Based on record review, the facility staff assigned to a resident neglected to ensure he received necessary ADL care and was left in bed for an extended period of time without help. The resident experienced pain, distress, and skin abrasions from the event, for 1 (#4) of 5 sampled residents. Findings include: Review of a Facility Reported Incident, dated 3/6/25, showed resident #4 was left unattended in his room. The resident was residing on the special care unit, and he was not provided cares by CNAs (NF10 and NF11) working on the unit. Review of resident #4's nursing progress notes, dated 3/6/25 at 11:42 a.m., showed: CNA called this nurse to resident's room. Upon entering, this nurse noted resident lying on his side at the foot of the bed between the mattress and the footboard. Resident's Left arm was bent and caught between mattress and footboard, elbow touching the floor. Resident screaming and crying, very combative to all staff. Resident did not want to be touched or moved. Resident was covered in BM, as was the floor, bed, and floor mats. Bed was noted to be high, except the foot of the bed. Resident was assisted from bed to floor by this nurse and 3 CNAs. Skin tears noted to back of left hand by thumb, left wrist, and RFA. Dark purple bruising noted to back of left hand. Large dark-colored mark noted to Left hip with an indentation in the middle, likely from pressure. 2 other nurses came to assist with cleaning the resident up and dressing skin tears. Skin tears cleansed with soapy water. Adaptic applied, covered with silicone bordered gauze. Resident rolled onto a blanket and lifted x4 staff onto bed. Resident very combative during cares, hitting staff and kicking staff, nearly kicking staff in the face [sic] Review of NF10's witness statement, written by NF4, dated 3/6/25, showed: . Resident [#4] door was cracked all night so staff could check on him. ½ to 1 hr checks were done thru out night. Approximatly at 0200 (2:00 a.m.) the othe CNA stated she had HA + stopped working contined to do checks . Around 6am care were being done on 2 other residents + cleaning of a room needed done . at this time [resident #4] started to yell out. Did walk down the hall and see Resident on the floor on matt. It was asked to other CNA (NF11) what to do and aid stated 'I can't do anything the day shift will be in. Continued to get people up as another Resident needed to be changed + gotten up for day. Employee stated she didn't feel comfortable with resident because he would yell + call CNA names and belittle her. Didn't think to tell the nurse. [sic] Review of NF10's employee personnel file showed NF10 was terminated on 3/13/25. NF10 received abuse, neglect, and resident rights training on 2/3/25 from NF3. Review of NF11's witness statement, written by NF4, dated 3/6/25, showed: Resident was checked and changed at 2030 (8:30 p.m.) + linen change he was taking off pullup up and peeing everywhere . Resident 0145 (1:45 a.m.) checked was sleeping brief wet + again took brief off + was peeing on bed lining changed and care done . Did no cares from 0400 (4:00 a.m.) to 0700 (7:00 a.m.) . Did not hear Resident from 0400 (4:00 a.m.) - till 0630 (6:30 a.m.) . [sic] Review of NF11's employee personnel file showed NF11 was terminated on 3/11/25 due to neglect. NF11 had a previous performance review on 12/12/24 which showed, Ensures residents are well cared for and look good when working in the SCU. NF11 had a discipline note signed by NF4 which showed a termination date of 3/11/25 with supporting information which showed, Cameras reviewed and CNA did not do any cares from 0200 (2:00 a.m.) to 0700 (7:00 a.m.) causing neglect to residents. Review of a facility document titled, Abuse and Neglect - Clinical Protocol, dated Quarter 3, 2018, showed: . 2. 'Neglect,' as defined at Section 483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.' . 5. Along with staff and management, the physician will help identify situations that might constitute or could be construed as neglect; for example . inattention to . resident wishes, inappropriate management of problematic behavior, recurrent failure to provide incontinence care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent a resident with dementia from eloping from the facility through the front entrance doors, leaving the facility property without supervision and accessing a public road, for 1 (#1) of 6 subsampled residents at risk for elopement. The resident sustained lacerations to his forehead after falling during the elopement. Findings include: Review of a facility reported incident, submitted to the State Survey Agency, dated 5/3/25 at 1:45 p.m., showed resident #1 was found outside of the facility by the police and was transported to the hospital for an evaluation. During an interview on 6/16/25 at 4:18 p.m., NF2 stated she received a call from the facility on 5/3/25. NF2 stated resident #1 was found at an apartment complex, on the ground, by a passerby who called the police and ambulance. NF2 stated resident #1 sustained a head laceration and was admitted to the hospital for observation. A call was placed to the police department on 6/18/25 at 12:40 p.m., and the police chief stated NF5 was the only staff member who could release the report for resident #1, regarding the incident