**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision and oversight to prevent falls for one resident, Resident #1, in a review of four sampled residents. The facility failed to implement and revise fall prevention interventions as indicated on the resident's care plan. Resident #1 had multiple falls with injuries. The facility census was 46. Review of the facility policy, revised March 2018, titled Falls - Clinical Protocol, showed the following: -The physician will help identify individuals with a history of falls and risk factors for falling: -Staff will ask the resident and the caregiver or family about a history of falling; -The staff and physician will document in the medical record a history of one or more recent falls (for example. within 90 days); -While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause; -In addition, the nurse shall assess, and document/report the following: -Precipitating factors, detail on how fall occurred; -The staff and practitioner will review each resident's risk factors for falling and document in the medical record; -The physician will identify medical conditions affecting fall risk (for example, a recent stroke or medications that cause dizziness; or hypotension) and the risk for significant complications of falls (for example, increased fracture risk in someone with osteoporosis or increased risk of bleeding in someone taking an anticoagulant); -The staff will evaluate and document falls that occur while the individual is in the facility; for example when and where they happen, any observations of the events, etc.; -Cause Identification: For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall; -Treatment/Management: Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences or falling; -Monitoring and Follow-Up: The staff with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling; a. Frail elderly individuals are often at greater risk for serious, adverse consequences or falls; b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. 1. Record review of Resident #1's undated face sheet showed the resident was admitted to the facility on [DATE]. The resident's diagnoses included dementia, history of falling, pain in left knee, muscle weakness, and abnormalities of gait and mobility. Record review of the resident's care plan, dated 3/19/21, showed the following: -The resident needs assistance with activities of daily living (ADLs) and wants to stay as independent as possible while at the facility; -Encourage and give verbal cuing to do all ADLs and give extra time and approach with patience; -Follow PT/OT/ST (physical therapy, occupational therapy, speech therapy recommendations. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 12/22/21, showed the following: -Severely impaired cognition; diagnoses of dementia; -Independent with transfers, bed mobility, toilet use, and locomotion on and off the unit, walking in the room and corridor; -Balance during transitions and walking steady at all times; -No documentation for falls or fall history; -Cane or crutch for mobility device. Record review of the resident's progress notes, dated 1/6/22 at 9:17 P.M., showed staff documented the following: -Unwitnessed fall; -The resident lay on the floor on his/her back; -The resident was trying to unplug something; -The resident was not sure if he/she hit his/her head; -The resident had left knee pain; -The resident was sent to the local hospital by ambulance for further evaluation and treatment. Record review of the resident's hospital records, dated 1/6/22, showed staff documented the following: -Performed an x-ray of left knee; -The resident had soft tissue swelling to the left knee. Review of the resident's physician notes, dated 1/10/22, showed the resident was not dependent on a wheelchair for mobility, but does use a wheelchair occasionally when she feels weak or unstable with his/her walker. Record review of the resident's physical therapy (PT) notes dated 1/12/22 and 3/1/22, showed the following: -PT evaluated the resident on 1/12/22; -The resident received physical therapy from 1/12/22 until discharged on 3/1/22; -The resident plateaued and was independent with mobility, transfers and standing. During an interview on 11/4/22 at 1:26 P.M., the Certified Occupational Therapy Assistant (COTA) said the following: -The resident received PT therapy from 1/12/22 until discharged on 3/1/22; -The resident ambulated with a single point cane as needed; -The resident transferred with minimal assistance; -On 3/2/22 the resident began restorative therapy to exercise arms and legs by walking for 15 minutes three times a week. Review of the resident's care plan showed no documentation facility staff developed a care plan with interventions to prevent falls after the resident fell on 1/6/22 that included the use of a walker or wheelchair, a single point cane or that he/she had received physical or restorative therapy. Review of the resident's progress notes, dated 5/1/22 at 2:10 P.M., showed the resident said his/her knees bothered him/her and he/she really thought he/she needed a wheelchair. Review of the resident's medical record showed no documentation to support the resident was offered or used a wheelchair. Record review of the resident's progress notes, dated 5/20/22 at 4:54 A.M., showed staff documented the following: -Unwitnessed fall; -The resident was found sitting on his/her bottom on the floor; -The resident was returning from the bathroom; -The resident had a five centimeter (cm) area on his/her right temple with an ecchymotic (bruised) area, swelling and abrasion; -The resident fell onto his/her right knee which was bruised and painful; -The resident's right elbow and right side of his/her forehead were bruised; -The bathroom floor was wet. Record review of the resident's progress notes, dated 5/21/22 at 11:37 A.M., showed staff documented the resident had tricompartmental osteoarthritis and prepatellar (arthritis of knee) soft tissue swelling. Record review of the resident's physical therapy (PT) notes dated 5/25/22 and 6/19/22 showed the following: -The resident was evaluated for PT on 5/25/22; -The resident plateaued , independent in mobility, transfers, standing, ambulating 50 feet with two turns on 6/19/22; -Recommendation for resident to ambulate with walker with standby assist; -The resident discharged on 6/19/22. During an interview on 11/4/22 at 1:26 P.M., the Certified Occupational Therapy Assistant (COTA) said the following: -The resident received PT therapy from 5/25/22 until discharged on 6/19/22; -On 5/25/22 physical therapy recommended the resident ambulate with a walker with standby assist to strengthen his/her right leg; -The resident transferred with minimal assistance; -On 6/20/22, the resident began restorative therapy to exercise arms and legs by walking for 15 minutes three times a week. Review of the resident's care plan, last updated 5/20/22, directed staff to keep the area near the bed free of clutter or fluids. There was no update to show the recommendation for the resident to ambulate with a walker with standby assistance. Record review of the resident's progress notes, dated 5/30/22 at 6:55 A.M., showed staff documented the following: -Unwitnessed fall; -The resident was found sitting on the side of the bed; -The resident was trying to put on shoes; -The resident slid to the floor; -No injury. Review of the resident's care plan, last updated 6/7/22 (eight days after 5/30/22 fall), showed maintenance placed nonskid strips on floor in front of bed to prevent slipping when sitting on the edge of bed. Observation on 9/29/22 at 1:25 P.M. showed there were no skid strips on the floor in front of the resident's bed. During interview on 9/29/22 at 1:30 P.M. Certified Nurse