**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to provide adequate supervision for 1 (#5) of 3 (#5, #6, and #7) residents reviewed for wandering. The facility failed to ensure staff appropriately supervised Resident #5 who was assessed to be a wanderer, unsafe smoker, and a high fall risk. This deficient practice resulted in an immediate jeopardy situation on the weekend of 02/15/2025 through 02/16/2025, when Resident #5, a severely cognitively impaired resident identified as a wanderer, unsafe smoker and high fall risk, entered the smoking patio while no staff were present to provide supervision. Resident #5 self-propel himself in his wheelchair through the gate of the smokers' patio onto the sidewalk along the resident patio exterior doors. When Resident #5 attempted to enter back through the gate into the smoking patio, he was unable to maneuver his wheelchair over the uneven concrete. He stood up from his wheelchair and fell onto the concrete walkway. Random Resident #R3 observed Resident #5 fall and was unable to locate the smoking attendant on the smoking patio. Random Resident #R3 went inside the facility and notified S14WC of Resident #5 being on the ground. This failure to provide adequate supervision for Resident #5 created a likelihood of serious injury for Resident #5 when he fell outside on the concrete. S1ADM was notified of the Immediate Jeopardy on 02/26/2025 at 2:15 p.m. This deficient practice continued at a potential for more than minimal harm for the 5 residents residing in the facility identified as moderate to high risk for wandering and elopement. Findings: Review of the facility's undated, Routine Resident Checks policy revealed the following, in part: Staff shall make routine resident checks to help maintain resident safety and well-being. Review of the facility's job description for the Smoke Monitor Attendant, dated 09/20/2024, revealed the following, in part: Responsibilities: 4. Responsible for monitoring all residents in the smoking area, monitoring the area, and intervening as needed for any resident safety issues. 6. Other assistance and assist all residents when needed. Review of facility's Staff Orientation Packet, revealed the following, in part: The smoking monitor attendant is on duty from 7 a.m. to 7 p.m., seven days per week . Further review revealed the Staff Orientation Packet was signed by S10CNA on 01/16/2025 and S13CNA on 12/03/2024, which indicated they received the training on the aforementioned dates. Review of Resident #5's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included the following; History of Cerebral Infarction, Hemiplegia and Hemiparesis, History of Falling, and Cognitive Communication Deficit. Review of Resident #5's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/06/2024 revealed Resident #5 was assessed by the facility to have a BIMS (Brief Interview Mental Status) of 3, indicating the resident was severely cognitively impaired. Further review revealed he self-propelled himself independently in his manual wheelchair. Review of Resident #5's Elopement Risk Evaluation, dated 02/13/2025, revealed the following, in part: 6. Does the resident wander? Yes. 8. Does the resident wander aimlessly or non-goal directed (i.e. confused, moves without purpose, may enter others' rooms and explore others' belongings)? Yes. Review of Resident #5's Fall Risk Assessments, dated 01/01/2024 through 02/24/2025, all indicated Resident #5 was identified by the facility to be a high fall risk. A review of Resident #5's Physician Orders, dated February 2025, revealed the following, in part: 11/17/2024 - Wanderguard monitoring; check placement and function of wanderguard bracelet every shift. 12/18/2024 - Unsafe smoker; smoker/monitor resident every shift. 02/13/2025 - Every 30 minute checks due to falls and census checks related to elopement risk. Review of Resident #5's Care Plan, dated 01/01/2025 through 02/24/2025, revealed the following, in part: Problem: Resident #5 is at risk for elopement Interventions: 02/13/2025 - Monitor Resident #5 every 30 minutes and keep wander guard in place. Problem: The resident has had an actual fall with no injury. Interventions: 01/16/2025 - Resident #5 had an unwitnessed fall, fall mat at bedside when resident in bed; 01/19/2025 - Resident #5 had an unwitnessed fall, concave mattress for bed edge definition; 01/23/2025 - Resident #5 had a witnessed fall, helmet cap in place while up in wheelchair; 02/04/2025 - Resident #5 had a witnessed fall, keep resident in high traffic areas; 02/08/2025 - Resident #5 had an unwitnessed fall, activity vest applied while up in wheelchair; and 02/13/2025 - Monitor every 30 minutes Review of Resident #5's CNA Task Log, dated 02/01/2025 through 02/26/2025, revealed the following, in part: Task: Census Checks every 30 minutes related to falls and elopement risk. Further review revealed no documented evidence to indicate Resident #5's 30 minute checks were performed as ordered during the timeframe reviewed. On 02/25/2025 at 4:40 p.m., an interview was conducted with Random Resident #R2, a cognitively intact resident. He confirmed he resided in Room C where his bed was located near the outside wall with a window overlooking the outside patio of the facility. He confirmed during the weekend of 02/15/2025 through 02/16/2025, while in his room, he heard someone shouting for help. He stated when he looked out of his bedroom window, he saw Resident #5 lying on the ground on the patio near his exterior door. He confirmed he went to the ward clerk desk and notified the nurse but could not recall her name. He confirmed after he reported the incident, he went outside to the smoking patio and there was no smoking aide present but there were residents out there smoking. On 02/25/2025 at 4:47 p.m., an interview was conducted with Random Resident #R3, a cognitively intact resident. He confirmed he recalled Resident #5 falling during the weekend of 2/15/2025 through 02/16/2025. He stated he went out to the smoking patio after lunch and confirmed a smoking aide was not present. He confirmed he saw Resident #5 self-propel himself out of the dining room door onto the smoking patio then continued through the patio gate onto the concrete walkway that ran alongside the rear of the building. He confirmed he watched Resident #5 self-propel himself to the end of the concrete walkway where he turned himself around and came back towards the smoking patio. He stated when Resident #5 attempted to self-propel himself back toward the gate of the smoking patio, his wheelchair got stuck on the uneven concrete. He stated after Resident #5 got stuck, he stood up and fell down to the concrete sidewalk. He confirmed no staff were present on the patio at the time Resident #5 fell so he went back inside the facility to the ward clerk desk to look for someone to assist Resident #5. On 02/24/2025 at 11:30 a.m., an interview was conducted with S13CNA. She confirmed she worked as the smoking aide during the weekend of 02/15/2025 through 02/16/2025. She confirmed she did not sit out on the smoking patio during her shift that weekend. She confirmed she sat at the ward clerk's desk or the main dining room throughout her entire shift unless an unsafe smoker came to her requesting to smoke. She confirmed she was aware Resident #5 was an unsafe smoker. She was unaware Resident #5 was a wanderer. She confirmed she was not aware Resident #5 had an unwitnessed fall on the smoking patio during the weekend of 02/15/2025 through 02/16/2025 while she was assigned as the smoking aide. On 02/25/2025 at 4:50 p.m., an observation of the smoking patio located to the rear of the facility was conducted. To the right of the smoking patio revealed a gate with a concrete sidewalk which extended from the gate to the sidewalk of the exterior patio doors for Hall B. It is noted the concrete sidewalk was not flushed together and was slightly elevated on the gate side of the sidewalk. On 02/25/2025 at 9:57 a.m., an interview was conducted with S9LPN. She confirmed Resident #5 self-propelled himself throughout the facility all day in his wheelchair. She confirmed he was assessed by the facility to be a wanderer and required a Wanderguard at all times. She confirmed Resident #5 had frequent falls because he could not remember to ask for staff assistance before attempting to stand or transfer himself. She confirmed Resident #5 was assessed to be an unsafe smoker and required supervision when he was outside smoking. She confirmed Resident #5 required increased supervision from staff due to all of the above and staff were aware to keep an eye on him. She confirmed every day a staff member was assigned to serve as the smoking aide and they were responsible for being outside on the patio to provide supervision and assistance for residents from 7:00 a.m. to 7:00 p.m. On 02/24/2025 at 11:32 a.m., an interview was conducted with S10CNA. She confirmed on the weekend of 02/15/2025 through 02/16/2025, she worked an extra shift as the smoking aide and remained on the smoking patio throughout her entire shift from 7:00 a.m. to 7:00 p.m. She confirmed Resident #5 was a very busy resident who moved himself around the facility all day long and required frequent monitoring every 30 minutes. She confirmed she was not aware Resident #5 had an unwitnessed fall on the smoking patio during the weekend of 02/15/2025 through 02/16/2025. On 02/24/2025 at 1:40 p.m., an interview was conducted with S12CNA. She confirmed there was a staff member assigned to be the smoking aide from 7:00 a.m. to 7:00 p.m. every day. She confirmed the smoking aide was responsible for remaining outside on the smoking patio throughout their shift to provide supervision to any residents who were outside. She confirmed she worked the weekend of 02/15/2025 through 02/16/2025 as Resident #5's CNA. She confirmed Resident #5 was a very busy resident who moved himself around the facility all day long and frequently fell because he could not remember to ask for staff assistance before attempting to stand or transfer himself. She stated on the weekend of 02/15/2025 through 02/16/2025, she was not aware Resident #5 had an unwitnessed fall on the smoking patio during the weekend of 02/15/2025 through 02/16/2025. On 02/24/2025 at 4:07 p.m., an interview was conducted with S14WC. She confirmed she worked during the weekend of 02/15/2025 through 02/16/2025. She confirmed during that weekend, after lunch a resident came to her desk in the lobby and reported Resident #5 had fallen outside. She confirmed she could not recall if this occurred on 02/15/2025 or 02/16/2025 but confirmed it was one of those days. She stated S15CNA was at the ward clerk desk when Resident #5's fall was reported. On 02/25/2025 at 4:59 p.m. an interview was conducted with S15CNA. She confirmed she worked during the weekend of 02/15/2025 through 02/16/2025 and was not assigned to Resident #5. She stated she was at the ward clerk desk when Random Resident #R3 reported Resident #5 fell and was on the ground outside the patio area. She stated she reported the fall to S16RN and they went outside together. She stated once they arrived outside, Resident #5 was noted in a sitting position on the ground outside of the gated smoking patio. She confirmed there should be an assigned smoking aide present on the patio every day from 7:00 a.m. to 7:00 p.m. but she could not recall if they were present when Resident #5 fell. On 02/25/2025 at 9:25 a.m., an interview was conducted with S16RN. She confirmed she was the day shift charge nurse during the weekend of 02/15/2025 through 02/16/2025. She stated she initially did not recall Resident #5 having an unwitnessed fall during that weekend. She then confirmed Resident #5 did have an unwitnessed fall during that weekend. She confirmed she did not recall who reported the fall to her or who assisted her, but confirmed the fall occurred after lunch around 1:00 p.m. She stated when she arrived outside Random Resident #R2 was near Resident #5. She confirmed Resident #5 was sitting on his bottom on the concrete walkway on the outside of the gated smoking patio. She stated she did not recall if there was a smoking aide on the smoking patio when the fall occurred or if anyone was assigned as the smoking aide that day. She confirmed there was a weekend recently when there was not an assigned smoking aide but could not be sure if it was the weekend of Resident #5's fall. On 02/25/2025 at 12:15 p.m., an interview was conducted with S17WC. She stated she was responsible for the smoking aide schedule. She stated there was a smoking aide assigned for every weekend in January 2025 and February 2025. She stated if the smoking aide did not show up on their assigned day, administration would pull the restorative aide or someone else until they called a worker in to supervise residents on the smoking patio. She further stated the assigned smoking aide should be present on the smoking patio from 7:00 a.m. to 7:00 p.m. She confirmed if the smoking aide was seated at her desk, residents would be able to enter the dining room and exit to the smoking patio without being seen. On 02/25/2025 at 12:28 p.m., an interview was conducted with S8ADON. She stated the smoking aide was assigned daily from 7:00 a.m. to 7:00 p.m. and was expected to be present on the smoking patio during their entire shift to provide supervision for residents outside. She stated the smoking aide should request another staff to relieve them prior to leaving the smoking patio for any breaks so the area was never left unattended. She confirmed if the smoking aide was seated at S17WC's desk, residents would be able to enter the dining room and exit to the smoking patio without being seen. On 02/25/2025 at 1:50 p.m., an interview was conducted with S1DON. He stated the smoking aide was assigned daily from 7:00 a.m. to 7:00 p.m. and was expected to be present on the smoking patio during their entire shift to provide supervision for residents outside. He stated the smoking aide should request another staff to relieve them prior to leaving the smoking patio for any breaks so the area was never left unattended. He confirmed new employees received the smoking policy and the policy/procedure was reviewed during orientation. He stated all CNA's were aware of the rules for the smoking aide, which was to remain on the patio at all times from 7:00 a.m. to 7:00 p.m. He confirmed the smoking patio should have supervision for all residents from 7:00 a.m. to 7:00 p.m. daily. He confirmed Resident #5 would not be safe outside without supervision and was care planned for high traffic areas, which included the smoking patio due to the presence of constant supervision in that area. The Immediate Jeopardy was removed on 02/27/2025 at 2:55 p.m., after it was determined through observation, interview, and record review; the facility implemented an acceptable Plan of Removal prior to the survey exit, which included: 1. The facility failed to ensure Resident who is at risk for falls and wandering, received adequate supervision on 02/15/2025 and 02/26/2025. All residents who are cognitively impaired, wander, and are at risk for falls are potentially affected by this deficient practice. 2. The outside patio fence gate is to remain closed. Starting on 02/27/2025, Administrator/DON/Designee will monitor the smoke patio area by using a monitoring form on 5 random days/week for 8 weeks then randomly to ensure adequate supervision provided to residents. Disciplinary action up to termination will take place if this occurs again. All staff will be in serviced beginning on 02/26/2025 by Administrator/DON/Designee on providing supervision to resident while out on smoke patio, the smoke monitor will remain outside and must be relieved by other staff to leave that area. All staff members will be required to complete the training prior to working their shift. In-service will be completed 02/27/2025, no employee will be allowed to begin their shift until the training, has been received. 