**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement interventions and provide supervision to prevent accidents/injuries to residents related to: 1) failure to prevent a fall with injuries for one resident (#56) out of four residents reviewed for falls; and 2) failure to ensure a safe environment for residents to smoke for two residents (#21, #41) out of two residents who required the use of a wheelchair. Residents were expected to sign a leave of absence (LOA) form and then navigate off facility grounds, unassisted, through the parking lot approximately 350 feet, over a large speed bump, and across large potholes, despite being assessed to require supervision during ambulation or requiring the use of a wheelchair. Findings included: 1. A review of the medical record for Resident #56 revealed a progress note dated 07/02/2025 at 6:35 a.m. “Resident attempted to get oob (out of bed) without assistance, found with left leg stuck inside rail and face on the floor, noted moderate amount of blood to resident's facial/nose area, resident remained on floor, positioned on right side, pending arrival of emergency services, MD (Medical Doctor) made aware of resident's state, attempts to reach residents son unsuccessful, no answer at this time will attempt at a later time” Further review of the medical record revealed she was admitted to the facility on [DATE], with diagnoses to include cognitive communication deficit (4/29/25); hypertension (4/29/25); major depressive disorder (4/29/25); encephalopathy (6/1/25); dementia (6/19/25); fracture of base of skull (7/3/25); contusion of scalp (7/3/25); history of falling (7/3/25). A review of the resident’s care plan dated 05/07/2025 to 07/28/2025, revealed the “Resident is at risk for falls and/or fall related injury r/t [related to]: generalized weakness. Resident will minimize risk of fall related injuries with staff intervention thru next review date.” Interventions included, “Observe for unsteadiness/dizziness when changing positions; provide assist as needed”. “Utilize total mechanical lift with staff assist of 2 for transfers”. “Remind resident to request assistance prior to ambulation/transfers as needed”. “Keep call light within reach.” A review of the Determination of Capacity to Give Informed Consent form dated 5/22/25, revealed that the Psychiatric Mental Health Nurse Practitioner (PMHNP) attested “I have assessed [Resident #56] on a consult requested by attending physician and have found he/she”…The PMHNP marked with an “x” “Lacks the capacity to make medical decisions.” Further review of the record revealed an encounter note dated 06/19/2025 by the PMHNP that stated This is an [AGE] years old patient with a past psychiatric history of depression and dementia. Prior to last visit, patient had symptoms of depression. During last visit, patient was confused. Patient had symptoms of dementia. Patient stated no history of depression or anxiety. Patient denied any mood swings or behavioral outbursts. Sleep and eating habits were noted as good. No medication changes were done. Facility is requiring a detail cognitive assessment as patient is showing behaviors related to memory problems and there has been change in patient baseline requiring recommendation on the care plan. Today, I saw this patient to perform that cognitive assessment and form the care plan. As per collected information the patient is very confused with repetitive speech. Staff reports no concerns at this time. Patient can not tell me her birthday or where she currently is. No other psychiatric symptoms observed. Staff report patient has gotten agitated during hygiene care. No side effects to current psych medications reported.” The note documented a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive impairment. On 6/26/25 the PMHNP documented on an encounter note, “Dementia with agitation: The history suggests that the patient had a gradual decline in memory, executive function, language, concentration, and fund of knowledge. These symptoms have caused distress and have affected the quality of life and activities of daily living. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. The memory loss has been followed by significant behavioral agitation as well.” The note documented a BIMS score of 7, indicating severe cognitive impairment. Review of the interdisciplinary team (IDT) notes dated 07/02/2025 at 9:03 a.m., “IDT reviewed 07/02/2025 with new intervention to apply bed bolsters to reduce the risk of future falls and enhance resident safety while in bed. This intervention will be added to the resident’s care plan and monitored for effectiveness.” A progress note dated 07/02/2025 at 2:16 p.m. This wroter [sic] called [Hospital] to get update on resident per Nurse[sic] she is admitted for non displaced skull FX [fracture], family notified. A review of the hospital speech-language pathology (SLP) evaluation note dated 07/02/25, “Assessment/Plan SLP Assessment Pt [patient] was cleared by nursing for SLP evaluation. Pt is A+OX1 [alert and oriented to self only], confused but cooperative. Pt presents from SNF [Skilled Nursing Facility], following GLF [ground level fall], with skull fx [fracture] and C-collar [cervical neck brace] in place. Strong and foul urine smell is noted in pt.'s room. Oral-facial examination is remarkable for reduced mandibular depression due to the presence of C-collar.” “Severe cognitive deficits are noted, however, pt is baseline mentation per notes.” On 7/16/25 at 5:07 p.m., an interview was conducted with the Director of Nursing (DON). She stated that the resident had a fall risk score of 10 (out of 20) on admission which was high but not “super high” She stated that when the resident returned to the facility they put bolsters in her bed (long cushions or pillows that provide support and can be used to prevent falls) and moved her closer to the nursing station. She stated prior to the fall they did not see the need to have any more interventions