Assistant (CNA) B said the following: -Staff removed the non skid strips from the resident's floor because the strips did not prevent the resident from falling, just from slipping; -The resident's family member refused a chair alarm; -The resident's walker was removed from the room because the resident would try to use it and kept falling. During an interview on 11/7/22 at 10:32 A.M. the maintenance supervisor said the following: -Maintenance staff placed nonskid strips on the resident's floor on 6/7/22; -Maintenance staff removed the nonskid strips on 9/25/22. Staff said the nonskid strips were keeping the resident from getting up safely to transfer. Record review of the resident's progress notes, dated 6/10/22 at 7:15 A.M., showed staff documented the following: -Unwitnessed fall; -The resident was found sitting on the floor; -The resident got up to close the bathroom door and lost his/her balance when turning around; -The resident fell onto his/her buttocks and hit his/her left shoulder on the wall; -Staff reminded the resident to use his/her walker. Record review of the resident's progress notes, dated 6/11/22 at 7:21 A.M., showed the staff documented the resident had bruising to the right side of his/her face from the fall. Review of the resident's physician notes, dated 6/16/22, showed the resident continued therapy. Encourage ambulation with cane or walker, only using wheelchair when necessary. With progression of his/her dementia and recent falls, the wheelchair may become a more common thing for safety. Review of the resident's care plan, dated 6/22/22, showed an intervention put in place to monitor and ensure the resident's ambulation devices are within reach at all times. Observation on 9/29/22 at 1:25 P.M. showed the following: -The resident sat in his/her wheelchair in his/her room; -No walker, wheelchair or cane within the resident's reach or in the resident's room. Record review of the resident's progress notes, dated 6/29/22 at 12:14 A.M., showed staff documented the following: -The resident was found sitting on the floor between the bed and chair, sitting on a pillow and wrapped up in his/her blankets; -The resident said he/she rolled out of bed when turning over. Review of the resident's care plan, last updated 6/22/22, showed no documentation facility staff evaluated current interventions or implemented new interventions to prevent falls after the resident fell out of bed on 6/29/22. Record review of the resident's progress notes, dated 7/5/22 at 2:45 P.M., showed staff documented at 6:20 A.M., the resident slid to the floor. No injuries. During an interview on 11/4/22 at 1:26 P.M., the COTA said the following: -The resident received PT therapy from 7/7/22 until he/she discharged on 7/12/22; -On 7/7/22 the physical therapy recommendation was for the resident to ambulate with a walker and with standby assist to strengthen his/her right leg; -The resident transferred with minimal assist; -The resident was evaluated and treated by occupational therapy (OT) on 7/12/22 until he/she was discharged on 8/19/22; -OT recommendation to educate the resident and staff on assisting the resident to maintain balance and need for assist. Review of the resident's care plan, last updated 7/6/22 showed the resident was referred to PT. There was no update to show the PT recommendations for walker use and stand by assist or restorative therapy. Record review of the resident's progress notes, dated 7/7/22 at 5:27 P.M. showed staff documented the following: -The resident was found on the floor in front of the bathroom door, sitting on his/her bottom, feet out in front of him/her; -The resident's roommate was in a wheelchair in front of the resident's feet; -The resident said he/she was trying to help his/her roommate get to the toilet, his/her feet slid out from under him/her and he/she landed on his/her bottom. Record review of the resident's progress notes, dated 7/7/22 at 6:05 P.M. and 6:24 P.M., showed staff documented the following: -Unwitnessed fall; -The resident ambulated with a walker from outside to inside the facility; -The resident hit the right side of his/her head on the dresser in the lobby area; -The resident with ½ inch gash to right forehead; complained of pain in head; -The resident with small bruise to right thumb; -911 called and are enroute; -Orders were received to send the resident to local hospital for evaluation and treatment. Record review of the resident's progress notes, dated 7/7/22 at 6:49 P.M. showed staff documented the resident was transferred to the local hospital for stitches. Record review of the resident's progress notes dated 7/8/22 at 1:29 A.M., showed staff documented the following: -Call made to local hospital and hospital staff said the resident was being admitted to local hospital for observation for a large hematoma to his/her right hip (as a result of the 7/7/22 fall); -Hospital staff said the resident's right leg was slightly shorter and he/she had a knee immobilizer to his/her right knee; -CT scan (form of x-ray) showed no fractures; -He/She had received five stitches to his/her head. Record review of the resident's progress notes, dated 7/8/22 at 12:15 P.M. showed the resident returned to facility from the local hospital. Review of the resident's medical record showed no documentation staff attempted to identify the root cause of the resident's fall on 7/7/22. Review of the resident's care plan, last updated 7/6/22, showed no documentation of the resident's falls on 7/7/22, and no documentation the resident went to the hospital and returned with a knee immobilizer or received stitches to the head. Record review of the resident's progress notes, dated 7/9/22 at 1:07 P.M. and 1:12 P.M., showed staff documented the following: -Resident had another fall (assisted to floor); -Staff notified the physician, verified supplemental O2 (oxygen) order; -The resident unaware of previous fall. Record review of the resident's PT notes dated 7/9/22 showed the resident was evaluated and began therapy on 7/9/22. Review of the resident's care plan, last updated 7/6/22, showed no documentation facility staff updated the resident's care plan documenting the fall of 7/9/22, the implementation of supplemental oxygen, physical therapy evaluation, or any new interventions put in place to prevent falls. Review of the resident's physician notes dated 7/14/22, showed the resident is having numerous falls, dementia progression and short-term memory very poor. He/She has repeatedly attempted to get up for one reason or another and then loses balance, slips and falls. All available fall precautions in place. However, he/she just does not remember to move slowly/carefully or with an assistive device. Orthostatic blood pressure checked and appears to be non-contributory. He/She has an orthopedic surgeon consult. Follow-up in one month. Record review of the resident's progress notes, dated 7/18/22 at 12:20 A.M. showed staff documented the following: -The resident was found sitting on the floor by his/her bed; -The resident said he/she was going to bathroom and when he/she stood up, his/her legs gave out. Review of the resident's care plan, last updated 7/6/22, showed no documentation facility staff updated, determined precipitating factors, evaluated or implemented new interventions after the resident's fall on 7/18/22. Review of the resident's significant change MDS, dated [DATE], showed the following: -Severely impaired cognition; -Independent with ambulation in room and unit; -Limited assistance of one person with transfers; -Balance during transitions and walking steady at all times; -Walker and wheelchair needed for mobility; -Two or more falls since admission or prior assessment with no injury; -One fall with major injury. Record