3. Starting on 02/27/2025, Administrator/DON/Designee will monitor the smoke patio area by using a monitoring form on 5 random days/week for 8 weeks then randomly to ensure adequate supervision provided to residents. Audit reports will be submitted to the Administrator and QAPI committee for review and new interventions implemented as needed. The facility asserts the likelihood for serious harm to any Resident no longer exists as of 02/27/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure residents remained free of accident hazards and received adequate supervision and assistance to prevent accidents. The facility failed to ensure: 1. An effective system was in place for nursing staff to identify and implement a resident's assessed transfer needs for 1 (#54) of 4 (#32, #38, #54, and #66) residents reviewed requiring a Hoyer lift for transfers; and 2. An effective system was in place for staff to implement safe smoking interventions for 3 (#49, #75, #87) of 4 (#49, #58, #75, and #87) residents reviewed for smoking. 1. This deficient practice resulted in an immediate jeopardy situation for Resident #54, a resident who required a Hoyer lift and 2 staff members' assistance for transfers, on 08/28/2024 at 3:45 p.m. when S4CNA transferred Resident #54 independently without a Hoyer lift. Resident #54 fell to the floor and sustained a laceration above her left eyebrow. Resident #54 was transferred to a local hospital, diagnosed with a Left Frontal Scalp Contusion, and required a tissue adhesive. The immediate jeopardy continued when interviews with CNAs and Nursing staff revealed they did not know how to identify residents' assessed transfer needs. S1ADM was notified of the immediate jeopardy situation on 09/18/2024 at 5:00 p.m. The Immediate Jeopardy was removed on 09/20/2024 at 3:10 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at the potential for more than minimal harm for any resident requiring assistive devices and/or supervision with transfers. Findings: 1. Review of the facility's undated policy titled, Safe Lifting and Movement of Residents revealed the following, in part: Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents'. Policy Interpretation and Implementation: 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Resident #54 Review of Resident #54's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Primary Disorders of Muscles, History of Falling, Generalized Muscle Weakness, Spinal Stenosis, Major Depressive Disorder, and Primary Generalized Osteoarthritis. Review of Resident #54's MDS with an ARD of 07/26/2024 revealed, in part, a BIMS summary score of 12, which indicated moderate cognitive impairment. Further review of the MDS revealed she was dependent on staff for transfers. Review of Resident #54's Physical Therapy Note dated 07/25/2024 revealed, in part, she required a Hoyer lift for transfers. Review of Resident #54's current Physician Orders dated September 2024 revealed no documentation indicating how much assistance, supervision, and/or assistive devices the resident required for transfers. Review of Resident #54's current Care Plan revealed the following, in part: Problem: At risk for falls Fall on 08/28/2024 Interventions: 08/28/2024 at 3:46 p.m., Resident sent to the emergency room for evaluation and treatment. Further review of Resident #54's care plan revealed no documentation of the amount of assistance, supervision, and/or assistive devices the resident required for transfers. Review of Resident #54's Resident Summary in the clinical record revealed no documentation of the amount of supervision and/or assistive devices Resident #54 required for transfers. Review of Resident #54's Nurse's Note dated 08/28/2024 at 10:57 p.m. by S34LPN revealed the following, in part: At 3:45 p.m., Resident was found on the floor bleeding from head; it was a witnessed fall. S4CNA said she was helping her out of the bed when the resident forcefully tried to get out on her own. Emergency Medical Services was called. Resident was transferred to a local hospital. Review of Resident #54's Incident Report dated 08/28/2024 at 3:46 p.m. revealed the following, in part: Incident type: Fall with head injury Associate involved: S4CNA Report prepared by: S34LPN Narrative of incident and description of injuries: S4CNA said she was helping the resident out of the bed when the resident forcefully tried to get out on her own. Resident noted with skin laceration above left eyebrow. Heavy bleeding from site noted with no complaints of pain or dizziness. On-call Nurse Practitioner notified and gave ok for emergency room transfer. Injury to head quarter size bleeding. Review of Resident #54's Hospital Records dated 08/28/2024 revealed the following, in part: HPI Assessment: Patient presented to the Emergency Department after a fall. Patient reports that she tripped and fell while being transferred to the bed with the help of the nurse. She states that she hit her head and has had a bad headache since. Progress Note: Left Frontal Scalp Contusion closed with tissue adhesive by the attending physician. An interview was conducted with Resident #54 on 09/17/2024 at 3:15 p.m. She stated, at the end of August 2024, S4CNA dropped her during a transfer. She stated, at the time of the transfer, she required a Hoyer lift with the assistance of two staff members for transfers. She explained S4CNA attempted to transfer her independently without a Hoyer lift, and she fell face first onto the floor. She stated, as a result of the fall, she sustained a laceration above her left eye, which required gluing in the Emergency Room. An interview was conducted with S4CNA on 09/17/2024 at 4:00 p.m. She stated, at the end of August 2024, she was assigned to Resident #54 on the evening shift. She stated at that time, she was working as needed with the facility. She stated she became full time with the facility on 09/01/2024. She stated on that particular evening, she was unaware how to identify a resident's transfer status. She stated Resident #54 was cognitively intact so she asked the resident how much assistance she needed to be transferred from the bed to the wheelchair. She stated Resident #54 stated she and S4CNA could do it together. She stated she attempted to transfer Resident #54 independently without the use of the Hoyer lift, and Resident #54 fell and landed on the floor face first. She stated, as a result of the fall, Resident #54 had a laceration above her left eye. An interview was conducted with S34LPN on 09/18/2024 at 2:29 p.m. She stated she was the nurse assigned to Resident #54 when she fell on [DATE] at 3:46 p.m. She stated S4CNA notified her that S4CNA was assisting Resident #54 with a transfer from the bed to the wheelchair when Resident #54 landed on the floor. She stated Resident #54 had a laceration above one of her eyes and was sent to the ER. She explained, 08/28/2024 was her first day working in the facility. She stated, at the time of the incident, she was unaware of the amount of assistance and supervision Resident #54 required with transfers, and she was unaware how to determine the amount of assistance and supervision Resident #54 required. She stated S4CNA was unaware of Resident #54's transfer status. An interview was conducted with S35RD on 09/18/2024 at 12:12 p.m. She stated the therapists determined the safest way to transfer each resident. She stated after the therapists completed their assessment, they communicated it with nursing verbally. She stated Resident #54 has required a Hoyer lift for transfers since 07/25/2024. She stated Resident #54's need for a Hoyer lift with transfers was verbally communicated with nursing. An interview was conducted with S36LPN on 09/18/2024 at 1:00 p.m. She stated the CNAs should be able to see each residents' transfer status in the ADL charting. She reviewed Resident #54's transfer status in the ADL documentation and confirmed there was not a transfer status listed for Resident #54. She demonstrated where the transfer lift status would be selected and confirmed it read choose one, which indicated it had not been selected. She confirmed Resident #54's transfer status was not in the care plan. She confirmed the left side of the screen, which read Resident Summary did not include Resident #54's transfer status. An interview was conducted with S10LPN on 09/18/2024 at 1:24 p.m. She stated if she was unsure how Resident #54 should be transferred, she would check the resident's Physician Orders. She reviewed Resident #54's current Physician Orders and confirmed there was no order for a Hoyer lift and/or transfer status. She reviewed Resident #54's Resident Summary, and confirmed it did not reveal how much assistance or supervision Resident #54 required for transfers or that she required a Hoyer lift. She confirmed she was unable to locate any documentation in Resident #54's Clinical Record to determine how much assistance and/or supervision Resident #54 required with transfers. An interview was conducted with S11CNA on 09/18/2024 at 9:09 a.m. She stated if she did not know the transfer status of a resident she would ask another staff or the resident. An interview was conducted with S37TP on 09/18/2024 at 9:18 a.m. She stated she was unaware of how to determine the transfer status of a resident. She stated if she was unsure of a resident's transfer status, she would ask another CNA or the resident. An interview was conducted with S38CNA on 09/18/2024 at 9:47 a.m. She stated there was not a particular place to look to identify a resident's transfer status. She stated when a new resident came into the facility, therapy evaluated them and verbally notified the CNAs how much assistance was needed. She confirmed the only way to know a resident's transfer status was by verbal communication. An interview was conducted with S39CNA on 09/18/2024 at 9:57 a.m. She stated she worked with residents every day and was familiar with each resident's capability. She stated she would transfer each resident based on that resident's capability. An interview was conducted with S27CNA on 09/18/2024 at 10:20 a.m. She stated verbal communication was how she knew how much assistance and supervision each resident required for transfers. She stated if she was unsure how much assistance or supervision the resident required for transfers, she would ask another CNA, the CNA supervisor, or the resident. She stated if a resident's transfer status changed, she was not sure she would be aware. An interview was conducted with S40CNA on 09/18/2024 at 1:15 p.m. She stated she determined how much assistance and supervision each resident required based on her own assessment. She stated there was nowhere for her to go and look to see what therapy determined was the safest for resident transfers. She reviewed Resident #54's ADL charting and Resident Summary and confirmed there was nowhere in the chart indicating the amount of supervision and/or assistance Resident #54 required for transfers. An interview was conducted with S36LPN on 09/18/2024 at 1:50 p.m. She stated she was unaware of how to update a Resident Summary in the resident's clinical record. She stated she did not know how to update anything in the record to be visualized by the CNAs. An interview was conducted with S29MDS on 09/18/2024 at 1:52 p.m. She stated she was unaware of how to update a Resident Summary in the resident's clinical record. She stated she did not know how to update anything in the record to be visible for the CNAs. An interview was conducted with S29MDS and S36LPN on 09/19/2024 at 9:09 a.m. S29MDS reviewed Resident #54's Therapy Note dated 07/25/2024 and confirmed that was the date Resident #54 was determined to require a Hoyer lift for transfers. S29MDS stated the direct care staff were verbally notified of Resident #54 requiring a Hoyer lift for transfers on 07/25/2024. S29MDS confirmed Resident #54 required a Hoyer lift with the assistance of two staff members at the time of her incident on 08/28/2024. S29MDS and S36LPN both stated they were unaware they were responsible to update the Resident Summary until the afternoon of 09/18/2024. S29MDS and S36LPN both stated they did not know how to update anything in a resident's record for the nurses and CNAs to visualize the amount of assistance or supervision required for transfers. S29MDS and S36LPN both stated the way the CNAs and nurses knew a resident's transfer status was verbal communication. An interview was conducted with S16CON on 09/18/2024 at 1:37 p.m. She stated the facility's process to determine a resident's transfer status was for therapy to assess the resident and notify nursing. She stated MDS Nurses were responsible to update the resident's chart, which included the Resident Summary so direct care staff would be able to identify the current transfer status. She stated the amount of assistance and supervision each resident required with transfers, or transfer status, should have been listed on the resident's Resident Summary. She stated all direct care staff should have known to look at the Resident Summary to determine the transfer status. She stated it was never acceptable for a CNA to self-assess a resident or ask the resident to determine transfer status. She stated if a resident was assessed by therapy to require a Hoyer lift for transfers, a Hoyer lift with two staff members should have been used for transfers. She stated MDS should have updated the residents' Resident Summary for the CNA staff to determine a residents transfer needs. 2. This deficient practice resulted in an Immediate Jeopardy situation for Resident #87, a resident identified as an unsafe smoker that required supervision, on 09/17/2024 at 9:00 a.m. when the resident was observed alone smoking a cigarette in an unapproved smoking area without the presence of staff. On 09/19/2024 at 9:25 a.m., Resident #75, a resident listed as a nonsmoker, was observed smoking unsupervised outside of his room with smoking paraphernalia. On 09/19/2024 at 10:55 a.m., Resident #49, a resident assessed as an unsafe smoker, was observed with smoking paraphernalia in his possession at an undesignated smoking time and area. Staff interviews revealed the facility did not have an effective system to assess and implement interventions for smokers. S1ADM was notified of the immediate jeopardy situation on 09/19/2024 at 4:40 p.m. The Immediate Jeopardy was removed on 09/20/2024 at 3:10 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at the potential for more than minimal harm for any resident requiring assessment, supervision or interventions for smoking safety. Findings: Review of facility's undated policy titled Smoking Policy revealed, in part: 1. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas at designated times, and in accordance with care plan. 2. Residents who are assessed as not being able to smoke safely will not be allowed to smoke without supervision. 3. If a resident exhibits dangerous behaviors with smoking paraphernalia such as smoking in non-designated areas . the resident will be considered unsafe to maintain smoking paraphernalia and it will be maintained for the resident at the nurse's station or other specified location. 