which occurred on 5/3/25. The police chief stated NF5 would not be in the office until 6/19/25. During an interview, on 6/18/25 at 12:55 p.m., staff member F stated on 5/3/25 at 11:30 a.m., he received a call from the police department stating a resident was located near an apartment complex. Staff member F stated the facility did a head count of all residents and realized resident #1 was missing from the facility. Staff member F stated he responded to the location where resident #1 was found and it appeared the resident had a laceration to his head. Staff member F stated the resident was transported by ambulance to the hospital for an evaluation. Staff member F stated NF6 responded to the front door alarm when resident #1 exited, but did not see any residents when he (NF6) scanned the outside perimeter of the facility. Staff member F stated he was not sure why NF6 did not do a head count of the residents in the facility after the alarm went off. During an interview, on 6/19/25 at 8:37 a.m., NF6 stated he responded to the front door alarm on 5/3/25 at 10:08 a.m. NF6 stated when he responded to the alarm, he exited the front door of the facility, and scanned the perimeter of the building. NF6 stated he did not see any residents outside. NF6 stated he received orientation when he started his employment, but never read the facility elopement policy. NF6 stated during his orientation, NF4 stated, You know all this, you can just sign the paper. Calls were placed to NF5 on 6/19/25 at 8:00 a.m. and 12:38 p.m., with voicemails left on both occasions requesting a return call regarding resident #1's incident on 5/3/25. No return call was received from NF5 by the end of the survey. Review of a facility document titled, Timeline for elopement of (resident #1), dated, 5/3/25, showed: - 10:06 a.m. (resident #1) exits the front doors and walks around the front of the building very quickly. - 10:08 a.m. staff member, (NF6), does exit the front doors, responding to the alarm, stands on the front patio and scans the immediate area and remains outside looking around the area for about 30 seconds and returns inside. - Camera footage reviewed by (NF3) 5/3/25 at noon. Review of resident #1's EHR showed resident #1 was admitted to the facility on [DATE] for skilled nursing services with a diagnosis of dementia. Review of resident #1's elopement risk assessment dated , 4/7/25, showed the resident was at risk for elopement with a score of 6. Review of resident #1's wander assessment dated , 4/7/25, showed the resident was at moderate risk for wandering with a score of 10. Review of resident #1's nursing progress notes showed the following: - On 4/7/25 at 5:45 p.m., resident #1 was found in another resident's bathroom. Resident #1 required redirection by the nurse back to his room. - On 4/7/25 at 8:00 p.m., a wander guard was placed on resident #1's right ankle. - On 4/16/25 at 12:40 p.m., resident #1 eloped from the front doors of the facility. The nurse responded to the alarm. Resident #1 resisted staff redirection and continued to walk away from the facility accompanied by the nurse. Resident #1 was eventually redirected by the nurse back into the facility. The resident was not unattended during the attempted elopement. - On 4/17/25 at 8:03 p.m., resident #1 was found on the service hallway setting off the door alarm. Resident #1 was redirected by staff back to the main part of the facility from the service hall to the D hall. - On 5/3/25 at 1:46 p.m., a call was received from the police department at 11:28 a.m. Resident #1 was found outside the facility at an apartment complex. Resident #1 was found by the nurse seated on a bench accompanied by two police. Resident #1 had an abrasion on his left forehead and appeared to guard his left arm. Emergency medical services were called, and the resident was taken to the emergency department for an evaluation. A written request for resident #1's 5/3/25 police report was made to the facility on 6/16/25 and 6/17/25. No documentation was received from the facility by the end of the survey. Review of the facility document titled, Process for triggered wanderguard alarm, undated, showed: 1. All staff will respond any door that is alarming. 2. Staff will immediately assess why the door is alarming. 3. Staff will walk the parameter of the area to identify if a resident has left the building. 4. If there is not an identified reason the door is alarming, a CODE GRAY must be announced on the overhead pager and all staff must respond to the C/D nurses station. 5. A full head count must be completed by staff. The A/B nurse will be responsible for assigning staff which residents to check on and/or locations to check. Staff will report completed assignments to the A/B nurse. 6. The administrator and Director of Nursing/on-call nurse, must be notified of any elopement. 