Buena Vida Nursing And Rehab Odessa

F-F689 Free of Accidents/Hazards/Supervision/Devices

On 4/4/2025 All facility staff were educated by the director of nursing that no residents may be left alone on

the smoking patio, staff are to light the resident cigarettes and return lighter to the receptacle for safe keeping. The facility administrator will review the lighter logs 5x weekly for compliance.

All in-service education will be completed by new hires at orientation and before assuming duties in the facility. This will be verified by the Administrator, Director of Nurses, or the Regional Compliance Nurse.

Monitoring:

Facility department heads or weekend manager on duty will conduct champion rounds 5x a week indefinitely

in every resident room and look for items not allowed per written company guidelines to include cigarette lighters. They will remove items not allowed if they identify any then report to DON/Administrator. Monitoring will start 4/5/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 675145 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675145 B. Wing 04/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Buena Vida Nursing and Rehab Odessa 3800 Englewood LN Odessa, TX 79762

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Regional Compliance Nurse will monitor during weekly visits and ask DON and Administrator what items are not allowed in residents room to include cigarette lighters and what to do if any are identified. They will be Level of Harm - Immediate questioned about the smoking policy and any identified violations. Monitoring will start 4/5/2025 and will jeopardy to resident health or continue for at least 8 weeks and prn thereafter. safety

The administrator / DON will assess five resident rooms for posted items not allowed to include cigarette Residents Affected - Some lighters, 5 days a week to ensure residents do not have any items not allowed in room to include cigarette lighters.

Regional Compliance Nurse will assess for compliance with posted items not allowed to include cigarette lighters, once weekly by verification of completion of facility assigned monitoring as listed above and visual verification of five rooms each week. Monitoring will start 4/5/2025and will continue for at least 8 weeks and prn thereafter.

Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 4.6.25.

Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through

observations, interviews, and record review from 4.5.25 at 3:37 PM to 4.6.25 at 5:52 PM as follows:

During an interview on 4.6.25 at 10:10 am FT stated she is one of the employees that takes them out for the smoke break. M-F 7a to 4p. She does the smoking break from 8:30-8:50 am. She stated she attended an In-service on items not allowed in room-she stated that they went over a list of items residents should not have in their rooms. She stated items such as scissors, lighters, glasses, anything that says, keep out of reach of children, corded things like air dryers, etc. she stated this was done to make sure there is nothing in

the room that anyone could hurt themselves with. She stated she was to keep an eye out for any of these items while working throughout the day. She stated if she does find something she would let the DON or Administrator know and they would go take care of it. She stated she attended an in-service on smoking policy-she stated there were no real changes to the smoking policy. She stated it was still to watch the residents if you are the one that takes them out. Residents are to have one cigarette at a time. And that the residents are to not be left alone at any time while outside smoking. She stated that residents should not have lighters or any other smoking related items. She stated she attended an in-service on smoking procedure-she stated that the new process for taking residents out to their smoking break was to get the smoking box which has all residents' cigarettes in it. She stated there was one lighter in the box now and you sign out that one lighter onto the log sheet, also you put the time the smoke break is happening on the log sheet. She stated you give each resident one cigarette, you light the cigarette, do not let resident do it, and watch the residents while they smoke. She stated once everyone has completed their cigarette, and everyone is back inside, you sign the one lighter back in and return the smoke box back to the med room.

Record review of in-services completed by FT with signature for the smoking policy on 3.31.25, items not allowed on 4.4.25, and smoking procedure on 4.3.25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 675145 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675145 B. Wing 04/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Buena Vida Nursing and Rehab Odessa 3800 Englewood LN Odessa, TX 79762

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an interview on 4.6.25 at 10:15 am Staff B stated she was the employee Monday through Friday that would take residents out to smoke break from 6:15 am to 6:35 am Monday through Friday. She stated she Level of Harm - Immediate attended an in-service on items not allowed in room-she stated the discussion covered all items that could be jeopardy to resident health or used to hurt themselves or others, may it be intentional or by accident. She stated things like sharp objects, safety aerosol cans, she said anything that can hurt anyone. She stated if she were to see anything in a resident's room that was not allowed, she would take the item to DON or Administrator and have them explain to the Residents Affected - Some resident why it was not allowed, or she would just inform either one of them of the item. She stated she attended an in-service on smoking policy she stated the smoking policy is pretty much the same, they just went over it. She stated it covers who can smoke, when to smoke, what is allowed, where its allowed. She stated the smoking policy is straight forward. She said oh, an assessment must be completed by any resident that is out there for a safe smoker assessment. She stated she attended an in-service on smoking procedure- she stated the new procedure was to get the box with all the residents' cigarettes in it. She stated that once everyone was outside, she would give each residents a cigarette, if they wanted a second cigarette, they must finish the first one first. She stated she would then light the cigarette for the residents individually, never giving the lighter to any of them. She stated that after everyone was done smoking and back inside, she would fill out the smoking log which indicated how many lighters she started the break with, how many ended with and her signature, with time of the smoke break.