review of the resident's progress notes, dated 7/29/22 at 9:22 P.M. showed staff documented the resident was helping his/her roommate and slid onto his/her knees. Review of the resident's physician order sheets showed an order dated 7/29/22 to discontinue the resident's immobilizer (hinged knee brace) and start progressive weight bearing with physical therapy, to include gait training and strengthening. Review of the resident's care plan, last updated 7/6/22, showed no documentation facility staff updated, or put new interventions in place after his/her fall on 7/29/22. Record review of the resident's progress notes, dated 8/9/22 at 6:50 P.M., showed staff documented the following: -The resident said he/she was packing up his/her belongings, lost balance and sat down on the floor; -Staff explained needing assistance with ambulation and call light in reach. (The physician's note dated 7/14/22 showed the resident's dementia had progressed, he/she had very poor short-term memory, and did not remember to use an assistive device when walking. Staff reminded the resident he/she needed assistance to use his/her call light after the resident fell on 8/9/22. Review showed no evidence staff implemented effective interventions after the resident fell.) Record review of the resident's progress notes, dated 8/12/22 at 4:20 P.M. showed staff documented the following: -Staff found the resident on his/her back on the floor; -The resident had a skin tear on his/her right forearm that measured 3 centimeters (cm) x 0.1 cm; -Another skin tear to his/her right forearm 2.5 cm x 0.1 cm; -Large hematoma to occipital area (back of the head) 3 cm x 3 cm ; -The resident complained of back pain, rated 8/10 (pain scale 1-10) and headache; -Skin tears cleaned and dressing applied; -Ice pack given for hematoma. Review of the resident's medical record showed no documentation staff attempted to identify the root cause of the resident's fall on 8/12/22. Review of the resident's care plan, last updated 8/18/22, showed staff was to provide the resident with a walker when able to safely ambulate with staff in room and encourage wheelchair use when not safe to walk. (the implementation of the walker was already a therapy recommendation on 7/7/22). Review of the resident's medical record showed no documentation as to who was to determine, or how it was to be determined, when the resident was not safe to walk and was to use a wheelchair. Record review of the resident's PT notes dated 8/19/22, showed the following: - The resident evaluated and began therapy on 7/9/22; - The resident plateaued, with stand by assist in mobility, transfers and standing; -The resident discharged from therapy on 8/19/22. Record review of the resident's progress notes, dated 8/23/22 at 7:30 P.M., showed staff documented the following: -Staff found the resident sitting on the bathroom floor; -The resident was very confused, talking to people who were not there; -Two staff assisted the resident into his/her wheelchair; -The resident was brought to the nurses desk for safety. Review of the resident's medical record showed no documentation staff identified the root cause of the resident's fall, and no documentation staff evaluated current interventions or update the care plan with new interventions after the resident fell 8/23/22. Record review of the resident's progress notes, dated 8/23/22 at 10:00 P.M. showed staff documented the following: -Staff heard the resident crying; -Entered his/her room and the resident was found sitting on the floor in front of his/her closet; -The resident said he/she was trying to find clothes for the boys to wear; -The resident's left leg was slightly shortened and rotated outward and the resident flinched with palpation (using hands while checking the body) to the posterior (back side) upper thigh; -The resident was sent to the local hospital for evaluation. Review of the resident's hospital emergency department records dated 8/24/22 showed the following: -Diagnosis was fall and pain in left hip; -Left hip and pelvis x-ray due to left hip pain; -discharged to facility, condition improved. Review of the resident's progress notes, dated 8/24/22 at 4:30 A.M., showed staff documented the following: -The resident returned to the facility from the hospital; -The emergency room nurse reported no fracture of the hip. Review of the resident's hand written care plan, showed staff added an intervention on 8/23/22 (no time), instructing staff to assist the resident to the bathroom after supper due to my fall. (The resident had two falls on 8/23/22, since the added intervention is not timed, it is unclear which fall this intervention is intended, neither fall involved the resident going to the bathroom or being found in the bathroom, one fall at 7:30 P.M. and the other at 10:00 P.M.) Review of the resident's progress notes, dated 8/24/22 at 4:18 P.M., showed staff documented they faxed the resident's physician about the resident falling and his/her behaviors and to request to increase Seroquel (antipsychotic medication). Review of the resident's physician order sheet, dated 8/27/22 at 12:42 P.M., showed staff documented orders were received to increase the resident's Seroquel to 50 milligrams (mg) in the morning and 25 mg at bedtime. Diagnoses included dementia and depression. Record review of the resident's progress notes, dated 8/31/22 at 6:45 P.M. showed staff documented the following: -Found the resident laying on the floor in front of his/her doorway; -The resident said he/she was brushing his/her patient's hair and lost balance. Review of the resident's care plan dated 8/31/22, handwritten intervention showed, Res (resident) education not to help roommate d/t (due to) my poor balance. (The physician's note dated 7/14/22 showed the resident's dementia had progressed, he/she had very poor short-term memory. Review showed no evidence staff implemented effective interventions after the resident fell on 8/31/22.) Review of the resident's progress notes, dated 9/1/22 at 5:03 P.M. showed the resident had a change in mental status. There resident was hard to arouse. Physician notified with orders to sent to the hospital for evaluation to treat. Review of the resident's progress notes, dated 9/1/22 at 10:23 P.M. showed the resident returned to the facility from the hospital with diagnosis of UTI (urinary tract infection) and was started on antibiotics Review of the resident's emergency department hospital records dated 9/1/22 showed the following: -The resident fell from an upright position while walking; -The resident has had multiple falls; -The resident is deconditioned; -Diagnosis of urinary tract infection, multiple falls Review of the resident's progress notes, dated 9/4/22 at 7:27 A.M., showed staff documented the following: -Seroquel 50 mg order changed to twice daily on 9/2/22; -Discontinued order for Seroquel 50 mg every morning. Review of the resident's progress notes dated 9/4/22 at 12:42 P.M., showed a dose increase of the resident's Seroquel at night. Review of the mayoclinic.org website, specifically for the medication Seroquel, showed precautions included: -This medicine should not be used to treat behavioral problems in older adult patients who have dementia or Alzheimer disease; -Seroquel may cause drowsiness, trouble with thinking, trouble with controlling body movements, or trouble with your vision, which may lead to falls, fractures, or other injuries; -Dizziness, lightheadedness, or fainting may occur, especially when you get up suddenly from a lying or sitting position. Review of the resident's physician notes, dated 9/8/22, showed the following: -Nursing staff are concerned the resident's memory is worsening, and the resident becomes upset when staff redirect him/her. -The