7. If a head count has been completed and a resident is not located, law enforcement will be notified. [sic]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to protect a resident's right to be free from physical and psychosocial abuse by facility staff for 1 (#7) of 13 sampled residents, causing resident #1 skin injuries, ongoing fear, and inability to sleep, fearing the specific staff involved would return to the facility. Findings include: During an observation and interview on 10/22/24 at 9:07 a.m., resident #7 was sitting in her wheelchair in her room. Resident #7 began to transfer herself from her wheelchair to her reclining chair. Resident #7 stated seven or eight weeks ago, one CNA, and one nurse, entered her room and woke her from a sound sleep and said, Get up, get up. You're going to the dining room. Resident #7 stated she told the nurse and CNA she did not eat in the dining room, and the nurse replied, You will today. Resident #7 stated the nurse and CNA then proceeded to undress her. Resident #7 stated the staff were, Tearing off my nightgown. Resident #7 stated she told the nurse and CNA to, Stop it as she was resisting care. Resident #7 said the CNA that was in the room called another CNA by radio for help. Resident #7 said the second CNA entered the room and helped transfer the resident to her wheelchair and then left her room. Resident #7 stated she was then transported by wheelchair down to the dining room, but she resisted by putting her feet down to the floor to try and stop the wheelchair from moving. Resident #7 said she really did not remember much else after that because she was in such a state of shock. Resident #7 said it took her three or four nights to settle down because she thought the staff would come back and harm her. During an interview on 10/23/24, at 4:17 p.m., staff member I reported on 8/22/24 the night shift nurse mentioned resident #7 had fallen out of her reclining chair on 8/21/24. Staff member I decided it would be best for the resident to go to the dining room for breakfast, so the resident could be monitored more closely. Staff member I asked staff member N to help get the resident ready and bring her to the dining room. Staff member I explained that as the CNA was helping the resident dress, she was called by staff member N back into the resident's room a few more times because the resident was resisting. Staff member I and N tried explaining to the resident that she couldn't stay in her room alone because no one would be able to assist her if she needed help. Staff member I stated resident #7 reacted with resistance, but staff were accustomed to this and maintained a firm approach to get her ready for breakfast. Once in the dining room, resident #7 was served her meal but tried to stand up unsteadily. Staff member I stated she then moved resident #7 to a regular chair instead of her wheelchair to keep her seated. Due to this, the resident would be unable to leave the dining room area as she was not in her wheelchair. During an interview on 10/24/24 at 2:30 p.m., staff member E stated on 8/22/24, resident #7 was sitting in her wheelchair crying at a desk located in the front office. Staff member E stated she stopped and spoke to resident #7 to make sure she was okay. Staff member E stated while speaking with the resident, staff member A approached her and resident #7 and asked if she would complete a skin assessment on resident #7. After resident #7 agreed to the assessment, staff member E transported resident #7 in her wheelchair to the bathroom located in the administration office. During the skin assessment of resident #7, staff member E found one bruise on the back mid right shoulder described as a dime in size and purple in color and one bruise on the outer right groin described as a quarter to nickel in size and purple in color. Staff member E stated resident #7 had scratch abrasions on her right forearm. Staff member E stated resident #7's skin assessment was completed on 8/22/24 shortly after the incident occurred and no medical treatment was required. A review of the facility surveillance footage received on 10/24/24 from law enforcement, dated 8/22/24, showed staff member N pushed resident #7 in her wheelchair into the dining room. Eight other residents were observed seated at dining room tables, each in their own wheelchair. Resident #7 appeared [NAME] sitting in her wheelchair with her hands resting in her lap. Resident #7 was left in her wheelchair in the dining room between two dining tables by staff member N. Staff member N then exited the dining room. Resident #7 was seen moving her wheelchair with her feet, heading toward the dining room exit. Staff member N re-entered the dining room and grabbed the handles on the back of resident #7's wheelchair. Staff member I entered the dining room and directed staff member N and resident #7 over to a dining table in the middle of the room. Staff member N pushed resident #7's wheelchair to the dining table. Staff member N placed resident #7's wheelchair brakes on and attempted to transfer the resident to a stationary chair. Resident #7 was seen resisting the transfer by pushing the staff members hands away from her body. Staff member N and I then placed their forearms under resident #7's upper arms. Resident #7 was seen attempting to resist the transfer by lifting her head and turning it to the right as she pushed staff member N and I's hands and arms away from her. Surveillance video did not show resident #7's meal at the dining table or resident #7 attempt to stand on her own prior to being transferred to a stationary chair. Review of resident #7's medical provider noted dated 8/22/24 at 4:53 p.m., showed: Assessment & Plan Offerred ED transfer after being transferred in rough fashion this AM by staff Staff have been suspended they transferred her rouhgly and are being investigated No ecchymosis today Pain seems more chronic than anything No further changes today [sic] Review of resident #7's Weekly Head to Toe Skin Check, dated 8/22/24, showed, . 