10. All personnel caring for residents with smoking restrictions will be alerted to the interventions. Resident #87 Review of Resident #87's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included: Quadriplegia C5-C7 incomplete, Tobacco use, Hereditary and Idiopathic Neuropathy, Progressive Spinal Muscle Atrophy, Central Cord Syndrome at C7 level of Cervical Spinal Cord Sequela, nicotine dependence. Review of Resident #87's admission MDS with an ARD of 06/20/2024 revealed a BIMS of 15, which indicated he was cognitively intact. Further review revealed functional limitations in range of motion to bilateral sides, current tobacco use, and that resident was dependent on staff for eating, oral hygiene, and toileting, dressing and personal hygiene. Review of Resident #87's safe smoking evaluation dated 06/19/2024 at 8:57 a.m. completed per S36LPN revealed: Range of motion with limitations, weak grasp with difficulty holding smoking material, impaired ability to see adequate light, smoking materials used by the resident cigarettes, resident is unable to independently and safely light smoking materials. Resident was deemed an unsafe smoker. Review of Physician's Orders dated 06/26/2024 revealed: Resident is deemed as an unsafe smoker. Review of Resident #87's Nurse's Note dated 07/27/2024 at 9:04 a.m. revealed the resident was informed by staff that smoking on the patio was not allowed and Resident #87 was informed of the designated area by the dining room with a smoker's aid. Signed by: S32LPN Review of Resident #87's current Care Plan revealed the following, in part: Problem: 09/01/2024-Resident wishes to smoke and is designated an unsafe and impaired smoker. This smoker requires observation or constant supervision or protective gear. Interventions: Provide resident with the following while smoking: observation, constant supervision, protective gear. An observation was conducted of Resident #87 on 09/17/2024 at 9:00 a.m. Resident #87 was smoking unsupervised on the patio outside of his room without protective gear. He had in his possession a pack of cigarettes and a yellow lighter. An observation was conducted of Resident #87 on 09/17/2024 at 3:33 p.m. Resident #87 was smoking unsupervised on the patio outside of his room without a protective gear. The resident was observed leaning forward in his wheelchair and using the hand rail to knock the ashes off the lit cigarette in his mouth. Numerous smoked cigarette butts were noted on the ground by his outdoor patio. An interview was conducted with Resident #87 on 09/17/2024 at 11:14 a.m. Resident #87 reported he smoked about a half pack of cigarettes a day, usually on his outdoor patio. He reported he can light his cigarette, but it takes two hands. An interview was conducted with S29MDS on 09/17/2024 at 4:11 p.m. S29MDS reported she was responsible for performing smoking assessments. She confirmed Resident #87 was an unsafe smoker due to limited motion with his hands, and should not have possession of cigarettes and lighters. She confirmed she was unaware Resident #87 was smoking unsupervised without protective gear in undesignated areas. An interview was conducted with S33LPN on 09/17/2024 at 3:59 p.m. S33LPN confirmed Resident #87 was an unsafe smoker. She confirmed she was unaware he was smoking unsupervised without protective gear in undesignated areas. An interview was conducted with S8CNS on 09/17/2024 at 4:26 p.m. S8CNS reported she was unaware Resident #87 was smoking unsupervised without protective gear in an undesignated area. An interview was conducted with S25AD on 09/18/2024 at 9:07 a.m. S25AD reported she was unaware which residents were safe or unsafe smokers, until she was provided a list on 09/17/2024 by administration staff. She confirmed she bought Resident #87 three packs of cigarettes and placed them in his top television dresser drawer in the past. An interview was conducted with S24SA on 09/18/2024 at 10:43 a.m. S24SA reported she was employed by the facility on 09/09/2024. She stated she was not provided with a safe or unsafe smokers list until the evening of 09/17/2024. She stated prior to 0917/2024 she was unaware of who was a safe or unsafe smoker or the interventions required. She reported the facility provided a lock box for resident's cigarettes on the evening of 09/17/2024. She stated prior to 09/17/2024 she did not have a lock box and each resident held their own cigarettes. An interview was conducted with S32LPN on 09/19/2024 at 12:05 p.m. S32LPN confirmed knowing Resident #87 was smoking in undesignated areas in July. She confirmed she did not report this incident to administration. An interview was conducted with S1ADM on 09/19/2024 at 1:04 p.m. S2DON, S16CON, and S1ADM were present for the interview. S1ADM confirmed residents should only be smoking in the designated smoking area. S16CON confirmed unsafe smokers should not possess cigarettes or lighters and should only smoke during constant supervision. Resident #75 Review of Resident #75's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included, in part, the following; Cerebral Infarction; Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side; Generalized Muscle Weakness; and Lack of Coordination. Further review of the clinical record revealed no documentation of Resident #75 being a smoker or a safe smoking evaluation being completed. Review of Resident #75's most recent MDS, with an ARD of 07/03/2024, revealed a BIMS of 15, which indicated the resident was cognitively intact. Further review revealed the resident required assistance from staff for eating, oral hygiene, toileting, showering/bathing and dressing. Review of the facility's Resident Smoker List conducted on 09/17/2024 revealed Resident #75 was not on the list to indicate he was a smoker. Review of Resident #75's Care Plan and Physician's Orders, dated 06/26/2024 through 09/17/2024, revealed no documentation of the resident's smoking status and needs. Review of Resident #75's Nurses Notes, dated 06/26/2024 through 09/17/2024, revealed staff were aware the resident smoked on the following dates: 07/01/2024 at 11:31 a.m. by S43LPN; 07/01/2024 at 7:15 p.m. by S43LPN; 08/16/2024 at 3:57 p.m. by S33LPN; 08/20/2024 at 3:55 a.m. by S42LPN; and 08/22/2024 at 5:48 a.m. by S42LPN. An observation and interview was conducted on 09/17/2024 at 9:25 a.m. with Resident #75. Resident #75 was observed seated in his wheelchair smoking a cigarette on the patio outside of his room. He confirmed this was where he typically smoked. A pack of cigarettes and a lighter were present in the cup holder of Resident #75's wheelchair. Resident #75 confirmed his smoking paraphernalia remained in his possession at all times and he was not aware of a designated smoking area. Resident #75 confirmed he was a smoker and had been since he was admitted to the facility in June 2024. Resident #75 confirmed he had not been assessed for smoking safety since he was admitted . An observation was conducted on 09/18/2024 at 9:25 a.m. of Resident #75 seated in his wheelchair inside of his room with a pack of cigarettes and a lighter in the cup holder. An interview was conducted on 09/19/2024 at 9:10 a.m. with S43LPN. S43LPN confirmed knowing Resident #75 was a smoker since he was admitted to the facility in June 2024. S43LPN confirmed Resident #75 frequently smoked on the patio outside of his room. S43LPN confirmed the patio outside of a resident's room was not considered a designated smoking area. S43LPN confirmed Resident #75 was allowed to keep his cigarettes and lighter on him at all times. S43LPN confirmed Resident #75 was not on the smokers list but she assumed he was left off by mistake. S43LPN confirmed floor nurses were not responsible for identifying a resident as a safe or unsafe smoker. S43LPN stated floor nurses and floor CNAs did not monitor residents while outside or hold their cigarettes or lighters. S43LPN confirmed she never made the MDS nurses aware Resident #75 was a smoker because they should be given that information by the admission team upon admit. S43LPN confirmed she was unaware floor nurses should alert anyone to a resident's smoking status. An interview was conducted on 09/18/2024 at 9:45 a.m. with S29MDS. S29MDS confirmed Resident # 75 was not identified as a smoker since admission to the facility. S29MDS confirmed Resident #75 had never been assessed to determine if he was a safe or unsafe smoker. S29MDS confirmed the MDS team had not been made aware Resident #75 was a smoker and required a safe smoking assessment. S29MDS stated when a resident was admitted to the facility, it was the responsibility of the floor nurse to alert the MDS team if a safe smoking evaluation was needed. S29MDS confirmed all residents who smoke should be identified immediately then assessed as either a safe or unsafe smoker with necessary interventions identified. S29MDS stated once a resident was identified as a smoker and determined safe or unsafe, they were added to the facility's smoker list and the list was updated for staff to reference. An interview was conducted on 09/19/2024 at 1:04 p.m. with S16CON. S16CON confirmed MDS was responsible for performing safe smoking assessments then updating the resident's plan of care. S16CON confirmed direct care staff should access care task in the computer for information on which residents are safe and unsafe smokers. S16CON confirmed all smoking residents should be assessed for smoking safety upon their admission. S16CON confirmed the facility had only one designated smoking area, which was the smoking patio to the rear of the dining room. S16CON confirmed residents should only smoke in the designated smoking area, not on the patios off of their rooms. An interview was conducted on 09/19/2024 at 6:00 p.m. with S1ADM. S1ADM stated when a resident was admitted to the facility, the facility reviewed their hospital paperwork to determine if they were a smoker. S1ADM stated the person completing the admission should also ask cognitive and verbal residents or their family member if they are a smoker. S1ADM stated once an admitting resident was identified as a smoker, MDS should be alerted by the person completing the admission that a safe smoking assessment should be performed. S1ADM confirmed all smoking residents should be assessed for being a safe or unsafe smoker. S1ADM reviewed Resident #75's admission paperwork and confirmed it indicated Resident #75 was not a smoker. S1ADM stated Resident #75's smoking status was obtained from his hospital paperwork not resident interview. S1ADM confirmed Resident #75 was cognitive and verbal and should have been interviewed regarding his smoking status during the admission process and he was not. S1ADM confirmed if floor staff observed Resident #75 as a smoker and did not see him on the smoker list, they should have alerted MDS or their supervisor to ensure the proper assessments had been completed. S1ADM confirmed upon Resident #75's admission to the facility, the facility failed to identify Resident #75 as a smoker and a safe smoking assessment was not performed. S1ADM confirmed residents were required to smoke in the designated smoking area where staff were present to supervise. S1ADM confirmed the patio off of resident rooms was not a designated smoking area and staff should not have allowed residents, including Resident #75, to smoke there. Resident #49 Review of the clinical record revealed Resident #49 was admitted to the facility on [DATE] with diagnosis which included Tobacco Use and Nicotine dependence, cigarettes. Review of Resident #49's most recent MDS, with an ARD 08/29/2024, revealed a BIMS of 15, which indicated the resident was cognitively intact. Further review revealed the resident used a manual wheelchair and required set up and clean up assistance with eating, partial to moderate assistance with toileting and bathing, and supervision or touching assistance with transfers. Review of Resident #49's Safe Smoking Evaluation dated 06/14/2024 revealed the resident was noncompliant in following smoking policies and all smoking materials must be kept at the nurse's station. Review of Resident #49's Physicians order dated 09/16/2024 revealed the following in part: Unsafe smoker: All smoking paraphernalia to be kept at nurse's station. Review of Resident #49's current Care Plan revealed the following: Problem: 08/29/2024 Resident wishes to smoke and is designated an Impaired Smoker. This smoker requires: observation or constant supervision history of smoking in room. Interventions: Resident will smoke safely at designated areas at scheduled times through next review, Provide resident with the following while smoking : Observation, Resident oriented to smoking procedure and areas, Resident will ask for smoking materials at main nurse's station An observation was made of Resident #49 on 09/19/2024 at 10:55 a.m. Resident #49 was sitting in his wheelchair with cigarettes beside him and lighter in his wheelchair cup holder. An interview was conducted with S12LPN on 09/19/2024 at 4:50 p.m. S12LPN stated Resident #49 was an unsafe smoker and should not keep his own smoking materials. An observation was conducted of Resident #49 on 09/19/2024 at 11:10 a.m. Resident #49 was observed in the hallway on his way to the smoking patio with cigarettes and a lighter in his possession. Immediately following the observation, S20SW walked into hallway and confirmed the resident had cigarette paraphernalia with him, she confirmed if a resident was assessed as an unsafe smoker they should not have smoking materials in their possession. An interview was conducted with S16CON on 09/19/2024 at 11:15a.m. S16CON confirmed Resident #49 had cigarettes and a lighter in his possession. She confirmed Resident #49 was an unsafe smoker and should not have the above in his possession.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety, as determined by resident assessments and individual plans of care. The facility failed to ensure: 1. An effective system was in place to ensure licensed nurses and nurse aids were competent to identify and implement a resident's assessed transfer needs for 1 (#54) of 4 (#32, #38, #54, and #66) residents reviewed requiring a Hoyer lift for transfers; and 2. An effective system was in place to ensure licensed nurses and nurse aids were competent to identify and implement safe smoking interventions for residents who smoked for 3 (#49, #75, #87) of 4 (#49, #58, #75, and #87) residents reviewed for smoking; and 3. An effective system was in place to ensure licensed nurses and nurse aids were competent in the skill sets required to meet resident needs for 10 of 10 (S4CNA, S9WCN, S11CNA, S24CNA, S27CNA, S38CNA, S40CNA, S43LPN, S47CNA, and S48CNA) personnel files reviewed for documentation of skills competency. 1. This deficient practice resulted in an immediate jeopardy situation for Resident #54, a resident who required a Hoyer lift and 2 staff members' assistance for transfers, on 08/28/2024 at 3:45 p.m. when S4CNA transferred Resident #54 independently without a Hoyer lift. Resident #54 fell to the floor and sustained a laceration above her left eyebrow. Resident #54 was transferred to a local hospital, diagnosed with a Left Frontal Scalp Contusion, and required a tissue adhesive. The immediate jeopardy continued when interviews with CNAs and Nursing staff revealed they did not know how to identify residents' assessed transfer needs. S1ADM was notified of the Immediate Jeopardy on 09/19/2024 at 4:40 p.m. The Immediate Jeopardy was removed on 09/20/2024 at 3:10 p.m., as confirmed by onsite verification through observations, interviews and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at the potential for more than minimal harm for any of the 75 residents requiring assistive devices and/or supervision with transfers. Cross Reference: F-689. Findings: 1. Review of the facility's undated policy titled, Safe Lifting and Movement of Residents revealed the following, in part: Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents'. Policy Interpretation and Implementation: 6. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Resident #54 Review of Resident #54's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Primary Disorders of Muscles, History of Falling, Generalized Muscle Weakness, Spinal Stenosis, and Primary Generalized Osteoarthritis. Review of Resident #54's MDS with an ARD of 07/26/2024 revealed, in part, a BIMS summary score of 12, which indicated moderate cognitive impairment. Further review of the MDS revealed she was dependent on staff for transfers. Review of Resident #54's Physical Therapy Note dated 07/25/2024 revealed, in part, she required a Hoyer lift for transfers. Review of Resident #54's current Care Plan revealed no documentation of the amount of assistance, supervision, and/or assistive devices required for transfers. Review of Resident #54's Resident Summary on 09/18/2024 in the clinical record revealed no documentation of the amount of supervision and/or assistive devices Resident #54 required for transfers. An interview was conducted with Resident #54 on 09/17/2024 at 3:15 p.m. She stated, at the end of August 2024, S4CNA dropped her during a transfer. She stated, at the time of the transfer, she required a Hoyer lift with the assistance of two staff members for transfers. She explained S4CNA attempted to transfer her independently without a Hoyer lift, and she fell face first onto the floor. She stated, as a result of the fall, she sustained a laceration above her left eye, which required gluing in the Emergency Room. An interview was conducted with S4CNA on 09/17/2024 at 4:00 p.m. She stated, at the end of August 2024, she was assigned to Resident #54 on the evening shift. She confirmed, at the time of the incident, she was unaware how to identify a resident's transfer status. She stated Resident #54 was cognitively intact so she asked the resident how much assistance she needed to be transferred from the bed to the wheelchair. She stated she attempted to transfer Resident #54 independently without the use of the Hoyer lift, and Resident #54 fell and landed on the floor face first. An interview was conducted with S4CNA on 09/18/2024 at 3:40 p.m. She stated upon hire she was made aware verbally of what each resident required in only the resident section she was working in. She stated she was not trained on how to determine the amount of assistance and/or supervision a resident needed for transfers. She stated she made her own assessment of the resident or asked the resident how much assistance they needed for transfers. She stated she had not been observed by anyone to ensure she was competent in performing tasks. An interview was conducted with S34LPN on 09/18/2024 at 2:29 p.m. She stated she was the nurse assigned to Resident #54 when she fell on [DATE] at 3:46 p.m. She stated, at the time of the incident, she was unaware of the amount of assistance and supervision Resident #54 required with transfers, and she was unaware how to determine the amount of assistance and supervision Resident #54 required. An interview was conducted with S35RD on 09/18/2024 at 12:12 p.m. She stated Resident #54 has required a Hoyer lift for transfers since 07/25/2024. An interview was conducted with S11CNA on 09/18/2024 at 9:09 a.m. She stated if she did not know the transfer status of a resident she would ask another staff or the resident. An interview was conducted with S37TP on 09/18/2024 at 9:18 a.m. She stated she was unaware of how to determine the transfer status of a resident. She stated if she was unsure of a resident's transfer status, she would ask another CNA or the resident. An interview was conducted with S38CNA on 09/18/2024 at 9:47 a.m. She stated there was not a particular place to look to identify a resident's transfer status. She stated when a new resident came into the facility, therapy evaluated them and verbally notified the CNAs how much assistance was needed. She confirmed the only way to know a resident's transfer status was by verbal communication. An interview was conducted with S39CNA on 09/18/2024 at 9:57 a.m. She stated she worked with residents every day and was familiar with each resident's capability. She stated she would transfer each resident based on that resident's capability. An interview was conducted with S27CNA on 09/18/2024 at 10:20 a.m. She stated verbal communication was how she knew how much assistance and supervision each resident required for transfers. She stated if she was unsure how much assistance or supervision the resident required for transfers, she would ask another CNA, the CNA supervisor, or the resident. She stated if a resident's transfer status changed, she was not sure she would be aware. An interview was conducted with S40CNA on 09/18/2024 at 1:15 p.m. She stated she determined how much assistance and supervision each resident required based on her own assessment. She stated there was nowhere for her to go and look to see what therapy determined was the safest for resident transfers. She reviewed Resident #54's ADL charting and Resident Summary and confirmed there was nowhere in the chart indicating the amount of supervision and/or assistance Resident #54 required for transfers. An interview was conducted with S29MDS and S36LPN on 09/19/2024 at 9:09 a.m. S29MDS reviewed Resident #54's Therapy Note dated 07/25/2024 and confirmed that was the date Resident #54 was determined to require a Hoyer lift for transfers. S29MDS stated the direct care staff were verbally notified of Resident #54 requiring a Hoyer lift for transfers on 07/25/2024. S29MDS confirmed Resident #54 required a Hoyer lift with the assistance of two staff members at the time of her incident on 08/28/2024. S29MDS and S36LPN both stated they were unaware they were responsible to update the Resident Summary until the afternoon of 09/18/2024. S29MDS and S36LPN both stated they did not know how, and were not trained, to update, anything in a resident's record for the nurses and CNAs to visualize the amount of assistance or supervision required for transfers. S29MDS and S36LPN both stated the way the CNAs and nurses knew a resident's transfer status was verbal communication. An interview was conducted with S16CON on 09/18/2024 at 1:37 p.m. She stated the facility's process to determine a resident's transfer status was for therapy to assess the resident and notify nursing. She stated MDS Nurses were responsible to update the resident's chart, which included the Resident Summary so direct care staff would be able to identify the current transfer status. She stated the amount of assistance and supervision each resident required with transfers, or transfer status, should have been listed on the resident's Resident Summary. She stated all direct care staff should have known to look at the Resident Summary to determine the transfer status. She stated it was never acceptable for a CNA to self-assess a resident or ask the resident to determine transfer status. She stated if a resident was assessed by therapy to require a Hoyer lift for transfers, a Hoyer lift with two staff members should have been used for transfers. An interview was conducted with S3ADN on 09/19/2024 at 9:50 a.m. She stated competency checks and skills checkoffs were supposed to be conducted on newly hired nursing staff by herself and S2DON, and CNAs were to be completed by S8CNS, however, competency and skills checkoffs had not been completed and there was no documentation they had been completed. She stated prior to yesterday afternoon, the amount of staff required and how to transfer a resident was not listed in the residents' clinical record, including the Resident Summary, for the CNAs to see. She stated prior to yesterday afternoon, the only process the facility had in place for a resident's transfer status was by word of mouth. She stated it was not acceptable for a CNA to assess a resident for their transfer status. 2. This deficient practice resulted in an Immediate Jeopardy situation for Resident #87, a resident identified as an unsafe smoker that required supervision, on 09/17/2024 at 9:00 a.m. when the resident was observed alone smoking a cigarette in an unapproved smoking area without the presence of staff or protective gear. On 09/19/2024 at 9:25 a.m., Resident #75, a resident listed as a nonsmoker, was observed smoking outside of his room with smoking paraphernalia unsupervised. On 09/19/2024 at 10:55 a.m., Resident #49, a resident assessed as an unsafe smoker, was observed with smoking paraphernalia in his possession at an undesignated smoking time and area. Staff interviews revealed the facility did not have an effective system to assess and implement interventions for smokers. The Immediate Jeopardy continued when interviews with CNAs and Nursing Staff revealed they did not know their role in identifying, assessing and implementing safe smoking interventions for residents who smoked. S1ADM was notified of the immediate jeopardy situation on 09/19/2024 at 4:40 p.m. The Immediate Jeopardy was removed on 09/20/2024 at 3:10 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at the potential for more than minimal harm for any of the 26 residents identified by the facility as being a smoker. Findings: 2. Review of facility's undated policy titled Smoking Policy revealed, in part: 1. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas at designated times, and in accordance with care plan. 2. Residents who are assessed as not being able to smoke safely will not be allowed to smoke without supervision. 3. If a resident exhibits dangerous behaviors with smoking paraphernalia such as smoking in non-designated areas . the resident will be considered unsafe to maintain smoking paraphernalia and it will be maintained for the at the nurses station or other specified location. 10. All personnel caring for residents with smoking restrictions will be alerted to the interventions. Resident #87 Review of Resident #87's Clinical Record revealed he was admitted to facility on 06/14/2024 with diagnoses which included: Tobacco use, and nicotine dependence. Review of Resident #87's Safe Smoking Evaluation dated 06/19/2024 at 8:57 a.m. completed per S36LPN revealed Resident #87 was deemed an unsafe smoker. Review of Physician's Orders dated 06/26/2024 revealed: Resident is deemed as an unsafe smoker. Review of Resident #87's current Care Plan revealed the following, in part: Problem: Onset date of 09/01/2024, Resident wishes to smoke and is designated an unsafe and impaired smoker. This smoker requires observation or constant supervision or protective gear. Further review revealed Resident #87 did not have a care plan for smoking prior to 09/01/2024. An observation was conducted of Resident #87 on 09/17/2024 at 3:33 p.m. Resident #87 was smoking unsupervised on the patio outside of his room without protective gear. The resident was observed leaning forward in his wheelchair and using the hand rail to knock the ashes off the lit cigarette in his mouth. Numerous smoked cigarette butts were noted on the ground by his outdoor patio. An interview was conducted with S29MDS at 4:11 p.m. She confirmed she was responsible for performing smoking assessments. She confirmed Resident #87 was an unsafe smoker due to limited motion with his hands, and should not have possession of cigarettes and lighters. She confirmed floor nurses and floor CNAs were responsible to notify her if they observed residents smoking in undesignated areas and/or without their smoking interventions. An interview was conducted with S25AD on 09/18/2024 at 9:07 a.m. She reported being unaware which residents were safe or unsafe smokers, until provided a list on 09/17/2024 per administration staff. She confirmed she bought Resident #87 three packs of cigarettes and placed them in his top television dresser drawer in the past without knowing he was an unsafe smoker. An interview was conducted with S24SA on 09/18/2024 at 10:43 a.m. She stated since she was employed she was not provided with a safe or unsafe smokers list until the evening of 09/17/2024, and she would depend on staff to tell her which were safe or unsafe smokers. She stated prior to 09/17/2024 she was unaware of who was a safe or unsafe smoker or the interventions required. She reported the facility provided a lock box for resident's cigarettes on the evening of 09/17/2024. She stated prior to 09/17/2024 she did not have a lock box and each resident held their own cigarettes. An interview was conducted with S32LPN on 09/19/2024 at 12:05 p.m. She confirmed knowing Resident #87 was smoking in undesignated areas in July. She confirmed she did not report this incident to administration as she thought they read her nurse's notes. An interview was conducted with S1ADM on 09/19/2024 at 1:04 p.m. He confirmed the facility's process for a newly admitted resident was to review their History and Physical, assess the resident and if they were a smoker, and if so MDS would perform a smoking evaluation. He confirmed the MDS nurses were responsible to update the computer system which staff could review to identify any safe or unsafe smokers. He reported MDS was also responsible for verbally communicating any changed smoking interventions with the staff during the 2:00 p.m. staff meeting. He confirmed residents should only smoke in the designated smoking area, unsafe smokers should not possess cigarettes or lighters, and unsafe smokers should only smoke during constant supervision. Resident #75 Review of Resident #75's Clinical Record revealed an admission date of 06/26/2024. Review of Resident #75's most recent MDS, with an ARD of 07/03/2024, revealed a BIMS of 15, which indicated the resident was cognitively intact. Review of the facility's Resident Smoker List conducted on 09/17/2024 revealed Resident #75 was not on the list to indicate he was a smoker. Review of Resident #75's Safe Smoking Evaluation on 09/17/2024 revealed no documented evidence a smoking evaluation was completed. Review of Resident #75's Physician Orders, dated 06/26/2024 through 09/17/2024, regarding his smoking status was attempted on 09/17/2024 with no documented evidence available for review. Review of Resident #75's current Care Plan, as of 09/17/2024, regarding his smoking status was attempted with no documented evidence available for review. Review of Resident #75's Nurses Notes revealed staff were aware the resident smoked on the following dates: 07/01/2024 at 11:31 a.m. by S43LPN; 07/01/2024 at 7:15 p.m. by S43LPN; 08/16/2024 at 3:57 p.m. by S33LPN; 08/20/2024 at 3:55 a.m. by S42LPN; and 08/22/2024 at 5:48 a.m. by S42LPN. An observation and interview was conducted with Resident #75 on 09/17/2024 at 9:25 a.m. Resident #75 was seated in his wheelchair smoking a cigarette on the patio outside of his room and confirmed this was where he typically smoked. Resident #75 confirmed he was a smoker and had been since he admitted to the facility in June of 2024. Resident #75 confirmed he had not been assessed for smoking safety since he was admitted nor had any members of the staff observed him smoking. A pack of cigarettes and a lighter was present in the cup holder of Resident #75's wheelchair. Resident #75 confirmed his smoking paraphernalia remained in his possession at all times and he was not aware he was only supposed to smoke in a designated smoking area. An interview was conducted with S29MDS on 09/18/2024 at 9:45 a.m. S29MDS stated upon a resident's admission to the facility, it was the responsibility of the floor nurse to alert the MDS team if a resident was a smoker so they could be assessed for smoking safety. S29MDS confirmed the MDS team was responsible for performing resident smoking assessments to determine safe or unsafe smoker. S29MDS confirmed the MDS team was responsible for using the smoking assessment results to update a resident's care plan with smoking interventions to ensure resident safety. S29MDS confirmed the MDS team was responsible for updating the facility's list of smoking residents, which also identified if they were safe or unsafe. S29MDS stated the list of smoking residents was kept at all nurses stations and all staff were expected to use it and assist with ensuring interventions were implemented. S29MDS stated if a resident was not on the list as a smoker but staff saw them smoking, the staff member should alert MDS to perform a smoking assessment. S29MDS confirmed all residents who smoke should be identified immediately and assessed as either a safe or unsafe smoker with necessary interventions identified and implemented. S29MDS confirmed Resident #75 was admitted to the facility on [DATE]. S29MDS confirmed