than those listed on the care plan. Offering that the resident should have called for assistance and she did not, so she fell. She further offered that the facility could not protect every resident at all times from falling. She was asked if there should have been more supervision of the resident due to her dementia and confusion she stated the resident was capable of calling for assistance and she did not. On 07/17/2025 at 9:59 a.m., an interview was conducted with the PMHNP, during which she stated she last saw the resident on 06/26/2025 and found her to be confused, alert to self only, very confused, garbled speech, dementia with agitation and exit seeking, She was not told the resident had a fall and if she had been she would have seen her for a follow up. In her opinion she was not able to request assistance or call for assistance. She stated she should have been notified of the resident’s fall, the hospital visit would make her “unstable” which would have required her to be seen the next day. On 07/17/2025 at 2:02 p.m., a telephone interview was conducted with the son of Resident #56, during which he stated that the facility called him and informed him that the resident was found alongside the bed and was sent to the Emergency Room. He reported that she is always confused and was confused at the time she fell. They called him that morning. He stated that they have given her a special mattress and moved her closer to the nursing station to keep a better eye on her. On 07/17/2025 at 4:38 p.m., a telephone interview was conducted with Staff G, Licensed Practical Nurse (LPN) who stated she was working with the resident the morning of her fall. She stated that the patient was very confused and would not have known what the call light was and would not have be able to use it to call for assistance. She stated that she did rounds every two hours and that the resident had been asleep the last she had checked on her. She said the CNAs (Certified Nursing Assistants) are in and out. The resident had not tried to get out of bed before and when she entered the room she was on the floor. 2. During an interview on 07/14/2025 at 5:05 p.m., Resident #41 was observed in a wheelchair in the parking lot of the facility. Resident #41 stated he was smoking. I have to sign out on a Leave of Absence (LOA) and go past the fence to smoke. Sometimes I go and hide in the cover patio area. I put my butts out in my pile. The lady at the front desk keeps my lighter and cigarettes.” No staff or smoking receptacles were observed in the area where Resident #41 was smoking. Review of Resident #41's admission record revealed an admission date of 04/21/2025. Resident #41 was admitted to the facility with diagnoses of muscle weakness (generalized), other abnormalities of gait and mobility, unsteadiness on feet, and nicotine dependence, unspecified, uncomplicated. Review of Resident #41's Quarterly MDS dated [DATE] revealed, Section C. Cognitive Patterns a Brief Interview Mental Status (BIMS) of 15 out of 15 showing intact cognition. Review of Resident #41’s Care Plan dated 04/22/2025 revealed: Focus: “[Resident #41] desires to smoke. [Resident #41] has been assessed as able to smoke: independently. Goal: [Resident #41] will adhere to the smoking policy daily thru the next review date. Resident will demonstrate safe smoking practices thru the next review date. Interventions: Monitor for signs of unsafe smoking practices; Return smoking material to designated staff upon re-entry to the facility from LOA; Maintain smoking materials in designated area; Provide redirection if resident is observed in any unsafe smoking practices. Seek the assistance of managers/supervisors if needed; Observe for decline in hand dexterity; decline in cognition; decreased alertness while smoking; inability to safely dispose of ashes, butts; new or worsening vision impairments; and decreased ability to safely hold cigarette, as needed.” Review of Resident #41’s smoking assessment dated [DATE] revealed: Does the resident use, or have a desire to use, tobacco products/e-cigarettes? Yes 3. Observation a. does the resident remain alert during smoking? Yes Can the resident safely light a cigarette or smoking product, or ignite an e-cigarette device? Yes c. Is the resident able to safely hold a cigarette/smoking product/e- cigarette device? Yes d. Can the resident dispose of ashes, butts, and e- cigarette devices properly? Yes Is the resident free of visible upper extremity tremors? Yes f. Is the resident free from contractures in their hands, wrist, or elbows that impair their ability to smoke? Yes g. Is the resident free from loss of mobility, reduced movement, weakness, or paralysis to the dominant upper extremity? Yes h. Is the resident free from vision issues that impair their ability to smoke? Yes i. Total score for observation 0. During an interview on 07/15/2025 at 3:59 p.m., Staff Z, Unit Manager, stated she completed the smoking assessment for Resident #41 at his admission in April. “I answer the questions on the smoking assessment by marking yes to the questions. I did not observe Resident #41 smoking. I see him smoking when I leave for the day and see him out on the sidewalk smoking. I was told to make sure that all the residents who smoke have a smoking assessment completed and created new smoking assessments for all the residents today (07/15/2025). She had not seen the smoking policy/guideline form and was unsure where it came from. 3. During an interview and observation on 07/14/2025 at 5:15 p.m., Resident #21 was observed on the edge of the facility driveway in between the main street and a yellow speed bump on the facility driveway. Resident #21 was observed holding onto her wheelchair, trying to move it across the speed bump. Resident #21 stated I am being punished because I am a smoker. We have to come all the way out here, off property to the sidewalk to smoke. I don’t understand why I can’t go right here underneath this tree. No