3. Wound documentation and notes: bruise to right shoulder scratch to right forearm small bruise to right upper thigh. [sic] Review of resident #7's EMR medical provider note, dated 8/28/24 at 1:30 p.m., showed, . Patient was physically assaulted by three individuals at her nursing home, resulting in multiple bruises and emotional distress. She is fearful, especially at night, and is having difficulty sleeping. The incident has left [Resident #7] in a state of heightened fear and anxiety, particularly at night. She is constantly on edge, reacting to every sound and expressing fear that the perpetrators might return. This emotional distress has also affected her sleep; she has difficulty falling asleep and staying asleep due to her heightened fear and anxiety. She stated that she hears every footstep in her hallway she is constantly worried about the return of the perpetrators. [Resident #7]'s [family member] is also upset about the incident, which has caused [Resident #7] feelings of guilt and sadness. She expressed regret that despite moving to the nursing home for safety reasons, she does not feel safe. In terms of medication changes, [Resident #7] would like her quetiapine dosage to be increased at night to help with her sleep issues. Review of resident #7's care plan, with a revision date of 9/20/24 showed: Focus: [Resident #7] has a physical functioning deficit related to osteoarthritis pain. Goal: [Resident #7] will maintain current level of physical functioning through next review target date of 11/11/24. Interventions: Dressing assistance of one, able to stand to transfer independent or with assist x one. Not able to walk. Is independent in eating. Chooses to remain in room for meals. Focus: [Resident #7] has a behavioral complex care plan due to behavioral presentations as evidenced by periods of verbal behaviors towards others and tearful episodes with emotional dysregulation. Goal: [Resident #7] will not exhibit a behavioral decline through next review target date 11/11/2024. Intervention: If [Resident #7] cannot be redirected or calmed, and if safe to do so, staff to attempt to perform cares at a later time after [Resident #7] is calmer. [sic] Review of Resident #7's MDS with an ARD of 7/14/24, showed the following: . Section C, BIMS score 15; cognitively intact. . Section GG, Functional Abilities and Goals: - eating; independent. - upper body dressing; set up or clean up assistance. - lower body dressing; independent. - putting on or taking off footwear; independent. - personal hygiene; independent. - wheel 50 feet with two turns; independent. - wheel 150 feet; independent. A review of a Facility Reported Incident, sent to the State Survey Agency, showed a staff to resident abuse report was submited for the interaction resident #7 had with facility staff on 8/22/24. The report showed the facility identified the abuse after it occurred, suspended the staff for resident protection, made the initial report of abuse to the State Survey Agency, investigated the event, and put corrective measures in place. The facility investigation failed to address root causes, and the fact multiple staff were involved, but all failed to intervene or stop the abuse from occurring at the time of the event, or report it as alleged abuse immediately after, in an attempt to prevent future recurrences.

Based on observation, interview, and record review, the facility failed to maintain an effective system for tracking resident weights, identifying weight loss, and implementing nutritional interventions for 2 (#s 12 and 49) of 2 sampled residents. Resident #49 had a severe weight loss, and #12 had a significant weight loss. Findings include: 1. During an observation on 2/14/23 at 9:50 a.m., resident #49 was lying in a low bed on his side. Resident #49 had his eyes closed and did not rouse to his name being spoken in a normal voice. Resident #49 had hollow cheeks with temporal wasting. The resident was left undisturbed. During an interview on 2/15/23 at 9:44 a.m., staff member I stated resident #49 had begun declining before Christmas. Staff member I stated she had discussed resident #49's care with his POA and agreed to give the resident what he wanted to eat and drink, and not to force him to get out of bed if the resident did not want to get up. Staff member I stated the resident was sleeping more but would take food and fluids when awake. The staff fed him as much as possible when he was awake. Staff member I stated the facility had identified an issue with inaccurate resident weights and had provided education to the CNAs regarding the correct procedure for weighing residents. Staff member I could not remember exactly when the education had occurred, but believed it was late December of 2022 or January of 2023. Staff member I stated if she identified an inaccurate weight, she asked the CNA to re-weigh the resident. Staff member I was not able to explain why the inaccurate weights obtained on 1/15/23 and 1/19/23 were not corrected. Review