the MDS team was not aware Resident #75 was a smoker. S29MDS confirmed Resident #75 was not assessed to determine if he was a safe or unsafe smoker and if he required any interventions for smoking safety. An interview was conducted with S33LPN on 09/18/2024 at 10:45 a.m. S33LPN confirmed she was aware Resident #75 was a smoker and could not say if he was on the smoking list or not. S33LPN confirmed Resident #75 frequently smoked on the patio outside of his room. S33LPN confirmed Resident #75 was allowed to keep his cigarettes and lighter on him at all times. S33LPN confirmed she never made the MDS nurses or anyone else aware Resident #75 was a smoker and was not aware she should. An interview was conducted with S27CNA on 09/19/2024 at 8:51 a.m. S27CNA stated if she saw a change in a resident's smoking status, she would check the list to see if they were safe or unsafe but was unaware she should alert anyone to their change in smoking status. An interview was conducted with S40CNA on 09/19/2024 at 9:00 a.m. S40CNA confirmed she frequently trained newly hired CNAs. S40CNA confirmed she did not provide any training to new hires regarding the facility's smoking procedure, identifying safe smokers, designated smoking areas or implementing safe smoking interventions. S40CNA confirmed floor CNAs did not have anything to do with the smoking process or alerting anyone of a newly admitted resident being a smoker. An interview was conducted with S43LPN on 09/19/2024 at 9:10 a.m. S43LPN confirmed she had been aware Resident #75 was a smoker since he admitted to the facility in June 2024. S43LPN confirmed Resident #75 frequently smoked on the patio outside of his room. S43LPN confirmed Resident #75 had been allowed to keep his cigarettes and lighter on him at all times. S43LPN confirmed Resident #75 was not on the smokers list and she assumed he was left off by mistake. S43LPN confirmed she never made the MDS nurses or anyone else aware Resident #75 was a smoker and was not aware she should. S43LPN stated she was under the impression residents were assessed for smoking status during admission and if they were a smoker they would be added to a list for MDS to assess for safety then the facility's overall list would be updated afterwards. S43LPN confirmed she was never trained or made aware of anything she should be doing or responsible for in regards to identifying or implementing interventions for smoking residents. S43LPN confirmed the patio outside of a resident's room was not considered a designated smoking area. S43LPN confirmed she had never intervened to have them smoke in the designated area. S43LPN confirmed she was not aware direct care staff were responsible for intervening when residents smoked in undesignated areas or when they were not following smoking safety protocol. S43LPN confirmed she was not aware direct care staff were responsible for confiscating smoking paraphernalia from residents who were not supposed to have it in their possession. S43LPN confirmed she was not aware direct care staff were responsible for monitoring residents while outside, even if smoking, and were responsible for holding smoking paraphernalia at the nurses station then handing it out at smoking times. S43LPN confirmed she was not aware floor nurses were responsible for identifying a resident as a safe or an unsafe smoker and were responsible for notifying anyone of a resident's smoking status. S43LPN confirmed she was unaware floor nurses should alert anyone to a resident's smoking status. S43LPN confirmed she could not recall receiving any specific training on the smoking policy or her responsibilities in regards to residents who smoke. S43LPN stated she the facility had a smoking attendant so anything smoking related was their responsibility. An interview was conducted with S34LPN on 09/19/2024 at 9:15 a.m. S34LPN confirmed she was unaware she should know if a resident was a safe or unsafe smoker and did not know where to find that information. S34LPN confirmed she was unaware she should notify anyone of a resident's change in smoking status. An interview was conducted with S16CON on 09/19/2024 at 1:04 p.m. S16CON confirmed the MDS team was responsible for performing safe smoking assessments then updating the resident's plan of care, and updating administrative staff during the daily 2pm staff meeting. S16CON reported the MDS team would verbally alert direct care staff of any changes in interventions. S16CON confirmed direct care staff should access care tasks in the computer charting system to review information on which residents are safe or an unsafe smokers and what interventions should be implemented for each resident. S16CON confirmed the smoking policy and resident specific smoking interventions should be monitored and implemented by all members of staff to ensure resident safety. S16CON confirmed all smoking residents should be assessed for smoking safety upon their admission. S16CON confirmed if a resident was found to be a smoker but had not been identified previously, she would expect the person who identified the information to alert their supervisor or the MDS team so a smoking assessment could be performed. S16CON confirmed the facility had only one designated smoking area, which was the smoking patio to the rear of the dining room. S16CON confirmed residents should only smoke in the designated smoking area, not on the patios off of their rooms. S16CON confirmed she would expect floor staff to inform residents not to smoke on their patios and to make their supervisor or someone in administration aware if a resident remained noncompliant with this policy. An interview was conducted with S1ADM on 09/19/2024 at 6:00 p.m. S1ADM stated when a resident was admitted to the facility, the facility reviewed their hospital paperwork to determine if they were a smoker. S1ADM stated the person completing their admission paperwork should also interview the resident or their family member to confirm if they were a smoker. S1ADM stated once a resident was identified as a smoker, MDS should be alerted by the person completing the admission that a safe smoking assessment should be performed. S1ADM confirmed if a resident was found to be a smoker but had not been identified previously, he would expect the person who identified the information to alert their supervisor or the MDS team so a smoking assessment could be performed. S1ADM confirmed all smoking residents should be assessed for being a safe or unsafe smoker. S1ADM confirmed residents were required to smoke in the designated smoking area where staff were present to supervise. S1ADM confirmed the patio off of resident rooms was not considered a designated smoking area and staff should not have allowed residents to smoke there. S1ADM reviewed Resident #75's admission paperwork and confirmed it indicated Resident #75 was not a smoker. S1ADM stated Resident #75's smoking status was obtained from his hospital paperwork received prior to admission. S1ADM confirmed Resident #75's smoking status should have also been verified with him upon admission. S1ADM confirmed if floor staff later identified Resident #75 to be a smoker and did not see him on the smoker list, they should have alerted MDS or their supervisor to ensure the proper assessments were completed. S1ADM confirmed upon Resident #75's admission to the facility, the facility failed to identify Resident #75 as a smoker and a safe smoking assessment was not performed. S1ADM confirmed floor staff should not have been allowing Resident #75 to smoke unsupervised on his patio. Resident #49 Review of the clinical record revealed Resident #49 was admitted to the facility on [DATE] with diagnosis which included Tobacco Use and Nicotine dependence, cigarettes. Review of Resident #49's Safe Smoking Evaluation, dated 6/14/2024, revealed resident was noncompliant in following smoking policies and all smoking materials must be kept a the nurses station. Review of Resident #49's current Physicians Order revealed, in part, the following: 09/16/2024 - Unsafe smoker: All smoking paraphernalia to be kept at nurse's station. Review of Resident #49's Care Plan revealed, in part, the following: Problem: 8/29/2024 - Resident wishes to smoke and is designated an Impaired Smoker. This smoker requires observation or constant supervision. Has a history of smoking in his room. Further review revealed Resident #87 did not have a care plan for smoking prior to 08/29/2024. An observation was made of Resident #49 on 09/19/2024 at 10:55 a.m. Resident #49 was sitting in his wheelchair with cigarettes beside him and lighter in his wheelchair cup holder. An observation was conducted of Resident #49 on 09/19/2024 at 11:10 a.m. Resident #49 was observed in the hallway on his way to the smoking patio with cigarettes and a lighter in his possession. Immediately following the observation, S20SW walked into hallway and confirmed the resident had cigarette paraphernalia with him, she confirmed if a resident was assessed as an unsafe smoker they should not have smoking materials in their possession. 3. Review of the facility's Competency Skills Check Offs was attempted for the following employees with no documented evidence produced for review: S4CNA; S9RN; S11CNA; S24CNA; S27CNA; S38CNA; S40CNA; S43LPN; S47CNA; and S48CNA. An interview was conducted with S9RN on 09/19/2024 at 8:54 a.m. S9RN confirmed she began working at the facility 2 months ago. S9RN confirmed the facility did not require her to perform competency skills check offs prior to being allowed to provide care to residents independently. An interview was conducted with S27CNA on 09/19/2024 at 9:09 a.m. S27CNA confirmed she was responsible for training newly hired CNAs. S27CNA confirmed she did not perform competency skills check offs for any of the newly hired CNAs and had never monitored them in other ways to ensure they were competent before they were allowed to provide direct resident care independently. S27CNA confirmed the facility had not required her to perform competency skills check offs annually. An interview was conducted with S43LPN on 09/19/2024 at 9:10 a.m. S43LPN stated she began working at the facility 6 months ago. S43LPN confirmed the facility did not require her to perform competency skills check offs prior to being allowed to provide direct resident care independently. An interview was conducted with S40CNA on 09/19/2024 at 9:00 a.m. S40CNA confirmed she frequently trained newly hired CNAs. S40CNA confirmed she would only teach the new hire the things she was doing in her normal day with her current resident assignment; there was no checklist of things to cover. S40CNA confirmed she did not perform competency skills check offs for any of the newly hired CNAs and had never monitored them in other ways to ensure they were competent before they were allowed to provide direct resident care independently. S40CNA confirmed the facility had not required her to perform competency skills check offs annually. An interview was conducted with S3ADN on 09/19/2024 at 10:07 a.m. S3ADN confirmed she, S8CNS, and S2DON were responsible for ensuring direct care staff were competent to perform their jobs. S3ADN stated CNAs, upon hire and annually, performed a competency skills check offs with either herself or S2DON. S3ADN confirmed she did not have any documentation of staff competency skills check offs. S3ADN confirmed new hire and annual competency skills check offs were given to the human resources department to be kept in employee files. An interview was conducted with S31HR on 09/19/2024 at 9:07 a.m. S31HR confirmed she was responsible for maintaining personnel files. S31HR confirmed she was never given any new hire or annual competency skills check offs to be put in employee files. S31HR reviewed the requested personnel files and confirmed the files did not contain any competency skills check offs in them. An interview was conducted with S2DON on 09/19/2024 at 9:01 a.m. S2DON stated training for direct care CNA's and LPN's consisted of 3 days of shadowing a preceptor on their assigned floor. S[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to: 1. Ensure licensed nurses and nurse aids were trained and competent to update, implement, and identify a resident's assessed transfer needs for 1 (#54) of 4 (#32, #38, #54, and #66) residents reviewed requiring a Hoyer lift for transfers; 2. Ensure licensed nurses and nurse aids were trained and competent to implement and identify safe smoking interventions for residents who smoked for 3 (#49, #75, #87) of 4 (#49, #58, #75, and #87) residents reviewed for smoking; and 3. Ensure licensed nurses and nurse aids were competent in the skills sets required to meet resident needs for 10 of 10 (S4CNA, S9RN, S11CNA, S24SA, S27CNA, S38CNA, S40CNA, S43LPN, S47CNA, and S48CNA) personnel files reviewed for competency skills check offs. Cross Reference: F689 and F726. 1. This deficient practice resulted in an immediate jeopardy situation for Resident #54, a resident who required a Hoyer lift and 2 staff members' assistance for transfers, on 08/28/2024 at 3:45 p.m. when S4CNA transferred Resident #54 independently without a Hoyer lift. Resident #54 fell to the floor and sustained a laceration above her left eyebrow. Resident #54 was transferred to a local hospital, diagnosed with a Left Frontal Scalp Contusion, and required a tissue adhesive. The immediate jeopardy continued when interviews with CNAs and Nursing staff revealed they did not know how to identify residents' assessed transfer needs. S1ADM was notified of the Immediate Jeopardy on 09/19/2024 at 4:40 p.m. The Immediate Jeopardy was removed on 09/20/2024 at 3:10 p.m., as confirmed by onsite verification through observations, interviews and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at the potential for more than minimal harm for any of the 75 residents requiring assistive devices and/or supervision with transfers. Findings: 1. Review of the facility's undated policy titled, Safe Lifting and Movement of Residents revealed the following, in part: Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents'. Policy Interpretation and Implementation: 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will documents resident transferring and lifting needs in the care plan. 6. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Review of S4CNA's personnel file revealed a hire date of 12/23/2023. Further review revealed no documented evidence of any performance evaluations or competency/skills check offs were completed. Review of S11CNA's personnel file revealed a hire date of 03/06/2024. Further review revealed no documented evidence of any performance evaluations or competency/skills check offs for safe lifting were completed. Review of S27CNA's personnel file revealed a hire date of 12/28/2020. Further review revealed no documented evidence of any performance evaluations or competency/skills check offs for safe lifting were completed. Review of S38CNA's personnel file revealed a hire date of 10/03/2023. Further review revealed no documented evidence of any performance evaluations or competency/skills check offs for safe lifting were completed. Resident #54 Review of Resident #54's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Primary Disorders of Muscles, History of Falling, Generalized Muscle Weakness, Spinal Stenosis, Major Depressive Disorder, and Primary Generalized Osteoarthritis. Further review revealed the resident was dependent on staff and required a Hoyer lift for transfers. Review of Resident #54's current Care Plan revealed no documentation of the amount of assistance, supervision, and/or assistive devices required for transfers. Review of Resident #54's Resident Summary in the clinical record revealed no documentation of the amount of supervision and/or assistive devices Resident #54 required for transfers. An interview was conducted with Resident #54 on 09/17/2024 at 3:15 p.m. She stated, at the end of August 2024, S4CNA dropped her during a transfer. She explained S4CNA attempted to transfer her independently without a Hoyer lift, and she fell face first onto the floor. She stated, as a result of the fall, she sustained a laceration above her left eye, which required gluing in the Emergency Room. An interview was conducted with S4CNA on 09/17/2024 at 4:00 p.m. She stated, at the end of August 2024, she was assigned to Resident #54 on the evening shift. She confirmed, at the time of the incident, she was unaware how to identify a resident's transfer status. She stated she attempted to transfer Resident #54 independently without the use of the Hoyer lift, and Resident #54 fell and landed on the floor face first. An interview was conducted with S34LPN on 09/18/2024 at 2:29 p.m. She stated she was the nurse assigned to Resident #54 when she fell on [DATE] at 3:46 p.m. She stated, at the time of the incident, she was unaware of the amount of assistance and supervision Resident #54 required with transfers, and she was unaware how to determine the amount of assistance and supervision Resident #54 required. An interview was conducted with S29MDS and S36LPN on 09/19/2024 at 9:09 a.m. S29MDS confirmed Resident #54 was determined to require a Hoyer lift for transfers on 07/25/2024. S29MDS stated direct care staff were verbally notified of Resident #54 requiring a Hoyer lift for transfers on 07/25/2024. S29MDS confirmed Resident #54 required a Hoyer lift with the assistance of two staff members at the time of her incident on 08/28/2024. S29MDS and S36LPN both stated they were unaware they were responsible to update the Resident Summary to show a resident's transfer status until the afternoon of 09/18/2024. S29MDS and S36LPN both stated they did not know how, and were not trained, to update anything in a resident's record for the nurses and CNAs to visualize the amount of assistance or supervision required for transfers. S29MDS and S36LPN both stated the way the CNAs and nurses knew a resident's transfer status was verbal communication. An interview was conducted with S16CON on 09/18/2024 at 1:37 p.m. She stated the facility's process to determine a resident's transfer status was for therapy to assess the resident and notify nursing. She stated MDS Nurses were responsible to update the resident's chart, which included the Resident Summary so direct care staff would be able to identify the current transfer status. She stated the amount of assistance and supervision each resident required with transfers, or transfer status, should have been listed on the resident's Resident Summary. She stated all direct care staff should have known to look at the Resident Summary to determine the transfer status. She stated it was never acceptable for a CNA to self-assess a resident or ask the resident to determine transfer status. She stated if a resident was assessed to require a Hoyer lift for transfers, a Hoyer lift with two staff members should have been used for transfers. She stated MDS should have updated the residents' Resident Summary for the CNA staff to determine a residents transfer needs. An interview was conducted with S3ADN on 09/19/24 at 9:50 a.m. She stated competency checks and skills checkoffs were supposed to be conducted on newly hired nursing staff by herself and S2DON, and CNAs were to be completed by S8CNS, however, competency and skills checkoffs had not been completed and there was no documentation they had been completed. She stated prior to yesterday afternoon, the amount of staff required and how to transfer a resident was not listed in the residents' clinical record for the CNAs to see. She stated prior to yesterday afternoon, the only process the facility had in place for a resident's transfer status was by word of mouth. She stated it was not acceptable for a CNA to assess a resident for their transfer status. 2. This deficient practice resulted in an Immediate Jeopardy situation for Resident #87, a resident identified as an unsafe smoker that required supervision, on 09/17/2024 at 9:00 a.m. when the resident was observed alone smoking a cigarette in an unapproved smoking area without the presence of staff or protective gear. On 09/19/2024 at 9:25 a.m., Resident #75, a resident listed as a nonsmoker, was observed smoking outside of his room with smoking paraphernalia unsupervised. On 09/19/2024 at 10:55 a.m., Resident #49, a resident assessed as an unsafe smoker, was observed with smoking paraphernalia in his possession at an undesignated smoking time and area. Staff interviews revealed the facility did not have an effective system to assess and implement interventions for smokers. The Immediate Jeopardy continued when interviews with CNAs and Nursing Staff revealed they did not know their role in identifying, assessing and implementing safe smoking interventions for residents who smoked. S1ADM was notified of the immediate jeopardy situation on 09/19/2024 at 4:40 p.m. The Immediate Jeopardy was removed on 09/20/2024 at 3:10 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at the potential for more than minimal harm for any of the 26 smoking residents requiring assessment, supervision or interventions for smoking safety. Findings: 2. Review of facility's undated policy titled Smoking Policy revealed, in part: 1. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas at designated times, and in accordance with care plan. 2. Residents who are assessed as not being able to smoke safely will not be allowed to smoke without supervision. 3. If a resident exhibits dangerous behaviors with smoking paraphernalia such as smoking in non-designated areas . the resident will be considered unsafe to maintain smoking paraphernalia and it will be maintained for the at the nurses station or other specified location. 10. All personnel caring for residents with smoking restrictions will be alerted to the interventions. Resident #87 Review of Resident #87's Clinical Record revealed he was admitted to facility on 06/14/2024 with diagnoses which included: Tobacco use, and nicotine dependence. Review of Resident #87's Safe Smoking Evaluation dated 06/19/2024 at 8:57 a.m. completed per S36LPN revealed Resident #87 was deemed an unsafe smoker. Review of Resident #87's Physician Order, dated 06/26/2024, revealed resident deemed an unsafe smoker. Review of Resident #87's current Care Plan revealed the following, in part: Problem: Onset date of 09/01/2024 Resident wishes to smoke and is designated an unsafe and impaired smoker. This smoker requires observation or constant supervision or protective gear. Further review revealed Resident #87 did not have a care plan for smoking prior to 09/01/2024. An observation was conducted of Resident #87 on 09/17/2024 at 3:33 p.m. Resident #87 was smoking unsupervised on the patio outside of his room without a smoking apron. The resident was observed leaning forward in his wheelchair and using the hand rail to knock the ashes off the lit cigarette in his mouth. Numerous smoked cigarette butts were noted on the ground by his outdoor patio. An interview was conducted with S29MDS on 09/17/2024 at 4:11 p.m. S29MDS confirmed she was responsible for performing the facility's safe smoking assessments. S29MDS confirmed Resident #87 was an unsafe smoker due to limited use of both hands, and should not be in possession of cigarettes or lights. An interview was conducted with S25AD on 09/18/2024 at 9:07 a.m. S25AD confirmed she was not made aware which residents were safe or unsafe smokers. S25AD confirmed she had purchased Resident #87's cigarettes in the past then given them to him to keep in his possession. An interview was conducted with S24SA on 09/18/2024 at 10:43 a.m. S24SA confirmed she was responsible for supervising resident smoking in the facility's designated smoking area. She confirmed she was not made aware which residents were safe or unsafe smokers. She confirmed she was not made aware of what interventions the facility's unsafe smokers required. She confirmed she was not provided with a lock box to store resident's smoking paraphernalia and was not aware she should. She confirmed all smoking residents were allowed to hold their own smoking paraphernalia at all times. An interview was conducted with S1ADM on 09/19/2024 at 1:04 p.m. He confirmed the facility's process for a newly admitted resident was to review their hospitalization paperwork and to assess the resident in person. S1ADM confirmed if a resident was a smoker, MDS should perform a safe smoking assessment. He confirmed MDS nurses were responsible to update the computer system to allow floor staff to identify safe or unsafe smokers and the interventions they required. S1ADM confirmed MDS was also responsible for verbally communicating any changes in interventions to the facility's staff during the daily 2pm staff meeting. He confirmed residents were only allowed to smoke in the designated smoking area. He confirmed unsafe smokers should not have smoking paraphernalia in their possession and should only smoke with constant staff supervision. S1ADM confirmed the facility's policies and procedures were not implemented to provide supervision and prevent accidents for resident's that smoke. Resident #75 Review of Resident #75's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #75's most recent MDS, with an ARD of 07/03/2024, revealed a BIMS of 15, which indicated the resident was cognitively intact. Review of the facility's Resident Smoker List conducted on 09/17/2024 revealed Resident #75 was not on the list to indicate he was a smoker. Review of Resident #75's Safe Smoking Evaluation on 09/17/2024 revealed no documented evidence a smoking evaluation was completed. Review of Resident #75's Physician Orders, dated 06/26/2024 through 09/17/2024, regarding his smoking status was attempted on 09/17/2024 with no documented evidence available for review. Review of Resident #75's current Care Plan, as of 09/17/2024, regarding his smoking status was attempted with no documented evidence available for review. An observation and interview was conducted with Resident #75 on 09/17/2024 at 9:25 a.m. Resident #75 was seated in his wheelchair smoking a cigarette on the patio outside of his room and confirmed this was where he typically smoked. Resident #75 confirmed he was a smoker and had been since he admitted to the facility in June of 2024. Resident #75 confirmed he had not been assessed for smoking safety since he was admitted nor had any members of the staff observed him smoking. A pack of cigarettes and a lighter was present in the cup holder of Resident #75's wheelchair. Resident #75 confirmed his smoking paraphernalia remained in his possession at all times and he was not aware he was only supposed to smoke in a designated smoking area. An interview was conducted with S29MDS on 09/18/2024 at 9:45 a.m. S29MDS stated upon a resident's admission to the facility, it was the responsibility of the floor nurse to alert the MDS team if a resident was a smoker so they could be assessed for smoking safety. S29MDS confirmed the MDS team was responsible for performing resident smoking assessments to determine safe or an unsafe smoker. S29MDS confirmed the MDS team was responsible for using their smoking assessment results to update a resident's care plan with smoking interventions to ensure resident safety. S29MDS confirmed the MDS team was responsible for updating the facility's list of smoking residents, which also identified if they were safe or unsafe. S29MDS stated the list of smoking residents was kept at all nurses stations and all staff were expected to use it and assist with ensuring interventions were implemented. S29MDS stated if a resident was not on the list as a smoker but staff saw them smoking, the staff member should alert MDS to perform a smoking assessment. S29MDS confirmed all residents who smoke should be identified immediately and assessed as either a safe or non-safe smoker with necessary interventions identified and implemented. S29MDS confirmed Resident #75 was admitted to the facility on [DATE]. S29MDS confirmed the MDS team was not aware Resident #75 was a smoker. S29MDS confirmed Resident #75 was never assessed to determine if he was a safe or an unsafe smoker and if he required any interventions for smoking safety. An interview was conducted with S40CNA on 09/19/2024 at 9:00 a.m. S40CNA confirmed she frequently trained newly hired CNAs. S40CNA confirmed she did not provide any training to new hires regarding the facility's smoking procedure, identifying safe smokers, designated smoking areas or implementing safe smoking interventions. S40CNA confirmed floor CNAs did not have anything to do with the smoking process or alerting anyone of a newly admitted resident being a smoker. An interview was conducted with S16CON on 09/19/2024 at 1:04 p.m. S16CON confirmed the MDS team was responsible for performing safe smoking assessments then updating the resident's plan of care, and updating administrative staff during the daily 2pm staff meeting. S16CON reported the MDS team would verbally alert direct care staff of any changes in interventions. S16CON confirmed direct care staff should access care tasks in the computer charting system to review information on which residents are safe or an unsafe smokers and what interventions should be implemented for each resident. S16CON confirmed the smoking policy and resident specific smoking interventions should be monitored and implemented by all members of staff to ensure resident safety. S16CON confirmed all smoking residents should be assessed for smoking safety upon their admission. S16CON confirmed if a resident was found to be a smoker but had not been identified previously, she would expect the person who identified the information to alert their supervisor or the MDS team so a smoking assessment could be performed. S16CON confirmed the facility had only one designated smoking area, which was the smoking patio to the rear of the dining room. S16CON confirmed residents should only smoke in the designated smoking area, not on the patios off of their rooms. S16CON confirmed she would expect floor staff to inform residents not to smoke on their patios and to make their supervisor or someone in administration aware if a resident remained noncompliant with this policy. An interview was conducted with S1ADM on 09/19/2024 at 6:00 p.m. S1ADM stated when a resident was admitted to the facility, the facility reviewed their hospital paperwork to determine if they were a smoker. S1ADM stated the person completing their admission paperwork should also interview the resident or their family member to confirm if they are a smoker. S1ADM stated once a resident was identified as a smoker, MDS should be alerted by the person completing the admission that a safe smoking assessment should be performed. S1ADM confirmed if a resident was found to be a smoker but had not been identified previously, he would expect the person who identified the information to alert their supervisor or the MDS team so a smoking assessment could be performed. S1ADM confirmed all smoking residents should be assessed for being a safe or an unsafe smoker. S1ADM confirmed residents were required to smoke in the designated smoking area where staff were present to supervise. S1ADM confirmed the patio off of resident rooms was not considered a designated smoking area and staff should not have been allowing residents to smoke there. S1ADM reviewed Resident #75's admission paperwork and confirmed it indicated Resident #75 was not a smoker. S1ADM stated Resident #75's smoking status was obtained from his hospital paperwork received prior to admission and since Resident #75 was cognitive, his smoking status should have also been verified with him upon admission. S1ADM confirmed if floor staff later identified Resident #75 to be a smoker and did not see him on the smoker list, they should have alerted MDS or their supervisor to ensure the proper