Record review of in-services completed by Staff B with signature for the smoking policy on 3.31.25, items not allowed on 3.31.25, and smoking procedure on 4.4.25.

During an interview on 4.6.25 at 10:30 am CNA B stated she normally works 6a to 2p. She stated she is one of the employees that will take the residents out on smoke break. She stated she attended an in-service on items not allowed in room, she stated this was one she kind of all did already, but it was nice to see it written.

She stated basically while she was working at any time, she was to keep a look out for any items in residents' rooms or on their persons that was not allowed. She stated these items were like scissors, glasses, aerosols, electrical wires, etc. she stated this was being done to protect the residents and make sure everyone is safe in the building and no accidents to occur. She stated she attended an in-service on smoking policy she stated the smoking policy did not change. She stated that it was an overview of the smoking policy and the importance of sticking to it. She stated it covers what residents were allowed to smoke, where they were allowed to go what items should not be left with them etc., she stated it was straight forward. She stated she attended an in-service on smoking procedure she stated that the new procedure is to get the smoking box and check for a lighter and how many. She stated she was to go outside with the residents, hand out 1 smoke to each resident, light the smoke for them, and monitor the residents while they were outside smoking. She stated that she was to fill out the smoking log sheet, which indicated how many lighters smoke break started with, how many ended with, smoke break time and her signature indicated she did take them out and that the lighter was returned.

Record review of in-services completed by CNA B with signature for the smoking policy on 3.31.25, items not allowed on 3.31.25, and smoking procedure on 4.4.25.

During an observation on 4.6.25 at 10:30 am smoke break with employee CNA B she handed all resident one cigarette at this time, she individually lit the residents a cigarette. She watched all the residents until they were done, and they all headed inside. Once they were all inside, she signed the log she indicated the one lighter was still with her and she returned the box to the med room. Observation of log was documented and fully completed since yesterday 4.5.25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 675145 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675145 B. Wing 04/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Buena Vida Nursing and Rehab Odessa 3800 Englewood LN Odessa, TX 79762

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During a phone interview on 4.6.25 at 10:50 am LVN B stated she works Monday through Saturday. She stated she usually takes the residents out for the 10:30pm smoke break every day. She stated that this week Level of Harm - Immediate was a lot of in-services, covering smoking procedure, smoking policy, and items not allowed. She stated she jeopardy to resident health or attended an in-service on items not allowed in room-she stated that the was not just focused on lighters but safety focused on all items that could be harmful to the resident. She stated that the in-service was done to have all staff look out for lighters, scissors, electrical wires, glass that could break, etc. she stated basically anything Residents Affected - Some that could be used or could be an accident to the resident was removed from the residents' rooms and family member was contacted regarding the item that was removed. She stated she attended an in-service on smoking policy she stated the smoking policy is the same, assessment must be completed on any resident going out to smoke. She stated where they are allowed to smoke, monitoring the resident while smoking.

She stated never leaving the residents alone and that none of the items can be kept on the residents that have to do with smoking. She stated she attended an in-service on smoking procedure-she stated the new procedure is to get the smoke box with all the cigarettes for the residents, take the residents out, give each resident 1 smoke, light it for them, once finished if the resident wants a second cigarette they are allowed if

the first was completed. She stated once everyone was done smoking, she would fill out the log indicating that she started with one lighter and ended with one lighter. She stated that if she were to find the box with no lighter, she would inform the administrator or don immediately.

Record review of in-services completed by LVN B with signature for the smoking policy on 3.31.25, items not allowed on 3.31.25, and smoking procedure on 4.4.25.

During an interview on 4.6.25 at 11:10 am HR stated she works m-f from 8a to 5p. she stated she is the staff that takes the resident outs for smoke break at 4pm. She stated she attended an in-service on items not allowed in room she stated that this in-service was over all the items that are not allowed in residents rooms that could cause harm to them or their roommates or anyone in the building. She stated that she was to look out for items such as lighters, electrical devices like coffee makers and items like that. she stated anything that could cause any sort of harm. She stated anything that had a label that stated keep out of reach of children would be removed as well. She stated she was part of the champion rounds which would be done daily by her and other heads of departments. She stated they were to look for those items, removed those items if found, inform administrator or don and they would educate the resident on the item and reason for removal. She stated she attended an in-service on smoking policy she stated that policy remained the same.

She stated its about who and where which residents could go to smoke and are allowed to smoke. She stated it covered the process to be notated as a smoker in the facility. She stated it covered monitoring of the residents and overall compliance of smoking in the facility. She stated she attended an in-service on smoking procedure-she stated that the new process is to take all residents out with the smoke box. She stated there should only be one lighter in the box. She stated she was to give each resident one cigarette and only allow them one at a time. She stated she was to

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 675145