of resident #49's nursing progress notes, dated between 12/5/22 and 2/13/23, showed a gradual decline in the resident's mobility and oral intake of food and fluids. None of the nursing progress notes noted the resident's weight loss from 154 pounds (12/26/22) down to 117.6 pounds on 2/13/23, issues with the outlier weights documented on 1/15/23 and 1/19/23, or notification of the resident's physician or the dietician regarding his weight loss. Review of resident #49's weights, dated between 12/11/22 and 2/13/23, showed the following weight changes: - 12/11/22 - 148 pounds, - 12/26/22 - 154 pounds, - 12/29/22 - 140 pounds, - 1/1/23 - 142 pounds, - 1/8/23 - 136 pounds, - 1/12/23 - 129 pounds, - 1/15/23 - 171 pounds - Incorrect - 1/19/23 - 170 pounds - Incorrect - 2/5/23 - 126 pounds, and - 2/13/23 - 117.6 pounds. Review of resident #49's physician progress note, dated 12/8/22, failed to include anything about the resident's weight loss, despite a weight loss of 11 pounds in the previous two months (158 pounds on 10/3/22 and 147 pounds on 12/1/22). There were no changes in the resident's treatment documented on the note. Review of resident #49's nutrition note, dated 1/25/23, and completed by staff member H, failed to show the resident's weight loss after 1/1/23. There were no changes in the resident's plan of care documented on the note. Review of resident #49's physician progress note, dated 2/4/23, showed a 20-pound weight loss with refusal to eat. The physician progress note showed a feeding tube was not recommended and contradicted the nutrition note from 1/25/23 which showed the resident's weight was stable. There were no changes in the resident's treatment documented on the note. During an interview on 2/15/23 at 4:30 p.m., staff member H stated she was responsible for performing nutritional assessments for residents, and she visited the facility monthly if the weather was cooperative. Otherwise, she did video visits if she was unable to get to the facility. When asked why she used resident #49's weight from 1/1/23, rather than a more current weight, staff member H stated she was not sure why she had not used the most current weight. Staff member H stated she had not been notified of any problems with resident #49, despite his severe weight loss, and had not notified resident #49's provider regarding his severe weight loss. 2. During an observation on 2/14/23 at 9:17 a.m., resident #12 was seated in the day room of the secure care unit. His hair was messy, he had facial whiskers, and his pants were cinched up. Resident #12 had a Danish on a plate in front of him. It was cut into small pieces. Staff member I would stop by resident #12's table, get a piece of Danish on a fork, and coax resident #12 to eat it. During an interview on 2/14/23 at 9:20 a.m., staff member I said resident #12 did not eat much most days. Staff member I said resident #12 got four to five health shakes every day. She said some days the health shakes were the only thing resident #12 would have. Review of resident #12's Weights and Heights Report, dated 8/2/22 to 2/13/23, showed resident #12 weighed 150 pounds on 1/10/23. On 2/13/23 resident #12 weighed 139 pounds for a weight loss of 11 pounds or 7.33%. That was a significant weight loss in 30 days. Review of resident #12's Nutrition Assessment, dated 2/13/23, identified a weight loss of 6% in 30 days from 1/3/23 (148 pounds) to 2/13/23 (139 pounds). Review of resident #12's Nutrition Care Plan, last edited on 6/14/22, failed to identify a significant weight loss, what the weight loss was related to, or show a reason for his weight loss. The only interventions the facility had in place were [Brand Name] Plus at meals, 1:00 p.m., to encourage resident #12 to have two to three snacks a day, and to provide him with a regular diet. Review of the facility's menu showed the facility provided five meals per day to the residents. These meals consisted of a continental breakfast from 7 a.m. to 9 a.m., brunch at 10 a.m., a substantial snack at 1 p.m., dinner at 4 p.m., and another substantial snack at 7 p.m During an interview on 2/15/23 at 4:41 p.m., staff member H said resident #12's appetite waxes and wanes due to his disease process. Staff member H said she had never thought about using three meals a day as an intervention to prevent weight loss.

Based on interview and record review, the facility failed to ensure the dietitian, and the dietary manager, accurately assessed and communicated the nutritional needs of 1 (#49) of 1 sampled resident. This deficient practice resulted in the failure to intervene for a resident with a severe weight loss. Findings include: During an interview on 2/15/23 at 4:30 p.m., staff member H stated she was responsible for performing nutritional assessments for residents. Staff member H stated she visited the facility monthly, either in person or via video conference. Staff member H stated she depended on staff member G to notify her if there were any nutritional issues with the residents. Staff member H stated she had not been notified by staff member G of any nutritional issues with resident #49, and was not aware of his severe weight loss. When asked why she had used resident #49's weight from 1/1/23 in the 1/25/23 nutrition note, rather than a more current