resident continues to fall, mostly out of bed, likely because he/she has forgotten that he/she needs assistance; -The resident started on Depakote (anticonvulsant also used for bipolar disorders (mental illness). Review of the resident's care plan dated 9/8/22, showed staff documented handwritten intervention please monitor as I started Depakote for my behaviors. (no description of what behaviors were) Review of the goodrx.com website, specifically for the medication Depakote, showed Depakote is often used to reduce aggressive behavior in elderly patients with dementia. These drugs can unfortunately cause dizziness, confusion, and sedation as side effects. Record review of the resident's progress notes, dated 9/12/22 at 8:28 P.M., showed staff documented the following: -Staff heard the resident yelling for help; -The resident was found sitting on floor next to the bed; -The alarm on the closet was on, but did not sound with movement as it should have; -The resident said he/she slid out of bed when reaching to get a drink from bedside table; -No apparent injury. Review of the resident's care plan dated 9/12/22, showed an intervention including staff education about alarm to make sure on when I'm in bed. (this was not an effective intervention as the resident knew how to turn the alarm off). Review of the resident's significant change MDS, dated [DATE], showed the following: -Severely impaired cognition; -Independent with ambulation in room and unit; -Limited assistance of one person with transfers; -Balance not steady during walking; -Walker and wheelchair needed for mobility; -Two or more falls since admission or prior assessment with no injury; -One fall with major injury. Review of the resident's physical therapy note dated 9/27/22 showed the following: -PT evaluated the resident; -The resident received PT therapy from 9/27/22 (certification service until 10/26/22); -The resident is at risk for decrease in level of mobility and falls; -The resident is oriented to person; - Therapy recommendation, the resident would benefit from a wheelchair alarm. Record review of the resident's progress notes, dated 9/28/22 at 12:21 A.M , late entry for 9/27/22 at 7:00 P.M., showed staff documented the following: -Witnessed fall by another resident; -The resident lost balance after standing up from his/her wheelchair to turn around to see another resident and sat on his/her bottom on the floor; -Staff assisted back into wheelchair. Review of the resident's medical record showed no documentation staff identified the root cause of the resident's fall, and no documentation staff evaluated current interventions or update the care plan with new interventions after the resident fell on 9/27/22. Observation on 9/29/22 at 1:25 P.M. showed the following: - The resident sat in his/her wheelchair; - No walker or cane in room. During an interview on 9/29/22 at 1:26 P.M. the resident said the following: - He/She does not know where his/her walker went and he/she used to have one; - He/She does not remember having falls; - He/She does not want to fall. Review of the resident's fall risk assessment dated [DATE] showed the following: -Balance problem while standing and walking; -Change in gait pattern; -Decreased muscular coordination, unstable when making turns; -Requires use of assistive devices; -Takes medications including antidepressants, antipsychotics and narcotics; -Three or more falls; -Has cognitive, neuromuscular/functional and orthopedic conditions; -Score of 30 with a score of 10 or more representing high risk for falls. Record review of the resident's progress notes, dated 10/12/22 at 9:08 A.M. showed staff documented the following: -The resident sat on the floor next to the bed; -The resident was trying to get into the bed; -Staff assisted the resident into bed; -The resident then wanted to transfer to his/her wheel chair, transferred by staff; -Staff brought the resident to the nurses station. Review of the resident's written care plan, showed staff added an intervention on 10/12/22 (no time), instructing staff to get the resident up and toilet him/her and to remind him/her to use his/her call light. (The physician's note dated 7/14/22 showed the resident's dementia had progressed and he/she had very poor short-term memory. This fall also occured at 9:08 A.M., so toileting at midnight would not be an appropriate timely intervention.) Record review of the resident's progress notes, dated 10/22/22 at 4:06 A.M. showed staff documented the following: -The resident was found lying on the bathroom floor; -He/She had been in his/her wheelchair and then tried to ambulate, losing balance; -He/She lay on his/her left side, no shortening of legs or abnormalities, no bumps, bruises or contusions (bruises); -Assisted to wheelchair then back to toilet. Review of the resident's written care plan, showed staff added an intervention on 10/22/22 (no time), instructing staff to assist the resident to the bathroom after activities. (The fall occured at 4:06 A.M., this fall would not have been after an activity.) Record review of the resident's progress notes, dated 10/24/22 at 6:35 A.M. showed staff documented the following: -The resident was in the dining room; -The resident got out of his/her wheelchair and attempted to ambulate across the room to get another cup of coffee; (it was care planned if the resident ambulated it was to be with a walker and staff standby assist); -The resident lost his/her balance and fell onto his/her left side; -The resident complained of pain in his/her left rib cage; -Bruising noted on left rib cage from 10/21/22 fall; -The resident complained of pain in his/her ribs and with inspiration (breathing in). Review of the resident's written care plan, showed staff added an intervention on 10/24/22 (no time), instructing staff to reorient the resident to the wheelchair and assess his/her needs when he/she was restless. (The physician's note dated 7/14/22 showed the resident's dementia had progressed and he/she had very poor short-term memory. The progress note mentions nothing of the resident being restless.) During an interview on 9/29/22 at 1:30 P.M. Certified Nurse Aide (CNA) B said the following: -The resident is a fall risk; -The resident's family member refused bed and chair alarms for the resident; -The resident's family member placed a motion sensor located at end of the resident's bed mounted on the resident's closet; -The motion sensor alarms when sensing movement in the resident's room; - The motion sensor was within reach of the resident; -The resident knows how to turn off the motion sensor; -Staff know the resident knows how to turn off the motion sensor alarm due to the resident being out of bed when making rounds and the alarm was turned off; - The staff removed the skid strips from the resident's floor because it would put a stop to him/her from sliding on the floor, however the strips did not prevent the resident from falling; - The resident's walker was removed from the room due to the resident trying to use it and he/she kept falling. During an interview on 9/29/22 at 1:30 P.M., the activity director said the following: -The resident has dementia, so staff have to remind the resident to stay in h[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #29's care plan, dated 9/11/18, showed the following: -The resident was at risk for falling related to balance impairment and confusion; -The resident often refused assistance. Staff should re-approach the resident often and check on the resident frequently because he/she did not use the call light; -Give the resident verbal cues to use the assist device and keep it reach at all times; -If the resident is observed attempting unsafe tasks, walk the resident to the couch by the