seizures(uncontrolled body movement), and unspecified psychosis( when people lose some contact with reality, this might involve seeing or hearing things that other people cannot see or hear). A review of Patient 6’s History and Physical dated 12/12/2023, indicated the patient is alert oriented to self, location, city and year. The H&P indicated Patient 6 was admitted for concern for inability to care to self, placement. A review of Patient 6’s MDS dated 1/29/2024 indicated that the patient has moderately impaired cognition. During the review of Patient 6’s care plan, Patient 6 did not have a care plan developed for being a smoker while residing in the facility and for smoking within the facility premises. 7. A review of Patient 7’s Admission Record indicated the facility admitted a 76 year old male on 3/30/2023 with diagnoses including Parkinsonism (a disorder of the central nervous system that affects movement, often including tremors), heart failure (occurs when the heart muscle doesn't pump blood as well as it should), and quadriplegia (paralysis(the loss of the ability to move ) that affects all a person's limbs and body from the neck down). A review of Patient 7’s History and Physical dated 3/31/2023, indicated that the patient did not have the capacity to understand and make decision. A review of Patient 7’s MDS dated 1/10/2024, indicated that the patient has moderately impaired cognition. A review of Patient 7’s Physician orders for 2/01/2024, indicated “Oxygen at 2-3 liter per minute via nasal cannula continuously.” A review of Patient 7’s Care Plan dated 12/12/2023 indicated Patient 7 was on oxygen therapy related to shortness of breath. The care plan goal indicated Patient 7 will have no sign and symptom of poor oxygen absorption. A review of Patient 7’s Care Plan dated 3/30/2023, indicated the Patient is at risk for abnormal pulse shortness of breath, chest pain, edema and elevated blood pressure related to history diagnosis of heart failure. The care plan goal indicated the patient will be free from shortness of breath after nursing intervention. 8. A review of Patient 8’s Admission Record indicated the facility admitted a 81 year old female on 2/2/2024, with the diagnoses including metabolic encephalopathy(brain disease that alters brain function and can appear as confusion, memory loss, personality changes and/or coma in the most severe form), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), and pressure ulcer (Injury to skin and underlying tissue). A review of Patient 8’s History and Physical dated 2/5/2024, indicated the patient did not have the capacity to understand and make decision. A review of Patient 8’s MDS dated 2/9/2024 indicated that the patient has severe cognitive impairment (the ability or mental action or process of acquiring knowledge and understanding). A review of Patient 8’s Physician Orders for 2/07/2024, indicated “May titrate oxygen at 2 – 5 liter per minute via nasal cannula as needed to maintain oxygen Saturation 92% and above.” A review of Patient 8’s Care Plan dated 2/14/2024, indicated Patient 8 needs special care related to oxygen use. The care plan approaches included to maintain the oxygen flow rate and concentration with humidification as ordered and do not allow tobacco use while oxygen is in use, do not permit oil, grease, or other combustible material to come in contact with cylinders, and administer oxygen only with safety functioning. During an interview on 2/14/2024 at 11:48 AM, AA 1 stated patients smoke in the facility’s courtyard patio next to Patient 7 and Patient 8’s room with sliding exit doors facing the patio. AA 1 stated that the courtyard patio was not a true designated smoking area because the smoking area needs to be outside the facility 6 feet away from the building. AA 1 stated there was no fire extinguisher placed near the courtyard patio where patients’ smokes. AA1 stated he was not aware where the closest fire extinguisher was located around the facility. AA 1 stated if a patient would be on fire, he would use his clothes to put out the fire. During an observation and interview on 2/14/2024 at 12:21 PM, in the presence of License Vocational Nurse (LVN) 1, Patient 7 was lying in bed while receiving oxygen therapy at 2.5 liters per minute (L/min) via nasal cannula (NC-a device used to deliver supplemental oxygen that should be placed directly on the patient's nostrils) connected to the oxygen concentrator (a medical device that concentrates oxygen from environmental air used for supplemental oxygen) located at the bedside. LVN 1 stated Patient 7 was on oxygen continuously at 2.5 liters per minute. During an observation and interview inside Patient 8’s room on 2/14/2024 at 12:23 PM, with LVN 1, Patient 8 was lying in bed while receiving oxygen therapy at 2.5 liters per minute via NC connected to the oxygen concentrator located at the bedside. LVN 1 stated Patient 8 was on oxygen continuously at 2.5 liters per minute. During subsequent interview on 2/14/2024 at 12:26 PM, LVN 1 stated patients should not smoke next to Patient 7 and Patient 8’s room who had exit sliding doors to the courtyard patio. LVN 1 stated there was a sign indicating “No Smoking” by the courtyard patio because both Patient 7 and 8 is on oxygen. LVN 1 stated both Patients 7 and 8 would suffer from secondhand smoking complications. LVN 1 stated the pa