weight, staff member H stated she was not sure why she had not used the most current weight. Staff member H stated she may have questioned the accuracy of the weights, but was not able to specifically explain why the resident's current weight was not used or why she had not identified resident #49's severe weight loss. Staff member H stated she depended on staff member G to notify her of specific resident nutritional concerns. Staff member H stated if staff member G did not notify her, she had no reason to further investigate a resident's nutritional needs. Staff member H was not at the facility full time, per the interview. This surveyor attempted to interview staff member G during the survey. The staff member was not available for interview. A review of staff member G's educational information showed staff member G held the necessary certification to carry out the functions of the food and nutrition services, taking into consideration resident assessments, individual plans of care, the number, acuity, and diagnosis of the facility population, in the absence of staff member H, who was not at the facility full time. Review of the facility's policy titled, Nourishment At Risk, not dated, showed: RD regularly tracks and identifies weights that show a gain or loss. RD will initiate interventions and inform the interdisciplinary team. The policy showed the dietitian assessed the nutritional needs of the residents and developed an individualized plan of care for the resident. Refer to F692 Nutrition/hydration Status Maintenance, F657 Care Plan Timing and Revision for additional details related to resident #49's severe weight loss.

Based on observation, interview, and record review, the facility failed to accurately assess and provide supervision for the safety of 1 (#18) of 4 sampled residents for smoking; failed to implement effective fall interventions for a resident who had significant fall history and risk factors for more falls for 1 (#12) of 5 sampled residents for falls; failed to provide supervision for residents in the secured nursing unit while residents were in common areas for 4 (#s 11, 12, 13, and 16) of 4 sampled residents. Findings include: 1. Smoking During an observation and interview on 11/3/22 at 10:00 a.m., resident #18 stated he had a lighter explode in his face when he tried to light a cigarette. Resident #18 said he did not remember if he was outside or in his room at the time it occurred. Resident #18 said he did not remember if he was wearing his oxygen at the time of the incident, and he did not remember ever having a lighter explode prior to the incident. Resident #18 was seated in his recliner, covered with a blanket, and had his oxygen via nasal cannula in place. The burns on his face appeared to be healed. During an interview on 11/3/22 at 10:30 a.m., staff member C said the facility had no specific answers for where resident #18 acquired the lighter. Staff member D said they believed the lighter was purchased for resident #18 by another resident that was able to leave the facility and shop independently. However, the resident denied purchasing the lighter for resident #18. Staff member A said resident #18 was found to have a lighter prior to the incident and had given the lighter to facility staff, and it was added to the smoking container. Staff member A said resident #18 was told he could not have a lighter and understood. Staff member A said resident #18 was provided the smoking policy to read and a verbal agreement to follow the facility smoking policy was obtained from the resident. Staff member A said resident #18 was observed by other residents digging thru the fire suppression trash can between smoke breaks when staff were not supervising him outside. The fire suppression trash cans did not have a lock that prevented residents from accessing the contents. Staff member C said the facility believes resident #18 acquired the butts found in his room from the fire suppression trash can. Staff member C said, We were aware of the incident that occurred at his prior facility and believed it was because they (residents) were not supervised while smoking at that facility. The resident was not in a controlled environment. We believed that it would not occur if he was in a controlled environment at our facility. Review of resident #18's progress note, dated 10/13/22 at 4:15 p.m., showed resident #18 was short on funds to purchase cigarettes, and the cigarettes he had were all he had left, but the facility would work on getting him more soon. It was explained to resident #18 that borrowing cigarettes from other residents was not allowed. Review of resident #18's progress note, dated 10/13/22 at 6:12 p.m., showed resident #18 was noted to have a cigarette hidden in his hat. Review of resident #18's progress note, dated 10/14/22 at 7:03 p.m., showed a CNA was called to resident #18's room for assistance. Resident #18 had a lighter and had tried to light a cigarette with his oxygen on. It had exploded in his face causing burns to his face. Review of resident #18's progress note, dated 10/15/22 at 12:23 p.m., showed: Late entry: prior to resident being sent out to hospital for treatment of his burns, on the evening of 10/14/22, resident did allow this RN to look in coat pockets. Resident did state