nurse's station to be in line of sight of staff; -Attempt to toilet the resident before and after each meal and during bed checks. Review of the resident's Significant Change in Status Assessment Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 11/30/18, showed the following: -Diagnoses included dementia and anxiety; -Required extensive assistance of one staff for bed mobility, transfers, walking, toilet use, and hygiene; -Utilized a walker -One fall without injury since the previous assessment. Review of the resident's nurse's note, dated 1/20/19 at 11:41 P.M., showed the resident had been in the recliner and crawled out of it while it was still reclined. Staff found the resident on the floor facing the bathroom with slippers removed. Staff assisted the resident off the floor and to the bathroom. Review of the resident's fall event report, dated 1/20/19, showed the resident fell in his/her room. No immediate interventions were listed for this fall. Review of the resident's care plan showed an update on 1/20/19 to ensure the resident had on non-skid footwear at all times. Review of the resident's nurse's note, dated 1/21/19 at 11:50 P.M., showed staff heard the resident hollering from his/her room. The resident hit the back of his/her head on the wheelchair pedal. There was a moderate amount of blood on the floor. The resident had a 2.0 centimeter (cm) puncture gash on the back of the head. Staff cleaned the area well and contacted the physician who gave orders to send the resident to the emergency room. The resident left the facility by ambulance at 12:30 A.M. Review of the resident's fall event report, dated 1/21/19, showed the resident fell in his/her room. The resident had been in bed previously. The resident sustained a laceration to the back of the head. The immediate intervention was first aide to the resident. Review of the resident's care plan showed an update on 1/21/19 that the resident could recline the recliner chair but would forget to put the foot rest down before trying to exit the chair. Staff should offer to put the foot rest down and check on the resident frequently while in the recliner. (The resident's care plan did not address the resident's fall from bed on 1/21/19). Review of the resident's nurse's note, dated 1/24/19 at 11:05 P.M., showed staff found the resident on the floor of his/her room. There was a small bump on the back of the resident's head and a minimal amount of blood. The resident reported the back of his/her head was tender and complained of pain in his/her back and rib area. Review of the resident's fall event report, dated 1/24/19, showed the resident had an unwitnessed fall and sustained a small bump to the back of the head that bled a minimal amount. There was no other information documented on the report. Review of the resident's care plan showed an update on 1/25/19 to keep the resident engaged. The resident got bored easily and was more likely to attempt unsafe tasks if left alone in the room. Include the resident in activities and keep the resident in areas that help keep him/her stimulated. Review of the resident's nurse's note, dated 1/28/19 at 7:50 A.M., showed staff found the resident on the floor between the bed and the recliner. The resident complained of pain in the right hip area and would not bear weight on the right leg. The physician ordered the resident be sent to emergency room for evaluation. The resident returned to the facility at 12:03 P.M. the same day. The x-rays of the pelvis and hip were negative for fractures. The resident was found to have a urinary tract infection and received orders for antibiotic therapy. Staff did not complete a fall event report for the resident's fall on 1/28/19. Review of the resident's care plan showed an update on 1/28/19, the resident was at higher risk for falls when he/she had an infection. Monitor the resident for signs and symptoms of infection. Review of the resident's care plan showed an update on 1/31/19, due to fall trends, the resident's toileting has been scheduled for 10:30 P.M. and 5:00 A.M. Review of the resident's nurse's note, dated 2/22/19 at 9:05 P.M., showed staff observed the resident trying to get out of the wheelchair into the recliner but slid to the floor before staff could reach him/her. There were no injuries noted. Review of the resident's fall event report, dated 2/22/19, showed staff observed the resident fall in his/her room. There was no injury. The immediate intervention provided for the resident was rest. Review of the resident's care plan showed an update on 2/25/19 to not leave the resident unattended in the wheelchair in his/her room. The resident would attempt to self-transfer. Toilet the resident and help him/her to the bed or recliner. Review of the resident's nurse's note, dated 2/25/19 at 9:34 P.M., showed the resident had been resting in bed. Staff then found the resident on his/her hands and knees in front of the recliner. The resident said he/she was trying to get to the bathroom. Staff assisted the resident up and to the bathroom and then back to bed. Review of the fall event report, dated 2/25/19, showed the resident fell in his/her room. There was no injury. The immediate intervention provided for the resident was rest. Review of the resident's care plan showed an update on 2/26/19 to toilet the resident before assisting him/her to bed. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Required extensive assistance of one staff for bed mobility, transfers, walking, toilet use, and hygiene; -Utilized a walker -Two or more falls without injury since the previous assessment; -Two or more falls with injury since the previous assessment. Review of the resident's nurse's note, dated 3/6/19 at 8:00 A.M., showed staff found the resident on the floor in the bathroom with blood noted on the floor. Staff assisted the resident up to the wheelchair. The resident sustained lacerations to the left forehead, left cheek, and left upper arm. The physician was contacted and gave orders to send the resident to the emergency room. The ambulance arrived and the resident left the facility at 8:45 A.M. At 12:25 P.M., the hospital called the facility and reported the resident's forehead laceration was down to the skull which required sutures. The left cheek and left arm wound were cleaned and dressed. The resident was ready to be discharged back to the facility. Review of the resident's fall event report, dated 3/6/19, showed the resident fell in the bathroom. It appeared the resident got himself/herself to the bathroom, and with incontinence brief pulled down, fell and hit the left side of his/her body. The resident sustained bruising and lacerations. The immediate intervention was sending the resident to the emergency room. Review of the resident's care plan showed an update on 3/6/19, the resident would forget to use the call light and attempt to get up unassisted if left alone in the bathroom. Stay with the resident to keep him/her safe. (The resident got into the bathroom on his/her own on 3/6/19, staff did not assist the resident to the toilet). Review of the resident's nurse's note, dated 3/11/19 at 11:30 P.M., showed staff heard the resident hollering for help and found him/her on the floor on his/her bottom near the bed. The resident tried to lift himself/herself into bed. No new injuries although facial bruising remained form the previous fall. Staff assisted the resident to bed. Review of the resident's fall event report, dated 3/11/19, showed the resident had an unwitnessed fall in his/her room. The resident had been returning from the bathroom. The immediate intervention provided was rest. Review of the resident's care plan showed no update after the fall on 3/11/19. Review of the resident's nurse's note, dated 