assessments were completed. S1ADM confirmed upon Resident #75's admission to the facility, the facility failed to identify Resident #75 as a smoker and a safe smoking assessment was not performed. S1ADM confirmed floor staff should not have been allowing Resident #75 to smoke unsupervised on his patio. S1ADM confirmed the facility's policies and procedures were not followed and implemented as they should if a resident identified by staff to be a smoker was not assessed for smoking safety and was being allowed to knowingly smoke unsupervised in an undesignated smoking area. Resident #49 Review of Resident #49's Clinical Record revealed he was admitted to the facility on [DATE] with diagnosis which included Tobacco Use and Nicotine dependence, cigarettes. Review of Resident #49's Safe Smoking Evaluation, dated 6/14/2024, revealed resident was noncompliant in following smoking policies and all smoking materials must be kept a the nurses station. Review of Resident #49's current Physicians Order revealed, in part, the following: 09/16/2024 - Unsafe smoker: All smoking paraphernalia to be kept at nurse's station. Review of Resident #49's Care Plan revealed, in part, the following: Problem: 8/29/2024 - Resident wishes to smoke and is designated an Impaired Smoker. Interventions: This smoker requires observation or constant supervision. Has a history of smoking in his room. Further review revealed Resident #87 did not have a care plan for smoking prior to 08/29/2024. An observation was made of Resident #49 on 09/19/2024 at 10:55 a.m. Resident #49 was sitting in his wheelchair with cigarettes beside him and lighter in his wheelchair cup holder. An observation was conducted of Resident #49 on 09/19/2024 at 11:10 a.m. Resident #49 was observed in the hallway on his way to the smoking patio with cigarettes and a lighter in his possession. Immediately following the observation, S20SW walked into hallway and confirmed the resident had cigarette paraphernalia with him, she confirmed if a resident was assessed as an unsafe smoker they should not have smoking materials in their possession. An interview was conducted with S16CON on 09/19/2024 at 11:15 a.m. S16CON confirmed a resident assessed to be an unsafe smoker should not have cigarettes and lighter in their possession. S16CON confirmed the facility's policies and procedures had not been followed and implemented as they should if Resident #49 possessed a cigarette and lighter when not under staff supervision. 3. Review of Annual and/or New Hire Competency Skills Check Offs was attempted for the following employees with no documented evidence produced for review: S4CNA; S9RN; S11CNA; S24SA; S27CNA; S38CNA; S40CNA; S43LPN; S47CNA; and S48CNA. An interview was conducted with S27CNA on 09/19/2024 at 9:09 a.m. S27CNA confirmed she worked at the facility for 9 years. S27CNA confirmed she was responsible for training newly hired CNAs. S27CNA confirmed she did not perform competency skills check offs for any of the newly hired CNAs and had never monitored them in other ways to ensure they were competent before they were allowed to provide direct resident care independently. S27CNA confirmed the facility had not required her to perform competency skills check offs annually. An interview was conducted with S40CNA on 09/19/2024 at 9:00 a.m. S40CNA confirmed she worked at the facility for over 10 years. S40CNA confirmed she frequently trained newly hired CNAs. S40CNA confirmed she did not perform competency skills check offs for any of the newly hired CNAs and had never monitored them in other ways to ensure they were competent before they were allowed to provide direct resident care independently. S40CNA confirmed the facility had not required her to perform competency skills check offs annually. An interview was conducted with S3ADN on 09/19/2024 at 10:07 a.m. S3ADN confirmed she, S8CNS, and S2DON were responsible for ensuring direct care staff were trained and competent to perform their jobs. S3ADN stated CNAs, upon hire and annually, performed a competency skills check offs with either herself or S2DON. S3ADN confirmed she did not have any documentation of staff competency skills check offs. S3ADN confirmed new hire and annual competency skills check offs were given to the human resources department to be kept in employee files. An interview was conducted with S31HR on 09/19/2024 at 9:07 a.m. S31HR confirmed she was responsible for maintaining personnel files. S31HR confirmed she was never given any new hire or annual competency skills check offs to be put in employee files. S31HR reviewed the requested personnel files and confirmed the files did not contain any competency skills check offs in them. An interview was conducted with S2DON on 09/19/2024 at 9:01 a.m. S2DON stated training for direct care CNA's and LPN's consisted of 3 days of shadowing a preceptor on their assigned floor. S2DON stated after shadowing was complete, new hire competency was determined by their preceptor by asking the preceptor if they felt the new employee was ready to work independently. S2DON confirmed she was unaware if the facility conducted or documented new hire and annual competency skills check offs for their direct care staff. An interview was conducted with S41COO on 09/19/2024 at 9:55 a.m. S41COO confirmed competency checks and skills checkoffs were supposed to be conducted on newly hired nursing staff by S3ADN and S2DON, and CNAs were to be completed by S8CNS, however, competency and skills checkoffs had not been completed and there was no documentation they had been completed. S41COO confirmed the facility's policies and procedures had not been implemented as they should if direct care nurses and CNAs were allowed to provide direct care to residents without first demonstrating their competency through competency checks and skills checkoffs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice by failing to ensure device site care orders were obtained and clarified for 2 (#1 and #3) of 5 (#1, #2, #3, #5, and #6) residents reviewed for indwelling devices. This deficient practice resulted in an Immediate Jeopardy situation on 05/02/2024 when Resident #1 was admitted to the facility with a Percutaneous Endoscopic Gastrostomy (PEG) tube and a nephrostomy tube. Upon Resident #1's admission, the facility failed to ensure orders were obtained and entered for site monitoring and dressing changes. This resulted in Resident #1 receiving no dressing changes or site monitoring for the PEG and nephrostomy sites from admission through 05/12/2024. On 05/12/2024, Resident #1 was transferred to the local emergency room for an elevated temperature and altered mental status. Resident #1's hospital diagnoses included Sepsis, Nephrostomy associated Urinary Tract Infection (UTI), and Infected PEG tube. S1ADM and S2DON were notified of the Immediate Jeopardy situation on 06/05/2024 at 5:17 p.m. The Immediate Jeopardy was removed on 06/06/2024 at 8:20 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at more than minimal harm for the residents who were admitted or readmitted to the facility. Findings: Review of the facility's Standing Orders revised on 07/07/2023 included: Peg Care: Clean daily with soap and water. Notify NP/MD if any purulent drainage. Review of the facility's undated policy titled admission Orders revealed the following, in part: Policy Explanation and Compliance Guidelines: 1. The written orders should include at a minimum: c. Routine care orders 2. The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission. Review of the facility's undated policy titled Nephrostomy and Cystostomy Tube Care and Maintenance revealed the following, in part: Policy Explanation and Compliance Guidelines: 2. The care and maintenance of nephrostomy tubes shall be in accordance with physician orders. The orders shall specify the type and frequency of dressing changes and emptying of collection bags along with any special instructions. Resident #1 Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included Quadriplegia and Traumatic Brain Injury. Review of Resident #1's Physician's Orders, Medication Administration Record (MAR), Treatment Administration Record (TAR), and Nurses' Notes, all dated May 2024, revealed no documentation of PEG tube site care, nephrostomy tube site care, or that monitoring had been completed. Review of Resident #1's Hospital Medical Records, dated 05/12/2024, revealed the following, in part: -Temperature 101.2 -Medical Decision Making Diagnoses: Sepsis, Severe Sepsis, Septic Shock, Nephrostomy associated UTI, infected PEG tube, and Pneumonia. -Patient had a bandage over the left nephrostomy tube that appeared old and crusted. There was also purulent discharge around the PEG site. -Physical Exam: Abdominal: Peg tube in left upper abdomen. There is some purulent type drainage from this. Genitourinary: There is a nephrostomy tube in the left flank. This is covered with a bandage that appears to be quite old. It was crusted and peeling from the skin. There was purulent drainage on the bandage that was dried. Review of Resident #1's Hospital Medical Records dated 05/14/2024 revealed the following, in part: Wound cultures from PEG site growing staph and gram negative rods. Continue Cefepime and Vancomycin. Urinary Tract Infection associated with nephrostomy catheter-urinalysis consistent with UTI. On 06/04/2024 at 8:47 a.m., an interview was conducted with the Case Manager of the local emergency department. She stated Resident #1, a nonverbal resident, was transferred from the facility to the hospital in early May 2024. She stated Resident #1 presented to the hospital with purulent drainage around her PEG tube site and a dressing over the nephrostomy tube site that was old and crusted. On 06/04/2024 at 12:30 p.m., an interview was conducted with S2DON. She stated she was unaware who was responsible for PEG and nephrostomy dressing changes or where it was charted. On 06/04/2024 at 2:02 p.m., an interview was conducted with S6LPN, who provided care to Resident #1 in May 2024. She verified Resident #1 was admitted to the facility with a PEG and nephrostomy tube. She stated floor nurses were responsible for changing PEG site dressings and the wound care nurse was responsible for changing nephrostomy site dressings. She verified there was no order for Resident #1 to have PEG site monitoring or care. She stated if she provided care to Resident #1's PEG site she would have documented it in the nurse's notes. She stated she was unaware if Resident #1 had nephrostomy site care orders since wound care was responsible. She confirmed she did not change Resident #1's nephrostomy site dressing while she was admitted in May and stated if she would have, she would have documented it in the nurse's notes. On 06/05/2024 at 9:23 a.m., an interview was conducted with S14WC. She stated floor nurses were responsible for changing the dressings on PEG tubes and nephrostomy tubes. She stated all residents had to have a split gauze over the site if they had a PEG tube. She stated the facility had a standing order for PEG tube site care the nurses could enter in the resident's electronic medical record. She stated after the standing order was entered by the nurse, the dressing change would populate on the MAR for the nurses to complete. She stated she was not sure how often nephrostomy tube site dressings were changed because she was not responsible for nephrostomy tube sites. She confirmed she did not change Resident #1's PEG tube or nephrostomy tube dressings while the resident was admitted in May. On 06/06/2024 at 9:53 a.m., an interview was conducted with S5LPN, who provided care to Resident #1 in May 2024. She stated Resident #1 was admitted to the facility with a PEG and nephrostomy tube. She stated she did not know who was responsible for completing nephrostomy site dressing changes. She stated the floor nurses completed PEG site dressing changes. She confirmed she did not change the dressing to Resident #1's nephrostomy site while she was admitted in May. She stated if she completed site care it would have been documented in the residents MAR. She stated S15ADON or S16UM were responsible for entering orders for newly admitted residents. She verified orders should have been entered on admit for PEG and nephrostomy site care. She confirmed when no orders were entered, the floor nurses should have called and obtained an order to care for Resident #1's PEG site and nephrostomy tube site. On 06/06/2024 at 10:38 a.m., an interview was conducted with S11LPN, who provided care to Resident #1 in May 2024. She stated Resident #1 was admitted to the facility with a PEG and nephrostomy tube. She stated wound care nurses were responsible for PEG tube and nephrostomy tube dressing changes. She confirmed she did not change Resident #1's PEG tube or nephrostomy tube dressings while she was admitted in May. She stated if site care was performed, it would have been documented in the residents MAR or TAR. She confirmed all residents with PEG tubes and nephrostomy tubes should have orders to monitor the site and change the dressings. On 06/06/2024 at 1:42 p.m., an interview was conducted with S13LPN, who provided care to Resident #1 in May 2024. She stated Resident #1 was admitted to the facility with a PEG and nephrostomy tube. She stated she never completed a full skin assessment on Resident #1 since she worked overnight. She stated floor nurses were responsible for PEG tube and nephrostomy tube dressing changes. She confirmed she did not change Resident #1's PEG tube and nephrostomy tube dressings while she was admitted in May. She stated dressing changes were documented in the resident's MAR. She stated for any indwelling device, there should be an order to monitor the site and change the dressing. She stated if a resident did not have an order for site care or monitoring, the floor nurse should call the doctor and obtain an order because care would need to be provided to the site(s). On 06/05/2024 at 11:00 a.m., an interview was conducted with S16UM. She stated for residents who had PEG tubes and nephrostomy tubes, there would be an order which read, Monitor site q (every) shift. She stated nurses should monitor those sites for redness, swelling, tenderness, and drainage. She stated floor nurses were responsible for changing dressings to PEG tube and nephrostomy tube sites. She stated all residents who had PEG tubes had a split gauze dressing to the site. She stated nurses should change PEG tube dressings daily and as needed. She stated orders for nephrostomy dressing changes would come from the doctor. She stated it was the floor nurses responsibility to change the nephrostomy dressing as ordered. On 06/05/2024 at 11:22 a.m., an interview was conducted with S15ADON. She stated the floor nurse was responsible for site care and dressing changes to all indwelling devices, including PEG and nephrostomy tubes. She stated wound care nurses were responsible for wounds only. She stated she was responsible for putting the admission orders in for Resident #1. She stated she did not receive orders to change the dressing for Resident #1's nephrostomy tube upon admission. She confirmed she should have called the doctor to obtain orders for the nephrostomy tube dressing changes and did not. She stated she did not enter orders to monitor the sites for Resident #1's PEG tube and nephrostomy tube and should have. On 06/05/2024 at 2:38 p.m., an interview was conducted with S2DON. She stated S15ADON or S16UM were responsible for putting in orders for newly admitted residents. She stated any resident who had an indwelling device, such as a PEG tube or nephrostomy tube needed to have orders to monitor the site and orders for dressing changes. She stated it was the floor nurses responsibility to change PEG tube and nephrostomy tube dressings. She reviewed Resident #1's physician orders and confirmed the resident did not have orders to monitor the sites or