that he didn't have any cigarettes in his coat pockets. One broken cigarette and one broken short cigar were found in pocket. Also was found two butts in pocket, one to a cigar and one to a cigarette. nurse did also find a cigarette butt in garbage can in room after resident left for medical treatment. Review of a resident #18's Smoking Assessment, dated 9/22/22 showed: . (Resident #18) has dementia and hx of TBI and he is safety aware. Review of a facility document, Type of Event, dated 10/14/22 showed: . An incident report was completed on September 28 2022. Resident (#18) was out on the smokers patio digging through the ashtray, found a cigarette butt and lit it. Resident had a lighter in his pocket per incident report. Investigation noted that social service spoke to the resident, reviewed the policy and resident agreed to turn the lighter into social services it was unsure if the resident had signed the resident smoking agreement at the time the incident occurred. As per nursing conversation with resident daughter the daughter stated that this incident of the residence sustaining burns while attempting to light a cigarette with oxygen was not the first time prior to this event [sic]. Review of a facility document, Root Cause Analysis, not dated, showed: . Questions surrounding direct supervision - whether they are being supervised adequately -smoking box outside of eyesight of CNA? -Another resident reported seeing (resident #18) sneak cigarettes out of the smoking box when CNA's back is turned . 2. Falls During and interview and observation on 11/3/22 at 8:23 a.m., staff member G said resident #12 likes to walk and can not see. Resident #12 tends to fall and was difficult to redirect because he became agitated if people got too close to him. Resident #12's vision was bad, and he would walk into things and trip over things because he could not see them. He would reach out and grab other residents trying to navigate, and the other residents would strike out, not understanding he was grabbing them to steady himself. Staff member G said she did not know what more to do for resident #12's falls. If staff made an attempt to help him, he became agitated and would strike out, so staff would keep him in sight and attempt to anticipate his behaviors and falls. Staff tried to balance his behaviors and falls. Resident #12 was observed wandering throughout the secured unit with a staff member following at a distance. The day room was long and narrow, lined with recliners and chairs on both sides of the room. When residents were seated in the recliners and not reclined, their feet would extend out into the walkway through the room, becoming a tripping hazard. Residents were asked to move their legs so other residents could pass and they would become agitated with staff. During an interview on 11/3/22 at 10:30 a.m., staff member C said the aides stay with resident #12 as much as possible. Resident #12 does not see well and will not wear his glasses; he startles and then gets combative and falls. Staff member C said resident #12 will go up to other residents and grab them, trying to orient himself, and it will cause an altercation. He will also run up and down the secured unit hallway. Staff member C said the facility is focused on keeping resident #12 from injury when he falls. Staff member C said the facility was aware of the issue with falls and had started a process improvement plan a year ago. Record review of a facility document, Report of Falls, dated for the month of September and October 2022, showed resident #12 had three falls in September (9/3/22, 9/9/22, and 9/13/22) and more in October (10/1/22, 10/8/22 x2, 10/15/22, 10/24/22 x2, and 10/26/22). Record review of resident #12's care plan, not dated, showed: Title: Increased Risk for Falls . Evidenced by: History of falls - Needs supervision and cueing w/transfers and ambulation at times - Poor Vision - Resistive to assist-aggressive behaviors Goal: (Resident #12) will be free from falls through next review. (Resident #12) will be free from injury if he does fall thru next review. . Approaches: - Offer toileting when rounding or when (resident#12) is restless and wandering. - Encourage (resident #12) to change positions slowly - Encourage (resident #12) to wear non-slip footwear at all times . .- Assist (resident #12) to sit properly in the recliners in the Day Room - Monitor for ill side effects from his medication - (Resident #12) prefers to have a night light on in his room at night - (Resident #12) to sit on a pressure pad when sitting in a recliner in the Day Room - Distract and assist to walk outdoors if agitated and needs redirection - if able - (Resident #12) will have spill proof cup with fluids at bedside to avoid spills on floor. 