5/2/19 at 1:57 A.M., showed the resident had no ill effects from sliding to the floor from the recliner. Staff did not complete a fall event report for the fall on 5/2/19. Review of the resident's care plan showed an update on 5/2/19 to observe the resident frequently and place in a supervised area when out of bed (repeated intervention from 10/28/18). Review of the resident's nurse's note, dated 5/9/19 at 5:39 A.M., showed staff found the resident on the floor near the foot of the roommate's bed. No injury was noted. Review of the resident's fall event report, dated 5/9/19, showed the resident had an unwitnessed fall. Staff had just assisted the resident to the bathroom and returned him/her to bed. There was no immediate intervention implemented following this fall. Review of the resident's care plan showed an update on 5/9/19 to keep the resident's walker in reach when he/she was in the recliner or bed. Review of the resident's nurse's note, dated 6/13/19 at 4:09 A.M., showed staff heard a noise and upon investigation found the resident on the floor next to the bed on his/her right side. The resident complained of right hip and pelvic pain. The right leg was rotated outward. The nurse called the physician and received an order to send the resident to the emergency room. The resident was transported to the emergency room by ambulance. At 6:54 A.M., hospital staff called and informed facility staff the resident was being admitted to the hospital for a femoral head (hip) fracture. Review of the resident's fall event report, dated 6/13/19, showed the resident had an unwitnessed fall in his/her room. There was an injury to the right hip and pelvis. Review of the resident's care plan showed no update following the fall on 6/13/19. During a telephone interview on 8/1/19 at 1:20 P.M., the MDS Coordinator said after review of some of the resident's falls it was not clear what the rationale was behind several of the interventions implemented, such as checking on the resident frequently while in the recliner on 1/21/19 when the resident had fallen from bed, or not leaving the resident unattended in the wheelchair on 2/25/19 when the resident had again fallen from bed. The MDS Coordinator did not find where any intervention had been attempted after the resident's fall on 3/11/19. The MDS Coordinator did not find a fall investigation completed for the resident's fall on 5/3/19 and felt it had been missed. The MDS Coordinator said there was no new intervention added after the resident's fall on 6/13/19 that resulted in a fracture. The resident now required assistance of two staff and was no longer able to get up on his/her own, although he/she may still attempt to do so. During a telephone interview on 8/1/19 at 1:30 P.M., the Director of Nursing (DON) said he/she expected staff to add interventions to prevent falls to the care plan. Staff discussed resident falls at a weekly meeting, and staff discussed interventions to prevent falls such as frequent monitoring. Interventions should be based on the root cause of the fall. The DON said some of the interventions for Resident #29's falls did not make sense after looking at the details of the falls, such as monitoring the resident frequently in the recliner or not leaving the resident unattended in the wheelchair when the resident had fallen from bed. Interventions to prevent falls should be reassessed periodically to determine if they are appropriate or need to be revised. 6. Review of Resident #17's face sheet showed the following: -admission date 2/23/19; -Diagnoses included Alzheimer's disease, cognitive communication deficit, major depressive disorder single episode, and anxiety disorder. Review of the resident's elopement risk assessment, completed 2/23/19, showed the following: -The resident has anger regarding facility placement; -The resident verbalizes statements about leaving; -The resident recently moved to the facility; -The resident has Alzheimer's disease; -Interventions: Activities, door alarm band (Wanderguard), occupational therapy, physical therapy, reality orientation and redirection; -The resident is at risk for elopement; -Wanderguard applied. Review of the resident's care plan for behavioral symptoms, dated 2/25/19, showed the following: -The resident wanders and has attempted to elope; -Allow the resident to call his/her family if he/she becomes difficult to redirect; -Engage the resident in self-care and physical activities to channel energy, as tolerated; -Provide safe, quiet, low-stimuli environment during delusional periods; -Redirect the resident with available activities if you see him/her packing or hear him/her talking about leaving the facility. Review of the resident's physician orders showed an order dated 3/1/19 to check Wanderguard placement three times a day. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident made himself/herself understood and understands others; -Severe cognitive impairment; -Independent in walking throughout the facility; -Utilized a walker for mobility; -Wandering did not occur in the look back period. Review of the resident's progress notes showed on 6/8/19 at 8:05 A.M., the resident walked to his/her room and came out. He/She said he/she had packed his/her belongings and was leaving. The resident began screaming about leaving this place. Various attempts with various staff members to redirect him/her were unsuccessful. The resident began wandering throughout the facility attempting to elope. The resident said, I have to find my car. My (spouse) wants me home and I have the car. I have to go. The resident became increasingly anxious and kept saying, I have to get out of here. Review of the resident's physician's progress notes, dated 7/2/19, showed the resident continues to demand to go home when seen and states he/she does not need to be in the facility. Review of the resident's progress notes showed the following: -On 7/7/19 at 9:33 P.M., the resident kept asking for boxes to pack his/her things because I'm going home tonight and I'm going to pack my clothes out to the car. The resident was trying to find a way out. He/She stood at the nurses desk hollering he/she wanted to go home and how can we keep him/her locked up; -On 7/17/19 at 6:15 P.M., a visitor brought the resident in from outside. The visitor said he/she found the resident on the ground. The resident had scraped areas on his/her forehead, the bridge of his/her nose, chin, and both knees. The resident's Wanderguard was not on at this time. The resident said it fell off and he/she threw it away. There resident was confused about where he/she was. Review of the facility's investigation of the incident on 7/17/19, showed the Director of Nursing (DON) spoke with all staff who worked on the date of the incident. The staff said they were unaware of the resident leaving. The staff reported seeing the resident eating in the dining room at meal time, but none were sure when the resident left the dining room. The nurses station was unattended, CNAs were assisting residents, and the licensed practical nurse (LPN) and certified medication technician (CMT) were passing medications. Staff watched the cameras and noted the resident left the facility out the activity door without his/her walker. Staff did not hear any alarms. When the resident was returned to the facility, he/she was not wearing his/her Wanderguard bracelet. The resident said it broke off and he/she threw it away. Staff found the resident's walker in his/her room. During an interview on 7/31/19 at 10:30 A.M., the community member who found the resident on 7/17/19 said the following: -At approximately 6:00 P.M., he/she and his/her spouse sat on their back porch and heard someone call for help several different times; -He/She and