change the dressings for the PEG tube and nephrostomy tube sites. She confirmed when an order was not obtained or entered into the residents electronic medical record, it did not populate in the MAR or TAR for the nurses to complete. She confirmed there was no documentation Resident #1's PEG site and nephrostomy site had been monitored and dressing changes performed. She stated Resident #1's nephrostomy site and PEG site should have been monitored and any concerns reported to the Nurse Practitioner. She confirmed Resident #1 should have had dressing changes completed to the PEG and nephrostomy tube sites. Resident #3 Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Paraplegia and Neuromuscular Dysfunction of Bladder. Review of Resident #3's Quarterly MDS with an ARD of 05/02/2024 revealed the resident had a BIMS of 12, which indicated he was moderately cognitively impaired. Review of Resident #3's Physician's Orders, Medication Administration Record (MAR), Treatment Administration Record (TAR), and Nurses' Notes, all dated February 2024, revealed no documentation of PEG tube site care, nephrostomy tube site care, or that monitoring had been completed. Review of Resident #3's Nurses Notes, dated February 2024, revealed no documentation nephrostomy tube site care or monitoring had been completed. Further review revealed on 02/18/2024 at 9:05 a.m., S12LPN wrote Resident #3's nephrostomy tube was out. The resident stated it had been in for 2 ½ weeks but had not been connected to a drainage bag and was not in use. He denied being in pain and the on call Nurse Practitioner was notified. On 06/05/2024 at 10:10 a.m., an interview was conducted with Resident #3. Resident #3 was fully oriented and able to carry on an appropriate conversation. He stated he had a nephrostomy tube that got pulled out accidentally a few months ago. He stated the nephrostomy tube had been inserted for a few weeks when it came out. He stated the wound care nurse changed the dressing to the nephrostomy site a few times when she was completing his wound care dressing changes because the dressing was crusty and nasty. He stated the nurses did not know they were responsible for changing his nephrostomy tube dressing. He stated the nurses who took care of him did not look at the dressing at all while he had the nephrostomy tube. He stated the nurses thought the wound care nurse was changing the dressing, but if he did not have pressure ulcers, it would have never gotten changed. On 06/05/2024 at 10:50 a.m., an interview was conducted with S14WC. She stated Resident #3 had a nephrostomy tube a few months ago. She stated it was the floor nurses responsibility to change the nephrostomy tube dressings. She stated she remembered changing Resident #3's nephrostomy tube dressing a few times while she was changing his pressure ulcer dressings. She stated she could not recall if there was drainage on the dressing when she changed it. She stated when she did change Resident #3's nephrostomy dressing, she verbally notified the nurse. On 06/05/2024 at 11:30 a.m., an interview was conducted with S6LPN. She stated Resident #3 was completely oriented. She stated Resident #3 had a nephrostomy tube but she did not know when it was taken out. She stated she never changed Resident #3's nephrostomy tube dressing. She stated if she needed to change a dressing she would know because there would be an order for the nurse to change the dressing in the resident's chart. She stated there were no orders to change Resident #3's nephrostomy dressing. On 06/06/2024 at 9:43 a.m., an interview was conducted with S5LPN. She stated Resident #3 was completely oriented. She stated he had a nephrostomy tube but it had been out for a few months. She stated she never changed Resident #3's nephrostomy tube dressing while he had the nephrostomy tube in place. She stated she was unsure who changed the nephrostomy tube dressings. On 06/10/2024 at 3:10 p.m., an interview was conducted with S2DON. She reviewed Resident #3's physician orders from February 2024. She confirmed Resident #3 had a nephrostomy tube during February 2024 and there were no orders to monitor the nephrostomy site or provide dressing changes to it. She verified without a Physician's order, it would not populate on the MAR/TAR for the nurses to change the dressing. She confirmed there was no documentation wound care was performed to Resident #3's nephrostomy tube site while the tube was in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a cognitively impaired resident, who exhibited exit-seeking behaviors, was adequately supervised to prevent unsafe wandering and elopement for 1 (#7) of 2 (#7 and #8) residents reviewed with wander guards. This deficient practice resulted in an immediate jeopardy situation for Resident #7, a severely cognitively impaired resident with exit seeking behaviors, on the morning of 05/20/2024. At approximately 9:05 a.m., a Good Samaritan alerted the facility that Resident #7 was in a parking lot. After being alerted to Resident #7's elopement from the facility, staff located the resident in a parking lot, 1.1 miles away from the facility, across a high trafficked four-lane divided highway next to the interstate. The facility implemented corrective actions which were completed by 05/28/2024, prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the clinical record for Resident #7 revealed he was admitted to the facility on [DATE] with diagnoses of Other Neurological Conditions, Aphasia, Cerebral Vascular Accident, Alcohol Use Unspecified with Withdrawal and Encephalopathy. Review of the Admit 5 day Assessment MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/27/2024, revealed Resident #7 had a BIMS (Brief Interview for Mental Status) of 4 which indicated severe cognitive impairment. Further review revealed Resident #7 wore a wander guard daily. Review of the Elopement Risk assessment dated [DATE] revealed Resident #7 had an Elopement Risk Score of 11. A score of 9 or greater indicated the resident was at risk for elopement. Resident #7 had intermittent confusion and wandered around the facility. Resident #7 required assistance with ambulation. A wander guard was placed for safety. Review of the current Care Plan for Resident #7 revealed the following: Start Date: 02/06/2024- Resident is at risk for elopement. Updated: 05/01/2024- Resident noted removing wander guard. Wander guard replaced. Updated: 05/20/2024- Resident was observed walking in the parking lot at a fast food chain with a bag of clothes. Intervention: 04/22/2024- Q1 hour checks 05/1/2024- Electric monitoring device attached to resident's wheelchair due to him removing off of person 05/20/2024- Resident assisted back to the facility by staff, kept in high traffic areas and relocated to a facility with a secure unit. Review of the Nurse's Notes for Resident #7 revealed the following: 04/22/2024 at 7:59 p.m.- Nurse found Resident #7 in room with window open. Resident #7 had wheelchair folded up and was trying to shove wheelchair through window. Nurse asked resident what he was doing and Resident #7 stated, I am leaving. Situation was reported to NP and DON. Resident #7 was moved closer to nurse's station and hourly checks were implemented. Signed by S16UM. 04/23/2024 at 12:10 p.m.- Resident #7 requires redirection when attempting to wander off unit. Signed by S19LPN. 05/01/2024 at 2:27 p.m.- Resident #7 was noted removing wander guard from leg. Staff aware and replaced wander guard. Signed by S20MDS. 05/20/2024 at 9:45 a.m.- Visitor came into the facility and spoke with S17UC. He asked if the facility had a resident by the name of Resident #7. Visitor stated there was a man at a fast food chain who identified himself as Resident #7. DON and three other nursing staff left in private vehicles. Upon arrival, Resident #7 was observed walking in the parking lot with a bag of clothes and a plastic shower rod (as if it were a cane). Resident #7 was brought back to the facility. Wander guard was not on Resident #7. Resident #7 was placed in a high traffic area near the main nurse's station. Resident #7 was transferred to sister facility. Signed by S2DON. 05/20/2024 at 12:03 p.m.- Resident #7 keeps repeating, I want to get out of here. Signed by S16UM. Review of a written statement from S18LPN revealed the following: On 05/20/2024, I made rounds on residents. Resident #7 at 7:00 a.m. was in room and in bed. At 8:00 a.m. I saw Resident #7 ambulating down the hall and I assumed he was going to the dining room for breakfast. Review of a written statement from S17UC revealed the following: On 05/20/2024, around 8:45 a.m. Resident #7 came to the Nurse's Station to leave. I redirected him down the hall. I observed him going down the hall. Review of the facility's Incident Reports revealed Resident #7 was found off of the facility's premises on 05/20/2024 at 9:05 a.m. by a Good Samaritan. On 06/06/2024 at 5:45 p.m., an interview was conducted with S17UC. She stated Resident #7 frequently stated he wanted to leave the facility. She stated Resident #7 kept taking his wander guard off so facility staff placed it on his wheelchair. She stated on the morning of 05/20/2024, Resident #7 attempted to get out of the front door while sitting in his wheelchair. She stated the alarm went off and the doors locked so the resident could not get out of the building. She stated Resident #7 went to her and told her he wanted to leave. She stated she walked Resident #7 back to his room which was the last time she saw him. On 06/06/2024 at 5:48 p.m., an interview was conducted with S16UM. She stated Resident #7 frequently made comments he wanted to leave the facility. She stated Resident #7's wander guard was placed on his wheelchair because he kept taking it off of his ankles. She stated on the morning of 05/20/2024 around 8:30 a.m. a Good Samaritan entered the facility and notified them Resident #7 was off premises at a nearby fast food chain's parking lot. On 06/06/2024 at 2:20 p.m., an interview was conducted with S2DON. She confirmed Resident #7 eloped from the facility on 05/20/2024. She confirmed Resident #7 left the facility grounds and was found by a Good Samaritan over a mile away from the facility after being gone for an undetermined amount of time. She confirmed the Good Samaritan came to the facility to let them know the location of their resident. On 06/06/2024 at 6:45 p.m., an interview was conducted with S1ADM. He stated staff relied on the wander guard to prevent elopement. He confirmed Resident #7 left the building and the facility's premises without being noticed or without staff realizing. He confirmed there had not been enough supervision present to prevent Resident #7's elopement and should have been. The facility had implemented the following actions to correct the deficient practice: 1.) 05/20/2024-Resident was returned to the facility safely. Head-to-toe assessment was performed, resident without injury. 2.) 05/20/2024- Resident was placed in high traffic area by unit clerk in line of site and was later transferred to another facility with a secure unit. 3.) 05/21/2024- All residents with wander guards were assessed to ensure wander guards were in place and functioning properly. Staff was in-serviced on hourly census checks for residents at risk for elopements. 4.) 05/21/2024- Nursing staff to perform hourly census checks for residents with wander guards. DON/Designee to perform weekly checks for wander guard functionality, elopements are discussed weekly in high-risk meeting. The elopement binders are reviewed weekly. Throughout the survey from 06/04/2024 to 06/10/2024, staff were observed making frequent rounds. Observations were made of the front door alarming and staff responding appropriately. Interviews with random staff revealed staff had received training on elopement and the importance to ensure all residents with wander guards had them on and were checked hourly.

Based on interviews and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to ensure all admission orders were obtained, clarified, and entered into the resident's electronic medical record. The facility failed to ensure Resident #1 had physician orders for PEG and nephrostomy site care. This deficient practice resulted in an Immediate Jeopardy situation on 05/02/2024 when Resident #1 was admitted to the facility with a Percutaneous Endoscopic Gastrostomy (PEG) tube and a nephrostomy tube. Upon Resident #1's admission, the facility failed to ensure orders were obtained and entered for site monitoring and dressing changes. This resulted in Resident #1 receiving no dressing changes or site monitoring for the PEG and nephrostomy sites from admission through 05/12/2023. On 05/12/2024, Resident #1 was transferred to the local emergency room for an elevated temperature and altered mental status. Resident #1's hospital diagnoses included Sepsis, Nephrostomy associated Urinary Tract Infection (UTI), and Infected PEG tube. S1ADM and S2DON were notified of the Immediate Jeopardy situation on 06/05/2024 at 5:17 p.m. The Immediate Jeopardy was removed on 06/06/2024 at 8:20 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at more than minimal harm for the residents who were admitted or readmitted to the facility. Findings: Cross Reference F684 On 06/04/2024 at 12:30 p.m., an interview was conducted with S2DON. She stated she was unaware who was responsible for PEG and nephrostomy dressing changes or where it was charted. On 06/05/2024 at 11:00 a.m., an interview was conducted with S16UM. She stated for residents who had PEG tubes and nephrostomy tubes, there would be an order which read, Monitor site q shift. She stated nurses should monitor those sites for redness, swelling, tenderness, and drainage. She stated floor nurses were responsible for changing dressings to PEG tube and nephrostomy tube sites. She stated all residents who had PEG tubes had a split gauze dressing to the site. She stated nurses should change PEG tube dressings daily and as needed. She stated orders for nephrostomy dressing changes would come from the doctor. She stated it was the floor nurses responsibility to change the nephrostomy dressing as ordered. She stated every morning herself, S14WC, S15ADON and S2DON met together for a morning meeting and discussed all newly admitted residents and reviewed their orders to ensure they were appropriate. On 06/05/2024 at 11:22 a.m., an interview was conducted with S15ADON. She stated she was responsible for putting the admission orders in for Resident #1 and ensuring they were correct. She stated she did not receive orders to change the dressing for Resident #1's nephrostomy tube upon admission. She confirmed she should have called the doctor to obtain orders for the nephrostomy tube dressing changes and did not. She stated she did not enter orders to monitor the sites for Resident #1's PEG tube and nephrostomy tube and should have. On 06/05/2024 at 2:38 p.m., an interview was conducted with S2DON. She stated S15ADON or S16UM were responsible for putting in orders for newly admitted residents. She stated any resident who had an indwelling device, such as a PEG tube or nephrostomy tube needed to have orders to monitor the site and orders for dressing changes. She reviewed Resident #1's physician orders and confirmed the resident did not have orders to monitor the sites or change the dressings for the PEG tube and nephrostomy tube sites. She confirmed when an order was not obtained or entered into the residents electronic medical record, it did not populate in the MAR or TAR for the nurses to complete. She confirmed there was no documentation Resident #1's PEG site and nephrostomy site had been monitored and dressing changes performed. She stated Resident #1's nephrostomy site and PEG site should have been monitored and any concerns reported to the Nurse Practitioner. She confirmed Resident #1 should have had dressing changes completed to the PEG and nephrostomy tube sites.