10/26/22 . Review of resident #12's Fast Investigation reports, showed: - The FAST committee reviewed the fall that occurred on 10/1/22, another resident made physical contact, throwing resident (#12) on to the floor. Root cause of the fall was determined to be that, resident was thrown on the floor by another resident. The Fast committee implemented one staff member to be positioned just outside the doorway to the day room during rounds, to keep both residents within line of site. - The FAST committee reviewed two falls that occurred on 10/8/22 when resident #12 fell while ambulating in the secured unit hallway. The committee determined that resident #12 did not sustain any injury related to the falls. The root cause of the falls was determined to be loss of balance while ambulating resulting in resident #12 falling to the floor. The FAST committee found, Resident's (#12) goal for no injury was met. Will continue with current POC. - The FAST Investigation, dated 10/19/22, showed the FAST committee reviewed the fall that occurred on 10/15/22 where resident #12 was leaning back while ambulating, and this resulted in him falling. The committee determined resident #12 did not sustain any injury related to the fall. The committee determined the root cause of the fall was leaning back while ambulating. The FAST committee found, Resident's (#12's) goal of being free of injury with falls was met. No new interventions implemented. Will continue to follow current POC. - The FAST Investigation, dated 10/28/22, showed the FAST committee reviewed three falls. The first fall on 10/24/22 at 6:40 a.m., was determined to be caused by resident fatigue, related to the resident being up all night. The second fall, on 10/24/22 at 3:50 p.m., was determined to be an assisted fall, and resident #12 was leaning back while ambulating. The third fall 10/26/22 at 1:15 a.m. was determined to be caused by spilled water jug near resident #12's bed. The committee determined resident #12 did not sustain any injury related to the falls. The FAST committee implemented, . Staff to continue following current plan of care to prevent injuries. A spill proof cup with fluids kept at bedside. Offer or insert ear plugs if resident allows. Review of a facility document, Fall Prevention & Management, not dated, showed: . B. After level of fall risk has been identified appropriate intervention strategies will be implemented. Interventions considered will include but not be limited to the following: 1. Low bed 2. Non-slip grip footwear 3. Assign resident to bed that allows resident to exit towards stronger side 4. Lock moveable transfer equipment prior to transfer 5. Non-skid floor mat or strips 6. Adequate nighttime lighting 7. Medication review 8. Exercise program 9. Toileting program 10. Scoop mattress 11. Fall mat beside bed 12. Hip, elbow or knee protectors 13. Alarm system (bed, floor, door, etc.) 14. Move closer to nursing station . 3. Supervision During an interview on 11/3/22 at 8:23 a.m., staff member G said resident #13 was very independent and thinks he does not need assistance when he actually needs a lot of assistance. He was very unpredictable with his behaviors. Staff member G said staff has been instructed to keep resident #13 in line of sight at all times and to follow him. Review of facility document, Investigation of Suspected Abuse, dated 10/6/22 showed resident #12 and #13 were involved in an altercation in the secured unit hallway. Resident #12 reached out, looking for direction or someone to hold on to. Resident #12 encountered resident #13, and resident #13 grabbed resident #12, and threw him down. Review of a facility document, FAST Investigation, dated 10/7/22 showed the FAST committee reviewed the fall that occurred on 10/1/22, and another resident made physical contact, throwing resident (#12) on to the floor. The root cause of the fall was determined to be that resident was thrown on the floor by another resident. The Fast committee implemented one staff member to be positioned just outside the doorway to the day room during rounds, to keep both residents within line of site. Review of a facility reported incident, dated 10/14/22, and sent to the State Survey Agency, showed: Three staff members were assisting other residents in their rooms, and the remaining staff member was in the day room overseeing the residents in that area. Review of resident #13's care plan, not dated, showed: . Approaches: -Keep (resident #13) in line of sight at all times . - (Resident #13) must be monitored at all times. Ensure (resident #13) does not enter room next . door through the bathroom. - When resident #13 is ambulating, he must be followed at a distance, remaining in your line of sight. Review of a facility reported incident, dated 10/21/22, showed resident #11 and #16 were involved in an altercation in the secured unit hallway. The altercation occurred at the change of shift, and six staff members were present at the time of the incident. Two staff members were on their phones. All staff were questioned, and all staff were unaware of the location, of resident #11 or #16, at the time of the event. Review of a facility document, Investigation of Suspected Abuse, dated 10/26/22 showed: . Through this investigation it was discovered that the incident occurred within feet of the day room where all of the staff were located. Most of the staff reported that they were sitting opposite the hallway where the incident occurred. One staff member reported she was sitting around the corner from where the incident occurred. Furthermore, it was discovered that two staff members were on their phones at the time this incident occurred. . The DON also reviewed the expectations of care in the SCU, the policy on cell phone use, and the importance of knowing where the residents are at all times.