his/her spouse drove around on their golf cart and found the resident in a driveway to a house a little over a block away; -The resident had fallen and was standing back up when he/she got to him/her. The resident had a cut on his/her nose and was bleeding. The resident did not have a walker with him/her; -The resident said he/she was looking for a family member's house. The community member asked the resident to get on his/her golf cart and he/she would take the resident to where he/she was going; -As they passed by the facility, the resident said he/she needed to stop in there first. He/She assisted the resident inside the facility and to the nurses station. Observation on 7/31/19 at 10:40 A.M., showed the community member identified the location where he/she found the resident. The driveway was made of gravel and had a culvert on either side. The driveway was across the street and down the street from the facility lawn. There were no sidewalks along either side of the street. From the driveway, along the street to the facility's grassy lawn was 45 steps, or approximately 135 feet. Along the grassy lawn to the activity door exit was 103 steps, or approximately 310 feet. During an interview on 7/30 at 8:08 A.M., the DON said the following: -The resident was always wanting to leave the facility. He/She has a Wanderguard due to his/her comments of wanting to leave; -All doors in the facility were equipped with the Wanderguard alarms; -The charge nurses check the residents' Wanderguard bracelets for placement every shift; -The exit door located by the activity room was equipped with a Wanderguard alarm and also an alarm that sounds at the nurses station when the door was open; -Earlier in the day on 7/17/19 at approximately 2:30 P.M., there was a storm in the area that caused the door alarms to go off. He/She was unsure if someone turned off the door alarms at the nurses station due to the alarm going off; -The resident left the facility through the exit door by the activity room at 5:15 P.M. as verified by the video footage. The exit door by the activity room was alarmed with a Wanderguard alarm but the resident was not wearing his/her Wanderguard bracelet; -He/She was the charge nurse on 7/17/19 and had not checked for placement of the resident's Wanderguard bracelet prior to the resident leaving the facility; -At the time the resident left the facility, no staff were present at the nurses station; -At 6:15 P.M., a visitor brought the resident back into the facility. The visitor did not say where he/she found the resident. The DON originally thought the person who brought the resident back to the facility was someone who had taken the resident out for a car ride and was bringing the resident back to the facility. Observation on 7/30/19 at 8:45 A.M. showed a box mounted on the wall behind the nurses station. The box had lights with toggle switches underneath them to turn the alarm on or off. The lights were turned on (indicating the alarms were turned on) for the North, South, and activity doors. The lights for the back entrance, the lobby and the business offices were turned off, indicating the alarms on these doors were turned off. A sign was posted on the box read, all door alarms should be turned on between 8:00 P.M. and 9:00 P.M. During an interview on 7/30/18 at 8:51 A.M., Registered Nurse (RN) G said during the day, the door alarms on the North and South doors and the activity hall door are turned on. The door alarms on the doors to the lobby, business office, and back door (staff entrance) are turned off. All the doors have a Wanderguard alarm. The resident has a Wanderguard. During interview on 7/31/19 at 2:10 P.M., Nurse Aide (NA) J said the following: -He/She arrived at the facility for his/her shift between 5:30 P.M. and 6:00 P.M. on 7/17/19. He/She went outside at 6:00 P.M. to have supper with CNA K. Another staff reported to him/her the resident had left the facility and was back; -Staff were not aware the resident was gone from the facility until after he/she returned; -After the resident returned, he/she told staff his/her Wanderguard bracelet fell off. The resident also told staff he/she left the facility through the door by the activity room; -He/She was not aware of any door alarms sounding that night. During an interview on 7/31/19 at 11:44 A.M., CNA K said he/she was outside with NA J when the resident returned to the facility. He/She did not hear any alarms to alert staff the resident had left through the activity exit door. Staff did not know the resident was gone until he/she returned to the facility. During an interview on 7/31/19 at 8:27 A.M., CNA E said the following: -He/She worked on the evening shift on 7/17/19; -He/She did not hear any door alarms sound in the facility; -He/She did not remember when he/she last saw the resident on 7/17/19. He/She was in a room with another resident when the resident arrived back to the facility. During interview on 7/30/19 at 3:05 P.M., CMT I said the following: -On 7/17/19, he/she observed the resident in the dining room for supper. The resident said he/she was going to bed and went down the hall toward his/her room. The next thing he/she knew, the resident was coming in through the front door; -He/She was working on the resident's hall when the resident was gone. He/She did not hear any alarms sound in the facility; -The resident did not have his/her Wanderguard bracelet on; -It had stormed that day around 3:00 P.M. which set off the door alarms at the nurses station. Staff shut off the alarms and turn them back on at times so they stop sounding. He/She did not turn off any alarms on 7/17/19. During interviews on 7/30/19 at 2:55 P.M. and 7/31/19 at 4:21 P.M., LPN H said the following: -He/She was the medication nurse on the evening shift on 7/17/19; -The door alarm panel located at the nurses station was going off during the evening shift on 7/17/19 due to the storms. He/She was unsure which door was alarming but he/she heard them. Someone had to reset the alarms when they sounded in order for the alarm to stop, but he/she was unsure who reset the alarms; -He/She was in the medication room when a community member brought the resident into the facility. He/She didn't think anyone noticed the resident was gone from the facility; -He/She heard the community member found the resident a couple blocks from the facility. During an interview on 7/31/19 at 1:00 P.M., the maintenance supervisor and maintenance staff M said the following: -The charge nurse was responsible to turn the door alarms on at the nurses station and lock the exit doors between 8:00 P.M. and 9:00 P.M.; -Lightening during storms will cause the Wanderguard alarms locally at the doors to alarm, however, no one has reported any problems with the door alarms located at the nurses station; -The maintenance supervisor was unsure what occurred on 7/17/19 related to the door alarms, however, he heard there was a new nurse who wasn't sure what the alarm was and what it meant and shut off the alarm; -The facility was not doing anything different related to the door and the door alarms since the incident on 7/17/19. During an interview on 7/31/19 at 4:35 P.M., the DON said the following: -The facility determined because of the storm, someone must have shut off the door alarm because the alarm did not sound when the resident left through the exit door near the activity room; -She was the charge nurse on 7/17/19, but did not check the alarm panel that evening. Social services staff turned the alarms on when they left the facility around 5:00 P.M.; -She had not discussed the problems with the door alarms alarming during a storm with the maintenance staff. During an interview on 8/1/19 at 2:45 P.M., the administrator said the Wanderguard alarm on the exit door by the business office alarms locally at the door during storms. She was not aware of any problems with the door alarms, located at the nurses station, alarming during storms. 