staff or smoking receptacles were observed in the area where Resident #21 was smoking. Review of Resident #21's admission record revealed an admission date of 07/08/2025. Resident #21 was admitted to the facility with diagnosis to include other abnormalities of gait and mobility, unsteadiness on feet, other specified disorders of bone density and structure, and nicotine dependence, unspecified, uncomplicated. Review of Resident #21's physician orders revealed an order dated 07/10/2025, resident may go on LOA unsupervised. Review of Resident #21's Medicare 5 Day MDS dated [DATE] revealed Section C. Cognitive Patterns, a Brief Interview Mental Status (BIMS) of 14 out of 15 showing intact cognition. Review of section GG. Functional Abilities revealed, for mobility, Resident #21 requires partial/moderate assistance for sit to stand, chair/bed-to-chair transfer, walk 10 feet 1 step (curb). Resident #21 uses manual wheelchair for mobility. Review of Resident #21's care plan dated 07/09/2025 revealed: “Focus: [Resident #21] desires to smoke. [Resident #21] has been assessed as able to smoke: Resident /responsible party have been informed of the facility smoking policy. Goal: [Resident #21] will adhere to the smoking policy daily thru the next review date; Resident will demonstrate safe smoking practices thru the next review date. Interventions: Monitor for signs of unsafe smoking practices; Provide redirection if resident is observed in any unsafe smoking practices; Seek the assistance of managers/supervisors if needed; Observe for decline in hand dexterity; decline in cognition; decreased alertness while smoking; inability to safely dispose of ashes, butts; new or worsening vision impairments; and decreased ability to safely hold cigarette, as needed; Inform resident of smoking cessation options upon resident request prn[as needed].” Review of Resident #21’s smoking assessment dated [DATE] revealed: Does the resident use, or have a desire to use, tobacco products/e-cigarettes? Yes …3. Observation a. does the resident remain alert during smoking? Yes b. Can the resident safely light a cigarette or smoking product, or ignite an e-cigarrete device? Yes c. Is the resident able to safely hold a cigarette/smoking product/e-cigarette device? Yes d. Can the resident dispose of ashes, butts, and e- cigarette devices properly? Yes Is the resident free of visible upper extremity tremors? Yes f. Is the resident free from contractures in their hands, wrist, or elbows that impair their ability to smoke? Yes g. Is the resident free from loss of mobility, reduced movement, weakness, or paralysis to the dominant upper extremity? Yes h. Is the resident free from vision issues that impair their ability to smoke? Yes i. Total score for observation 0. During an interview on 07/16/2025 at 11:15 a.m., the Director of Therapy stated Resident #21 is in Physical Therapy (PT) and Occupational Therapy (OT) as of 07/08/2025. PT is working with her on bed mobility, transfers and ambulation. Resident #21 is a standby assist which is close supervision or contact guarding to make sure she is safe when standing. “She should have someone standing next to her when she is out of her wheelchair. Resident would not be considered safe to ambulate on her own.” During an interview on 7/15/2025 at 4:05 p.m., the Director of Nursing (DON) stated the policy is we are a nonsmoking facility. Residents are assessed to see if they are a safe smoker, “I would assume they are watching the resident smoke if they are documenting on the observation of the smoking assessment. I don’t have to see someone physically smoking to assess if they have a tremor. There are a couple of things on the smoking assessment under the observation that do not require them to watch the resident smoking.” During an interview on 07/17/2025 at 3:25 p.m., the Nursing Home Administrator (NHA) stated “We are a non-smoking facility and if residents want to smoke, they sign out LOA and go off the premises to smoke. No there are no smoking receptacles or anywhere for cigarettes to be discarded outside. The nurses do a smoking assessment with the residents. I have never looked at the smoking assessment. If it says observation I would expect there to be an observation of the residents smoking. I have never watched any residents travel through the parking lot to the sidewalk so I cannot say if the parking lot is safe. There are speed bumps, and holes in the parking lot.” Review of the facility’s undated policy titled Safety and Supervision of Residents, undated, revealed “Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision, and assistance to prevent accidents are facility-wide priorities…Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through our combination of employee training, employee monitoring, and reporting processes; reviews of safety and incident/accident data; in a facility wide commitment to safety at all levels of the organization. 3. When accident hazards are identified, the QAPI [Quality Assurance and Performance Improvement]/safety committee shall evaluate and analyze the cause of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. 5. The QAPI committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary. Individualized, Resident Centered Approach to Safety: 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the facility environment including adequate supervision and assistive devices…6. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach for safety, which considers the hazards identified in the facility environment and individual resident risk factors, and then adjust interventions accordingly. 7. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual residents assessed needs and physician order. 8. The type and frequency of resident supervision may vary among residents and over time for the same resident. 9. Due to their complexity and scope, certain resident risk factors environmental hazards are addressed and dedicated policy and procedures.”