7. Review of Resident #8's annual MDS, dated [DATE], showed the following: -Diagnoses included heart failure, high blood pressure, arthritis and depression; -Required extensive assistance of one staff for transfers; -Balance was not steady during transitions but was able to stabilize without human assistance; -Utilized a cane. Review of the resident's care plan, last revised on 5/14/19, showed the following: -The resident required assistance of one staff for activities of daily living; -Required verbal cues to complete activities of daily living; -At risk for falls due to balance problems; -Required reminders and cuing about safety; -Utilized a cane; -Had confusion and depression; -The resident was allowed to go outside and smoke unsupervised. Review of the resident's nurse's note, dated 7/20/19 at 2:59 P.M. showed the resident was not in his/her room. Staff searched the entire building. The family, DON, and administrator were notified. 911 was notified when the resident was not located after thirty minutes. Non-nursing personnel searched the outside premises. The resident was found three blocks away from the facility and staff returned the resident via personal vehicle. Review of the facility's investigation of events, dated 7/20/19, showed the following: -At 2:07 P.M. staff noted the resident was not in his/her room. Staff searched the inside and outside of the building; -Two staff searched the surrounding area in personal vehicles; -The dietary manager found the resident three blocks from the facility and returned him/her to the facilty at 2:41 P.M. During an interview on 7/29/19 at 9:33 A.M. the resident said he/she went outside to smoke. There were no set smoke times. About two or three weeks ago he/she went outside and decided to go for a walk to his/her house. It was very hot that day so he/she sat down by a tree. A neighbor found the resident under a tree. One of the staff came and brought the him/her back to the facility in a vehicle. He/She just got too hot and worn out to make it any further. During an interview CNA B said he/she worked on 7/20/19 and saw the resident go out to smoke. He/She thought the resident was with a family member. He/She went to find the resident at 2:00 P.M. and the resident was not in his/her room. Staff began looking inside and outside of the building. The dietary manager found the resident and returned him/her to the facility. It was a very hot day and the resident was hot and flushed. During an interview on 7//30/19 at 1:16 P.M. the dietary manager said he/she worked on 7/20/19 and saw the resident in the dining room at the noon meal. At about 2:00 P.M. staff asked if he/she had seen the resident. He/She offered to go look for the resident in his/her vehicle and saw a group of people standing around. He/She saw the resident seated under a tree on the ground about three blocks from the back of the facility. One of the people present was on off duty Emergency Medical Technician (EMT) and had checked the resident's vital signs. It was a very hot day and the resident was sweaty and flushed. The resident said he/she was just trying to get home but couldn't make it any further. During an interview on 7/31/19 at 8:30 A.M. and 8/1/19 at 2:40 P.M. the DON said she reviewed the facility camera footage from 7/20/19 and the resident exited through the front door of the facility at 12:17 P.M. The resident always wore long sleeved shirts and blue jeans. It was very hot on 7/20/19. There were not any current specific instructions for staff to increase monitoring of residents when they were outside during extreme temperatures. She would expect staff to increase monitoring of residents who were outside during extreme temperatures and check on them at least every 15 minutes if they observed the resident go outside. Even for those residents who had been assessed as able to go outside and smoke unsupervised. During a telephone interview on 8/1/19 at 2:45 P.M. the administrator said the facility did not have a written policy for monitoring of residents during extreme temperatures. She would expect staff to use common sense and ask the resident to smoke one cigarette instead of two and try to educate the resident on the dangers of being outside during hot temperatures. Review of the temperature history for the facility area on 7/20/19 per WeatherUndergound. com showed the following: -At 11:55 A.M. the temperature was 91 degrees Fahrenheit (F), with a relative humidity of 57%, making the heat index 97 degrees F.; -At 12:55 P.M. the temperature was 93 degrees F, with a relative humidity of 54%,making the heat index 101 degrees F; -At 1:55 p.m. the temperature was 95 degrees F, with a relative humidity of 52%, making the heat index 106 degrees F. Review of the heat index chart from Weather Undergound showed the following: -For people in high risk groups, including the elderly, for heat indices of 90-105 degrees F, should use extreme caution as this group is at particular risk for sunstroke, muscle cramps and or heat exhaustion with prolonged exposure or physical activity; -For heat indices of 15-129 degrees F, people in high risk groups were in likely danger of sunstroke and heat exhaustion, heatstroke was possible with prolonged exposure and /or physical activity. 8. Review of Resident #142's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's physician order sheet (POS) for July 2019 showed an order for oxygen at four liters per nasal cannula. Review of the resident's Smoking Evaluation, dated 7/23/19, showed the following: -The resident smokes cigarettes; -He/She wears oxygen continually and needs help taking it off to smoke; -In a wheelchair, needs help to go out to smoke. Review of the resident's care plan, dated 7/23/19, showed the following: -He/She smokes cigarettes; -He/She requires direct supervision while smoking; -The resident's oxygen must be removed and left in the building while he/she smokes. Observation on 7/30/19 at 8:30 A.M. showed CNA F propelled the resident outside the front entrance door in a wheelchair. The resident had a portable oxygen tank on the back of the wheelchair. Once outside, CNA F removed the resident's nasal cannula from his/her nose, laid the tubing on top of the oxygen tank, and turned the oxygen regulator to zero. CNA F assisted the resident to light a cigarette. The resident smoked his/her cigarette with the oxygen tank in place on the back of his/her chair. A few moments later, the Social Service Director went outside and removed the oxygen tank from the resident's wheelchair and placed it in a holder in the front entryway of the building. Observation on 7/31/19 at 8:10 A.M., showed the following; -The resident sat outside in his/her wheelchair smoking a cigarette; -An oxygen tank and tubing were attached/located on the resident's wheelchair; the oxygen tubing hung over the handle of the wheelchair, the oxygen was turned off, the oxygen tank level was at 100 psi (pounds per square inch); -The DON sat on a bench with the resident; -The DON then walked inside the building and Social Service Director (SSD) went outside and removed the oxygen tank and tubing from the resident's wheelchair, took the tank inside the building and then remained with the resident outside. During interview on 7/31/19 at 8:18 A.M., the SSD said the following: -She tries to monitor the smoking and remind staff as they go out the door to take the tank and tubing off the wheelchair and leave it in the carrier by the door; -The oxygen tank should not be outside with the resident when smoking; -The char[TRUNCATED]